[Senate Hearing 113-]
[From the U.S. Government Publishing Office]



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

                              ----------                              

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

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

                         DEPARTMENTAL WITNESSES

                       RAILROAD RETIREMENT BOARD

   Prepared Statement of Michael S. Schwartz, Chairman of the Board; 
  Walter A. Barrows, Labor Member of the Board; and Jerome F. Kever, 
                     Management Member of the Board

    Mr. Chairman and members of the committee: We are pleased to 
present the following information to support the Railroad Retirement 
Board's (RRB) fiscal year 2014 budget request of $111,739,000 for our 
retirement, unemployment and other programs.
    The RRB administers comprehensive retirement/survivor and 
unemployment/sickness insurance benefit programs for railroad workers 
and their families under the Railroad Retirement and Railroad 
Unemployment Insurance Acts. The RRB also has administrative 
responsibilities under the Social Security Act for certain benefit 
payments and Medicare coverage for railroad workers. The RRB has also 
administered special economic recovery payments and extended 
unemployment benefits under the American Recovery and Reinvestment Act 
of 2009 (Public Law 111-5) and extended unemployment benefits under the 
Worker, Homeownership, and Business Assistance Act of 2009 (Public Law 
111-92). More recently, we have administered extended unemployment 
benefits under the Tax Relief, Unemployment Insurance Reauthorization, 
and Job Creation Act of 2010 (Public Law 111-312), the Temporary 
Payroll Tax Cut Continuation Act of 2011 (Public Law 112-78), the 
Middle Class Tax Relief and Job Creation Act of 2012 (Public Law 112-
96) and the American Taxpayer Relief Act of 2012 (Public Law 112-240).
    During fiscal year 2012, the RRB paid $11.4 billion, net of 
recoveries, in retirement/survivor benefits to about 573,000 
beneficiaries. We also paid $76 million in net unemployment/sickness 
insurance benefits to about 26,000 claimants. Temporary extended 
unemployment benefits paid were $7.2 million. In addition, the RRB paid 
benefits on behalf of the Social Security Administration amounting to 
$1.4 billion to about 114,000 beneficiaries.

               PROPOSED FUNDING FOR AGENCY ADMINISTRATION

    The President's proposed budget would provide $111,739,000 for 
agency operations, which would enable us to maintain a staffing level 
of 860 full-time equivalent staff years (FTEs) in 2014. The proposed 
budget would also provide $2,860,500 for information technology (IT) 
investments. This includes $2,100,000 for the final phase of our system 
processing for excess earnings data (SPEED) application. The remaining 
$760,500 would be used for other technology investments in network 
operations, and e-Government. In addition, the proposed budget would 
provide $600,000 for a Voice over the Internet Protocol system that 
provides a significant return on investment to our communications 
infrastructure in the areas of day-to-day operations and cost 
containment.

                            AGENCY STAFFING

    The RRB's dedicated and experienced workforce is the foundation for 
our tradition of excellence in customer service and satisfaction. Like 
many Federal agencies, however, the RRB has a number of employees at or 
near retirement age. About 65 percent of our employees have 20 or more 
years of service, and over 36 percent of our current workforce will be 
eligible for retirement by fiscal year 2014. To help prepare for the 
expected staff turnover in the near future, we are placing increased 
emphasis on modernization strategies to convert manual workloads to 
automated and strategic management of human capital. Our human capital 
plans provide for employee support and knowledge transfer, which will 
enable the RRB to continue achieving its mission. In addition, with the 
agency's formal human capital plan, succession plan and various action 
plans in place, we are ensuring that succession management supports a 
systematic approach to ensuring a continuous supply of the best talent 
through helping individuals develop to their full potential.
    In connection with these workforce planning efforts, the 
President's budget request includes a legislative proposal to enable 
the RRB to utilize various hiring authorities available to other 
Federal agencies. Section 7(b)(9) of the Railroad Retirement Act 
contains language requiring that all employees of the RRB, except for 
one assistant for each Board Member, must be hired under the 
competitive civil service. We propose to eliminate this requirement, 
thereby enabling the RRB to use various hiring authorities offered by 
the Office of Personnel Management. Also, our budget request includes a 
legislative proposal to clarify the authority of the Railroad 
Retirement Board to hire attorneys through competitive civil service.

                  INFORMATION TECHNOLOGY IMPROVEMENTS

    We are actively pursuing further automation and modernization of 
the RRB's various processing systems to support the agency's mission to 
administer benefit programs for railroad workers and their families. In 
fiscal year 2014, funding is included for contractor support to 
complete the full design of the System Processing Excess Earnings Data 
(SPEED) application. The SPEED application, started in 2006, is being 
built in phases to accommodate complex transactions and system 
interconnections. Once completed, SPEED will automate time consuming 
and complex manual processing of annuity adjustments resulting from 
post retirement work/earnings by employee and spouse annuitants. We 
expect automation of this workload to reduce staffing requirements and 
reduce improper payments through increased timeliness in handling.

                        OTHER REQUESTED FUNDING

    The President's proposed budget includes $39 million to fund the 
continuing phase-out of vested dual benefits, plus a 2 percent 
contingency reserve, $780,000, which ``shall be available proportional 
to the amount by which the product of recipients and the average 
benefit received exceeds the amount available for payment of vested 
dual benefits.'' In addition, the President's proposed budget includes 
$150,000 for interest related to uncashed railroad retirement checks.

                  FINANCIAL STATUS OF THE TRUST FUNDS

    Railroad Retirement Accounts.--The RRB continues to coordinate its 
activities with the National Railroad Retirement Investment Trust 
(Trust), which was established by the Railroad Retirement and 
Survivors' Improvement Act of 2001 (RRSIA) to manage and invest 
railroad retirement assets. Pursuant to the RRSIA, the RRB has 
transferred a total of $21.276 billion to the Trust. All of these 
transfers were made in fiscal years 2002 through 2004. The Trust has 
invested the transferred funds, and the results of these investments 
are reported to the RRB and posted periodically on the RRB's website. 
The net asset value of Trust-managed assets on September 30, 2012, was 
approximately $23.6 billion, an increase of almost $1.5 billion from 
the previous year. Through December 2012, the Trust had transferred 
approximately $13.9 billion to the Railroad Retirement Board for 
payment of railroad retirement benefits.
    In June 2012, we released the report on the railroad retirement 
system required by Sections 15 and 22 of the Railroad Retirement Act of 
1974, and Section 502 of the Railroad Retirement Solvency Act of 1983. 
The 25th Actuarial Valuation addressed the 75-year period 2011-2085, 
and included projections of the status of the retirement trust funds 
under three employment assumptions. These indicated that barring a 
sudden, unanticipated, large decrease in railroad employment or 
substantial investment losses, the railroad retirement system would 
experience no cash flow problems for the next 23 years. Even under the 
most pessimistic assumption, the cash flow problems would not occur 
until the year 2035. The report did not recommend any change in the 
rate of tax imposed by current law on employers and employees.
    Railroad Unemployment Insurance Account.--The RRB's latest annual 
report on the financial status of the railroad unemployment insurance 
system was issued in June 2012. The report indicated that even as 
maximum daily benefit rates rise 44 percent (from $66 to $95) from 2011 
to 2022, experience-based contribution rates are expected to keep the 
unemployment insurance system solvent, except for small, short-term 
cash-flow problems in 2015, under the most pessimistic assumption. 
However, projections show quick repayment of any loans by the end of 
fiscal year 2016.
    Unemployment levels are the single most significant factor 
affecting the financial status of the railroad unemployment insurance 
system. However, the system's experience-rating provisions, which 
adjust contribution rates for changing benefit levels, and its 
surcharge trigger for maintaining a minimum balance, help to ensure 
financial stability in the event of adverse economic conditions. No 
financing changes were recommended at this time by the report.
    Thank you for your consideration of our budget request. We will be 
happy to provide further information in response to any questions you 
may have.
                                 ______
                                 

                      OFFICE OF INSPECTOR GENERAL

       Prepared Statement of Martin J. Dickman, Inspector General
    Mr. Chairman and members of the subcommittee: My name is Martin J. 
Dickman, and I am the Inspector General for the Railroad Retirement 
Board. I would like to thank you, Mr. Chairman, and the members of the 
subcommittee for your continued support of the Office of Inspector 
General.

                             BUDGET REQUEST

    The President's proposed budget for fiscal year 2014 would provide 
$8,877,000 to the Office of Inspector General (OIG) to ensure the 
continuation of the OIG's independent oversight of the Railroad 
Retirement Board (RRB). During fiscal year 2014, the OIG will focus on 
areas affecting program performance; the efficiency and effectiveness 
of agency operations; and areas of potential fraud, waste and abuse.

                         OPERATIONAL COMPONENTS

    The OIG has three operational components: the immediate Office of 
the Inspector General, the Office of Audit (OA), and the Office of 
Investigations (OI). The OIG conducts operations from several 
locations: the RRB's headquarters in Chicago, Illinois; an 
investigative field office in Philadelphia, Pennsylvania; and five 
domicile investigative offices located in Virginia, Texas, California, 
Florida, and New York. These domicile offices provide more effective 
and efficient coordination with other Inspector General offices and 
traditional law enforcement agencies, with which the OIG works joint 
investigations.

                            OFFICE OF AUDIT

    The mission of the Office of Audit is to promote economy, 
efficiency, and effectiveness in the administration of RRB programs and 
detect and prevent fraud and abuse in such programs. To accomplish its 
mission, OA conducts financial, performance, and compliance audits and 
evaluations of RRB programs. In addition, OA develops the OIG's 
response to audit-related requirements and requests for information.
    During fiscal year 2014, OA will focus on areas affecting program 
performance; the efficiency and effectiveness of agency operations; and 
areas of potential fraud, waste, and abuse. OA will continue its 
emphasis on long-term systemic problems and solutions, and will address 
major issues that affect the RRB's service to rail beneficiaries and 
their families. OA has identified four broad areas of potential audit 
coverage: Financial Accountability; Railroad Retirement Act & Railroad 
Unemployment Insurance Act Benefit Program Operations; Railroad 
Medicare Program Operations; and Security, Privacy, and Information 
Management. OA must also accomplish the following mandated activities 
with its own staff: Audit of the RRB's financial statements pursuant to 
the requirements of the Accountability of Tax Dollars Act of 2002, 
evaluation of information security pursuant to the Federal Information 
Security Management Act (FISMA), and an audit of the RRB's compliance 
with the Improper Payments Elimination and Recovery Act of 2010.
    During fiscal year 2014, OA will complete the audit of the RRB's 
fiscal year 2013 financial statements and begin its audit of the 
agency's fiscal year 2014 financial statements. OA contracts with a 
consulting actuary for technical assistance in auditing the RRB's 
``Statement of Social Insurance'', which became basic financial 
information effective in fiscal year 2006. In addition to performing 
the annual evaluation of information security, OA also conducts audits 
of individual computer application systems which are required to 
support the annual FISMA evaluation. Our work in this area is targeted 
toward the identification and elimination of security deficiencies and 
system vulnerabilities, including controls over sensitive personally 
identifiable information.
    OA undertakes additional projects with the objective of allocating 
available audit resources to areas in which they will have the greatest 
value. In making that determination, OA considers staff availability, 
current trends in management, Congressional and Presidential concerns.

                        OFFICE OF INVESTIGATIONS

    The Office of Investigations (OI) focuses its efforts on 
identifying, investigating, and presenting cases for prosecution, 
throughout the United States, concerning fraud in RRB benefit programs. 
OI conducts investigations relating to the fraudulent receipt of RRB 
disability, unemployment, sickness, and retirement/survivor benefits. 
OI investigates railroad employers and unions when there is an 
indication that they have submitted false reports to the RRB. OI also 
conducts investigations involving fraudulent claims submitted to the 
Railroad Medicare Program. These investigative efforts can result in 
criminal convictions, administrative sanctions, civil penalties, and 
the recovery of program benefit funds.

              OI INVESTIGATIVE RESULTS FOR FISCAL YEAR 2012
------------------------------------------------------------------------
                      Indictments/                         Recoveries/
 Civil Judgments      Informations       Convictions       Receivables
------------------------------------------------------------------------
            26                106                85     \1\ $77,405,487
------------------------------------------------------------------------
\1\ This total includes the results of joint investigations with other
  agencies.

    OI anticipates an ongoing caseload of about 450 investigations in 
fiscal year 2014. During fiscal year 2012, OI opened 168 new cases and 
closed 258. At present, OI has cases open in 48 States, the District of 
Columbia, and Canada with estimated fraud losses of nearly $124 
million. Disability fraud cases represent the largest portion of Ol's 
total caseload. These cases involve more complicated schemes and often 
result in the recovery of substantial amounts for the RRB's trust 
funds. They also require considerable resources such as travel by 
special agents to conduct surveillance, numerous witness interviews, 
and more sophisticated investigative techniques. Additionally, these 
fraud investigations are extremely document-intensive and require 
forensic financial analysis.
    Of particular significance is an ongoing disability fraud 
investigation in New York. To date, 32 individuals have been indicted 
(23 have pled guilty), and OI agents will likely have to spend a 
substantial amount of time traveling to New York for continuing 
investigations and trial preparation in fiscal year 2014.
    During fiscal year 2014, OI will continue to coordinate its efforts 
with agency program managers to address vulnerabilities in benefit 
programs that allow fraudulent activity to occur and will recommend 
changes to ensure program integrity. OI plans to continue proactive 
projects to identify fraud matters that are not detected through the 
agency's program policing mechanisms.

                               CONCLUSION

    In fiscal year 2014, the OIG will continue to focus its resources 
on the review and improvement of RRB operations and will conduct 
activities to ensure the integrity of the agency's trust funds. This 
office will continue to work with agency officials to ensure the agency 
is providing quality service to railroad workers and their families. 
The OIG will also aggressively pursue all individuals who engage in 
activities to fraudulently receive RRB funds. The OIG will continue to 
keep the subcommittee and other members of Congress informed of any 
agency operational problems or deficiencies. The OIG sincerely 
appreciates its cooperative relationship with the agency and the 
ongoing assistance extended to its staff during the performance of 
their audits and investigations. Thank you for your consideration.
                                 ______
                                 

                  CORPORATION FOR PUBLIC BROADCASTING

       Prepared Statement of Patricia Harrison, President and CEO

    Chairman Harkin and distinguished members of the subcommittee, 
thank you for allowing me to submit this testimony on behalf of 
America's public media service--public television and public radio--on-
air, online and in the community. The Corporation for Public 
Broadcasting (CPB) requests $445 million for fiscal year 2016 and $27.3 
million for the Department of Education's Ready To Learn program in 
fiscal year 2014.
    Since 1967, the Corporation for Public Broadcasting has served as 
the steward of continuing Federal appropriations for public television 
and radio. Today we are a system comprising more than 1,400 locally 
owned and locally operated public radio and television stations serving 
local rural and urban communities throughout the country. More than 98 
percent of the American people turn to American public media for high 
quality content that educates, informs, inspires and entertains. Public 
media's commitment to early and lifelong learning, available to all 
citizens, helps strengthen our civil society and our democracy. Our 
trusted, noncommercial services available for free to all Americans is 
especially important to those living in rural communities where the 
local public media station is the only source of broadcast news, 
information and educational programming.
    The financial support for the public broadcasting system that is 
derived from the Federal appropriation is the essential investment 
keeping public media free and commercial free for all Americans. Former 
President Ronald Reagan said, ``government should provide the spark and 
the private sector should do the rest.'' And what stations do with the 
spark of Federal dollars, which amounts to approximately 15 percent of 
a stations budget, results in a uniquely entrepreneurial and American 
public media system with a track record of proven benefits delivered 
through stations to the American people.
    Federal money is the indispensible foundation upon which stations 
build and raise, on average, at least six times the amount they receive 
from the Federal Government. And it is this initial investment in 
public media that keeps it commercial free and available to all 
Americans for free. However, smaller stations serving rural, minority 
and other underserved communities are hard pressed to raise six times 
the Federal appropriation which can represent 40 percent of their 
budget. While their communities do the best they can in terms of 
financial support, the fact is, without the Federal appropriation these 
stations would cease to exist.
    No matter what their size, all public media stations work for, and 
are accountable to, the people in the communities they serve. That 
connection is important because as stations acquire national 
programming, they also produce local content and services based on the 
needs of their respective communities.
    As the steward of these important taxpayer dollars, CPB ensures 
that 95 cents of every dollar received goes to support local stations 
and the programs and services they offer to their communities; no more 
than five cents of every dollar goes to the administration of funding 
programs and overhead. Approximately 19 percent of CPB's funding is 
directed to the production or acquisition of programming, making CPB 
the largest single funder of content for children's programming such as 
Sesame Street and Daniel Tiger's Neighborhood; for public affairs 
programming such as PBS NewsHour, Morning Edition and Frontline; and 
for programming such as Nova, Nature, American Experience, StoryCorps 
and the films of Ken Burns.
    The Public Broadcasting Act ensures diversity in this programming 
by requiring CPB to fund independent and minority producers. CPB 
fulfills this obligation, in part, by funding the Independent 
Television Service, the five Minority Consortia entities in television 
(which represent African American, Latino, Asian American, Native 
American and Pacific Islander producers), several public radio 
consortia (Latino Public Radio Consortia, African American Public Radio 
Stations, and Native Public Media) and numerous minority public radio 
stations. In addition, CPB, through its Diversity and Innovation fund, 
makes direct investments in the development of diverse primetime and 
children's broadcast programs as well as innovative digital content.
    In the past year, CPB provided support for Southern California 
Public Radio's launch of the ``One Nation Media Project,'' which 
produces quality, multimedia journalism that engages a general audience 
while emphasizing topics that resonate authentically with multiethnic 
communities; the production of America Revisited, a three-part series 
by filmmaker Stanley Nelson on the history of African Americans; a 
documentary called The Graduates by filmmaker Bernardo Ruiz, which 
looks at the education challenges faced by Latino boys and girls; and 
PARALYMPICS, which introduces American audiences to high performing 
disabled athletes and the biomechanics of disabled sports.
    For an investment of approximately $1.35 per American per year, 
public broadcasting stations are able to train teachers and help 
educate America's children in school and at home; provide in-depth 
journalism that informs citizens about important issues in their 
neighborhoods, their country, and around the globe; make the arts 
accessible to all Americans; and provide emergency alert services for 
their communities.

                  CORPORATION FOR PUBLIC BROADCASTING

    CPB's mission is to facilitate the development of, and ensure 
universal access to, high-quality noncommercial programming and 
telecommunications services, and to strengthen and advance public 
broadcasting's service to the American people. CPB does not own or 
operate public broadcasting stations, or govern the national public 
media organizations. As steward of these important funds, we ensure 
these monies are invested in stations that serve our communities and 
programs that help strengthen our civil society.
    CPB strategically focuses investments through the lens of what we 
refer to as the ``Three D's''--Digital, Diversity and Dialogue. This 
refers to support for innovation on digital platforms, extending public 
media's reach and service over multiple platforms; content that is for, 
by and about Americans of all backgrounds; and services that foster 
dialogue and a deeper engagement between the American people and the 
public service media organizations that serve them.
    One example of a CPB investment that embodies each of the Three D's 
is our investment in education. Public broadcasting's contribution to 
education--from early childhood through adult learning--is well 
documented. We are America's largest classroom, with proven content 
available to all children, including those who cannot afford preschool. 
Our content is repeatedly regarded as ``most trusted'' by parents, 
caregivers and teachers. Now, building upon our success in early 
childhood education, CPB is leading a national initiative to help 
communities address the high school dropout crisis called, ``American 
Graduate: Let's Make It Happen.'' More than 75 public media stations 
located in 33 States with at-risk communities are working with more 
than 800 national and community-based partners to mobilize and bring 
together diverse stakeholders and community organizations; filling 
voids in information, resources and solutions; building and sharing 
best practices for teacher training and student engagement; creating 
local programming around the dropout issue unique to their communities, 
and leveraging digital media and technology to engage students in an 
effort to keep them on the path to graduation.

    CORPORATION FOR PUBLIC BROADCASTING'S REQUEST FOR APPROPRIATIONS

    Our fiscal year 2016 request balances the fiscal reality facing our 
Nation with the bare fact that stations are struggling to provide 
service to their communities in the face of shrinking non-Federal 
revenues--a $239 million, or 10.8 percent, drop between fiscal year 
2008 and fiscal year 2011. Even with these challenges, public 
broadcasting contributes to American society in many ways that are 
worthy of greater Federal investment. In fiscal year 2016, CPB will 
continue to support a range of programming and initiatives through 
which stations provide a valuable and trusted service to millions of 
Americans.
    CPB Base Appropriation (Fiscal Year 2016).--CPB requests a $445 
million advance appropriation for fiscal year 2016, to be spent in 
accordance with the Public Broadcasting Act's funding formula. The two-
year advance appropriation for public broadcasting, in place since 
1976, is the most important part of the ``firewall'' that Congress 
constructed between Federal funding and the programs that appear on 
public television and radio. President Gerald Ford, who initially 
proposed a five-year advance appropriation for CPB, said it best when 
he said that advance funding ``is a constructive approach to the 
sensitive relationship between Federal funding and freedom of 
expression. It would eliminate the scrutiny of programming that could 
be associated with the normal budgetary and appropriations processes of 
the government.''
    Ready To Learn (Fiscal Year 2014).--CPB requests that the U.S. 
Department of Education's Ready To Learn (RTL) program be funded at 
$27.3 million, the same level as fiscal year 2013. Mr. Chairman, 
education is the heart of public media. RTL is a partnership between 
the Department, CPB, PBS and local public television stations that 
leverages the power of digital television technology, the Internet, 
gaming platforms and other media to help millions of young children 
learn the reading and math skills they need to succeed in school. The 
partnership's work over the past few years has demonstrably increased 
reading scores particularly among low-income children and is helping to 
erase the performance gap between children from low-income households 
and their more affluent peers. An appropriation of $27.3 million in 
fiscal year 2014 will enable RTL to develop tools to improve children's 
performance in math as well as reading and bring on-the-ground, 
station-convened early learning activities to more communities.
    All told, the Federal contribution to public media through CPB 
amounts to $1.35 per American per year, and the return on investment to 
the American taxpayer can be measured in the numbers of children now 
ready to learn in school; through in-depth news and public affairs 
programming on the local, State, national and international level; 
unmatched, commercial-free children's programming; formal and informal 
educational instruction for all ages; or inspiring arts and cultural 
content.
    Americans no longer sit back and experience appointment television 
or radio. They are on the move and public media is there with them, 
utilizing today's technology to provide content of value to millions of 
citizens who trust us to deliver content that matters and is relevant 
to their lives today.
    Mr. Chairman and members of the subcommittee, thank you again for 
allowing CPB to submit this testimony. On behalf of the public 
broadcasting community, including the stations in your States and those 
they serve, we sincerely appreciate your support.

                       NONDEPARTMENTAL WITNESSES

        Prepared Statement of the Academy of Radiology Research

    Thank you for providing the Academy of Radiology Research with the 
opportunity to submit testimony on fiscal year 2014 funding for the 
National Institutes of Health (NIH). The imaging research community 
deeply appreciates the subcommittee's leadership in recommending a 
baseline increase to NIH funding in fiscal year 2013. This represented 
a much-needed step in the right direction for medical research.
    After the sequestration cut of 5.1 percent to the NIH in fiscal 
year 2013, the final appropriation for the agency will be approximately 
$29.3 billion (assuming a relatively flat fiscal year 2013 level). 
Looking back to fiscal year 2004, NIH funding stood at $27.8 billion--
which means our engine for medical breakthroughs in the U.S. has grown 
a total of 5.02 percent over the past decade, or at a compounded 
annualized rate of 0.54 percent. While we acknowledge that the 
subcommittee is not responsible for the sequester, the annualized 
growth rate for NIH over the past decade without sequestration (1.01 
percent) also does not reflect that of an innovation economy.
    NIH Director Francis Collins, M.D., Ph.D., recently stated before 
the subcommittee on March 5 that other nations are ``ramping up their 
support of biomedical research because they've read our playbook.'' 
Indeed, unlike the U.S., both emerging and developed economies continue 
to prioritize public funding for medical research and development. 
China alone is committing an average of $60 billion per year to 
biotechnology over the next 5 years--double the budget of the NIH. If 
NIH had continued its historical annual rate of growth (6.5 percent) 
from the 1960s to 1998 after the ``doubling,'' it would now be 
supported at $46.7 billion a year. Even a smaller but sustainable level 
of 4 percent annual growth since 2004 would put NIH funding at $38.5 
billion today.
    It is also important to note that NIH Directors did not wake up to 
a -5.1 percent sequester order on March 2, and are just now finding 
superfluous areas to trim, fat to cut, or duplication to eradicate. 
Directors and their staff have managed flat budgets, with eroding 
purchasing power, for the past decade. The sequester reductions are 
squarely on highly meritorious proposals.
    It is time to move NIH back into meaningful positive direction, 
ensuring that it can sustain and grow the number of multi-year 
investigator-initiated research grants, the foundation of our Nation's 
biomedical research enterprise. We ask that the subcommittee prioritize 
NIH even within the statutorily imposed flat budget caps, and begin 
reinvigorating medical research.

 THE NATIONAL INSTITUTE OF BIOMEDICAL IMAGING AND BIOENGINEERING AS AN 
               INCUBATOR AND SUPPLIER OF NEW TECHNOLOGIES

    Since the 1980s, many clinical and technological advances in CT, 
MRI, PET imaging, and image-guided therapies have been developed 
through funding from the National Institute for Biomedical Imaging and 
Bioengineering (NIBIB). Radiology research is truly an 
interdisciplinary science, bringing together physicians, physicists, 
mathematicians, chemists, computer scientists, physiologists and others 
from numerous scientific fields. This strong and diverse research 
pipeline has helped solidify the U.S. as the world leader in the basic 
research, development, and commercialization of advanced medical 
imaging technologies. It also makes the investment in NIBIB's research 
particularly valuable, as there are three distinct outputs from NIBIB 
research:
  --bench-to-bedside imaging tools that help medical professionals 
        diagnose, treat, and monitor a wide array of diseases and 
        conditions, saving millions of lives each year;
  --bench-to-bench interdisciplinary research tools that have given 
        thousands of researchers in other fields game-changing new ways 
        to tackle the diseases that they study; and
  --a pipeline for commercial imaging products, as medical imaging 
        devices represent one of the Nation's healthiest export 
        industries, providing tens of thousands of high-skilled jobs 
        across the country and adding positively to the Nation's gross 
        domestic product.

Imaging Research as a Bench-to-Bedside Tool
    One recent NIBIB-funded discovery--magnetic resonance elastography 
(MR elastography)--highlights just how radiology researchers are 
constantly pushing the technological envelope to improve human health. 
It has long been known that diseased tissue has different mechanical 
properties that surrounding normal tissue. Specifically, it tends to 
exhibit a slightly more rigid structure as the disease takes over. 
Previously, the only way to know that this was occurring was after a 
biopsy, usually late in the disease's progression. However, radiology 
researchers knew that if they could use advanced imaging to see these 
slight biomechanical changes in tissue stiffness, patients and fellow 
physicians would have a powerful new tool to find tumors earlier than 
ever before.
    NIBIB researchers found that by passing MRI waves through diseased 
tissue--such as a liver tumor--that they could use new algorithms and 
gradients to quantitatively measure and image the tissue's rigidity or 
stiffness. This has tremendous clinical implications, as a number of 
diseases including liver disease, breast cancer, prostate cancer, and 
many others can be detected at the earliest stages using MR 
elastography. Patients suspected of liver disease or cancer may think 
they are getting ``an MRI.'' However, at places like Mayo Clinic, the 
radiologists are likely using a new and better imaging test made 
possible with taxpayer-supported imaging R&D.
    total amount of grants using advanced imaging tools produced by 
radiology research, and as a percent of the total nih budget, 2001-2012



Imaging as a Bench-to-Bench Research Tool
    Researchers in nearly every field of study at NIH are taking 
advantage of imaging tools being developed by NIBIB and radiology 
researchers, using advanced imaging technologies to improve their 
understanding of disease and accelerate treatments. Demonstrating the 
scope of the imaging research ``toolkit,'' every NIH Institute funded 
projects that utilized imaging in fiscal year 2011, and nearly half of 
all Institutes invested 10 percent or more of their budget to imaging 
projects in fiscal year 2011. Of the 239 NIH Research, Disease and 
Condition Categorization (RCDC) codes at NIH, imaging projects were 
funded in 211 (88 percent) of all diseases being studied. The largest 
funder was the National Cancer Institute (NCI) at $527 million (10 
percent), while other ICs dedicating more than 10 percent of their 
budget to imaging projects also align with some of the Nation's most 
pressing health concerns, such as Alzheimer's (NIA--17 percent), 
neurological disorders and stroke (NINDS--19 percent), and heart 
disease (NHLBI--12 percent). Across the NIH research enterprise, there 
is a large and sustained consumer demand for new imaging projects being 
developed by NIBIB researchers.

Imaging Research as a Pipeline for One of America's Strongest 
        Industries
    The Department of Commerce identifies medical imaging equipment as 
one of the country's strongest projected exports for the coming decade. 
NIBIB research will play a key collaborative role in helping to cement 
U.S. leadership in the imaging sector by fortifying the pipeline for 
state-of-the-art imaging equipment. The downstream economic impact from 
NIBIB research is significant, as GE's MRI division alone supports over 
19,000 full-time positions in the U.S., while exporting over 1,000 MRI 
magnets per year from its MRI manufacturing facility in Florence, South 
Carolina.
    Although relatively small at $338 million in fiscal year 2012, the 
NIBIB is especially important as the Federal incubator for innovation 
in the rapidly moving field of medical imaging. Given its three-legged 
return on investment as a supplier of new technologies for patient 
care, a developer of game-changing new technologies for scientists in 
all fields, and a pipeline for a key domestic sector, we request a 
shift in the NIH portfolio for greater investment in imaging R&D.
    A global benchmark for R&D spending for an innovation economy is 3 
percent of GDP. We recommend that the NIH portfolio begin to be 
readjusted in fiscal year 2014 to allow for this same investment in 
imaging R&D, increasing the proportion of funding to NIBIB from the 
current 1.10 percent of the NIH budget to 3.0 percent over the next 5 
years. This path to increased imaging R&D would call for a $70 million 
increase for NIBIB in fiscal year 2014.
                                 ______
                                 
                  Prepared Statement of AcademyHealth

    AcademyHealth is pleased to offer this testimony regarding the role 
of health services research in improving our Nation's health and the 
performance of the health care and public health systems. 
AcademyHealth's mission is to support research that leads to 
accessible, high value, high-quality health care; reduces disparities; 
and improves health. We represent the interests of more than 4,400 
scientists and policy experts and 160 organizations that produce and 
use research to improve health and health care. We advocate for the 
funding to support health services research; a robust environment to 
produce this research; and its more widespread dissemination and use.
    As medical research discovers for cures for disease, health 
services research discovers cures for the health system. This research 
diagnoses problems in health care and public health delivery and 
identifies solutions to improve outcomes for more people, at greater 
value. This research is used by patients, health care providers, public 
health professionals, hospitals, employers, and public and private 
payers to enhance consumer choice, improve patient safety, and promote 
high quality care.
    Finding new ways to get the most out of every health care dollar is 
critical to our Nation's long-term fiscal health. Like any corporation 
making sure it is developing and providing high quality products, the 
Federal Government--as the Nation's largest health care purchaser--has 
a responsibility to get the most value out of every taxpayer dollar it 
spends on Medicare, Medicaid, Children's Health Insurance Program, and 
veterans' and service members' health. Health services research into 
the merits of different policy options for delivery system 
transformation, patient-centered quality improvement, community health, 
and disease prevention offers policymakers in both the public and 
private sectors the information they need to improve quality and 
outcomes, identify waste, eliminate fraud, increase efficiency and 
value, and promote personal choice.
    Put plainly, health services research helps Americans get their 
money's worth when it comes health care. We need more of it, not less. 
Despite the positive impact health services research has had on the 
U.S. health care system, and the potential for future improvements in 
quality and value, the United States spends less than one cent of every 
health care dollar on this research; research that can help Americans 
spend their health care dollars more wisely and make more informed 
health care choices.
    We respectfully ask that the subcommittee instead consider the 
value of health services research and strengthen its capacity to 
address the pressing challenges America faces in providing access to 
high-quality, efficient care. The following list summarizes 
AcademyHealth's fiscal year 2014 funding recommendations for agencies 
that support health services research and health data under the 
subcommittee's jurisdiction.

               AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

    The Agency for Healthcare Research and Quality (AHRQ) is the 
Federal health services research agency with the sole purpose of 
improving health care. AHRQ funds health services research and health 
care improvement programs in universities, medical centers, and 
research institutions that are transforming people's health in 
communities in every State around the Nation. The science funded by 
AHRQ provides consumers and their health care professionals with 
valuable evidence to make health care decisions. For example, medical 
societies use AHRQ-funded research to inform their recommendations for 
treatment of type 2 diabetes and rheumatoid arthritis. These evidence-
informed recommendations give physicians a foundation for describing 
what the best care looks like, so millions of patients living with 
these and other conditions may determine what the right care might be 
for them.
    AHRQ's research also provides the basis for protocols that prevent 
medical errors and reduce hospital-acquired infections (HAI), and 
improve patient experiences and outcomes. For example, AHRQ's evidence-
based Comprehensive Unit-based Safety Program to Prevent Healthcare-
Associated Infections (CUSP)--first applied on a large scale in 2003 
across more than 100 ICUs across Michigan--saved more than 1,500 lives 
and nearly $200 million in the program's first 18 months. The protocols 
have since been expanded to hospitals in all 50 States, the District of 
Columbia, and Puerto Rico to continue the national implementation of 
this approach for reducing HAIs.
    AcademyHealth joins the Friends of AHRQ--an alliance of health 
professional, research, consumer, and employer organizations that 
support the agency--in recommending an overall funding level of $434 
million for AHRQ in fiscal year 2014, consistent with the President's 
request.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

    The National Center for Health Statistics (NCHS) is the Nation's 
principal health statistics agency. Housed within the Centers for 
Disease Control and Prevention (CDC), it provides critical data on all 
aspects of our health care system through data cooperatives and surveys 
that serve as a gold standard for data collection around the world. 
AcademyHealth appreciates the subcommittee's support of NCHS in recent 
years. Such efforts have allowed NCHS to reinstate data collection and 
quality control efforts, continue the collection of vital statistics, 
and enhanced the agency's ability to modernize surveys to reflect 
changes in demography, geography, and health delivery.
    We join the Friends of NCHS--an alliance of health professional, 
research, consumer, industry, and employer organizations that support 
the agency--in recommending an overall funding level of $181.5 million 
for NCHS in fiscal year 2014, consistent with the President's request. 
This funding will put the agency on track to become a fully 
functioning, 21st Century, national statistical agency.

                     NATIONAL INSTITUTES OF HEALTH

    NIH spends approximately $1 billion on health services research 
annually--roughly 3 percent of its entire budget--making it the largest 
Federal sponsor of health services research. We join the research 
community in seeking at least $32 billion for NIH in fiscal year 2014. 
NIH has an important role in the Federal health services research 
continuum, and is well-positioned to ensure that discoveries from 
clinical trials are effectively translated into health care delivery. 
AcademyHealth supports efforts to help NIH foster greater coordination 
of its health services research investment among its institutes and 
across other Federal agencies to avoid duplication.
    AcademyHealth also recommends that the Clinical and Translational 
Science Awards (CTSA) through the National Center for Advancing 
Translational Sciences (NCATS) sustain investment in the full spectrum 
of translational research (T1-T4). The CTSA program enables innovative 
research teams to speed discovery and advance science aimed at 
improving our Nation's health. The program encourages collaboration in 
solving complex health and research challenges and finding ways to turn 
their discoveries into practical solutions for patients.

               CENTERS FOR MEDICARE AND MEDICAID SERVICES

    Steady funding decreases for the Office of Research, Development 
and Information have hindered CMS's ability to meet its statutory 
requirements and conduct new research to strengthen public insurance 
programs, which together cover nearly 100 million Americans and 
comprise 45 percent of America's total health expenditures. As these 
Federal entitlement programs continue to pose significant budget 
challenges for both Federal and State governments, it is critical that 
we adequately fund research to evaluate the programs' efficiency and 
effectiveness and seek ways to manage their projected spending growth. 
AcademyHealth supports CMS's discretionary research and development 
budget to improve the effectiveness and efficiency of these programs.
    In conclusion, the accomplishments of health services research 
would not be possible without the leadership and support of this 
subcommittee. We hope the subcommittee gives strong consideration to 
our fiscal year 2014 funding recommendations for the Federal agencies 
funding health services research and health data. If you have questions 
or comments about this testimony or wish to know more about health 
services research, please contact Lisa Simpson, President and CEO of 
AcademyHealth, or [email protected].
                                 ______
                                 
      Prepared Statement of the Ad Hoc Group for Medical Research

    The Ad Hoc Group for Medical Research is a coalition of more than 
300 patient and voluntary health groups, medical and scientific 
societies, academic and research organizations, and industry. We 
appreciate the opportunity to submit this statement in support of 
enhancing the Federal investment in biomedical, behavioral, and 
population-based research conducted and supported by the National 
Institutes of Health (NIH).
    We are deeply grateful to the subcommittee for its long-standing 
and bipartisan leadership in support of NIH. These are difficult times 
for our Nation and for people all around the globe, but we believe that 
science and innovation are essential if we are to continue to improve 
our Nation's health, sustain our leadership in medical research, and 
remain competitive in today's global information and innovation-based 
economy. The Ad Hoc Group recommends that NIH receive at least $32 
billion in fiscal year 2014. We believe this amount is the minimum 
level of funding needed to accommodate the rising costs of medical 
research and to help mitigate the effects of sequestration. The Ad Hoc 
Group also encourages the subcommittee to work to stop the pernicious 
cuts to research funding that squander invaluable scientific 
opportunities, discourage up and coming scientists, threaten medical 
progress and continued improvements in our Nation's health, and 
jeopardize our economic vitality.

NIH: A Public-Private Partnership to Save Lives and Provide Hope
    The partnership between NIH and America's scientists, medical 
schools, teaching hospitals, universities, and research institutions is 
a unique and highly-productive relationship, leveraging the full 
strength of our Nation's research enterprise to foster discovery, 
improve our understanding of the underlying cause of disease, and 
develop the next generation of medical advancements. Approximately 84 
percent of the NIH's budget goes to more than 300,000 research 
positions at over 2,500 universities and research institutions located 
in every State.
    The Federal Government has a unique role in supporting medical 
research. No other public, corporate or charitable entity is willing or 
able to provide the broad and sustained funding for the cutting edge 
basic research necessary to yield new innovations and technologies in 
the future.
    Research funded by NIH has contributed to nearly every medical 
treatment, diagnostic tool, and medical device developed in modern 
history, and we all are enjoying longer, healthier lives thanks to the 
Federal Government's wise investment in this lifesaving agency. From 
the major advances--including a nearly 70 percent reduction in the 
death rate for coronary heart disease and stroke--to moving stories of 
personalized medicine--such as children with rare diseases like dopa-
responsive dystopia, whose prognosis has been transformed from severely 
disabled to happy and healthy through genomic medicine--NIH's role in 
improving human health has been extraordinary. NIH research impacts the 
full spectrum of the human experience, resulting in a 40 percent 
decline in infant mortality over the past 20 years, as well as a 30 
percent decrease in chronic disability among seniors. For patients and 
their families, NIH is the ``National Institutes of Hope.''
    NIH is the world's premiere supporter of merit-reviewed, 
investigator-initiated basic research. This fundamental understanding 
of how disease works and insight into the cellular, molecular, and 
genetic processes underlying life itself, including the impact of 
social environment on these processes, underpin our ability to conquer 
devastating illnesses. The application of the results of basic research 
to the detection, diagnosis, treatment, and prevention of disease is 
the ultimate goal of medical research. Ensuring a steady pipeline of 
basic research discoveries while also supporting the translational 
efforts necessary to bring the promise of this knowledge to fruition 
requires a sustained investment in NIH.
    The research supported by NIH drives not only medical progress but 
also local and national economic activity, creating skilled, high-
paying jobs and fostering new products and industries. According to a 
report released by United for Medical Research, a coalition of 
scientific advocates, institutions and industries, in fiscal year 2011, 
NIH-funded research supported an estimated 432,000 jobs all across the 
United States, enabled 13 States to experience job growth of more than 
10,000 jobs, and generated more than $62 billion in new economic 
activity. Another report, produced by Tripp Umbach, calculated a $2.60 
return on investment for every public dollar spent on research at 
American medical schools and teaching hospitals.

Sequestration Threatens Scientific Momentum
    As patients, health care providers, and scientists we are deeply 
disturbed about the impact the more than 5 percent cut in NIH funding 
under sequestration in the current fiscal year will have on our ability 
to sustain the scientific momentum that has contributed so greatly to 
our Nation's health and our economic vitality. But sequestration 
represents only the latest threat to the viability of this Nation's 
medical research enterprise, following a decade when NIH has lost 
nearly one-fifth of its buying power after inflation.
    The leadership and staff at NIH and its Institutes and Centers has 
engaged patient groups, scientific societies, and research institutions 
to identify emerging research opportunities and urgent health needs, 
and has worked resolutely to prioritize precious Federal dollars to 
those areas demonstrating the greatest promise. But a continued erosion 
of our national commitment to medical research threatens our ability to 
support a medical research enterprise that is capable of taking full 
advantage of existing and emerging scientific opportunities.
    Perhaps one of the greatest concerns is the obstacle these 
continued cuts will present to the next generation of scientists, who 
will see training funds slashed and the possibility of sustaining a 
career in research diminished. NIH also plays a significant role in 
supporting the next generation of innovators, the young and talented 
scientists and physicians who will be responsible for the breakthroughs 
of tomorrow. Appearing before the House Labor-HHS-Education 
Appropriations Subcommittee on March 5, NIH Director Francis Collins, 
M.D., Ph.D., said, ``That's our seed corn. It has been the strength of 
America . . . the biomedical research community, their creativity, 
their innovative instincts, and we're putting that at serious risk as 
we see this kind of downturn in the support for research.''
    The challenges of maintaining a cadre of physician-scientists to 
facilitate translation of basic research to human medicine, ensuring a 
biomedical workforce that reflects the racial and gender diversity of 
our citizenry, and maximizing our Nation's human capital to solve our 
most pressing health problems will only be addressed through continued 
support of NIH.

NIH is Critical to U.S. Competitiveness
    Our country still has the most robust medical research capacity in 
the world, but that capacity simply cannot weather repeated blows such 
as persistent below-inflation funding levels and cuts of sequestration, 
which jeopardize our competitive edge in an increasingly innovation-
based global marketplace. Dr. Collins testified earlier this year that 
other nations are ``ramping up their support of biomedical research 
because they've read our playbook.'' A 2012 report from the Information 
Technology and Innovation Foundation stated, ``China, for example, has 
identified biotechnology as one of seven key strategic and emerging 
(SEI) pillar industries and has pledged to invest $308.5 billion in 
biotechnology over the next 5 years. This means that, if current trends 
in biomedical research investment continue, the U.S. Government's 
investment in life sciences research over the ensuing half-decade is 
likely to be barely half that of China's in current dollars, and 
roughly one-quarter of China's level as a share of GDP . . . . Other 
countries are also investing more in biomedical research relative to 
the sizes of their economies. When it comes to Government funding for 
pharmaceutical industry-performed research, Korea's government provides 
seven times more funding as a share of GDP than does the United States, 
while Singapore and Taiwan provide five and three times as much, 
respectively.''
    Talented medical researchers from all over the world, who once 
flocked to the U.S. for training and stayed to contribute to our 
innovation-driven economy, are now returning to better opportunities in 
their home countries. We cannot afford to lose that intellectual 
capacity, much less the jobs and industries fueled by medical research. 
The U.S. has been the global leader in medical research because of 
Congress's bipartisan recognition of NIH's critical role. To maintain 
our dominance, we must reaffirm this commitment to provide NIH the 
funds needed to maintain our competitive edge.

NIH: An Answer to Challenging Times
    The Ad Hoc Group's members recognize the tremendous challenges 
facing our Nation's economy and acknowledge the difficult decisions 
that must be made to restore our country's fiscal health. Nevertheless, 
we believe strongly that NIH is an essential part of the solution to 
the Nation's economic restoration. Strengthening our commitment to 
medical research, through robust funding of the NIH, is a critical 
element in ensuring the health and well-being of the American people 
and our economy.
    Therefore, the Ad Hoc Group for Medical Research respectfully 
requests that the subcommittee recognize NIH as an urgent national 
priority and provide at least $32 billion in the fiscal year 2014 
appropriations bill.
                                 ______
                                 
          Prepared Statement of the AIDS Healthcare Foundation

    Dear Mr. Chairman Harkin and Ranking Member Moran: My name is Tom 
Myers, and I am the General Counsel for the AIDS Healthcare Foundation 
(AHF). AHF hereby submits the following testimony and funding request 
in the amount of $2,422,178,000 for the Ryan White CARE Act for fiscal 
year 2014:
    Consistent with goal number 4 of the National HIV/AIDS Strategy for 
the United States--``Achieving a More Coordinated Response to the HIV 
Epidemic in the United States''--appropriations for the Ryan White CARE 
Act (the ``CARE Act'') in fiscal year 2014 presents a unique 
opportunity to harmonize the CARE Act with the Strategy's three main 
goals:
  --Reducing New HIV Infections;
  --Increasing Access to Care and Improving Health Outcomes for People 
        Living With HIV; and
  --Reducing HIV-Related Health Disparities.
    Funding of the CARE Act at the requested level will allow the CARE 
Act to be harmonized with the changes in health care delivery to be 
brought about by the Affordable Care Act (``ACA'') to provide a more 
comprehensive and more effective response to the HIV epidemic in the 
U.S.
    The current state and trends of the HIV/AIDS epidemic in the United 
States should guide how to harmonize the CARE Act with Health Care 
Reform and the National HIV/AIDS Strategy.
    While the future is always uncertain, and it is unclear exactly 
what the consequences of the ACA will be, there are a number of facts 
that can help determine necessary funding for the CARE Act:
  --There will be a need for a robust CARE Act, in its current form, 
        for the foreseeable future.--The implementation of Medicaid 
        expansion and insurance exchanges will be neither a quick nor 
        complete process. Full-scale change is not set to begin until 
        2014, and even now, many States, including those with some of 
        the largest HIV/AIDS populations such as Texas and Georgia--are 
        delaying or foregoing participating in Medicaid expansion or 
        setting up exchanges. As a result, the safety net that is the 
        CARE Act will need to remain largely intact until this process 
        is complete, and will need to be available for those States the 
        do not fully implement the ACA.
  --Most Americans with HIV are not linked to or retained in HIV 
        care.--Many American still do not know their HIV status, are 
        not linked to HIV care, and are not retained in HIV care. In 
        fact, a minority of all Americans with HIV are on 
        antiretroviral treatment. Supporting access to and maintenance 
        of care will be critical to ending the epidemic.
  --Neither Medicaid nor insurance exchanges may provide all the 
        services currently available under the CARE Act.--The CARE Act 
        understands that effectively treating a complex, chronic 
        disease like HIV requires a number of approaches, disciplines, 
        and services. Insurance plans and Medicaid, in both of which 
        people living with HIV area small minority of participants, may 
        not be organized with the needs of people living with HIV in 
        mind, and may not offer the full range of services provided by 
        the CARE Act.
  --20 percent of Americans with HIV are unaware of their status.--This 
        group is thought unwittingly to be the source of 70 percent of 
        all new infections. The HIV epidemic in the Untied States will 
        not end until this group is made aware of their status, and are 
        brought into care.
  --Treatment is Prevention.--One of the consensuses emerging from the 
        recent International AIDS Conference is that HIV treatment, 
        which can reduce the chances of infection by up to 96 percent, 
        is the most effective and the most cost effective way to 
        prevent new infections. Getting people living with HIV into 
        care, and keeping them adherent to treatment, will be the key 
        to ending this epidemic.
  --The HIV Epidemic in the U.S. continues to trend South, and in 
        Communities of Color.--Recent publications have documented and 
        highlighted the enormous disparities in HIV rates and new 
        infections in the South, and among communities of color. 
        Addressing these disparities, in many States that have 
        expressed a reluctance to implement the ACA, will be paramount 
        in fighting the epidemic.
    Given the above facts, in order to ensure that adequate care, 
treatment and prevention services are available to fully combat the 
HIV/AIDS epidemic in the United States, funding the Care Act at the 
requested level is required. Thank you for your attention and support 
in this matter. We look forward to working with you to ensure that the 
CARE Act continues to be part of an effective, comprehensive program to 
end HIV/AIDS in America.
                                 ______
                                 
                Prepared Statement of the AIDS Institute

    Dear Chairman Harkin and members of the subcommittee: My name is 
Carl Schmid, Deputy Executive Director of the AIDS Institute. The AIDS 
Institute, a national public policy, research, advocacy, and education 
organization, is pleased to offer comments in support of critical HIV/
AIDS programs as part of the fiscal year 2014 Labor, Health and Human 
Services, Education, and Related Agencies appropriation measure. We 
thank you for supporting these programs over the years, and hope you 
will do your best to adequately fund them in the future in order to 
provide for and protect the health of many Americans.
    HIV/AIDS remains one of the world's worst health pandemics. 
According to the CDC, in the U.S. over 636,000 people have died of AIDS 
and there are 50,000 new infections each year. A record 1.2 million 
people in the U.S. are living with HIV. Persons of minority races and 
ethnicities are disproportionately affected. African Americans, who 
make up just 12 percent of the population, account for 44 percent of 
the new infections. HIV/AIDS disproportionately affects low income 
people; nearly 90 percent of Ryan White Program clients have a 
household income of less than 200 percent of the Federal Poverty Level.
    The U.S. Government has played a leading role in fighting HIV/AIDS, 
both here and abroad. The vast majority of the discretionary programs 
supporting domestic HIV/AIDS efforts are funded through this 
subcommittee. We are keenly aware of current budget constraints and 
competing interests for limited dollars, but programs that prevent and 
treat HIV are inherently in the Federal interest as they protect the 
public health against a highly infectious virus. If left unaddressed it 
will certainly lead to increased infections, more deaths, and higher 
health costs.
    With the advent of antiretroviral medicines, HIV has turned from a 
near certain death sentence to a treatable chronic disease if people 
have access to consistent and affordable health care and medications. 
Through prevention, care and treatment, and research we now have the 
ability to actually end AIDS. In 2011, a ground-breaking clinical trial 
(HPTN 052)--named the scientific breakthrough of the year by Science 
magazine--found that HIV treatment not only saves the lives of people 
with HIV, but also reduces HIV transmission by more than 96 percent--
proving that HIV treatment is also HIV prevention. In order to realize 
these benefits, people with HIV must be diagnosed through testing, 
linked to and retained in care and treatment.
    We also have a National HIV/AIDS Strategy that sets clear goals and 
priorities, and brings all the Federal agencies addressing HIV together 
to ensure Federal resources are well coordinated.
    With all these positive developments it would be a shame to go 
backwards, but that is what could happen given the sequestration and 
budget cuts that are impacting the Ryan White Program at HRSA, HIV and 
Hepatitis prevention programs at the CDC, and research at the NIH.

The Ryan White HIV/AIDS Program
    The Ryan White HIV/AIDS Program provides some level of medical 
care, drug treatment, and support services to approximately 546,000 
low-income, uninsured, and underinsured individuals with HIV/AIDS. With 
people living longer and continued new diagnoses, the demands on the 
program continue to grow and many needs remain unmet. According to the 
CDC, only 37 percent of people living with HIV in the U.S. are retained 
in HIV care, only 33 percent have been prescribed antiretroviral 
treatment, and only 25 percent are virally suppressed. We have a long 
way to go before we can realize the dream of an AIDS-free generation. 
With continued funding we can reverse these trends.
    The AIDS Drug Assistance Program (ADAP), one component of the Ryan 
White Program, provides States with funds to pay for medications for 
over 200,000 people. Over the last couple of years, as more infections 
were identified due to increased HIV testing and people lost their jobs 
and health insurance, demand on the program far outpaced its budget. 
This led to ADAP wait lists of 9,300 people. We are thankful that 
President Obama and Congress allocated additional funds, which when 
combined with assistance from pharmaceutical companies reduced the wait 
lists to less than 50 people today.
    This could all change because $35 million transferred by President 
Obama on World AIDS Day 2011 for ADAP was not continued in the fiscal 
year 2013 Continuing Resolution. While we are hopeful the President 
will transfer some of this funding again, it is critical that the $35 
million be maintained in fiscal year 2014. If it is not, an estimated 
8,000 patients currently taking medications through ADAP will risk 
losing access to their lifesaving medications. This would be very 
dangerous as once antiretroviral treatment begins, the drugs must be 
taken every day without interruption or resistance to medications will 
occur.
    On top of this loss of funding, sequestration has reduced current 
ADAP funding by another $45 million. The loss of this funding could 
force States to stop paying for medications to another 14,000 people 
currently taking medications. We urge you to do all you can to prevent 
this and ensure ADAP and the rest of the Ryan White Program receive 
adequate funding to keep up with the growing demand. According to 
NASTAD, enrollment in ADAP increased last year by 13,500 people, or 8 
percent. While it will be not sufficient, we are pleased the President 
has requested an increase of $10 million to ADAP in fiscal year 2014 
for a total of $943.3 million.
    With this increased demand for medications comes a corresponding 
increase in medical care and support services provided by all other 
parts of the program. Sequestration will be reducing these services by 
over $70 million in 2013. We urge the Committee to restore these 
harmful cuts and ensure the entire Ryan White Program is adequately 
funded in fiscal year 2014.
    We are looking forward to implementation of the expanded 
opportunities for health care coverage under the Affordable Care Act 
(ACA). While it will result in some cost shifting for medications and 
primary care, it will never be a substitute for the Ryan White Program. 
Over 70 percent of Ryan White Program clients today have some sort of 
insurance coverage, mostly through traditional Medicaid and Medicare. 
Their coverage will not change with health reform; the Ryan White 
Program will be needed as it is today for coverage completion services. 
The Medicaid expansion is a State option and about half of the States 
are not moving forward with it at this time. As ACA is implemented, 
benefits will differ from State to State and there will be many gaps 
that will have to be filled by the Ryan White Program. Plans will not 
offer all comprehensive essential support services, such as case 
management, transportation, and nutritional services, that are needed 
to ensure retention in medical care and adherence to drug treatment. 
For example, Part D of the Ryan White Program provides family-centered 
care to women, infants, children, and youth living with HIV/AIDS. This 
approach of coordinated, comprehensive, and culturally competent care 
leads to better health outcomes. Therefore, the Ryan White Program, 
while it may need to change in the future, must continue and must be 
adequately funded.

CDC HIV Prevention
    As a Nation, we must do more to prevent new HIV infections, but we 
only allocate 3 percent of our HIV/AIDS spending towards prevention. 
All the care and treatments costs would be saved if we did not have the 
infections in the first place. Preventing just one infection would save 
$355,000 in future lifetime medical costs. Preventing all the new 
50,000 cases in just 1 year would translate into an astounding $18 
billion saved in lifetime medical costs.
    With more people living with HIV than ever before, there are 
greater chances of HIV transmission. The CDC and its grantees have been 
doing their best with limited resources to keep the number of 
infections stable, but that is not good enough. It is focusing 
resources on those populations and communities most impacted by HIV and 
investing in those programs that will prevent the most number of 
infections. This means more of its resources will be going to the South 
and focusing on gay men. One group in particular that needs additional 
study and resources is young black gay men, who experienced a 38 
percent increase in new infections from 2008-2010.
    With over 200,000 people living with HIV who are unaware of their 
infection, the CDC is also focused on increased testing programs. 
Testing people early and linking them to care and treatment is critical 
not only for their own health outcomes but also in preventing new 
infections. It is estimated that sequestration would reduce the annual 
number of HIV tests by 424,000.
    The CDC estimates that in 2010, 26 percent of all new HIV 
infections occurred among youth ages 13 to 24. Nearly 75 percent of 
those infections were among young gay men. Clearly, we must do a better 
job of educating the youth of our Nation, including gay youth, about 
HIV. To compound matters, the HIV Division of Adolescent and School 
Health (DASH) lost 25 percent of its budget in fiscal year 2012. We ask 
that the subcommittee restore this $10 million cut.
    For the first year of sequestration, CDC's HIV prevention programs 
will be cut by over $40 million, which will put at risk all the recent 
progress we are making in reducing the number of new infections.
    The President has proposed to replace the sequester and increase 
CDC's HIV prevention programs by $10 million in fiscal year 2014. 
Additionally, he has proposed redirecting some current HIV testing 
funding to assist State health departments and others to develop 
billing systems for HIV testing. The AIDS Institute supports this 
initiative so that States and others can take advantage of the coverage 
of preventive services under the Affordable Care Act.

HIV/AIDS Research at the National Institutes of Health (NIH)
    While we have made great strides in the area of HIV/AIDS, there is 
still a long way to go. Continued research at the NIH is necessary to 
learn more about the disease and to develop new treatments and 
prevention tools. Work continues on vaccine research and we look 
forward to an eventual cure. Sequestration will mean loss of $163 
million in HIV/AIDS research funding, and 297 HIV/AIDS research grants 
would go unfunded.

Viral Hepatitis
    There are over 5.3 million people in the U.S. infected with viral 
hepatitis, and seventy-five percent are not aware of their infection, 
yet hepatitis prevention at the CDC is funded at only $30 million. This 
is insufficient to provide basic public health services such as 
education, counseling and testing. Increased funding is needed to 
implement the HHS Viral Hepatitis Action Plan and the strategy in the 
Institute of Medicine (IOM) report, Hepatitis and Liver Cancer: A 
National Strategy for Prevention and Control of Hepatitis B and C.
    The AIDS Institute urges the Federal Government to make a greater 
commitment to Hepatitis prevention. For fiscal year 2014, we request an 
increase of at least $6 million for a total of $36.6 million.

Policy Riders
    The AIDS Institute is opposed to using the appropriations process 
as a vehicle to repeal or prevent the implementation of current law or 
ban funding for certain activities or organizations. This includes 
implementation of the Affordable Care Act. We also urge you not to 
interfere with the implementation of programs, such as syringe exchange 
programs, which are scientifically proven to be effective in the 
prevention of HIV and Hepatitis.
    Again, we thank you for your continued support of these critical 
programs important to so many individuals and communities nationwide. 
We have made great progress, but we are still far from achieving our 
goal of an AIDS-free generation. We now have the tools, but we need 
continued leadership and the necessary resources to realize our goal. 
Thank you.
                                 ______
                                 
                   Prepared Statement of AIDS United

    On behalf of AIDS United and our diverse partner organizations I am 
pleased to submit this testimony to the Members of this subcommittee on 
the urgency of needed funding for the fiscal year 2014 domestic HIV/
AIDS portfolio. AIDS United is a national organization that seeks to 
end the AIDS epidemic in the United States by combining private-sector 
fundraising, philanthropy, coalition building, public policy expertise, 
and advocacy--as well as a network of passionate local and State 
partners--to respond effectively and efficiently to the HIV/AIDS 
epidemic in the communities most impacted by the epidemic. Through its 
unique Public/Private Partnerships, Public Policy Committee and 
targeted special grant-making initiatives, AIDS United represents over 
300 grassroots organizations. These organizations provide HIV 
prevention, care, treatment, and support services to underserved 
individuals and populations most impacted by the HIV/AIDS epidemic 
including communities of color, women and gay and bisexual men and men 
who have sex with men (MSM) as well as education and training to 
providers of treatment services.
    AIDS United understands the fiscal environment that the country is 
wrestling with right now is austere. However, we know that investment 
in prevention and retention in HIV care are critical in lowering the 
number of new infections in the domestic HIV epidemic. As competing 
budget priorities are weighed please keep in mind that HIV is 100 
percent preventable, if we as a Nation muster up the political will and 
funding to address domestic HIV on level that meets the needs of the 
epidemic.
    I write to request increased funding for the domestic HIV/AIDS 
portfolio in fiscal year 2014 to help reach the National HIV/AIDS 
Strategy (NHAS) vision: ``The United States will become a place where 
new HIV infections are rare and when they do occur, every person, 
regardless of age, gender, race/ethnicity, sexual orientation, gender 
identity, or socio-economic circumstance, will have unfettered access 
to high quality, life extending care, free from stigma and 
discrimination.'' To reach this vision, NHAS states three primary goals 
on which we must focus our efforts.
    The first NHAS goal calls for: ``Reducing the number of people who 
become infected with HIV.'' To continue progress in achieving this 
goal, the Centers for Disease Control and Prevention's (CDC) National 
Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (Center) 
needs to be funded at the HIV/AIDS community's request of $1.460 
billion to ensure that prevention messages can be targeted to reach 
hard to reach populations who do not believe they are vulnerable to HIV 
infection as well as the approximately 20 percent of HIV positive 
individuals who are unaware of their HIV status. President Obama's 
fiscal year 2014 request for the Center is an increase of $71.3 million 
(including the Working Capital Fund); AIDS United feels this is the 
minimum amount that must be incorporated this year in order to reach 
the high impact prevention targets the CDC has developed. According to 
the CDC, the estimated return on investment for CDC dollars spent has 
been 350,000 HIV infections averted and $125 billion in direct medical 
costs saved. Preventing an HIV infection is less costly than treating 
HIV disease.
    AIDS United draws the subcommittee's attention to an important HIV 
prevention policy issue that does not require direct funding. We urge 
the sub-committee to include syringe access language that was enacted 
into law in fiscal year 2010 and fiscal year 2011. Unfortunately, 
fiscal year 2012 restored an obsolete rider that bans the use of 
Federal funds for syringe exchange despite clear evidence that syringe 
exchange programs reduce HIV and hepatitis C infections and reduce 
substance abuse as well. The fiscal year 2011 language states that 
Federal funding may be used for syringe exchange programs unless local 
public health or local law enforcement authorities deem a site to be 
``inappropriate.'' This language best ensures authentic local control 
and lets local communities make their own decisions about how best to 
prevent new HIV and hepatitis infections. Sixteen percent of HIV/AIDS 
cases and more than 55 percent of hepatitis C cases are directly or 
indirectly related to injection drug use. Numerous studies have shown 
that syringe exchange programs are a cost-effective means to lower 
rates of HIV/AIDS and viral hepatitis, reduce the use of illegal drugs 
and help connect people to medical treatment, including substance abuse 
treatment.
    ``Increasing access to care and optimizing health outcomes for 
people living with HIV'' is the second NHAS primary goal. The CDC 
estimates that 1.2 million people are living with HIV in the United 
States. All of these individuals need to have access to care, but since 
HIV disease is often a disease of poverty many HIV positive individuals 
are uninsured or underinsured. The Ryan White CARE Act will continue to 
play a critical role for some of our Nation's most vulnerable citizen's 
even after full implementation of the Affordable Care Act (ACA) by 
ensuring coverage completion, addressing gaps in care, ensuring 
affordability of care, and the provision of HIV services to those left 
out of reform. In short it will be needed to continue in its role as 
the payer of last resort for more than 600,000 individuals, both while 
People Living with HIV/AIDS move into new coverage eligibility over the 
next years of ACA implementation and afterwards. In fact approximately 
75 percent of those served by Ryan White Programs have access to some 
type of health insurance, but continue to count on essential care and 
financial support services that only the Ryan White Program provides
    The implementation of the ACA will begin in January of 2014, 3 
months after the beginning of fiscal year 2014 and current and ongoing 
investments in the Ryan White Program are essential to ensure that the 
U.S. builds on the experience of Ryan White Program providers in 
helping find people living with HIV, linking them to care and ensuring 
effective treatment, saving lives and eventually helping to end the 
HIV/AIDS epidemic. By law most Ryan White Program grantees must use 75 
percent or more of their funds to provide ``core medical services'' 
including medication. The remaining funding is used by grantees to 
provide services that can help to ensure people living with HIV are 
able to access, be retained and adhere to regular treatment and care. 
There will continue to be a strong need to provide these services 
critical to good outcomes across the HIV ``treatment cascade'' not 
covered or inadequately covered by Medicaid expansion or plans in State 
and Federal health insurance marketplaces. In fact data shows that 70 
percent of clients who receive Ryan White Program funded care reach 
viral suppression as opposed to just 28 percent of the overall 
population.
    It remains crucial that the Ryan White Program get a substantial 
increase from this subcommittee. The community believes an increase of 
$442.6 million is needed to address all parts of the program, but the 
Ryan White program must receive at least the President's fiscal year 
2014 requested increase of $186.5 million.
    Another important component of the Ryan White Program that is 
important for increasing access to care is the AIDS Drug Assistance 
Program (ADAP). ADAP provides medications for treating people with HIV 
who cannot access Medicaid or private health insurance. ADAP is able to 
assist with co-pays for individuals as well. While the waiting list is 
not large at this time, ADAP is in a continual State of flux. The World 
AIDS Day funding that President Obama included in fiscal year 2012 ADAP 
and Part C funding did not transition to the base for the Continuing 
Resolution for fiscal year 2013. The community is working with the 
Administration on this fix, but this funding must be included in the 
base for fiscal year 2014 to ensure those on medication can continue 
their medications. While we acknowledge the President's request for an 
increase of $92 million for ADAP, AIDS United urges the subcommittee to 
provide an fiscal year 2014 increase of at least $214.7 million for 
this vital, life-saving program.
    Addressing workforce issues is important to achieving the goal of 
increasing access to care and improving health outcomes. The AIDS 
Education and Training Centers (AETCs), a component of Part F of the 
Ryan White Program, supports workforce development and training for 
doctors, advanced practice nurses, physicians' assistants, nurses, oral 
health professionals, and pharmacists about HIV treatment, HIV testing, 
viral hepatitis, and other HIV co-morbidities. AIDS United urges the 
subcommittee to provide a total of $42.2 million for Ryan White Part F/
AETCs, an increase of $5.3 million over the fiscal year 2013 funding 
level.
    The third NHAS goal calls for reducing HIV-related health 
disparities. Racial and ethnic communities continue to be impacted 
disproportionately and at alarming rates. The impact on black women and 
gay and bisexual men of color is particularly disturbing. The Minority 
HIV/AIDS Initiative (MAI) benefits African American, Latino, Asian and 
Pacific Islander, and Native American and Alaska Native communities 
across the country. It is essential that the MAI be fully funded in 
fiscal year 2014 at $610 million.
    The Social Innovation Fund (SIF) administered by the Corporation 
for National and Community Service, leverages Federal and private 
resources to support innovative community-based programs that work in 
improving economic opportunity and healthy futures. SIF funded sites 
across the country have used $95 million in Federal investments to 
leverage $250 million of additional private support. AIDS United 
partners are using SIF to expand access to care, improve individual 
health outcomes, and strengthen local service systems to connect 
marginalized individuals living with HIV to high quality supportive 
services and health care. AIDS United urges the subcommittee to provide 
a total of $49 million for SIF, consistent with the Administration 
request.
    AmeriCorps, also administered by the Corporation for National and 
Community Services, provides opportunities for over 70,000 individuals 
to make an intensive commitment to community service to meet critical 
needs in education, public safety, and health. Participants in AIDS 
United's AmeriCorps Program deliver vital HIV-related services and 
resources while training the next generation of HIV/AIDS leaders. AIDS 
United urges the subcommittee to meet the Administration request of 
$346 million for fiscal year 2014 funding level for the AmeriCorps 
State and national programs.
    After nearly 32 years, the HIV epidemic is a continuing crisis in 
the United States. Progress that has been made, however, has enabled 
more and more people to speak of an end of AIDS in America. We can 
achieve that by expanding resources for domestic HIV prevention, care 
and treatment, and research efforts to meet the goals of the National 
HIV/AIDS Strategy. On behalf of its partner organizations and the many 
thousands of HIV positive Americans and those affected by HIV who they 
serve, AIDS United, urges the subcommittee to consider and support the 
fiscal year 2014 funding levels that we have outlined.
                                 ______
                                 
           Prepared Statement of Alliance for Aging Research

    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee: My name is Cynthia A. Bens, Vice President of Public 
Policy for Alliance for Aging Research. For more than 25 years, the 
not-for-profit Alliance for Aging Research, www.agingresearch.org, has 
advocated for medical research to improve the quality of life and 
health for all Americans as we grow older. Our efforts have included 
supporting increased Federal funding of aging research by the National 
Institutes of Health (NIH), through the National Institute on Aging 
(NIA) and other NIH institutes and centers. The Alliance appreciates 
the opportunity to submit testimony highlighting the important role 
that the NIH plays in facilitating aging-related medical research 
activities and the ever more urgent need for sustained Federal 
investment and focus to advance scientific discoveries to keep 
individuals healthier longer.
    The Alliance for Aging Research supports funding the NIH at $32 
billion in fiscal year 2014 with a minimum of $1.4 billion in funding 
for the NIA specifically. This level of support would allow the NIH and 
the NIA to adequately fund new and existing research projects, 
accelerating progress toward findings which could prevent, treat, slow 
the progression or even possibly cure conditions related to aging.
    The National Institute on Aging (NIA) at NIH leads the national 
scientific effort to understand the nature of aging in order to promote 
the health and well-being of older adults. Congress established the NIA 
in 1974 to conduct research on aging processes, age-related diseases, 
and special problems and needs of the aged; train and develop research 
scientists; provide research resources; and disseminate information on 
health and research advances. NIA is also the primary Federal agency on 
Alzheimer's disease research. The NIA has been at the forefront of some 
of the most important advances in aging research and translational 
programs, including:
  --Development of the drug-eluting coronary stent, used to open 
        arterial blockages in the heart during angioplasty. Nearly two 
        million people worldwide have received these stents, which 
        reduce subsequent narrowing rates to three to 6 percent.
  --The NIA's Diabetes Prevention Program demonstrated that diet and 
        exercise were the most effective ways to reduce the risk of 
        diabetes in high-risk older people. The clinical trial 
        intervention showed a 71 percent reduction in diabetes among 
        participants 60 and older.
  --Karlene Ball, an NIA grantee, developed Useful Field of View 
        (UFOV), which is the area where someone can extract visual 
        information at a glance without head or eye movements. Research 
        found that training UFOV can prospectively reduce automobile 
        crash rates by half. Several State Motor Vehicle Departments 
        are using and testing UFOV, and Allstate Insurance Company and 
        State Farm offer discounts with this training.
  --NIA-funded research led by Mary Tinetti, M.D., of the Yale 
        University School of Medicine found that training clinical 
        staff in falls prevention practices and strategies can help 
        reduce serious falls by 9 percent and the need for related 
        medical care by 11percent among seniors aged 70 and older, 
        reducing the incidence and cost of hospitalizations.
  --Researchers from the Alzheimer's Disease Neuroimaging Initiative 
        showed that changes in the levels of certain proteins in 
        cerebrospinal fluid may correlate with the risk and progression 
        of Alzheimer's disease. These biomarkers may be used in the 
        future to identify individuals at risk of developing the 
        disease. In addition, measuring amyloid in the brain may prove 
        promising as a diagnostic tool.
  --NIA-funded clinical trials REACH I and REACH II developed and 
        tested strategies for helping caregivers manage the stress and 
        emotional burden of caring for people with dementia. The first 
        study showed a significant improvement in caregivers' sense of 
        burden, social support, depression and health, as well as in 
        care recipients' behavior problems and mood. The U.S. 
        Department of Veterans Affairs successfully used REACH 
        strategies in a demonstration project with 19 of its Home Based 
        Primary Care programs, which treat frail individuals with 
        dementia and caregivers in their homes, and it is now 
        considering using REACH throughout its system. Additionally, 
        the REACH OUT program at the Administration on Aging is 
        beginning to implement these strategies through local social 
        service agencies.
    Research toward healthier aging has never been more critical for so 
many Americans. Older Americans now make up the fastest growing segment 
of the population. According to the U.S. Census Bureau, the number of 
people age 65 and older will more than double between 2010 and 2050 to 
88.5 million, or 20 percent of the population, and those 85 and older 
will increase three-fold, to 19 million. Diseases such as type 2 
diabetes, cancer, neurological diseases, heart disease, and 
osteoporosis that largely occur late in life are increasingly driving 
the need for healthcare services in this country. Many other dreaded 
diseases of aging like Alzheimer's disease are expected to become more 
prevalent as the number of older Americans increases. We believe that 
preventing, treating or curing diseases of aging is perhaps the single 
most effective strategy available to reduce national spending on health 
care.
    Consider that the average 75-year old has three chronic health 
conditions and takes five prescription medications. Six diseases- heart 
disease, stroke, cancer, diabetes, Alzheimer's and Parkinson's 
diseases--cost the U.S. over $1 trillion each year. The number of 
Americans age 65 and older with Alzheimer's disease is projected to 
more than double over the next 17 years. Cancer incidence is projected 
to increase by about 45 percent between 2010-2030, largely because of 
cancer diagnoses in older Americans and minorities. By 2030, people 
aged 65 and older will represent 70 percent of all cancer diagnoses in 
the U.S.
    The rising tide of chronic diseases of aging threatens to overwhelm 
the U.S. health care system in the coming years. Research which leads 
to a better understanding of the aging process and human vulnerability 
to age-related diseases could be the key to helping Americans live 
longer, more productive lives, and simultaneously reduce the need for 
care to manage costly chronic diseases. Scientists who study aging now 
generally agree that aging is malleable and capable of being slowed. 
Rapid progress in recent years toward understanding and making use of 
this malleability has paved the way for breakthroughs that could 
increase human health in later life by opposing the primary risk factor 
for virtually every disease we face as we grow older--aging itself. 
Better understating of this ``common denominator'' of disease could 
usher in a new era of preventive medicine, enabling interventions that 
stave off everything from dementia to cancer to osteoporosis. As we now 
confront unprecedented aging of our population and staggering increases 
in chronic age-related diseases and disabilities, a modest extensions 
of healthy lifespan could produce outsized returns of extended 
productivity, reduced caregiver burdens, lessened Medicare spending, 
and more effective healthcare in future years.
    The NIA leads national research efforts within the NIH to better 
understand the aging process and ways to better maintain the health and 
independence of Americans as they age. NIA is poised to accelerate the 
scientific discoveries. The science of aging is showing increasing 
power to address the leading public health challenges of our time. 
Leaders in the biology of aging believe it is now realistically 
possible to develop interventions that slow the aging process and 
greatly reduce the risk of many diseases and disabilities, including 
cancer, diabetes, Alzheimer's disease, vision loss and bone and joint 
disorders. While there has been great progress in aging research, a 
large gap remains between promising basic research and healthcare 
applications. Closing that gap will require considerable focus and 
investment. Key aging processes have been identified by leading 
scientists as potentially yielding crucial answers in the next 3-10 
years. These include stress response at the cellular level, cell 
turnover and repair mechanisms, and inflammation.
    A central theme in modern aging research--perhaps its key insight--
is that the mutations, diets, and drugs that extend lifespan in 
laboratory animals by slowing aging often increase the resistance of 
cells, and animals, to toxic agents and other forms of stress. These 
discoveries have two main implications, each of which is likely to lead 
to major advances in anti-aging science in the near future. First is 
the suggestion that stress resistance may itself be the facilitator 
(rather than merely the companion) of the exceptional lifespan in these 
animal models, hinting that studies of agents that modulate resistance 
to stress could be a potent source of valuable clinical leverage and 
preventive medicines. Second is the observation that the mutations that 
slow aging augment resistance to multiple varieties of stress--not just 
oxidation, or radiation damage, or heavy metal toxins, but rather 
resistance to all of these at the same time.
    The implication is that cells have ``master switches,'' which, like 
rheostats that can brighten or dim all lights in a room, can tweak a 
wide range of protective intracellular circuits to tune the rate of 
aging differently in long-lived versus short-lived individuals and 
species. If this is correct, research aimed at identifying these master 
switches, and fine-tuning them in ways that slow aging without unwanted 
side-effects, could effectively postpone all of the physiological 
disorders of aging through manipulation of the aging rate itself. 
Researchers have formulated, and are beginning to pursue, new ways to 
test these concepts by analysis of invertebrates, cells lines, 
laboratory animals and humans, and by comparing animals of species that 
age more quickly or slowly.
    One hallmark of aging tissues is their reduced ability to 
regenerate and repair. Many tissues are replenished by stem cells. In 
some aged tissues, stem cell numbers drop. In others, the number of 
stem cells changes very little--but they malfunction. Little is 
currently known about these stem cell declines, but one suspected cause 
is the accumulation of ``senescent'' cells. Cellular senescence stops 
damaged or distressed cells from dividing, which protects against 
cancer. At advanced ages, however, the accumulation of senescent cells 
may limit regeneration and repair, a phenomenon that has raised many 
questions. Do senescent cells, for instance, alter tissue 
``microenvironments,'' such that the tissue loses its regenerative 
powers or paradoxically fuel the lethal proliferation of cancer cells? 
A robust research initiative on these issues promises to illuminate the 
roots of a broad range of diseases and disabling conditions, such as 
osteoporosis, the loss of lean muscle mass with age, and the age-
related degeneration of joints and spinal discs. The research is also 
essential for the development of stem cell therapies, the promise of 
which has generated much public excitement in recent years. This is 
because implanting stem cells to renew damaged tissues in older people 
may not succeed without a better understanding of why such cells lose 
vitality with age. Importantly, research in this area would also help 
determine whether interventions that enhance cellular proliferative 
powers would pose an unacceptable cancer risk.
    Acute inflammation is necessary for protection from invading 
pathogens or foreign bodies and the healing of wounds, but as we age 
many of us experience chronic, low-level inflammation. Such insidious 
inflammation is thought to be a major driver of fatal diseases of 
aging, including cancer, heart disease, and Alzheimer's disease, as 
well as of osteoporosis, loss of lean muscle mass after middle age, 
anemia in the elderly, and cognitive decline after 70. Just about 
everything that goes wrong with our bodies as we age appears to have an 
important inflammatory component, and low-level inflammation may well 
be a significant contributor to the overall aging process itself. As 
the underlying mechanisms of age-related inflammation are better 
understood, researchers should be able to identify interventions that 
can safely curtail its deleterious effects beginning in mid-life, 
broadly enhancing later-life, and with negligible risk of side effects.
    While important advances have been made toward understanding how 
aging is linked to disease in an effort to add healthy years to life, 
such a goal cannot be achieved in a timely way without financial 
support. An increase in funding for aging research is urgently needed 
to enable scientists to capitalize on the field's recent exciting 
discoveries. For the past year and a half, the Alliance for Aging 
Research, has led the Healthspan Campaign--an awareness campaign to 
educate the public and policymakers about the need to focus and 
adequately fund basic research into the underlying processes of aging--
that if targeted can extend a person's healthy years of life. In 
addition to increased resources, we believed that the field could 
benefit from the creation of a trans-NIH initiative that could improve 
the quality and pace of research that advances the understanding aging, 
its impact on age-related diseases, and the development of 
interventions to extend human healthspan. Throughout the first half of 
2012 the Alliance and its Healthspan Campaign partners met with 
leadership of the National Institute on Aging (NIA), the National 
Institute of Neurological Diseases and Stroke (NINDS), the National 
Institute of Arthritis Musculoskeletal and Skin Diseases (NIAMS), the 
National Institute of Diabetes Digestive and Kidney Diseases (NIDDK), 
the National Heart Lung and Blood Institute (NHLBI), and the National 
Cancer Institute (NCI). As a result of this advocacy, in less than 6 
months the NIA--through its Division of Aging Biology--took the lead in 
establishing a Geroscience Interest Group (GSIG) to coordinate 
discussion and action across the NIH on understanding the role aging 
plays in our susceptibility to age-related diseases. Of the 27 
Institutes and Centers that make up the NIH, 20 are now members of the 
GSIG--making it the top interest group at the NIH.
    The GSIG was written up in the March/April 2012 issue of ``The NIH 
Catalyst,'' the NIH's intramural research newsletter, and Dr. Felipe 
Sierra, NIA Division of Aging Biology Director and GSIG Coordinator, 
was awarded an NIH Director's award for his groundbreaking work with 
the GSIG. The work of the GSIG was recognized in report language in the 
fiscal year 2013 Senate Labor, Health and Human Services (LHHS) 
Appropriations bill. To date the GSIG has held four educational 
seminars on topics ranging from age-dependent mechanisms in Alzheimer's 
and Parkinson's diseases to insights on aging from Hutchinson-Gilford 
Progeria Syndrome. The group convened a major workshop on inflammation 
and aging in the fall of 2012 that resulted in a meaningful joint 
funding proposal across several NIH institutes. Planning is now 
underway for a larger and more impactful meeting in fall of 2013 on 
multiple processes of aging and disease. This meeting will produce many 
other promising priority areas for further collaboration.
    The field of aging research is poised to make transformational 
gains in the near future but we can only capitalize on this potential 
if the NIH is properly resourced across institutes and centers. Few if 
any areas for investing research dollars offer greater potential 
returns for public health. The Alliance for Aging Research supports 
funding the NIH at $32 billion in fiscal year 2014 with a minimum of 
$1.4 billion in funding for the NIA specifically. This level of support 
would allow the NIH and the NIA to adequately fund new and existing 
research projects, accelerating progress toward findings which could 
prevent, treat, slow the progression or even possibly cure conditions 
related to aging. With a tsunami of age driven chronic ailments looming 
as our population grows older, an increased emphasis on NIH's aging 
research activities has never been more urgent, with potential to 
impact so many Americans.
    Therapies that delay aging would lessen our healthcare system's 
dependence on a strategy of trying to address diseases of aging one at 
a time, often after it is too late for meaningful benefit. They would 
also address the fact that while advances in lowering mortality from 
heart attack and stroke have dramatically increased life expectancy, 
they have left us vulnerable to other age-related diseases and 
disorders that develop in parallel, such as Alzheimer's disease, 
diabetes, and frailty. Properly focused and funded research could 
benefit millions of people by adding active, healthy, and productive 
years to life. Furthermore, the research will provide insights into the 
causes of and strategies for reducing the periods of disability that 
generally occur at the end of life.
    Mr. Chairman, the Alliance for Aging Research thanks you for the 
opportunity to outline the challenges posed by the aging population 
that lie ahead as you consider the fiscal year 2014 appropriations for 
the NIH and we would be happy to furnish additional information upon 
request.
                                 ______
                                 
           Prepared Statement of the Alzheimer's Association

    The Alzheimer's Association appreciates the opportunity to comment 
on the fiscal year 2014 appropriations for Alzheimer's disease 
research, education, outreach and support at the U.S. Department of 
Health and Human Services.
    Founded in 1980, the Alzheimer's Association is the world's leading 
voluntary health organization in Alzheimer's care, support and 
research. Our mission is to eliminate Alzheimer's disease and other 
dementias through the advancement of research; to provide and enhance 
care and support for all affected; and to reduce the risk of dementia 
through the promotion of brain health. As the world's largest nonprofit 
funder of Alzheimer's research, the Association is committed to 
accelerating progress of new treatments, preventions and, ultimately, a 
cure. Through our funded projects and partnerships, we have been part 
of every major research advancement over the past 30 years. Likewise, 
the Association works to enhance care and provide support for all those 
affected by Alzheimer's and reaches millions of people affected by 
Alzheimer's and their caregivers.

Alzheimer's Impact on the American People and the Economy
    In addition to the human suffering caused by the disease, 
Alzheimer's is creating an enormous strain on the health care system, 
families and the Federal budget. Alzheimer's is a progressive brain 
disorder that damages and eventually destroys brain cells, leading to a 
loss of memory, thinking and other brain functions. Ultimately, 
Alzheimer's is fatal. Currently, Alzheimer's is the sixth leading cause 
of death in the United States and the only one of the top ten without a 
means to prevent, cure or slow its progression. Over 5 million 
Americans are living with Alzheimer's, with 200,000 under the age of 
65.
    A Federal commitment can lower costs and improve health outcomes 
for people living with Alzheimer's today and in the future. By making 
Alzheimer's a national priority, we can create the same successes that 
we have been able to achieve in other diseases that have been 
prioritized by the Federal Government. Leadership from the Federal 
Government has helped to lower the number of deaths from other major 
diseases like heart disease, HIV/AIDS, many cancers, heart disease and 
stroke. While those deaths have declined, deaths from Alzheimer's have 
increased 68 percent between 2000 and 2010.
    Alzheimer's is the most expensive disease in America. In fact, an 
NIH-funded study in the New England Journal of Medicine confirmed that 
Alzheimer's is the most costly disease in America, with costs set to 
skyrocket at unprecedented rates. In 2013, America is estimated to 
spend $203 billion in direct costs for those with Alzheimer's, 
including $142 billion in costs to Medicare and Medicaid. Average per 
person Medicare costs for those with Alzheimer's and other dementias 
are three times higher than those without these conditions. Average per 
senior Medicaid spending is 19 times higher. A primary reason for these 
high costs is that Alzheimer's makes treating other diseases more 
expensive, as most individuals with Alzheimer's have one or more co-
morbidities that complicate the management of the condition(s) and 
increases costs. For example, a senior with diabetes and Alzheimer's 
costs Medicare 81 percent more than a senior who only has diabetes.
    If nothing is done, as many as 16 million Americans will have 
Alzheimer's disease by 2050 and costs will exceed $1.2 trillion (not 
adjusted for inflation), creating an enormous strain on the healthcare 
system, families and the Federal budget. The expense involved in caring 
for those with Alzheimer's is not just a long-term problem. As the 
current generation of baby boomers age, near-term costs for caring for 
those with Alzheimer's will balloon, as Medicare and Medicaid will 
cover more than two-thirds of the costs for their care.
    With Alzheimer's, it is not just those with the disease who 
suffer--it is also their caregivers and families. In 2012, 15.4 million 
family members and friends provided unpaid care valued at over $216 
billion. Caring for a person with Alzheimer's takes longer, lasts 
longer, is more personal and intrusive, and takes a heavy toll on the 
health of the caregivers themselves. More than 60 percent of 
Alzheimer's and dementia caregivers rate the emotional stress of 
caregiving as high or very high, with one-third reporting symptoms of 
depression. Caregiving also has a negative impact on health, 
employment, income and finances for countless American families. Due to 
the physical and emotional toll of caregiving on their own health, 
Alzheimer's and dementia caregivers had $9.1 billion in additional 
health costs in 2012.

Changing the Trajectory of Alzheimer's
    Until recently, there was no Federal Government strategy to address 
this looming crisis. In 2010, thanks to bipartisan support in Congress, 
the National Alzheimer's Project Act (NAPA) (Public Law 111-375) passed 
unanimously, requiring the creation of an annually-updated strategic 
National Alzheimer's Plan (Plan) to help those with the disease and 
their families today and to change the trajectory of the disease for 
the future. The Plan is required to include an evaluation of all 
federally-funded efforts in Alzheimer's research, care and services--
along with their outcomes. In addition, the Plan must outline priority 
actions to reduce the financial impact of Alzheimer's on Federal 
programs and on families; improve health outcomes for all Americans 
living with Alzheimer's; and improve the prevention, diagnosis, 
treatment, care, institutional-, home-, and community-based Alzheimer's 
programs for individuals with Alzheimer's and their caregivers. NAPA 
will allow Congress to assess whether the Nation is meeting the 
challenges of this disease for families, communities and the economy. 
Through its annual review process, NAPA will, for the first time, 
enable Congress and the American people to answer this simple question: 
Did we make satisfactory progress this past year in the fight against 
Alzheimer's?
    As mandated by NAPA, the Secretary of Health and Human Services, in 
collaboration with the Advisory Council on Alzheimer's Research, Care 
and Services, developed the first-ever National Plan to Address 
Alzheimer's Disease in May of 2012. The Advisory Council, composed of 
both Federal members and expert non-Federal members, is an integral 
part of the planning process as it advises the Secretary in developing 
and evaluating the annual Plan, makes recommendations to the Secretary 
and Congress, and assists in coordinating the work of Federal agencies 
involved in Alzheimer's research, care, and services.
    Having this Plan with measurable outcomes is important. But unless 
there are resources to implement the Plan and the will to abide by it, 
we cannot hope to make much progress. If we are going to succeed in the 
fight against Alzheimer's, Congress must provide the resources the 
scientists need. Understanding this, the President's fiscal year 2014 
budget request included $80 million for research activities at the 
National Institutes of Health (NIH) and $20 million for education, 
outreach, and caregiver support services at the Department of Health 
and Human Services (HHS). These funds are a critically needed down 
payment for research and services for Alzheimer's patients and their 
families.
    A disease-modifying or preventive therapy would not only save 
millions of lives but would save billions of dollars in health care 
costs. Specifically, a treatment that delayed the onset of Alzheimer's 
by 5 years (a treatment similar to anti-cholesterol drugs), would 
reduce Medicare and Medicaid spending nearly in half in 2050.
    Today, despite the Federal investment in Alzheimer's research, we 
are only just beginning to understand what causes the disease. 
Americans are growing increasingly concerned that we still lack 
effective treatments that will slow, stop, or cure the disease, and 
that the pace of progress in developing breakthrough discoveries is 
much too slow to significantly impact this growing crisis. For every 
$29,000 Medicare and Medicaid spend caring for individuals with 
Alzheimer's, the National Institutes of Health (NIH) spends only $100 
on Alzheimer's research. Scientists fundamentally believe that we have 
the ideas, the technology and the will to develop new Alzheimer's 
interventions, but that progress depends on a prioritized scientific 
agenda and on the resources necessary to carry out the scientific 
strategy for both discovery and translation for therapeutic 
development.
    Additional funding is in the NIH budget because their scientists 
have determined that additional research on Alzheimer's is a priority. 
Their budget request reflects the changing needs of the Alzheimer's 
community and the scientific opportunity. It is vital that Congress 
support the research projects the scientists at NIH deem necessary.
    However, Congress does have a responsibility to direct resources to 
solve the most serious problems. By every objective standard (whether 
cost to Medicare/Medicaid, families caring for individuals with 
Alzheimer's, or mortality rate), Alzheimer's is one of our most serious 
health problems--and it will only get worse as the Baby Boomer 
generation ages.
    Alzheimer's is the most expensive disease in the country not just 
because of the lack of adequate treatments, but also because our care 
systems do not effectively address dementia and its consequences. For 
too many individuals with Alzheimer's and their families, the system 
has failed them, and today we are unnecessarily losing the battle 
against this devastating disease. Despite the fact that an early and 
documented formal diagnosis allows individuals to participate in their 
own care planning, manage other chronic conditions, participate in 
clinical trials, and ultimately alleviate the burden on themselves and 
their loved ones, as many as half of the more than 5 million Americans 
with Alzheimer's have never received a formal diagnosis. Unless we 
create an effective, dementia-capable system that finds new solutions 
to providing high quality care, provides community support services and 
programs, and addresses Alzheimer's health disparities, Alzheimer's 
will overwhelm the health care system in the coming years. For example, 
people with Alzheimer's and other dementias have more than three times 
as many hospital stays as other older people. Furthermore, one out of 
seven individuals with Alzheimer's or another dementia lives alone and 
up to half of them do not have an identifiable caregiver. These 
individuals are more likely to need emergency medical services because 
of self-neglect or injury, and are found to be placed into nursing 
homes earlier, on average, than others with dementia. Ultimately, 
supporting individuals with Alzheimer's disease and their families and 
caregivers requires giving them the tools they need to plan for the 
future and ensuring the best quality of life for individuals and 
families affected by the disease.
    For all these reasons, it is vital that we make the investments in 
Alzheimer's that were laid out in the President's fiscal year 2014 
budget. The President's budget requested $100 million for research and 
support services because the needs of the Alzheimer's community have 
grown. The Alzheimer's Association urges Congress to support the 
President's budget request of $100 million for research, education, 
outreach and support activities and the priorities included in the 
National Alzheimer's Plan required under Public Law 111-375.

Additional Alzheimer's programs
    National Alzheimer's Call Center.--The National Alzheimer's Call 
Center, funded by the AoA, provides 24/7, year-round telephone support, 
crisis counseling, care consultation, and information and referral 
services in 140 languages for persons with Alzheimer's, their family 
members and informal caregivers. Trained professional staff and 
master's-level mental health professionals are available at all times. 
In the 12 month period ending July 31, 2011, the Call Center handled 
over 300,000 calls through its national and local partners, and its 
online message board received over 40,000 visits a month. Additionally, 
the Association provides a two-to-one match on the Federal dollars 
received for the call center. The Alzheimer's Association urges 
Congress to support $1.3 million for the National Alzheimer's Call 
Center.
    Healthy Brain Initiative (HBI).--The Centers for Disease Control 
and Prevention's (CDC) HBI program works to educate the public, the 
public health community and health professionals about Alzheimer's as a 
public health issue. Although there are currently no treatments to 
delay or stop the deterioration of brain cells caused by Alzheimer's, 
evidence suggests that preventing or controlling cardiovascular risk 
factors may benefit brain health. In light of the dramatic aging of the 
population, scientific advancements in risk behaviors, and the growing 
awareness of the significant health, social and economic burdens 
associated with cognitive decline, the Federal commitment to a public 
health response to this challenge is imperative. The fiscal year 2013 
Senate Labor-HHS bill included report language commending HBI for its 
leadership in bringing attention to the public health crisis of 
Alzheimer's disease and for its work on cognitive impairment data 
collection in 45 States, the District of Columbia and Puerto Rico. 
Additionally, the committee noted that developing a population-based 
surveillance system with longitudinal follow-up is a key recommendation 
in the National Public Road Map to Maintaining Cognitive Health, which 
was developed jointly by the CDC and the Alzheimer's Association. The 
bill increased funding for HBI by $10 million in order to further 
develop this system and to develop effective public health messages to 
promote cognitive health in older adults. The Alzheimer's Association 
urges Congress to support $11.8 million for the Healthy Brain 
Initiative.
    Alzheimer's Disease Supportive Services Program (ADSSP).--The ADSSP 
at the AoA supports family caregivers who provide countless hours of 
unpaid care, thereby enabling their family members with Alzheimer's and 
dementia to continue living in the community. The program develops 
coordinated, responsive and innovative community-based support service 
systems for individuals and families affected by Alzheimer's. The 
Alzheimer's Association urges Congress to support $13.4 million for the 
Alzheimer's Disease Supportive Services Program as recommended by the 
Advisory Council on Alzheimer's Research, Care and Services.

                               CONCLUSION

    The Association appreciates the steadfast support of the 
subcommittee and its priority setting activities. We look forward to 
continuing to work with Congress in order to address the Alzheimer's 
crisis. Alzheimer's is the costliest disease in the country and these 
costs are set to increase like for none other. It is vital that 
Congress supports the President's fiscal year 2014 budget request of an 
additional $100 million for Alzheimer's research, education, outreach 
and support activities to implement the National Alzheimer's Plan. We 
ask Congress to address Alzheimer's with the same bipartisan 
collaboration demonstrated in the passage of the National Alzheimer's 
Project Act (Public Law 111-375) and with a commitment equal to the 
scale of the crisis.
                                 ______
                                 
    Prepared Statement of the American Academy of Family Physicians

    The American Academy of Family Physicians (AAFP), representing 
110,600 family physicians and medical students nationwide, urges the 
Senate Appropriations Subcommittee on Labor, Health and Human Services, 
and Education to invest in our Nation's primary care physician 
workforce in the fiscal year 2014 appropriations bill to promote the 
efficient, effective delivery of health care by providing these 
appropriations for the Health Resources and Services Administration and 
the Agency for Healthcare Research and Quality:
  --At least $71 million for Health Professions Primary Care Training 
        and Enhancement authorized under Title VII, Section 747 of the 
        Public Health Service Act (PHSA);
  --$10 million for Teaching Health Centers development grants (PHSA 
        Title VII, Sec. 749A);
  --$4 million for Rural Physician Training Grants (PHSA Title VII, 
        Sec. 749B);
  --$122.2 million for the Office of Rural Health Programs (PHSA 
        Sec. Sec. 301, 330A, & 338J and Sec. Sec. 711 and 1820(j), 
        Title XVIII of the Social Security Act (SSA));
  --At least $305 million for the National Health Service Corps (PHSA 
        Sec. 338A, B, & I);
  --$120 million for the Primary Care Extension program (PHSA 
        Sec. 399V-1);
  --$3 million for the National Health Care Workforce Commission (ACA 
        Sec. 5101); and
  --$434 million for the Agency for Healthcare Research and Quality 
        (PHSA Sec. 487(d)(3), SSA Sec. 1142).
    The AAFP is one of the Nation's largest medical organizations, 
representing family physicians, family medicine residents, and medical 
students nationwide. Founded in 1947, our mission is to preserve and 
promote the science and art of family medicine and to ensure high-
quality, cost-effective health care for patients of all ages.

          HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA)

    Our Nation faces a shortage of primary care physicians. The total 
number of office visits to primary care physicians is projected to 
increase from 462 million in 2008 to 565 million in 2025 requiring 
nearly 52,000 additional primary care physicians by 2025.\1\ HRSA is 
the Federal agency charged with administering the health professions 
training programs authorized under Title VII of the Public Health 
Services Act and first enacted in 1963. We urge the Committee to 
provide at least $7 billion for HRSA in the fiscal year 2014 
appropriations bill.
    Title VII Health Professions Training Programs.--In the last 50 
years, Congress has revised the Title VII authority in order to meet 
our Nation's changing health care workforce needs. As the only medical 
specialty society devoted entirely to primary care, the AAFP is gravely 
concerned that a failure to provide adequate funding for the Title VII, 
Section 747 Primary Care Training and Enhancement (PCTE) program, will 
destabilize education and training support for family physicians. 
Between 1998 and 2008, in spite of persistent primary care physician 
shortages, family medicine lost 46 training programs and 390 residency 
positions, and general internal medicine lost nearly 900 positions.\2\ 
A study published in the Annals of Family Medicine on the impact of 
Title VII training programs found that physicians who work with the 
underserved in Community Health Centers and National Health Service 
Corps sites are more likely to have trained in Title VII-funded 
programs.\3\ Title VII primary care training grants are vital to 
departments of family medicine, general internal medicine, and general 
pediatrics; they strengthen curricula; and they offer incentives for 
training in underserved areas. In the coming years, medical services 
utilization is likely to rise given the increasing and aging population 
as well as the insured status of more people. These demographic trends 
will worsen family physician shortages. The AAFP urges the Committee to 
increase the level of Federal funding for primary care training to at 
least $71 million in fiscal year 2014 to support the continuing work of 
grantees and allow for a new grant cycle.
    Teaching Health Centers.--The AAFP has long called for reforms to 
graduate medical education programs to encourage the training of 
primary care residents in non-hospital settings where most primary care 
is delivered. An excellent first step is the innovative Teaching Health 
Centers program authorized under Title VII, Sec. 749A to increase 
primary care physician training capacity now administered by HRSA. 
Federal financing of graduate medical education has led to training 
mainly in hospital inpatient settings even though most patient care is 
delivered outside of hospitals in ambulatory settings. The Teaching 
Health Center program provides resources to any qualified community 
based ambulatory care setting that operates a primary care residency. 
We believe that this program requires an investment of $10 million in 
fiscal year 2014 for planning grants.
    Rural Health Needs.--HRSA's Office of Rural Health focuses on key 
rural health policy issues and administers targeted rural grant 
programs. As the medical specialty most likely to enter rural practice, 
family physicians recognize the need to dedicate resources to rural 
health needs. A recent study found that medical school rural programs 
(RPs) have had a significant impact on rural family physician supply 
and called for wider adoption of that model to substantially increase 
access to care in rural areas compared with greater reliance on 
international medical graduates or unfocused expansion of traditional 
medical schools.\4\ HRSA's Rural Physician Training Grant program will 
help medical schools recruit students most likely to practice medicine 
in rural communities. This program will help provide rural-focused 
experience and increase the number of medical school graduates who 
practice in underserved rural communities. The AAFP recommends that the 
Committee provide $4 million for Rural Physician Training Grants in 
fiscal year 2014.
    Primary Care in Underserved Areas.--The National Health Service 
Corps (NHSC) recruits and places medical professionals in Health 
Professional Shortage Areas to meet the need for health care in rural 
and medically underserved areas. The NHSC provides scholarships or loan 
repayment as incentives for physicians to enter primary care and 
provide health care to Americans in Health Professional Shortage Areas. 
By addressing medical school debt burdens, the NHSC also helps to 
ensure wider access to medical education opportunities. The AAFP 
recommends that the Committee provide at least the mandatory funding of 
$305 million for the NHSC in fiscal year 2014.
    The AAFP has worked closely with HRSA to promote data-driven 
community health center expansion. The mapping tool developed and 
managed by the Robert Graham Center for Policy Studies in Family 
Practice and Primary Care identifies areas in greatest need for 
federally Qualified Health Centers. Since the launch of the tool on 
July 1, 2010, the UDS Mapper has registered over 4,500 users and can be 
found at http://www.udsmapper.org/about.cfm.

           AGENCY FOR HEATLHCARE RESEARCH AND QUALITY (AHRQ)

    The mission of the Agency for Healthcare Research and Quality 
(AHRQ)--to improve the quality, safety, efficiency, and effectiveness 
of health care for all Americans--closely mirrors AAFP's own mission. 
AHRQ provides the critical evidence reviews that the AAFP and other 
physician specialty societies use to produce clinical practice 
guidelines. AHRQ promotes evidence-based patient safety practices. In 
addition, AHRQ takes research results from NIH where they restrict 
research subjects to limit the variables in clinical research and 
brings the practical information to the practicing physicians who treat 
patients without those clinical restrictions. AHRQ provides patient-
centered health research which improves health care quality by 
providing patients and physicians with state-of-the-science information 
on which medical treatments work best for a given condition. The AAFP 
asks that the Committee provide at least $434 million for AHRQ in 
fiscal year 2014.
    Primary Care Extension Program.--The AAFP supports AHRQ's Primary 
Care Extension Program to provide assistance to primary care physicians 
about evidence-based therapies and techniques so that they can 
incorporate them into their practice. As AHRQ develops more scientific 
evidence on best practices and effective clinical innovations, the 
Primary Care Extension Program will disseminate the information learned 
to primary care practices across the Nation in much the same way as the 
Federal Cooperative Extension Service provides small farms with the 
most current agricultural information and guidance. The AAFP recommends 
that the Committee provide $120 million for the AHRQ Primary Care 
Extension program in fiscal year 2014.

               NATIONAL HEALTH CARE WORKFORCE COMMISSION

    Appointed on September 30, 2010, the 15-member National Health Care 
Workforce Commission was intended to serve as a resource with a broad 
array of expertise. The Commission was directed to analyze current 
workforce distribution and needs; evaluate health care education and 
training; identify barriers to improved coordination at the Federal, 
State, and local levels and recommend ways to address them; and 
encourage innovations. There is broad consensus about the waning 
availability of primary care physicians in the United States, but 
estimates of the severity of the regional and local shortages vary. The 
AAFP supports the work of the Commission to analyze primary care 
shortages and propose innovations to help produce the physicians that 
our Nation needs and will need in the future. We request that the 
Committee provide $3 million in fiscal year 2014 so that this important 
Commission can begin this important work.
---------------------------------------------------------------------------
    \1\ Petterson, S, et al. Projecting US Primary Care Physician 
Workforce Needs: 2010-2015. Ann Fam Med 2012; vol.10 no. 6:503-509.
    \2\ Phillips RL and Turner, BJ. The Next Phase of Title VII Funding 
for Training Primary Care Physicians for America's Health Care Needs. 
Ann Fam Med 2012; vol.10 no. 2:163-168.
    \3\ Rittenhouse DR, et al. Impact of Title VII training programs on 
community health center staffing and national health service corps 
participation. Ann Fam Med 2008; vol. 6 no. 5:397-405.
    \4\ Rabinowitz,HK, et al. Medical School Rural Programs: A 
Comparison With International Medical Graduates in Addressing State-
Level Rural Family Physician and Primary Care Supply. Academic 
Medicine, Vol. 87, No. 4/April 2012.
---------------------------------------------------------------------------
                                 ______
                                 
      Prepared Statement of the American Academy of Ophthalmology

                           EXECUTIVE SUMMARY

    The American Academy of Ophthalmology requests fiscal year 2014 NIH 
funding of $32 billion, which reflects a $1.38 billion, or 4.5 percent 
increase, over fiscal year 2012, which consists of biomedical inflation 
of 2.8 percent plus modest growth. This recommendation reflects the 
minimum investment necessary to make up for the 20 percent loss in 
purchasing power over the last decade, as well as the impact of the 
sequester, which cut 5.1 percent or $1.6 billion from NIH's $30.8 
fiscal year 2013 billion budget.
    NIH, our Nation's biomedical research enterprise, is unique in 
that:
  --Its basic and clinical research has helped to understand the basis 
        of disease, thereby resulting in innovations in healthcare to 
        save and improve lives.
  --Its research serves an irreplaceable role the private sector could 
        not duplicate.
  --It has been shown through several studies to be a major force in 
        the economic health of communities across the Nation. The 
        latest United for Medical Research report estimates that NIH 
        funding supported more than 432,000 jobs in 2011, directly or 
        indirectly, and generated more than $62.1 billion in economic 
        activity.
    The Academy requests National Eye Institute (NEI) funding at $730 
million, commensurate with the overall NIH funding increase. The 
President's budget proposes an fiscal year 2014 NEI funding reduction 
of $2.1 million to a level $699 million which is unacceptable since:
  --It cuts 35 competing grants. The $36 million cut in fiscal year 
        2013 NEI funding due to the sequester has already translated 
        into a loss of an estimated 90 grants--any one of which holds 
        the promise to save or restore vision.
  --The cut jeopardizes NEI's ability to fund new and compelling 
        scientific ideas to advance research, which were identified 
        through its Audacious Goals Initiative.
  --Funding at $699 million is little more than 1 percent of the $68 
        billion annual cost of eye disease/vision impairment in the 
        U.S. With the majority of the 78 million Baby Boomers turning 
        65 years of age this decade and facing the greatest risk of 
        aging eye disease, a cut jeopardizes NEI's ability to meet the 
        vision challenges presented by this ``Silver Tsunami.''
Congress Must Improve Upon the President's Fiscal Year 2014 Request, 
        Since It Cuts NEI Funding by $2.1 Million, or 0.3 Percent Below 
        Fiscal Year 2012, Reducing It by $8 Million Below Its Base 
        Fiscal Year 2010 Level
    Despite the President's request increasing NIH funding by $471 
million, or 1.5 percent, over the fiscal year 2012 level of $30.6 
billion (net of transfers), it proposes to cut NEI by $2.1 million, or 
0.3 percent, below its fiscal year 2012 level of $701.3 million (net of 
transfers). Although the cut is primarily driven by an $8.9 million 
reduction due to the conclusion of the NEI-sponsored Ocular 
Complications of AIDS (SOCA) studies which are funded by the NIH Office 
of AIDS Research, it is still a cut and drives NEI funding in the wrong 
direction. The President's proposed fiscal year 2014 NEI funding level 
of $699 million falls $8 million below the base fiscal year 2010 level 
of $707 million, the highest NEI funding level ever prior to the 
addition of American Recovery and Reinvestment Act (ARRA) funding.
    Most importantly, the President's proposed fiscal year 2014 NEI cut 
of $2.1 million comes after the fiscal year 2013 sequester cut of $36 
million. The President's fiscal year 2014 budget would cut 35 competing 
grants from NEI funding, which follows the sequester's cut of an 
estimated 90 grants in fiscal year 2013--any one of which may hold the 
promise to save or restore vision.
    NEI is already facing enormous challenges this decade: each day, 
from 2011 to 2029, 10,000 citizens will turn 65 and be at greatest risk 
for eye disease; the African American and Hispanic populations are 
experiencing a disproportionately higher incidence of eye disease; and 
the epidemic of obesity is significantly increasing the incidence of 
diabetic retinopathy and diabetic macular edema. In 2009, Congress 
spoke volumes in passing S. Res. 209 and H. Res. 366, which designated 
2010-2020 as The Decade of Vision. With the fiscal year 2014 LHHS 
spending bill, Congress can act upon its past resolutions regarding 
vision and assure that NEI is adequately funded to meet these 
challenges.
    The Academy also requests NEI funding at $730 million since our 
Nation's investment in vision health is an investment in overall 
health. NEI's breakthrough research is a cost-effective investment, 
since it is leading to treatments and therapies that can ultimately 
delay, save, and prevent health expenditures, especially those 
associated with the Medicare and Medicaid programs. It can also 
increase productivity, help individuals to maintain their independence, 
and generally improve the quality of life, especially since vision loss 
is associated with increased depression and accelerated mortality.
    The very health of the vision research community is also at stake 
with a decrease in NEI funding. Not only will funding for new 
investigators be at risk, but also that of seasoned investigators, 
which threatens the continuity of research and the retention of trained 
staff, while making institutions more reliant on bridge and 
philanthropic funding. If an institution needs to let staff go, that 
usually means a highly-trained person is lost to another area of 
research or an institution in another State, or even another country.
    The proposed reduction in NEI funding threatens the United States' 
leadership in biomedical research in general, and vision research, 
specifically.

$730 Million Fiscal Year 2014 Funding Enables NEI To Pursue Audacious 
        Goals in Vision Research
    The NEI is in the middle of a novel planning initiative to identify 
long-term, 10-year goals in vision research. Under the auspices of the 
National Advisory Eye Council, this expansion of NEI program planning 
is designed to engage and energize the vision research community and 
help the NEI establish the most compelling research priorities by 
identifying one or more ``audacious goals.'' Most recently, NEI hosted 
200 representatives from every sector of the vision community, as well 
as Government scientists and regulators from various disciplines at the 
NEI's Audacious Goals Development meeting. NIH Director Francis 
Collins, M.D., Ph.D., was very enthusiastic about this initiative and 
urged the attendees to have a ``bold vision for vision'' by describing 
NEI's long tradition of leading in the biomedical research arena, 
including:
  --identifying more than 500 genes associated with vision loss, which 
        is one-quarter of all genes discovered to date; and
  --funding the successful human gene therapy trial for patients with 
        Leber Congenital Amaurosis, in which treated patients have 
        experienced vision improvement.
    The meeting's discussion topics were built around the 10 winning 
submissions from a pool of nearly 500 entries selected through NEI's 
Audacious Goals in Vision Research and Blindness Rehabilitation 
Challenge, a competition for bold and novel ideas to dramatically 
advance vision science. These ideas included restoring light 
sensitivity to the blind through gene-based therapies and visual 
prosthetics, pinpoint correction of defective genes, and growing 
healthy tissue from stem cells for ocular tissue transplants. 
Translating these and other research ideas into safe and effective 
treatments to save and restore vision requires adequate funding.
    As a result of past funding, the NEI has made great strides in 
determining the genetic basis of age-related macular degeneration 
(AMD)--the leading cause of blindness and a disease for which very 
little could be done just a few short years ago. NEI's AMD Gene 
Consortium, a network of international investigators, has just 
discovered seven new regions of the human genome--called loci--that are 
associated with increased risk of AMD. They also confirmed 12 loci 
already identified in previous studies. These loci implicate a variety 
of biological functions, including regulation of the immune system, 
maintenance of cellular structure, growth and permeability of blood 
vessels, lipid metabolism, and atherosclerosis. By understanding the 
genetic basis of the disease and underlying disease mechanisms, NEI can 
develop appropriate diagnostic and therapies.
    As an example of NEI-supported research that saves vision, in 
February 2013 the Food and Drug Administration (FDA) approved an 
implanted retinal prosthesis to treat adult patients with advanced 
retinitis pigmentosa (RP), a rare genetic condition that damages the 
retina and leads to blindness. A small video camera mounted on a pair 
of glasses sends images to a video processing unit that converts them 
to electronic data that is wirelessly transmitted to an array of 
electrodes implanted onto the retina. The device is enabling those who 
are otherwise completely blind to identify doors, crosswalks, and even 
utensils on a table. Although this ``Bionic Eye'' may have been a 
fantasy just a few short years ago, the NEI has always envisioned the 
future. Funding must be adequate for it to successfully pursue its goal 
of saving and restoring vision.

Blindness and Vision Loss is a Growing Public Health Problem That 
        Individuals Fear and Would Trade Years of Life To Avoid
    The NEI estimates that more than 38 million Americans age 40 and 
older experience blindness, low vision, or an age-related eye disease 
such as AMD, glaucoma, diabetic retinopathy, or cataracts. This is 
expected to grow to more than 50 million Americans by year 2020. 
Although the NEI estimates that the current annual cost of vision 
impairment and eye disease to the U.S. is $68 billion, this number does 
not fully quantify the impact of indirect healthcare costs, lost 
productivity, reduced independence, diminished quality of life, 
increased depression, and accelerated mortality. NEI's proposed fiscal 
year 2014 funding of $699 million reflects just a little more than 1 
percent of this annual cost of eye disease. The continuum of vision 
loss presents a major public health problem, as well as a significant 
financial challenge to both the public and private sectors.
    Vision loss also presents a real fear to most citizens:
  --In public opinion polls over the past 40 years, Americans have 
        consistently identified fear of vision loss as second only to 
        fear of cancer. NEI's Survey of Public Knowledge, Attitudes, 
        and Practices Related to Eye Health and Disease reported that 
        71 percent of respondents indicated that a loss of their 
        eyesight would rate as a ``10'' on a 1 to 10 scale, meaning 
        greatest impact on their life.
  --In patients with diabetes, going blind or experiencing vision loss 
        rank among the top four concerns about the disease. These 
        patients are so concerned about vision loss diminishing their 
        quality of life that those with nearly perfect vision (20/20 to 
        20/25) would be willing to trade 15 percent of their remaining 
        life for ``perfect vision,'' while those with moderate 
        impairment (20/30 to 20/100) would be willing to trade 22 
        percent of their remaining life for perfect vision. Patients 
        who are legally blind from diabetes (20/200 to 20/400) would be 
        willing to trade 36 percent of their remaining life to regain 
        perfect vision.

The Academy Urges Congress To Fund NIH At $32 Billion, NEI at $730 
        Million, in Fiscal Year 2014 To Ensure the Momentum of 
        Research, To Retain Trained Personnel, and Maintain U.S. 
        Leadership
            About the American Academy of Ophthalmology
    The American Academy of Ophthalmology is the largest national 
membership association of Eye M.D.s. Eye M.D.s are ophthalmologists, 
medical and osteopathic doctors who provide comprehensive eye care, 
including medical, surgical and optical care. More than 90 percent of 
practicing U.S. Eye M.D.s are Academy members, and the Academy has more 
than 7,000 international members.
                                 ______
                                 
   Prepared Statement of the American Academy of Physician Assistants

    On behalf of the 90,000 clinically practicing physician assistants 
in the United States, the American Academy of Physician Assistants 
(AAPA) is pleased to submit comments on fiscal year 2014 appropriations 
for Physician Assistant (PA) educational programs that are authorized 
through Title VII of the Public Health Service Act. AAPA respectfully 
request's the Senate Appropriations Committee to approve funding at 
existing levels for the Title VII health professions education 
program--$264,400,000, with an allocation of 15 percent of the Primary 
Care Training and Enhancement program line for physician assistant 
training.
    Title VII Health Professions Programs are essential to placing 
health professionals in medically underserved communities. A study 
published in the New York Times has shown we are currently short 9,000 
primary care physicians, and that number will grow to 65,000 primary 
care physicians in 15 years. According to the Health Resources and 
Services Administration (HRSA), an additional 31,000 health care 
practitioners are needed to alleviate existing professional shortages. 
Title VII funding encourages greater numbers of students to enter PA 
educational programs and to go into primary care, while increasing 
access to care for millions of Americans who live in medically 
underserved areas.
    Federal support for Title VII is authorized through section 747 of 
the Public Health Service Act. It is the only continuing Federal 
funding available to PA educational programs.
    In 2012, 12 PA programs received $2.3 million (5.9 percent of the 
total primary care medicine budget of $38.9 million) in Title VII 
funding, which was directed to primary care education and training 
programs designed to prepare PAs for practice in urban or rural 
medically underserved areas. Additionally, these funds were directed to 
supporting programs that assist Veteran's in their transition into 
becoming PAs in the civilian workforce. While the purview of the Title 
VII programs grant funding has expanded to include assisting returning 
combat veterans, the funds to PA programs from 2011 to 2012 has 
decreased by $879,000. More reductions to this budget will hurt new PA 
programs that need these funds to help with student recruitment, 
faculty development, and establishing clinical rotation cites.
    Diverse clinical rotation sites and recruitment programs are 
critical to PA education and are paramount to the Title VII primary 
care medicine program. A review of PA graduates from 1990--2009 
demonstrates that PAs who have graduated from PA educational programs 
supported by Title VII are 67 percent more likely to be from 
underrepresented minority populations and 47 percent more likely to 
work in a rural health clinic than graduates of programs that were not 
supported by Title VII.
    Title VII programs are essential to the development and training of 
primary health care professionals and, in turn, provide increased 
access to care by promoting health care delivery in medically 
underserved communities. We wish to thank the members of this 
subcommittee for your historical role in supporting funding for the 
health professions programs, and we hope that we can count on your 
support to augment funding to these important programs in fiscal year 
2014.

Overview of Physician Assistant Education
    The existing 170 accredited physician assistant educational 
programs are all located within schools of medicine or health sciences, 
universities, teaching hospitals, and the Armed Services. All PA 
educational programs are accredited by the Accreditation Review 
Commission on Education for the Physician Assistant.
    The typical PA program consists of 26 months of instruction, and 
the typical student has a bachelor's degree and about 4 years of prior 
health care experience. The PA curriculum includes 340 hours of basic 
sciences and nearly 1,600 hours of clinical medicine. On average, 
students devote more than 2,000 hours, or 50 to 55 weeks, to clinical 
education, divided between primary care medicine--family medicine, 
internal medicine, pediatrics, and obstetrics and gynecology--and 
various specialties, including surgery and surgical specialties, 
internal medicine subspecialties, emergency medicine, and psychiatry.
    After graduation from an accredited PA program, physician 
assistants must pass a national certifying examination developed by the 
National Commission on Certification of Physician Assistants. To 
maintain certification, PAs must log 100 continuing medical education 
hours every 2 years, and they must take a recertification exam every 6 
years.

Physician Assistant Practice
    Physician assistants (PAs) are licensed health professionals who 
practice medicine as members of a team with their supervising 
physicians. PAs exercise autonomy in medical decisionmaking and provide 
a broad range of medical and therapeutic services to diverse 
populations in rural and urban settings. In all 50 States, PAs carry 
out physician-delegated duties that are allowed by law and within the 
physician's scope of practice and the PA's training and experience. 
Additionally, PAs are delegated prescriptive privileges by their 
physician supervisors in all 50 States, the District of Columbia, and 
Guam. This allows PAs to practice in rural, medically underserved areas 
where they are often the only full-time medical provider.

PAs in Primary Care
    An estimated 30,000 PAs (30 percent of the profession) work in 
primary care across the nation--37 percent work in private practice 
(both physician group and solo practices); 3.1 percent practice in 
community health centers, 2.7 percent practice in certified rural 
health clinics, and 2.1 percent work in a federally qualified health 
center.
    PAs are also one of three primary care providers who work in the 
National Health Service Corps (NHSC). The NHSC is an important Federal 
program with nearly 10,000 healthcare providers, like PAs, who benefit 
from the program's loan-forgiveness and scholarships awards to those 
providers and students who commit 2 years to provide medical, dental 
and mental healthcare in medically underserved areas.
    Additionally, an estimated 2,790 PAs proudly work in community 
health centers (CHCs) around the country, some as CHC medical 
directors. Community health centers provide cost-effective healthcare 
throughout the country and serve as medical homes for millions in 
medically underserved areas. CHCs offer a wide variety of healthcare 
services through team-based care, providing high quality healthcare to 
CHC patients and significantly reducing medical expenses.

Critical Role of Title VII Public Health Service Act Programs
    In its February 2012 report to Congress, HRSA's Advisory Committee 
on Training in Primary Care Medicine and Dentistry wrote: ``The Title 
VII, section 747 grant programs have brought improvements in primary 
care education, faculty development, and workforce capacity. They have 
helped to identify and disseminate best practices to programs, 
accrediting bodies, and other stakeholders. These grants have permitted 
the development of innovative programs that benefit medical trainees 
throughout the country. Additionally, Title VII, section 747 grants are 
the foundation for programs that foster among academic leaders and 
trainees a sense of duty to provide care for underserved communities 
and populations.''
    Title VII programs are the only Federal educational programs that 
are designed to address the supply and distribution imbalances in the 
health professions. Since the establishment of Medicare, the costs of 
physician residencies, nurse training, and some allied health 
professions training have been paid through Graduate Medical Education 
(GME) funding; however, GME has never been available to support PA 
education. More importantly, GME was not intended to generate a supply 
of providers who are willing to work in the Nation's medically 
underserved communities--the purpose of Title VII.
    Furthermore, Title VII programs seek to recruit students who are 
from underserved minority and disadvantaged populations, which is a 
critical step towards reducing persistent health disparities among 
certain racial and ethnic U.S. populations. Research shows racial and 
ethnic health disparities cost the economy more than $230 billion in 
lost productivity and up to $1.24 trillion in indirect costs over 3 
years; and studies have found that health professionals from 
disadvantaged regions of the country are three to five times more 
likely to return to underserved areas to provide care which would help 
alleviate the current health disparity crisis in America.
    Support for educating PAs to practice in underserved communities is 
particularly important given the market demand for physician 
assistants. Title VII funding is a critical link in addressing the 
natural geographic mal-distribution of health care providers by 
exposing students to underserved sites during their training, where 
they frequently choose to practice following graduation. Currently, 36 
percent of PAs met their first clinical employer through their clinical 
rotations.

Supplementary Recommendations on fiscal year 2014 Funding
    The American Academy of Physician Assistants urges members of the 
Appropriations Committee to consider the inter-dependency of all public 
health agencies and programs when determining funding for fiscal year 
2014. For instance, while it is critical, now more than ever, to fund 
clinical research at the National Institutes of Health (NIH) and to 
have an infrastructure at the Centers for Disease Control and 
Prevention (CDC) that ensures a prompt response to an infectious 
disease outbreak or bioterrorist attack, the good work of both of these 
agencies will go unrealized if the Health Resources and Services 
Administration (HRSA) is inadequately funded.
    HRSA administers the ``people'' programs, such as Title VII, that 
bring the results of cutting edge research at NIH to patients through 
providers such as PAs who have been educated in Title VII-funded 
programs. Likewise, the CDC is heavily dependent upon an adequate 
supply of health care providers to be sure that disease outbreaks are 
reported, tracked, and contained.
    Thank you for the opportunity to present the American Academy of 
Physician Assistants' views on fiscal year 2014 appropriations 
concerning HRSA's Title VII Health Professions Program.
                                 ______
                                 
         Prepared Statement of the American Alliance of Museums

    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee, thank you for allowing me to submit this testimony. My 
name is Ford Bell and I serve as President of the American Alliance of 
Museums. I also submit this testimony on behalf of the larger museum 
community--including the American Association for State and Local 
History, the Association of Art Museum Directors, the Association of 
Science-Technology Centers, the Association of Science Museum 
Directors, the Association of Zoos and Aquariums, the Association of 
Children's Museums, the American Public Gardens Association, and 
Heritage Preservation--to request that the subcommittee make a renewed 
investment in museums in fiscal year 2014. We urge you to fully fund 
the Office of Museum Services (OMS) at the Institute of Museum and 
Library Services (IMLS) at its authorized level of $38.6 million.
    The Alliance is proud to represent the full range of our Nation's 
museums--including aquariums, art museums, botanic gardens, children's 
museums, culturally specific museums, historic sites, history museums, 
maritime museums, military museums, natural history museums, 
planetariums, presidential libraries, science and technology centers, 
and zoos, among others--along with the professional staff and 
volunteers who work for and with museums. We are honored to work on 
behalf of the country's 17,500 museums that employ 400,000 people and 
that annually spend more than $2 billion on educational programming, 
deliver 18 million instructional hours to students and teachers, and 
directly contribute $21 billion to their local economies.
    IMLS is the primary Federal agency that supports the Nation's 
museums, and OMS awards grants to help museums digitize, enhance and 
preserve their collections, provide teacher training, and create 
innovative, cross-cultural and multi-disciplinary programs and exhibits 
for schools and the public. The 2012-2016 IMLS Strategic Plan lists 
clear priorities: placing the learner at the center of the museum 
experience, promoting museums as strong community anchors, supporting 
museum stewardship of their collections, advising the President and 
Congress on how to sustain and increase public access to information 
and ideas, and serving as a model independent Federal agency maximizing 
value for the American public. IMLS is indeed a model Federal agency.
    In late 2010, a bill to reauthorize IMLS for 5 years was enacted 
(by voice vote in the House and unanimous consent in the Senate). The 
bipartisan reauthorization included several provisions proposed by the 
museum field, including enhanced support for conservation and 
preservation, emergency preparedness and response, and statewide 
capacity building. The reauthorization also specifically supports 
efforts at the State level to leverage museum resources, including 
statewide needs assessments and the development of State plans to 
improve and maximize museum services throughout the State. The bill 
(now Public Law 111-340) authorized $38.6 million for the IMLS Office 
of Museum Services to meet the growing demand for museum programs and 
services.
    The final, post-sequestration, fiscal year 2013 funding level for 
OMS of $29,245,034 represents a nearly 17 percent cut from the fiscal 
year 2010 appropriation of $35,212,000. However, President Obama's 
fiscal year 2014 budget proposes to partially restore these cuts by 
requesting $32,923,270 for the Office of Museum Services. We strongly 
applaud the increased request, especially under current budgetary 
constraints.
    To be clear, museums are essential in our communities for many 
reasons:
  --Museums are key education providers.--They design exhibitions, 
        educational programs, classroom kits, and online resources in 
        coordination with State, local and common core curriculum 
        standards in math, science, art, literacy, language arts, 
        history, civics and government, economics and financial 
        literacy, geography, and social studies. Museums also offer 
        experiential learning opportunities, STEM education, youth 
        training, and job preparedness. They reach beyond the scope of 
        instructional programming for schoolchildren by also providing 
        critical teacher training. There is a growing consensus that 
        whatever the new educational era looks like, it will focus on 
        the development of a core set of skills: critical thinking, the 
        ability to synthesize information, the ability to innovate, 
        creativity, and collaboration. Museums are uniquely situated to 
        help learners develop these core skills.
  --Museums create jobs and support local economies.--Museums serve as 
        economic engines, bolster local infrastructure, and spur 
        tourism. Both the U.S. Conference of Mayors and the National 
        Governors Association have noted that cultural assets such as 
        museums are essential to attracting businesses, a skilled 
        workforce, and local and international tourism.
  --Museums address community challenges.--Many museums offer programs 
        tailored to seniors, veterans, children with special needs, 
        persons with disabilities, and more, greatly expanding their 
        reach and impact. For example, some have programs designed 
        specifically for children on the autism spectrum, some are 
        teaching English as a Second Language, and some are working 
        directly with Alzheimer's patients. Many museums facilitate job 
        training programs, provide vegetable gardens for low-income 
        communities, or serve as locations for supervised visits 
        through the family court system. In 2012, more than 1,800 
        museums participated in the Blue Star Museums initiative, 
        offering free admission to all active duty and reserve military 
        personnel and their families from Memorial Day through Labor 
        Day.
  --Digitization and traveling exhibitions bring museum collections to 
        underserved populations.--Teachers, students, and researchers 
        benefit when cultural institutions are able to increase access 
        to trustworthy information through online collections and 
        traveling exhibits. Most museums, however, need more help in 
        digitizing collections.
    Grants to museums are highly competitive and decided through a 
rigorous, peer-reviewed process. Even the most ardent deficit hawks 
view the IMLS grant-making process as a model for the Nation. It would 
take approximately $129 million to fund all the grant applications that 
IMLS received from museums in 2012. But given the significant budget 
cuts, many highly-rated grant applications go unfunded each year:
  --Only 31 percent of Museums for America/Conservation Project Support 
        projects were funded;
  --Only 19 percent of National Leadership/21st Century Museum 
        Professionals/Sparks Ignition Grants for Museums/Connecting to 
        Collections Implementation projects were funded;
  --Only 61 percent of Native American/Hawaiian Museum Services 
        projects were funded; and
  --Only 33 percent of African American History and Culture projects 
        were funded.
    It should be noted that each time a museum grant is awarded, 
additional local and private funds are also leveraged. In addition to 
the required dollar-for-dollar match required of museums, grants often 
spur additional giving by private foundations and individual donors. A 
recent IMLS study found that 67 percent of museums that received 
Museums for America grants reported that their IMLS grant had 
positioned the museum to receive additional private funding.
    Here are just a few examples of how Office of Museum Services 
funding is used:
  --The Alliance-accredited National Czech and Slovak Museum and 
        Library in Cedar Rapids, Iowa will use its $148,351 Museums for 
        America grant awarded in 2011 to capture the personal stories 
        and family sagas of Czech and Slovak Cold War emigres recent 
        (post-Velvet Revolution) Czech and Slovak immigrants to 
        America. The project involves incorporating informational 
        content and video clips into a new permanent exhibition. Other 
        aspects of the project include design of a traveling exhibit, a 
        conference, and the publication of an issue of the museum's 
        journal, Slovo, which uses oral history content. This week, the 
        museum will also receive IMLS' National Medal for Museum and 
        Library Service, the country's highest honor for museums and 
        libraries, for its essential role in rebuilding a Cedar Rapids 
        neighborhood following devastating floods in 2008.
  --The Alliance-accredited Edwin A. Ulrich Museum of Art at Wichita 
        State University in Wichita, Kansas will use its $150,000 
        Conservation Project Support grant awarded in 2012 to continue 
        restoration work on Personnages Oiseaux, the 26 x 52 foot 
        glass-and-marble mosaic facade created and installed by Joan 
        Miro. The work is touted as ``an icon for the museum, the 
        university, the City of Wichita, and the State of Kansas.''
  --The Prince George's African American Museum & Cultural Center in 
        North Brentwood, Maryland will use its $147,308 African 
        American History and Culture grant to support a museum 
        curriculum and certification program. This grant, awarded in 
        2012, will increase professional knowledge and skills for 
        community college students. The museum will work in partnership 
        with the Workforce Development Program at Prince George's 
        Community College to create a curriculum model to share with 
        other community colleges. The certification program is a 
        training course revolving around a museum studies internship 
        project highlighting African American history. The project will 
        offer practical entry-level training experience to PGCC 
        students interested in pursuing careers in museums.
  --The Birmingham Zoo in Birmingham, Alabama will use its $133,000 
        Museums for America grant, awarded in 2012, to support its 
        Africa Zoo School program, which will aim to serve 1,200 
        students over 2 years. In partnership with Birmingham City 
        Schools, the project will target all seventh-grade students 
        within the city. Participating students, most attending low-
        performing schools, will attend a week-long ``Zoo School'' 
        session, where they will be introduced to the Trails of Africa 
        exhibit and will work through a related curriculum. The exhibit 
        is the basis of an interdisciplinary experience to teach about 
        the crisis of the elephant species' survival in Africa, the 
        cultures of people in Africa, and the scientific and 
        engineering research involved in sustaining these populations. 
        Students will develop critical thinking and problem-solving 
        skills, which they can adapt to the classroom and home.
    In closing, I would like to share with you for the record a recent 
letter to the subcommittee requesting funding for OMS signed by 24 of 
your Senate colleagues, including subcommittee members Senator Durbin, 
Senator Reed, and Senator Shaheen. Thank you once again for the 
opportunity to submit this testimony.
                                 ______
                                 
   Prepared Statement of the American Association for Dental Research

Introduction

    Mr. Chairman and members of the subcommittee, I am Peter Polverini, 
Dean of the University of Michigan School of Dentistry and President of 
the American Association for Dental Research (AADR). My testimony is on 
behalf of AADR. I thank the subcommittee for this opportunity to 
testify about the exciting advances in oral health science and for your 
past support of research at the National Institutes of Health (NIH). It 
is that support that makes it possible for the National Institute of 
Dental and Craniofacial Research (NIDCR) to improve oral health with 
the research it funds. The investments we make today will make it 
easier to treat and prevent oral health diseases and disorders in the 
future. Therefore, I am requesting that NIDCR receive a funding level 
of $450 million. My testimony will illustrate how scientific advances 
in oral health have benefited taxpayers, and explain some of the 
challenges that lie ahead.

What is the American Association for Dental Research?
    The AADR is a non-profit organization with more than 3,500 
individual members in the United States, as well as 46 institutional 
members spread across 26 States. Its mission is to: 1) advance research 
and increase knowledge for the improvement of oral health; 2) support 
and represent the oral health research community; and 3) facilitate the 
utilization and knowledge of research findings.

Why is Oral Health Important?
    Maintaining good oral health throughout life is critically 
important to systemic health and overall quality of life. If oral 
diseases and poor oral conditions go untreated, it becomes difficult to 
eat, drink, swallow, smile, talk, and maintain proper nutrition. In 
spite of the dramatic improvements in oral health over the years, it is 
still a major concern. Americans spent $108 Billion on dental 
expenditures in 2011, according to the Center for Medicare and Medicaid 
Services (CMS). While tooth decay and gum disease remain the most 
prevalent, complete tooth loss, oral cancer, and craniofacial 
congenital anomalies, like cleft lip and palate are also health and 
economic burdens to the American people. Tooth decay, or dental caries, 
is a very common disease where the minerals in the tooth structure are 
slowly dissolved out of the tooth to the point of cavitation--or a 
``cavity.'' Untreated dental decay in primary teeth affects 20 percent 
of children aged 2 to 5, and 25 percent of children 6 to 11. Untreated 
dental decay in permanent teeth also affects 20 to 25 percent of 
adults, depending on the age bracket. Moreover, we know there are 
significant oral health disparities across racial, ethnic, and 
socioeconomic groups.
    Scientists have discovered important linkages between gum disease, 
or periodontal disease, and heart disease, stroke, diabetes, and 
pancreatic cancer. The consequences of inflammation may be the common 
biologic factor explaining these linkages, but there are genetic 
factors as well. Further research is needed to understand these 
linkages, the potential for causal connections, and the effect of 
intervention or treatment of the oral diseases on systemic health.
Examples of Oral Health Research and Development:
    National Dental Practice-Based Research Network.--NIDCR recently 
awarded a seven-year grant that consolidates its dental practice-based 
research network initiative into a unified nationally coordinated 
effort. The consolidated initiative, renamed The National Dental 
Practice-Based Research Network (NDPBRN), is headquartered at the 
University of Alabama at Birmingham (UAB) School of Dentistry. A dental 
practice-based research network is an investigative union of practicing 
dentists and academic scientists. The network provides practitioners 
with an opportunity to propose or participate in research studies that 
address daily issues in oral health care. These studies help to expand 
the profession's evidence base and further refine care. According to 
NIDCR Director Martha Somerman, D.D.S., Ph.D., a national coordinating 
center streamlines the network structure for greater financial and 
administrative efficiency.
    Human papillomavirus (HPV).--HPV is frequently associated with 
cervical cancer. However, HPV is responsible for a rapidly growing type 
of oral cancer. According to Maura L. Gillison, MD, PhD, an oncologist 
and researcher at Ohio State University, rates of infection among men 
are about three times higher than among women. Oral cancers are likely 
to become the most common HPV-related cancer by 2020. The International 
Agency for Research against Cancer has acknowledged HPV as a risk 
factor for oropharyngeal cancer. Since not enough is known about HPV-
related oropharyngeal cancers to enable potentially lifesaving 
interventions, NIDCR plans to support research intended to provide a 
clearer picture of HPV-related oral cancers including their incidence, 
risk factors, and natural history.
    Point of Care Diagnostics.--NIDCR is supporting studies aimed at 
providing early, point of care, detection of both oral and systemic 
conditions (e.g. oral cancer, pancreatic cancer, diabetes, 
cardiovascular disease). Point of care diagnostics are often more 
desirable than standard laboratory methods. Disease specific biomarkers 
found in saliva have recently provided important insights on human 
health. Saliva provides for noninvasive testing, potentially increasing 
the number of adverse health conditions detected at an early stage. 
Access to early diagnostic tests can save thousands of lives a year and 
can be conducted from home or mobile facilities reaching populations 
with limited access to health care. In order for the promise of 
salivary diagnostics to become a reality, there needs to be further 
research on the specific biomarkers that are thought to be associated 
with health or certain disease states.
    Cleft Lip and/or Cleft Palate.--Craniofacial anomalies such as 
cleft lip and/or cleft palate (CLP) are among the most common birth 
defects. Both genetic and environmental factors contribute to oral 
clefts. Cleft lip is an abnormality in which the lip does not 
completely form during fetal development and cleft palate occurs when 
the roof of the mouth does not fully close, leaving an opening that can 
extend into the nasal cavity. Genome-wide association studies (GWAS) of 
cleft lip and/or cleft palate supported by NIDCR are providing 
important new leads about the role genetic factors and gene-environment 
interactions play in the development of these conditions. In addition, 
a DNA sequencing study is underway to identify less common genetic 
variants that influence the risk of developing cleft lip and/or cleft 
palate.
    Health Disparities Research Program.--Despite remarkable 
improvements in the oral health of the American population, not 
everyone in the Nation has benefited equally. Oral, dental and 
craniofacial conditions remain among the most common health problems 
for low-income, racial/ethnic minority, disadvantaged, disabled, and 
institutionalized individuals across the life span. Dental caries, 
periodontal disease, and oral and pharyngeal cancer are of particular 
concern. The NIDCR Health Disparities Research Program supports studies 
that provide a better understanding of the basis of health disparities 
and inequalities, develops and tests interventions targeted to 
underserved populations; and explores approaches to the dissemination 
and implementation of effective findings to assure rapid translation 
into practice, policy and action in communities.
    Chronic Pain.--NIDCR is an active participant in trans-NIH work on 
chronic pain. The Interagency Pain Research Coordinating Committee 
(IPRCC) is a Federal advisory committee created by the Department of 
Health and Human Services to enhance pain research efforts and promote 
collaboration across the Government, with the ultimate goals of 
advancing fundamental understanding of pain and improving pain-related 
treatment strategies.

Challenges to Research
    Today's investments in basic research on the fundamental causes and 
mechanisms of disease will have a great impact on future advances in 
health care. Investments in NIDCR are needed to support research to 
define the genetic and environmental risk factors for CLP, as well as 
to improve care for children with these disorders. More work needs to 
be done in order to understand HPV-related cancers, especially oral 
cancers given their increasing prevalence. These are just a couple of 
the many research challenges confronting oral health scientists. We 
urge Congress to make science a national priority.

Fiscal Year 2014 Budget Request
    As you can see, Mr. Chairman, there are many research opportunities 
that need to be pursued in order to improve patient care. In order for 
Americans to have access to better oral health care, funding for NIH 
overall, and particularly NIDCR, should be more consistent. The budget 
sequestration, which went into effect March 1st, will have a 
devastating impact on science. Not only does it affect grants and 
cooperative agreements, but continuation awards will be reduced or in 
some cases not issued, thereby impeding ongoing research. New grants 
and cooperative agreements will likely be re-scoped, delayed, or 
canceled. These actions have direct implications on the health and 
safety of Americans. Moreover, the across-the-board cuts harm the 
prospects for lasting deficit reduction by stifling a significant 
driver of economic growth. We ask that you craft a solution that 
recognizes NIH as a critical national priority by providing at least 
$32 billion in funding in the fiscal year 2014 Appropriations bill, of 
which we recommend that NIDCR be appropriated $450 million.
    Thank you for this opportunity to testify. We at AADR look forward 
to having the opportunity to work with the Congress and the Department 
of Health and Human Services to help build a strong and successful 
research enterprise.
                                 ______
                                 
 Prepared Statement of the American Association of Colleges of Nursing

    The American Association of Colleges of Nursing (AACN), which 
serves as the Nation's leading voice for baccalaureate and graduate 
nursing education, submits this testimony to the Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies regarding fiscal year 2014. AACN represents over 720 
schools of nursing that educate over 400,000 students and employ more 
than 16,000 full-time faculty members. Collectively, these institutions 
produce approximately half of our Nation's registered nurses (RNs) and 
all nurse faculty and researchers.
    AACN respectfully requests that nursing education, research, and 
practice are strongly supported in fiscal year 2014 through an 
investment of $251 million for the Health Resources and Services 
Administration's (HRSA) Nursing Workforce Development programs 
(authorized under Title VIII of the Public Health Service Act [42 
U.S.C. 296 et seq.]), $150 million for the National Institute of 
Nursing Research (NINR) within the National Institutes of Health (NIH), 
and $20 million for the Nurse-Managed Health Clinics (NMHCs) (Title III 
of the Public Health Service Act). A significant investment in these 
programs is paramount to ensuring that the nursing workforce can meet 
the healthcare needs of our country.

Demand for Nursing in Today's Healthcare System
    Current transformations within our healthcare system to both the 
patient and provider sectors are creating an overwhelming demand for 
nursing services. Data from the Bureau of Labor Statistics (BLS) 
Employment Projections for 2010-2020, reveals that by year 2020, an 
additional 1.2 million RNs will be needed to keep pace with the growing 
demand. More specifically, the report anticipates that the number of 
nursing jobs will grow from 2.74 million in 2010 to 3.45 million in 
2020. This projection translates to 712,000 nurses, or an increase of 
26 percent. In addition, BLS expects another 495,500 nurses will be 
needed to replace those soon to retire.
    The aging of the nursing workforce and America's patients 
underscores this alarming projection. According to the report The U.S. 
Nursing Workforce: Trends in Supply and Demand released by HRSA earlier 
this year, of the 2.8 million RNs currently practicing in America, 34.9 
percent are over age 50, and 8.5 percent are over age 60. As this large 
segment of the workforce begins to retire, the Nation will soon face a 
significant deficit in the number of experienced nurses available to 
provide services. Concurrent with the aging of the nursing workforce is 
the aging of America's Baby Boomer population. It is estimated that 
over 80 million Baby Boomers reached age 65 in 2011. As this population 
transitions into the Nation's oldest generation, these citizens will 
continue to require more primary care services related to chronic 
illness treatment, medication management, and patient education. A 
significant investment must be made in the education of new nurses to 
provide the Nation with the nursing services it requires.

Nursing Workforce Development Programs Answer the Call for an Expanded 
        RN Workforce
    In light of this demand, it is imperative that steadfast support 
for programs that educate future generations of nurses continues in 
fiscal year 2014. Investments made in the Title VIII Nursing Workforce 
Development programs today directly impact the supply and distribution 
of nurses entering into the pipeline for years to come. Between fiscal 
year 2007 and fiscal year 2011 alone, Title VIII programs supported 
over 300,000 nurses and nursing students across the country. These 
recipients are supported in academic and healthcare institutions and 
contribute to the advancement of nursing education, nursing science, 
and evidence-based practice. Title VIII programs bolster nursing 
education at all levels, from entry-level preparation through graduate 
study, and aid in the recruitment and retention of nurses in the 
workforce.
    Data from AACN's 2012-2013 Title VIII Student Recipient Survey 
highlight the significant influence that Title VIII dollars have on 
allowing more individuals to pursue nursing careers and for providing 
opportunities to practice in areas experiencing the greatest need for 
primary care services. The survey, which garnered responses from over 
1,100 students, reflects how Title VIII programs impact the 
professional nursing continuum from entry-level education through 
graduation, and into long-term career planning. For example, 65 percent 
of respondents report that Title VIII funding affected their decision 
to enter nursing school, and 74 percent of respondents state that Title 
VIII funding allowed them to attend school full-time. These programs 
alleviate the financial burden that often prevents many students from 
graduating into the workforce sooner.
    After graduation, respondents report that practicing in a community 
hospital or in an underserved community is ranked among their top 
career choices. Because Title VIII assistance relieves some of the 
pressure of finding a job based on salary, many students state they can 
pursue practice in an area they are truly passionate about: working 
with vulnerable populations to provide primary care, health promotion, 
and disease prevention. Moreover, personal testimony of several survey 
respondents reveals that many Title VIII recipients intend to practice 
in the community in which they were educated--a direct State 
investment.
    However, a significant barrier preventing a greater number of 
nurses from entering into the workforce is a lack of nursing faculty. 
Data from AACN's 2012-2013 survey on enrollment and graduations shows 
that nursing schools were forced to turn away 79,659 qualified 
applications from entry-level baccalaureate and graduate nursing 
programs in 2012 due primarily to faculty vacancies. In fact, AACN's 
Special Survey on Faculty Vacancy for Academic Year 2012-2013 reveals 
that baccalaureate and graduate nursing programs report an average 
faculty vacancy rate of 7.6 percent for full-time positions and 6.8 
percent for part-time positions. These vacancies limit the number of 
students admitted into nursing schools, and prevent more students from 
pursuing higher nursing education mandatory for career goals such as 
becoming an advanced practice registered nurse (APRN) or serving as 
nursing faculty. To counter this disparity, the Title VIII Nurse 
Faculty Loan Program aids in increasing nursing school enrollment 
capacity by supporting students pursuing graduate education, provided 
they serve as faculty for 4 years after graduation.
    AACN respectfully requests $251 million for the Nursing Workforce 
Development programs authorized under Title VIII of the Public Health 
Service Act in fiscal year 2014.

National Institute of Nursing Research Improves the Quality and 
        Quantity of Life
    As one of the 27 Institutes and Centers at the NIH, the NINR is 
dedicated to providing the health professions workforce with evidence-
based knowledge--an essential component to delivering high-quality, 
cost-effective care. NINR initiatives target chronic illnesses and 
communicable diseases that erode patient quality of life and the 
financial stability of patients, their families, and the healthcare 
system at large. For example, nurse scientists investigate how patient-
centered practices can empower individuals to improve management of 
costly symptoms related to chronic illness. Moreover, while other 
healthcare research focuses heavily on the curative aspect of health 
care, NINR's research is largely aimed at expanding health promotion 
and disease prevention. This endeavor is central to the mission of 
averting any further increases in the rates of cardiac disease, 
obesity, diabetes, cancer, and other devastating illnesses plaguing our 
Nation's population.
    One such study capturing this focus on prevention looked to reduce 
rates of high blood pressure among inner-city African-American males. 
This NINR-funded initiative supported a multidisciplinary healthcare 
team who educated this cohort and provided annual check-ups over the 
course of 3 years. The study resulted in the men practicing more 
healthy habits such as quitting smoking and moderating sodium intake. 
Furthermore, 44 percent of the men successfully lowered their blood 
pressure to within the normal range.
    NINR also funds research that advances innovation in healthcare 
practices. NINR has committed to undertaking a comprehensive 
examination of how genetics and genomics affect treatment options for 
certain patient populations, and offers intensive programs to educate 
participants on the role of molecular genetics in nursing practice.
    Additionally, NINR allocates a generous 6 percent of its overall 
budget to the education and training of nurse researchers, many of whom 
dually serve as nurse faculty within our Nation's nursing schools. This 
is crucial given the need for more doctorally prepared nurse faculty.
    AACN respectfully requests $150 million for the NINR in fiscal year 
2014.

Nurse-Managed Health Clinics Provide Primary Care and Clinical Training 
        Space
    More than ever, the healthcare workforce is questioning how it will 
successfully provide primary care services to millions of Americans in 
need. NMHCs offer one such solution. Managed by APRNs and often staffed 
by an interdisciplinary health provider team, NMHCs provide necessary 
primary care services to medically underserved communities. These 
centers treat patients regardless of their ability to pay, and serve as 
critical access points to keep patients out of the emergency room, 
saving the healthcare system millions of dollars annually. Moreover, 
NMHCs allow practitioners to foster a community environment conducive 
for patient teaching which is a critical facet of health promotion.
    Often associated with a school, college, university, department of 
nursing, federally qualified health center, or independent nonprofit 
healthcare agency, NMHCs also serve as clinical education training 
sites for students of nursing, medicine, physical therapy, social work, 
and ancillary healthcare services. This function is an essential aspect 
of these clinics as nursing schools report a lack of clinical training 
sites a primary barrier to accepting more new students into their 
programs.
    AACN respectfully requests $20 million for the Nurse-Managed Health 
Clinics in fiscal year 2014.
    AACN acknowledges the challenge set before the subcommittee of 
ensuring adequate healthcare services to the public while striving for 
financial sustainability. AACN respectfully urges the subcommittee's 
thoughtful consideration of our requests for the aforementioned 
programs that are vital to a robust nursing workforce and a healthy 
Nation. We ask that you do so by providing $251 million for the Title 
VIII Nursing Workforce Development programs, $150 million for the 
National Institute of Nursing Research, and $20 million for Nurse-
Managed Health Clinics in fiscal year 2014.
                                 ______
                                 
     Prepared Statement of the American Association of Colleges of 
                          Osteopathic Medicine

    On behalf of the American Association of Colleges of Osteopathic 
Medicine (AACOM), I am pleased to submit this testimony in support of 
vital funding for programs at the Health Resources Services 
Administration (HRSA), the National Institutes of Health (NIH), and the 
Agency for Healthcare Research and Quality (AHRQ) in fiscal year 2014. 
AACOM represents the administrations, faculty, and students of the 
Nation's 29 colleges of osteopathic medicine at 37 locations in 28 
States. Today, more than 21,000 students are enrolled in osteopathic 
medical schools. Nearly one in five U.S. medical students is training 
to be an osteopathic physician. AACOM strongly supports funding of $520 
million for HRSA's Title VII and VIII programs under the Public Health 
Service Act; funding the HRSA Teaching Health Center Graduate Medical 
Education (THCGME) Development Grants at $10 million minimally; 
sustainment of student scholarship and loan repayment programs for 
graduate and professional students at the U.S. Department of Education 
and opposition of any rescissions from the National Health Service 
Corps (NHSC) Fund created under the Affordable Care Act (ACA, Public 
Law 111-142 and Public Law 111-152); appropriating $3 million to fund 
the National Health Care Workforce Commission; sufficient funding for 
the NIH; and appropriating $430 million for the AHRQ.

Title VII
    The health professions education programs, authorized under Title 
VII of the Public Health Service Act and administered through HRSA, 
support the training and education of health practitioners to enhance 
the supply, diversity, and distribution of the health care workforce, 
acting as an essential part of the health care safety net and filling 
the gaps in the supply of health professionals not met by traditional 
market forces. Title VII and Title VIII nurse education programs are 
the only Federal programs designed to train clinicians in 
interdisciplinary settings to meet the needs of special and underserved 
populations, as well as increase minority representation in the health 
care workforce.
    According to HRSA, an additional 33,000 health care practitioners 
are needed to alleviate existing health professional shortages. 
Combined with faculty shortages across health professions disciplines, 
racial and ethnic disparities in health care, a growing, aging 
population, and the anticipated demand for increased access to care, 
these needs strain an already fragile health care system. AACOM 
appreciates the investments that have been made in these programs, and 
we urge the subcommittee to fund $520 million for the Title VII and 
VIII programs to include support for the following programs in order to 
include: the Primary Care Training and Enhancement (PCTE) Program, the 
Health Careers Opportunity Program (HCOP), the Centers of Excellence 
(COE), the Geriatric Education Centers (GECs) and the Area Health 
Education Centers (AHECs). Strengthening the workforce has been 
recognized as a national priority, and the investment in these programs 
recommended by AACOM will help meet the demand facing this country for 
a well-trained, diverse workforce.

Teaching Health Centers Graduate Medical Education Program
    HRSA's THCGME Program is the first of its kind to shift GME 
training to community-based care settings that emphasize primary care 
and prevention. It is uniquely positioned to provide much-needed 
primary care training in underserved populations. However, because the 
program is the first of its kind, most community-based settings do not 
have existing infrastructures to provide this training. AACOM strongly 
supports funding the THCGME Development Grants at $10 million 
minimally, which was the level of the fiscal year 2013 President's 
budget request. This funding would allow potential THCGME training 
sites to develop the infrastructure needed to administer residency 
training programs.

National Health Service Corps
    Approximately 50 million Americans live in communities with a 
shortage of health professionals, lacking adequate access to primary 
care. Through scholarships and loan repayment, the NHSC supports the 
recruitment and retention of primary care clinicians to practice in 
underserved communities. The self-reported average medical educational 
debt of graduates of colleges of osteopathic medicine (COMs) who 
borrowed to attend medical school increased from less than $121,000 in 
2000 to $205,674 for 2012 graduates, with 91 percent of 2012 graduates 
reporting that they had medical education debt. Today, nearly 10,000 
National Health Service Corps providers are providing primary care to 
approximately 10.4 million people at nearly 14,000 health care sites in 
urban, rural, and frontier areas. AACOM strongly supports the 
preservation of student scholarship and loan repayment programs for 
graduate and professional students. This critical funding works to 
address the primary care workforce shortage and advances innovative 
models of service, such as HRSA's Students to Service pilot program 
which provides loan repayment assistance to medical students in their 
last year of education in return for their commitment to practice.

Workforce Commission
    As the United States struggles to address health care provider 
shortages in certain specialties and in rural and underserved areas, 
the country lacks a defined policy to address these critical issues. 
The National Health Care Workforce Commission was designed to develop 
and evaluate training activities to meet demand for health care 
workers. Without funding, the Commission cannot identify barriers that 
may create and exacerbate workforce shortages and improve coordination 
on the Federal, State, and local levels. Having this type of 
coordinating body in place is becoming more critical as more Americans 
have insurance coverage and as the population ages, requiring access to 
care. For these reasons, AACOM recommends that $3 million be 
appropriated to fund the Commission.

National Institutes of Health
    Research funded by the National Institutes of Health (NIH) leads to 
important medical discoveries regarding the causes, treatments, and 
cures for common and rare diseases, as well as disease prevention. 
These efforts improve our Nation's health and save lives. To maintain a 
robust research agenda, further investment will be needed. AACOM 
recommends a sufficient level of funding for the NIH.
    In today's increasingly demanding and evolving medical curriculum, 
there is a critical need for more research geared toward evidence-based 
osteopathic medicine. AACOM believes that it is vitally important to 
maintain and increase funding for biomedical and clinical research in a 
variety of areas related to osteopathic principles and practice, 
including osteopathic manipulative medicine and comparative 
effectiveness. In this regard, AACOM encourages support for the NIH's 
National Center for Complementary and Alternative Medicine (NCCAM) to 
continue fulfilling this essential research role.

Agency for Healthcare Research and Quality
    AHRQ supports research to improve health care quality, reduce 
costs, advance patient safety, decrease medical errors, and broaden 
access to essential services. AHRQ plays an important role in producing 
the evidence base needed to improve our Nation's health and health 
care. The incremental increases for AHRQ's Patient Centered Health 
Research Program in recent years, as well as the funding provided to 
AHRQ in the American Recovery and Reinvestment Act of 2009 (ARRA), will 
help AHRQ generate more of this research and expand the infrastructure 
needed to increase capacity to produce this evidence. More investment 
is needed, however, to fulfill AHRQ's mission and broader research 
agenda, especially research in patient safety and prevention and care 
management research. AACOM recommends $430 million for AHRQ's base, 
discretionary budget. This investment will preserve AHRQ's current 
programs while helping to restore its critical health care safety, 
quality, and efficiency initiatives. AACOM is grateful for the 
opportunity to submit its views and looks forward to continuing to work 
with the subcommittee on these important matters.
                                 ______
                                 
  Prepared Statement of the the American Association of Immunologists

    The American Association of Immunologists (AAI), the world's 
largest professional association of research scientists and physicians 
who are experts on the immune system, respectfully submits this 
testimony regarding appropriations for the National Institutes of 
Health (NIH) for fiscal year 2014. AAI recommends an appropriation of 
at least $32 billion for NIH for fiscal year 2014 to enable NIH to 
support existing research projects, fund a limited number of 
outstanding new ones, and ensure that the brightest students and 
trainees are able to pursue careers in biomedical research in the 
United States.

The Irreplaceable Role of NIH in Advancing Biomedical Research
    NIH grants support the work of most biomedical scientists.\1\ The 
vast majority of AAI members who work in academia depend on NIH grants 
to support their research at universities, colleges and research 
institutions all around the country; many also teach the medical, 
graduate, and undergraduate students who will be the next generation of 
physicians and researchers. Many AAI members who work in Government are 
employed by the NIH; they depend on the NIH budget--as well as regular 
interaction with their private sector colleagues--to advance their 
work.\2\ Our industry members, who generally do not receive NIH grants 
or awards, nonetheless depend on scientific discoveries that are 
generated by NIH-funded researchers to catalyze translational research 
or develop products. No matter where on the spectrum of biomedical 
science researchers may work, they know that NIH is the lynchpin to, 
and essential ingredient for, success.
    NIH's irreplaceable role in our Nation's biomedical research 
enterprise is indisputable among scientists. And the partnership 
between Government-funded research and advancements in the private 
sector has never been more clear or more necessary: in a recent article 
in Forbes, three ``current and former leaders of major commercial and 
academic life science institutions'' (Marc Tessier-Lavigne, Ph.D., P. 
Roy Vagelos, M.D., and Elias Zerhouni, M.D.) \3\ compellingly argue 
that the ``tiny'' Federal investment in NIH research has reaped 
``enormous benefits--human and economic'' and that ``continued 
investment in basic science is . . . key to our economic 
competitiveness. America remains the world's leader in biotechnology 
and pharmaceutical discovery thanks to the strength of our research 
universities and other biomedical research institutions, which not only 
spawn countless biotechnology companies but also have attracted the R&D 
operations of most major pharmaceutical companies, which are keen to 
tap into our innovation.'' Those who suggest that the private sector 
can or will fill the gap left by inadequate NIH funding miss the 
essential point made by these internationally recognized scientific 
leaders: NIH-funded research and NIH leadership provide the foundation 
upon which commercial discovery and development depend.

Inadequate NIH Funding Threatens Human Health and U.S. Preeminence in 
        Medicine
    America's dominance in advancing basic biomedical research, 
discovering urgently needed treatments and cures, and ``growing'' 
brilliant young scientists has been unchallenged for more than fifty 
years. However, erosion of the NIH budget over the last decade has 
already led to the loss of grant funding among even the most highly 
qualified scientists, resulting in the closure of labs, the termination 
or interruption of important research, and the emigration of talented 
scientists to other countries that are investing heavily in their 
futures.\4\ For those scientists who are willing and able to continue, 
securing funding increasingly consumes their time--time that should be 
devoted to research and to mentoring the Nation's future researchers, 
inventors and innovators. And in a relatively new discipline such as 
immunology, where knowledge is expanding exponentially and the 
potential for even greater success is palpable, this shrinking of 
Federal resources is both alarming and a squandering of precious prior 
Federal investment.

The Immune System and Its Impact on Disease
    The functional immune system recognizes and attacks bacteria, 
viruses, and tumor cells inside the body. Many infectious agents, 
including influenza, HIV/AIDS, tuberculosis, malaria, and the common 
cold, challenge--and sometimes overcome--the defenses mounted by the 
immune system, resulting in disease. A malfunctioning immune system can 
attack our normal body tissues, causing ``autoimmune'' diseases or 
disorders, including Type 1 diabetes, multiple sclerosis, rheumatoid 
arthritis, asthma, allergies, inflammatory bowel diseases, and lupus. 
The immune system also plays a role in many other diseases and 
conditions, including cancer, Alzheimer's disease, obesity, Type II 
diabetes, and cardiovascular disease. Understanding the immune response 
is also crucial to developing protective vaccines against pathogens 
that might cause the next pandemic, man-made and natural infectious 
organisms (including plague, smallpox and anthrax) that could be used 
for bioterrorism, and environmental threats that could cause or 
exacerbate disease. Immunologists have made great progress in many of 
these areas, but solving key scientific questions that lead to 
prevention and cures cannot occur without investigator-initiated peer-
reviewed research supported by a strong, adequately funded NIH.\5\

Recent Immunological Advances and Their Promise for Tomorrow
    A potential cure for cancer?--NIH-funded scientists have 
demonstrated that they can remove a specific subset of immune cells (T 
lymphocytes) from individuals with cancer, genetically modify them in 
the laboratory to recognize the patient's own cancer cells, and 
administer those cells to the patient. This personalized immunotherapy 
has induced complete and partial remissions in patients in a recent 
clinical experiment. Scientists have also shown similar techniques 
could induce cures in other types of cancer, including metastatic 
melanoma (a type of skin cancer), which is one of the ten most common 
cancers.\6\
    A way to stop Alzheimer's disease?--Alzheimer's disease (AD) is a 
neurodegenerative disease of the brain that currently afflicts 5.4 
million Americans, mostly over age 65.\7\ While the cause of AD is 
unknown, researchers have recently found evidence of immune cells 
present in AD lesions, systemic alteration in the immune system of AD 
patients, and local inflammation in the brains of those with AD. Such 
recent discoveries are leading scientists to develop immune based 
therapies to treat AD patients, including monoclonal antibodies which 
target AD plaques for destruction, and DNA based vaccines. Such 
potential treatments are under development in many NIH-funded 
laboratories.
    New treatments for emerging zoonotic infectious diseases?--Zoonotic 
infections (human infections acquired from a different animal species) 
include avian influenza, SARS, hantavirus, dengue virus, Nipah virus, 
and West Nile virus. Although the overall incidence remains low, these 
infections can have high mortality rates and emerge without warning, as 
evidenced by the 2012 hantavirus outbreak in Yosemite National Park and 
the severe West Nile virus season.\8\ Developing preventive vaccines 
for these infections has proven difficult, and current treatments are 
limited. NIH-funded research on hantavirus and influenza A has shown an 
association between illness/death and an inappropriately strong immune 
response caused by an excessive release of cytokines (hormones of the 
immune system). Researchers are exploring whether limiting the 
inappropriate immune response during infection can reduce virus-induced 
illness and death.\9\

The Importance of Sustained NIH Funding to Research, Scientists and Our 
        Nation
    Despite strong Congressional support for biomedical research and 
NIH, fiscal pressures in recent years have resulted in flat or reduced 
NIH funding. After accounting for increases in biomedical research 
inflation, these budgets have eroded NIH's purchasing power by about 20 
percent since 2003. Under sequestration, with its fiscal year 2013 
budget cut of about 5.1 percent, NIH's purchasing power will be further 
reduced. AAI is deeply alarmed about this funding reduction and 
believes it could irreparably harm ongoing research, weaken the U.S. 
biomedical research enterprise, and enable global competitors to 
recruit away our best scientists.

Looking Ahead: The President's fiscal year 2014 Budget
    AAI greatly appreciates that the President's budget for fiscal year 
2014 reflects his deep commitment to research and innovation by 
providing increased funding for NIH. Although the increase ($471 
million, or 1.6 percent) is small, it includes $382 million to support 
an additional 351 research project grants, a welcome boost for 
researchers hit hard by an NIH budget eroded by inflation and 
sequestration.\10\ Although AAI believes, as stated above, that NIH 
needs a budget of at least $32 billion for fiscal year 2014, we 
appreciate that the President recognizes the urgent importance of 
investing in biomedical research to the health and economic well-being 
of the American people.

Conclusion
    AAI thanks the members and staff of the subcommittee for their 
strong bipartisan support for biomedical research, and urges an 
appropriation of at least $32 billion for NIH for fiscal year 2014 to 
fund important ongoing research, strengthen the biomedical research 
enterprise, and support the thousands of scientists across the Nation 
who devote their lives to finding the answers we need to prevent, 
treat, and cure disease.
---------------------------------------------------------------------------
    \1\ After a highly competitive peer review, NIH distributes most 
(more than 80 percent) of its $30.7 billion budget to scientists who 
conduct research at approximately 2,500 universities, medical schools, 
and other research institutions across the United States. About 11 
percent of its budget supports the work of the approximately 6,000 
scientists who work in NIH's own laboratories. http://nih.gov/about/
    \2\ AAI is concerned that Federal policy limits the ability of 
Government scientists to attend privately sponsored scientific meetings 
and conferences. See http://www.whitehouse.gov/sites/
default/files/omb/memoranda/2012/m-12-12.pdf http://www.hhs.gov/travel/
policies/2012_policy_
manual.pdf. Government scientists contribute significantly to 
scientific advancement in our field. Information exchange among 
scientists from Government, academia, industry and private research 
institutes is absolutely essential, and any barriers to the 
participation of Government scientists undermine the best interests of 
science.
    \3\ Dr. Lavigne is President of The Rockefeller University and 
former Chief Scientific Officer for Genentech Inc.; Dr. Vagelos is 
Chairman of Regeneron Pharmaceuticals and Retired Chairman and CEO of 
Merck & Co., Inc.; and Dr. Zerhouni is President of Research and 
Development for Sanofi and former Director of NIH. ``Legendary Drug 
Industry Executives Warn U.S. Science Cuts Endanger The Future,'' 
Forbes online (3/6/13) http://www.forbes.com/sites/matthewherper/2013/
03/06/drug-industry-greats-say-the-u-s-must-reverse-the-cuts-to-our-
investment-in-science/
    \4\ See ``U.S. cuts could lead to brain drain in medicine.'' The 
Baltimore Sun, 2/23/13, http://articles.baltimoresun.com/2013-02-23/
news/bs-md-research-funding-20130221_1_nih-grants-
researchers-head-first-grant. See also Atkinson, et al. 2012, 
``Leadership in Decline,'' The Information Technology and Innovation 
Foundation http://www2.itif.org/2012-leadership-in-decline.pdf
    \5\ NIH should robustly fund and primarily rely on individual 
investigator-initiated research, in which researchers working in 
institutions across the Nation submit applications to, and following 
independent peer review, receive grants from, NIH. Biomedical 
innovation and discovery are less likely to be achieved through ``top-
down'' science, in which the Government specifies the type of research 
it wishes to fund.
    \6\ See Kalos et al. 2011, ``T Cells with Chimeric Antigen 
Receptors Have Potent Antitumor Effects and Can Establish Memory in 
Patients with Advanced Leukemia,'' Science Translational Medicine, 3:95 
http://stm.sciencemag.org/content/3/95/95ra73.short; Porter et al. 
2011, ``Chimeric Antigen Receptor--Modified T Cells in Chronic Lymphoid 
Leukemia,'' N England J Med 365:725-733 http://www.nejm.org/doi/full/
10.1056/NEJMoa1103849.
    \7\ See http://www.alz.org/documents_custom/
2012_facts_figures_fact_sheet.pdf. The Alzheimer's Association 
estimates that up to 16 million people will have Alzheimer's by 2050. 
And the costs are staggering: ``In 2012, the direct costs of caring for 
those with Alzheimer's . . . . will total an estimated $200 billion . . 
. . Unless something is done, the costs of Alzheimer's in 2050 are 
estimated to total $1.1 trillion (in today's dollars). Costs to 
Medicare and Medicaid will increase nearly 500 percent.''
    \8\ See http://www.cdc.gov/hantavirus/outbreaks/yosemite-national-
park-2012.html and http://www.cdc.gov/ncidod/dvbid/westnile/index.htm.
    \9\ See Teijaro et al. 2011, ``Endothelial Cells Are Central 
Orchestrators of Cytokine Amplification during Influenza Virus 
Infection,'' Cell 146:980-991 http://www.sciencedirect.com/science/
article/pii/S009286741100941X.
    \10\ Given the scarcity of funding currently available to support 
ongoing and new research, AAI is concerned about the budget's 
relatively large funding level for new initiatives and targeted disease 
research, as well as substantial funding increases to rapidly grow some 
newer programs, potentially at the expense of investigator-initiated 
basic research.
---------------------------------------------------------------------------
                                 ______
                                 
  Prepared Statement of the American Association of Nurse Anesthetists

                                 FISCAL YEAR 2014 APPROPRIATIONS REQUEST SUMMARY
----------------------------------------------------------------------------------------------------------------
                                                                                          AANA Fiscal Year 2014
                                       Fiscal Year 2013 Actual  Fiscal Year 2014 Budget          Request
----------------------------------------------------------------------------------------------------------------
HHS/HRSA/BHPr Title 8 Advanced         Awaiting grant           Grant allocations not    $4 MM for nurse
 Education Nursing, Nurse Anesthetist   allocations--in fiscal   specified.               anesthesia education
 Education Reserve.                     year 2012 awards
                                        amounted to approx.
                                        $3.5MM.

Total for Advanced Education Nursing,  $60.8 MM for Advanced    Not yet available for    $83.925 MM for advanced
 from Title 8.                          Education Nursing        Advanced Education       education nursing
                                        postsequester estimate.  Nursing.
ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½
Title 8 HRSA BHPr Nursing Education    $220.4 MM postsequester  Not yet available......  $251.099 MM
 Programs.                              estimate.
----------------------------------------------------------------------------------------------------------------

About the American Association of Nurse Anesthetists (AANA) and 
        Certified Registered Nurse Anesthetists (CRNAs)
    The AANA is the professional association for more than 45,000 CRNAs 
and student nurse anesthetists, representing over 90 percent of the 
nurse anesthetists in the United States. Today, CRNAs deliver 
approximately 33 million anesthetics to patients each year in the U.S. 
CRNA services include administering the anesthetic, monitoring the 
patient's vital signs, staying with the patient throughout the surgery, 
and providing acute and chronic pain management services. CRNAs provide 
anesthesia for a wide variety of surgical cases and in some States are 
the sole anesthesia providers in almost 100 percent of rural hospitals, 
affording these medical facilities obstetrical, surgical, and trauma 
stabilization, and pain management capabilities. CRNAs work in every 
setting in which anesthesia is delivered, including hospital surgical 
suites and obstetrical delivery rooms, ambulatory surgical centers 
(ASCs), pain management units and the offices of dentists, podiatrists 
and plastic surgeons.
    Nurse anesthetists are experienced and highly trained anesthesia 
professionals whose record of patient safety is underscored by 
scientific research findings. The landmark Institute of Medicine report 
To Err is Human found in 2000 that anesthesia was 50 times safer then 
than in the 1980s. (Kohn L, Corrigan J, Donaldson M, ed. To Err is 
Human. Institute of Medicine, National Academy Press, Washington DC, 
2000.) Though many studies have demonstrated the high quality of nurse 
anesthesia care, the results of a new study published in Health Affairs 
led researchers to recommend that costly and duplicative supervision 
requirements for CRNAs be eliminated. Examining Medicare records from 
1999-2005, the study compared anesthesia outcomes in 14 States that 
opted-out of the Medicare physician supervision requirement for CRNAs 
with those that did not opt out. (To date, 17 States have opted-out.) 
The researchers found that anesthesia has continued to grow more safe 
in opt-out and non-opt-out States alike. (Dulisse B, Cromwell J. No 
Harm Found When Nurse Anesthetists Work Without Supervision By 
Physicians. Health Aff. 2010;29(8):1469-1475.)
    CRNAs provide the lion's share of anesthesia care required by our 
U.S. Armed Forces through active duty and the reserves, staffing ships, 
remote U.S. military bases, and forward surgical teams without 
physician anesthesiologist support. In addition, CRNAs predominate in 
rural and medically underserved areas, and where more Medicare patients 
live (Government Accountability Office. Medicare and private payment 
differences for anesthesia services. GAO-07-463, Washington DC, Jul. 
27, 2007. http://www.gao.gov/products/GAO-07-463).

Importance of and Request for HRSA Title 8 Nurse Anesthesia Education 
        Funding
    Our profession's chief request of the subcommittee is for $4 
million to be reserved for nurse anesthesia education and $83.925 
million for advanced education nursing from the HRSA Title 8 program, 
out of a total Title 8 budget of $251.099 million. We request that the 
Report accompanying the fiscal year 2014 Labor-HHS-Education 
Appropriations bill include the following language: ``Within the 
allocation, the Committee encourages HRSA to allocate funding at least 
at the fiscal year 2012 level for nurse anesthetist education.'' This 
funding request is justified by the safety and value proposition of 
nurse anesthesia, and by anticipated growth in demand for CRNA services 
as baby boomers retire, become Medicare eligible, and require more 
healthcare services. In making this request, we associate ourselves 
with the request made by The Nursing Community and Americans for 
Nursing Shortage Relief (ANSR) with respect to Title 8 and the National 
Institute of Nursing Research (NINR) at the National Institutes of 
Health.
    The Title 8 program, on which we will focus our testimony, is 
strongly supported by members of this subcommittee in the past, and is 
an effective means to help address nurse anesthesia workforce demand. 
In expectation for dramatic growth in the number of U.S. retirees and 
their healthcare needs, funding the advanced education nursing program 
at $83.925 million is necessary to meet the continuing demand for 
nursing faculty and other advanced education nursing services 
throughout the U.S.,. The program funds competitive grants that help 
enhance advanced nursing education and practice, and traineeships for 
individuals in advanced nursing education programs. It also targets 
resources toward increasing the number of providers in rural and 
underserved America and preparing providers at the master's and 
doctoral levels, thus increasing the supply of clinicians eligible to 
serve as nursing faculty, a critical need.
    Demand remains high for CRNA workforce in clinical and educational 
settings. A 2007 AANA nurse anesthesia workforce study found a 12.6 
percent CRNA vacancy rate in hospitals and a 12.5 percent faculty 
vacancy rate. The supply of clinical providers has increased in recent 
years, stimulated by increases in the number of CRNAs trained. From 
2002-2012, the annual number of nurse anesthesia educational program 
graduates increased from 1,362 to 2,469, according to the Council on 
Accreditation of Nurse Anesthesia Educational Programs (COA). The 
number of accredited nurse anesthesia educational programs grew from 85 
to 113. We anticipate increased demand for anesthesia services as the 
population ages, the number of clinical sites requiring anesthesia 
services grows, and a portion of the CRNA workforce retires.
    The capacity of our 113 nurse anesthesia educational programs to 
educate qualified applicants is limited by the number of faculty, the 
number and characteristics of clinical practice educational sites, and 
other factors--and they continue turning away hundreds of qualified 
applicants. A qualified applicant to a CRNA program is a bachelor's 
educated registered nurse who has spent at least 1 year serving in an 
acute care healthcare practice environment. They are prepared in nurse 
anesthesia educational programs located all across the country, 
including Arkansas, California, Connecticut, Georgia, Kentucky, 
Maryland, New York, Ohio, and Tennessee. To meet the nurse anesthesia 
workforce challenge, the capacity and number of CRNA schools must 
continue to grow and modernize with the latest advancements in 
simulation technology and distance learning consistent with improving 
educational quality and supplying demand for highly qualified 
providers. With the help of competitively awarded grants supported by 
Title 8 funding, the nurse anesthesia profession is making significant 
progress, but more is required.
    This progress is extremely cost-effective from the standpoint of 
Federal funding. Anesthesia can be provided by nurse anesthetists, 
physician anesthesiologists, or by CRNAs and anesthesiologists working 
together. Of these, the nurse anesthesia practice model is by far the 
most cost-effective, and ensures patient safety. (Hogan P et al. Cost 
effectiveness analysis of anesthesia providers. Nursing Economic$, Vol. 
28 No. 3, May-June 2010, p. 159 et seq.) Nurse anesthesia education 
represents a significant educational cost-benefit for competitively 
awarded Federal funding in support of CRNA educational programs.
Support for Safe Injection Practices and the Alliance for Injection 
        Safety
    As a leader in patient safety, the AANA has been playing a vigorous 
role in the development and projects of the Alliance for Injection 
Safety, intended to reduce and eventually eliminate the incidence of 
healthcare facility acquired infections. In the interest of promoting 
safe injection practice, and reducing the incidence of healthcare 
facility acquired infections, we associate ourselves with the AIS 
recommendation.
                                 ______
                                 
   Prepared Statement of the American Congress of Obstetricians and 
                             Gynecologists

    The American Congress of Obstetricians and Gynecologists (ACOG), 
representing 57,000 physicians and partners in women's health care, is 
pleased to offer this statement to the Senate Committee on 
Appropriations, Subcommittee on Labor, Health and Human Services, and 
Education. We thank Chairman Harkin, and the entire subcommittee for 
the opportunity to provide comments on some of the most important 
programs to women's health.
    Today, the U.S. lags behind other nations in healthy births, yet 
remains high in birth costs. ACOG's Making Obstetrics and Maternity 
Safer (MOMS) Initiative seeks to improve maternal and infant outcomes 
through investment in all aspects of the cycle of research, including 
comprehensive data collection and surveillance, biomedical research, 
and translation of research into evidence-based practice and programs 
delivered to women and babies. ACOG supports S. 425, the Quality Care 
for Moms and Babies Act, introduced by Sen. Debbie Stabenow, which 
would greatly improve maternity care delivery through quality 
collaboratives and quality measure development. This legislation 
depends on the investments made by Congress in research and programs 
that provide robust data to inform quality improvement initiatives. We 
urge you to make funding of the following programs and agencies a top 
priority in fiscal year 2014.

Data Collection and Surveillance at the Centers for Disease Control and 
        Prevention (CDC)
    In order to conduct robust research, uniform, accurate and 
comprehensive data and surveillance are critical. The National Center 
for Health Statistics is the Nation's principal health statistics 
agency and collects State data from records like birth certificates 
that give us raw, vital statistics. The birth certificate is the key to 
gathering vital information about both mother and baby during pregnancy 
and labor and delivery. The 2003 U.S.-standard birth certificate 
collects a wealth of knowledge in this area, yet not all States are 
using it. States without these resources are likely underreporting 
maternal and infant deaths and complications from childbirth and causes 
of these deaths remain unknown. Use must be expanded to all 50 States, 
ensuring that uniform, accurate data is collected nationwide. For 
fiscal year 2014, ACOG requests $162 for the National Center for Health 
Statistics and $18 million within that funding request to modernize the 
National Vitals Statistics System, which would help States update their 
birth and death records systems.
    The Pregnancy Risk Assessment Monitoring System (PRAMS) at CDC 
extends beyond vital statistics and surveys new mothers on their 
experiences and attitudes during pregnancy, with questions on a range 
of topics, including what their insurance covered, whether they had 
stressful experiences during pregnancy, when they initiated prenatal 
care, and what kinds of questions their doctor covered during prenatal 
care visits. By identifying trends and patterns in maternal health, 
researchers better understand indicators of preterm birth and other 
health conditions. This data allows CDC and State health departments to 
identify behaviors and environmental and health conditions that may 
lead to preterm births. Only 40 States use the PRAMS surveillance 
system today. ACOG requests adequate funding to expand PRAMS to all 
U.S. States and territories.

Biomedical Research at the National Institutes of Health (NIH)
    Biomedical research is critically important to understanding the 
causes of prematurity and developing effective prevention and treatment 
methods. Prematurity rates have increased almost 35 percent since 1981, 
and cost the Nation $26 billion annually, $51,600 for every infant born 
prematurely. Direct health care costs to employers for a premature baby 
average $41,610, 15 times higher than the $2,830 for a healthy, full-
term delivery. Research into maternal morbidity, beginning with 
developing a consensus definition for severe maternal morbidity, is an 
important component of understanding pregnancy outcomes, including 
prematurity. The National Institute on Child Health and Human 
Development (NICHD) has included in its Vision Statement a goal of 
determining the complex causes of prematurity and developing evidence-
based measures for its prevention within the next 10 years. Sustaining 
the investments at NIH is vital to achieving this goal, and therefore 
ACOG supports a minimum of $32 billion for NIH and $1.37 billion within 
that funding request for NICHD in fiscal year 2014.
    Adequate levels of research require a robust research workforce. 
The average investigator is in his/her forties before receiving their 
first NIH grant, a huge dis-incentive for students considering bio-
medical research as a career. Complicating matters, there is a gap 
between the number of women's reproductive health researchers being 
trained and the need for such research. Programs like the Women's 
Reproductive Health Research (WRHR) Career Development program, 
Reproductive Scientist Development Program (RSDP), and the Building 
Interdisciplinary Research Careers in Women's Health (BIRCWH) program 
all seek to address the shortfall of women's reproductive health 
researchers. At least 79 percent of BIRCWH grantees go on to apply for 
NIH grants, and 51 percent receive NIH grants, much higher than the 
average NIH success rate. Sequestration and other budget cuts threaten 
to undermine these programs at a critical juncture. For example, every 
$500,000 cut to the BIRCWH program results in one less BIRCWH scholar. 
A sustained investment in NIH funding will help ensure the continuation 
of these programs and help mitigate the negative consequences of budget 
uncertainty on the future research workforce.

Public Health Programs at the Health Resources and Services 
        Administration (HRSA) and the Centers for Disease Control and 
        Prevention (CDC)
    Projects at HRSA and CDC are integral to translating research 
findings into evidence-based practice changes in communities. Where NIH 
conducts research to identify causes of preterm birth, CDC and HRSA 
fund programs that provide resources to mothers to help prevent preterm 
birth, and help identify factors contributing to preterm birth and poor 
maternal outcomes. The Maternal Child Health Block Grant at HRSA is the 
only Federal program that exclusively focuses on improving the health 
of mothers and children. State and territorial health agencies and 
their partners use MCH Block Grant funds to reduce infant mortality, 
deliver services to children and youth with special health care needs, 
support comprehensive prenatal and postnatal care, screen newborns for 
genetic and hereditary health conditions, deliver childhood 
immunizations, and prevent childhood injuries.
    These early health care services help keep women and children 
healthy, eliminating the need for later costly care. For example, every 
$1 spent on preconception care for women with diabetes can reduce 
health costs by up to $5.19 by preventing costly complications in both 
mothers and babies. Every $1 spent on smoking cessation counseling for 
pregnant women saves $3 in neonatal intensive care costs. The MCH Block 
Grant has seen an almost $30 million decrease in funding in the past 5 
years alone. ACOG urges you not to cut the MCH Block Grant any further 
and for fiscal year 2014 we request $640 million for the Block Grant to 
maintain its current level of services.
    Family planning is essential to helping ensure healthy pregnancies 
and reducing the risk of preterm birth. The Title X Family Planning 
Program provides services to more than five million low-income men and 
women at more than 4,500 service delivery sites. Every $1 spent on 
family planning results in a $4 savings to Medicaid. Services provided 
at Title X clinics accounted for $3.4 billion in health care savings in 
2008 alone. ACOG supports $327 million for Title X in fiscal year 2014 
to sustain its level of services.
    The Healthy Start Program through HRSA promotes community-based 
programs that help reduce infant mortality and racial disparities in 
perinatal outcomes. These programs are encouraged to use the Fetal and 
Infant Mortality Review (FIMR) which brings together ob-gyn experts and 
local health departments to help specifically address local issues 
contributing to infant mortality. Today, more than 220 local programs 
in 42 States find FIMR a powerful tool to help reduce infant mortality, 
including understanding issues related to preterm delivery. For over 20 
years, ACOG has partnered with the Maternal and Child Health Bureau to 
sponsor the designated resource center for FIMR Programs, the National 
FIMR Program. ACOG supports $.5 million in fiscal year 2014 for HRSA to 
increase the number of Healthy Start programs that use FIMR.
    The Safe Motherhood Initiative at CDC works with State health 
departments to collect information on pregnancy-related deaths, track 
preterm births, and improve maternal outcomes. The Initiative also 
promotes preconception care, a key to reducing the risk of preterm 
birth. For fiscal year 2014, we recommend a sustained funding level of 
at least $44 million for the Safe Motherhood Program, and re-
instatement of the preterm birth sub-line at $2 million to ensure 
continued support for preterm birth research, as authorized by the 
PREEMIE Act.
    State and regional quality improvement initiatives encourage use of 
evidence-based quality improvement projects across hospitals and 
medical practices to reduce the rate of maternal and neonatal mortality 
and morbidity. For example, under the Ohio Perinatal Quality 
Collaborative, started in 2007 with funding from CDC, 21 OB teams in 25 
hospitals have decreased scheduled deliveries between 36 and 39 weeks 
gestation, in accordance with ACOG guidelines, significantly reducing 
pre-term births. According to a study conducted by Avalere, the 
estimated savings from initiatives aimed at reducing elective 
inductions pre-39 weeks ranges from $2.4 million to $9 million a year. 
S. 425, the Quality Care for Moms and Babies Act, would build on these 
efforts by providing resources to States to develop and grow maternity 
and perinatal quality collaboratives, and supporting the development 
and implementation of additional maternity care quality measures in 
Medicaid and CHIP. ACOG urges you to provide sufficient resources to 
HHS to help States expand upon or establish maternity and perinatal 
care quality collaborative programs.
    Again, we would like to thank the Committee for its consideration 
of funding for programs to improve women's health, and we urge you to 
consider our MOMS Initiative in fiscal year 2014.
                                 ______
                                 
        Prepared Statement of the American College of Physicians

    The American College of Physicians (ACP) is pleased to submit the 
following statement for the record on its priorities, as funded under 
the U.S. Department of Health & Human Services, for fiscal year 2014. 
ACP is the largest medical specialty organization and the second-
largest physician group in the United States. ACP members include 
133,000 internal medicine specialists (internists), related 
subspecialists, and medical students. Internal medicine physicians are 
specialists who apply scientific knowledge and clinical expertise to 
the diagnosis, treatment, and compassionate care of adults across the 
spectrum from health to complex illness.
    As the subcommittee begins deliberations on appropriations for 
fiscal year 2014, ACP is urging funding for the following proven 
programs to receive appropriations from the subcommittee:
  --Title VII, Section 747, Primary Care Training and Enhancement, at 
        no less than $71 million;
  --National Health Service Corps, $893,456,433 in discretionary 
        funding, in addition to the $305 million in enhanced funding 
        through the Community Health Centers Fund;
  --National Health Care Workforce Commission, $3 million;
  --Agency for Healthcare Research and Quality, $434 million; and
  --Centers for Medicare and Medicaid Services, Marketplace Operations, 
        $803.5 million.
    The United States is facing a growing shortage of physicians in key 
specialties, most notably in general internal medicine and family 
medicine--the specialties that provide primary care to most adult and 
adolescent patients. With enactment of the Affordable Care Act (ACA), 
we expect the demand for primary care services to increase with the 
addition of 27 million Americans receiving access to health insurance, 
once the law is fully implemented. Current projections indicate there 
will be a shortage of up to 44,000 primary care physicians for adults, 
even before the increased demand for health care services that will 
result from near universal coverage is taken into account (Colwill JM, 
Cultice JM, Kruse RL. Will generalist physician supply meet demands of 
an increasing and aging population? Health Aff (Millwood). 2008 May-
Jun;27(3):w232-41. Epub 2008 Apr 29. Accessed at http://
content.healthaffairs.org/content/27/3/w232.full on 14 January 2011.). 
Without critical funding for vital workforce programs, this physician 
shortage will only grow worse. A strong primary care infrastructure is 
an essential part of any high-functioning healthcare system, with over 
100 studies showing primary care is associated with better outcomes and 
lower costs of care (http://www.acponline.org/advocacy/where_we_stand/
policy/primary_shortage.pdf).
    The health professions education programs, authorized under Title 
VII of the Public Health Service Act and administered through the 
Health Resources and Services Administration (HRSA), support the 
training and education of health care providers to enhance the supply, 
diversity, and distribution of the health care workforce, filling the 
gaps in the supply of health professionals not met by traditional 
market forces, and are critical to help institutions and programs 
respond to the current and emerging challenges of ensuring all 
Americans have access to appropriate and timely health services. Within 
the Title VII program, we urge the subcommittee to fund the program the 
Section 747, Primary Care Training and Enhancement at $71 million, in 
order to maintain and expand the pipeline of primary care production 
and training. The Section 747 program is the only source of Federal 
training dollars available for general internal medicine, general 
pediatrics, and family medicine. For example, general internists, who 
have long been at the frontline of patient care, have benefitted from 
Title VII training models that promoted interdisciplinary training that 
helped prepare them to work with other health professionals, such as 
physician assistants, patient educators and psychologists. Without a 
substantial increase of funding, HRSA will not be able to carry out a 
competitive grant cycle for the third year in a row for physician 
training; the Nation needs new initiatives relating to increased 
training in inter-professional care, the patient-centered medical home, 
and other new competencies required in our developing health system.
    The College urges $893,456,433 in appropriations for the National 
Health Service Corps (NHSC), the amount authorized for fiscal year 2014 
under the ACA; this is in addition to the $305 million in enhanced 
funding the Health and Human Services Secretary has been given the 
authority to provide to the NHSC through the Community Health Care 
Fund. Since enactment of the ACA, the NHSC has awarded over $900 
million in scholarships and loan repayment to health care professionals 
to help expand the country's primary care workforce and meet the health 
care needs of communities across the country and there are nearly three 
times the number of NHSC clinicians working in communities across 
America than there were 3 years ago, increasing Americans' access to 
health care. With field strength of nearly 10,000 clinicians, NHSC 
members are providing culturally competent care to more than 10.4 
million people at nearly 14,000 NHSC-approved health care sites in 
urban, rural, and frontier areas. The increase in funds must be 
sustained to help address the health professionals' workforce shortage 
and growing maldistribution. The programs under NHSC have proven to 
make an impact in meeting the health care needs of the underserved, and 
with more appropriations, they can do more.
    We urge the subcommittee to fully fund the National Health Care 
Workforce Commission, as authorized by the ACA, at $3 million. The 
Commission is authorized to review current and projected health care 
workforce supply and demand and make recommendations to Congress and 
the Administration regarding national health care workforce priories, 
goals, and polices. Members of the Commission have been appointed but 
have not been able to do any work, due to a lack of funding. The 
College believes the Nation needs sound research methodologies embedded 
in its workforce policy to determine the Nation's current and future 
needs for the appropriate number of physicians by specialty and 
geographic areas; the work of the Commission is imperative to ensure 
Congress is creating the best policies for our Nation's needs.
    The Agency for Healthcare Research and Quality (AHRQ) is the 
leading public health service agency focused on health care quality. 
AHRQ's research provides the evidence-based information needed by 
consumers, providers, health plans, purchasers, and policymakers to 
make informed health care decisions. The College is dedicated to 
ensuring AHRQ's vital role in improving the quality of our Nation's 
health and recommends a budget of $434 million. This amount will allow 
AHRQ to help providers help patients by making evidence-informed 
decisions, fund research that serves as the evidence engine for much of 
the private sector's work to keep patients safe, make the healthcare 
market place more efficient by providing quality measures to health 
professionals, and ultimately, help transform health and health care.
    Finally, ACP is supportive of the President's request for $803.5 
million for the Centers for Medicare and Medicaid Services, Marketplace 
Operations in order to become fully operational by 2014 and carry out 
their duties as necessary. Such funding will allow the Federal 
Government to administer the insurance exchange, as authorized by the 
ACA, if a State declines to establish an exchange that meets Federal 
requirements. As of March 7, HHS has approved 24 States and the 
District of Columbia to fully or partially run their State's exchange, 
leaving 26 States which have not met approval or who have declined to 
run their own State exchange. If the subcommittee decides to deny the 
requested funds, it may make it much more difficult for the Federal 
Government to organize a federally-facilitated exchange in those 
States, raising questions about where and how their residents would get 
coverage. It is ACP's belief that all legal Americans--regardless of 
income level, health status, or geographic location--must have access 
to affordable health insurance.
    In conclusion, the College is keenly aware of the fiscal pressures 
facing the subcommittee today, but strongly believes the United States 
must invest in these programs in order to achieve a high performance 
health care system and build capacity in our primary care workforce and 
public health system. The College greatly appreciates the support of 
the subcommittee on these issues and looks forward to working with 
Congress as you begin to work on the fiscal year 2014 appropriations 
process.
                                 ______
                                 
   Prepared Statement of the American College of Preventive Medicine

    The American College of Preventive Medicine (ACPM) urges the House 
Labor, Health and Human Services, Education, and Related Agencies 
Appropriations Subcommittee to reaffirm its support for training 
preventive medicine physicians and other public health professionals by 
providing an increase of $5 million in fiscal year 2014 for preventive 
medicine residency training under the public health and preventive 
medicine line item in Title VII of the Public Health Service Act. ACPM 
also supports the recommendation of the Health Professions and Nursing 
Education Coalition that $520 million be appropriated in fiscal year 
2014 to support all health professions and nursing education and 
training programs authorized under Titles VII and VIII of the Public 
Health Service Act.
    In today's healthcare environment, the tools and expertise provided 
by preventive medicine physicians play an integral role in ensuring 
effective functioning of our Nation's public health system. These tools 
and skills include the ability to deliver evidence-based clinical 
preventive services, expertise in population-based health sciences, and 
knowledge of the social and behavioral determinants of health and 
disease. These are the tools employed by preventive medicine physicians 
who practice in public health agencies and in other healthcare settings 
where improving the health of populations, enhancing access to quality 
care, and reducing the costs of medical care are paramount. As the body 
of evidence supporting the effectiveness of clinical and population-
based interventions continues to expand, so does the need for 
specialists trained in preventive medicine.
    Organizations across the spectrum have recognized the growing 
demand for preventive medicine professionals. The Institute of Medicine 
released a report in 2007 calling for an expansion of preventive 
medicine training programs by an ``additional 400 residents per year,'' 
and the Accreditation Council on Graduate Medical Education (ACGME) 
recommends increased funding for preventive medicine residency training 
programs. Additionally, the Association of American Medical Colleges 
released statements in 2011 that stressed the importance of 
incorporating behavioral and social sciences in medical education as 
well as announcing changes to the Medical College Admission Test that 
would test applicants on their knowledge in these areas. Such measures 
strongly indicate increasing recognition of the need to take a broader 
view of health that goes beyond just clinical care--a view that is a 
unique focus and strength of preventive medicine residency training.
    In fact, preventive medicine is the only one of the 24 medical 
specialties recognized by the American Board of Medical Specialties 
that requires and provides training in both clinical medicine and 
public health. Preventive medicine physicians possess critical 
knowledge in population and community health issues; disease and injury 
prevention; disease surveillance and outbreak investigation; and public 
health research. They are well versed in leading collaborative efforts 
to improve health that include stakeholder groups from all aspects of 
an issue--including community, industry, healthcare provider, academic, 
payer, and government organizations--in addressing both healthcare-
related and social and behavioral determinants of health. Such 
diversity also illustrates the value preventive medicine physicians 
offer to many different sectors, industries, and organizations.
    According to the Health Resources and Services Administration 
(HRSA) and health workforce experts, there are personnel shortages in 
many public health occupations, including epidemiologists, 
biostatisticians, and environmental health workers among others. 
According to the 2012 Physician Specialty Data Book released by the 
Association of American Medical Colleges, preventive medicine had one 
of the biggest decrease (-25 percent) in the number of first-year ACGME 
residents and fellows between 2005 and 2010. ACPM is deeply concerned 
about the shortage of preventive medicine-trained physicians and the 
ominous trend of even fewer training opportunities. This deficiency in 
physicians trained to carry out core public health activities will lead 
to major gaps in the expertise needed to deliver clinical prevention 
and community public health. The impact on the health of those 
populations served by HRSA may be profound.
    Despite being recognized as an underdeveloped national resource and 
in shortage for many years, physicians training in the specialty of 
Preventive Medicine are the only medical residents whose graduate 
medical education (GME) costs are not supported by Medicare, Medicaid 
or other third party insurers. Training occurs outside hospital-based 
settings and therefore is not financed by GME payments to hospitals. 
Both training programs and residency graduates are rapidly declining at 
a time of unprecedented national, State, and community need for 
properly trained physicians in public health and disaster preparedness, 
prevention-oriented practices, quality improvement, and patient safety.
    Currently, residency programs scramble to patch together funding 
packages for their residents. Limited stipend support has made it 
difficult for programs to attract and retain high-quality applicants. 
Support for faculty and tuition has been almost non-existent. Directors 
of residency programs note that they receive many inquiries about and 
applications for training in preventive medicine; however, training 
slots often are not available for those highly qualified physicians who 
are not directly sponsored by an outside agency or who do not have 
specific interests in areas for which limited stipends are available 
(such as research in cancer prevention).
    HRSA--as authorized in Title VII of the Public Health Service Act--
is a critical funding source for several preventive medicine residency 
programs, as it represents the largest Federal funding source for these 
programs. HRSA funding ($3.8 million in fiscal year 2013) currently 
supports only 49 preventive medicine residents across 9 residency 
training programs. An increase of $5 million will allow HRSA to support 
nearly 60 new preventive medicine residents.
    Of note, the preventive medicine residency programs directly 
support the mission of the HRSA health professions programs by 
facilitating practice in underserved communities and promoting training 
opportunities for underrepresented minorities:
  --Thirty-five percent of HRSA-supported preventive medicine graduates 
        practice in medically underserved communities, a rate of almost 
        3.5 times the average for all health professionals. These 
        physicians are meeting a critical need in these underserved 
        communities.
  --Nearly one-fifth of preventive medicine residents funded through 
        HRSA programs are under-represented minorities, which is almost 
        twice the average of minority representation among all health 
        professionals.
  --Fourteen percent of all preventive medicine residents are under-
        represented minorities, the largest proportion of any medical 
        specialty.
    In addition to training under-represented minorities and generating 
physicians who work in medically underserved areas, preventive medicine 
residency programs equip our society with health professionals and 
public health leaders who possess the tools and skills needed in the 
fight against the chronic disease epidemic that is threatening the 
future of our Nation's health and prosperity. Correcting the root 
causes of this critical problem of chronic diseases will require a 
multidisciplinary approach that addresses issues of access to 
healthcare; social and environmental influences; and behavioral 
choices. ACPM applauds the initiation of programs such as the Community 
Transformation Grant that take this broad view of the determinants of 
chronic disease. However, any efforts to strengthen the public health 
infrastructure and transform our communities into places that encourage 
healthy choices must include measures to strengthen the existing 
training programs that help produce public health leaders.
    Many of the leaders of our Nation's local and State health 
departments are trained in preventive medicine. Their unique 
combination of expertise in both medical knowledge and public health 
makes them ideal choices to head the fight against chronic disease as 
well as other threats to our Nation's health. Their contributions are 
invaluable. Investing in the residency programs that provide physicians 
with the training and skills to take on these leadership positions is 
an essential part of keeping Americans healthy and productive. As such, 
the American College of Preventive Medicine urges the Labor, Health and 
Human Services, Education, and Related Agencies Appropriations 
Subcommittee to reaffirm its support for training preventive medicine 
physicians and other public health professionals by providing an 
increase of $5 million in fiscal year 2014 for preventive medicine 
residency training under the public health and preventive medicine line 
item in Title VII of the Public Health Service Act.
                                 ______
                                 
    Prepared Statement of the American Dental Education Association

    The American Dental Education Association (ADEA), on behalf of all 
66 U.S. dental schools, 700 dental residency training programs, nearly 
600 allied dental programs, as well as more than 12,000 faculty who 
educate and train the nearly 50,000 students and residents attending 
these institutions, submits this statement for the record and for your 
consideration as you begin to prioritize fiscal year 2014 appropriation 
requests. ADEA urges you to preserve the funding and fundamental 
structure of Federal programs that provide prevention of dental 
disease, access to oral health care for underserved populations, and 
access to careers in dentistry and oral health services. It is at these 
academic dental institutions that future practitioners and researchers 
gain their knowledge, where the majority of dental research is 
conducted, and where significant dental care is provided. Services are 
provided through campus and offsite dental clinics where students and 
faculty provide patient care to the uninsured and underserved 
populations. However, in order to continue to provide these services, 
there must be adequate funding. Therefore, it is critical that funding 
for oral health care, delivery of services, and research be preserved 
in order to ensure the level of care that is necessary for all segments 
of the population.
    We are asking the committee to maintain adequate funding for the 
dental programs in Title VII of the Public Health Service Act; the 
National Institutes of Health (NIH) and the National Institute of 
Dental and Craniofacial Research (NIDCR); the Dental Health Improvement 
Act; Part F of the Ryan White HIV/AIDS Treatment and Modernization Act: 
the Dental Reimbursement Program and the Community-Based Dental 
Partnerships Program; and State-Based Oral Health Programs at the 
Centers for Disease Control and Prevention (CDC). These programs 
enhance and sustain State oral health departments, fund public health 
programs proven to prevent oral disease, fund research to eradicate 
dental disease, and fund programs to develop an adequate workforce of 
dentists with advanced training to serve all segments of the population 
including the underserved, the elderly, and those suffering from 
chronic and life-threatening diseases.

$32 million for Primary Oral Healthcare Workforce Improvements (HHS)
    The dental programs in Title VII, Section 748 of the Public Health 
Service Act that provide training in general, pediatric, and public 
health dentistry and dental hygiene are critical. Support for these 
programs will help to ensure there will be an adequate oral health care 
workforce to care for the American public. The funding supports pre-
doctoral oral health education and postdoctoral pediatric, general, and 
public health dentistry training. The investment that Title VII makes 
not only helps to educate dentists and dental hygienists, but also 
expands access to care for underserved communities.
    Additionally, Section 748 addresses the shortage of professors in 
dental schools with the dental faculty loan repayment program and 
faculty development courses for those who teach pediatric, general, or 
public health dentistry or dental hygiene. There are currently almost 
300 open faculty positions in dental schools. These two programs 
provide schools with assistance in recruiting and retaining faculty. 
ADEA is increasingly concerned that with projected restrained funding, 
the oral health research community will not be able to grow and that 
the pipeline of new researchers will be inadequate to the future need.
    Title VII Diversity and Student Aid programs play a critical role 
in helping to diversify the health profession's student body and 
thereby the health care workforce. For the last several years, these 
programs have not received adequate funding to sustain the progress 
that is necessary to meet the challenges of an increasingly diverse 
U.S. population. The ADEA is most concerned that the Administration did 
not request any funds for the Health Careers Opportunity Program 
(HCOP). This program provides a vital source of support for oral health 
professionals serving underserved and disadvantaged patients by 
providing a pipeline for such individuals to learn about careers in 
health care generally and dentistry specifically that is not available 
through other workforce programs.

$15 million for Part F of the Ryan White HIV/AIDS Treatment and 
        Modernization Act: Dental Reimbursement Program (DRP) and the 
        Community-Based Dental Partnerships Program
    Patients with compromised immune systems are more prone to oral 
infections like periodontal disease and tooth decay. By providing 
reimbursement to dental schools and schools of dental hygiene, the 
Dental Reimbursement Program (DRP) provides access to quality dental 
care for people living with HIV/AIDS while simultaneously providing 
educational and training opportunities to dental residents, dental 
students, and dental hygiene students who deliver the care. DRP is a 
cost-effective Federal/institutional partnership that provides partial 
reimbursement to academic dental institutions for costs incurred in 
providing dental care to people living with HIV/AIDS. This program is 
only reimbursing dental schools for the unreimbursed costs at 36.5 
percent of those costs, continuing the shift of the cost burden to the 
schools. This path is not sustainable to provide the necessary care.

$450 million for the National Institute of Dental and Craniofacial 
        Research (NIDCR)
    Discoveries stemming from dental research have reduced the burden 
of oral diseases, led to better oral health for millions of Americans, 
and uncovered important associations between oral and systemic health. 
Dental researchers are poised to make breakthroughs that can result in 
dramatic progress in medicine and health, such as repairing natural 
form and function to faces destroyed by disease, accident, or war 
injuries; diagnosing systemic disease from saliva instead of blood 
samples; and deciphering the complex interactions and causes of oral 
health disparities involving social, economic, cultural, environmental, 
racial, ethnic, and biological factors. Dental research is the 
underpinning of the profession of dentistry. With grants from NIDCR, 
dental researchers in academic dental institutions have built a base of 
scientific and clinical knowledge that has been used to enhance the 
quality of the Nation's oral health and overall health.
    Also, dental scientists are putting science to work for the benefit 
of the health care system through translational research, comparative 
effectiveness research, health information technology, health research 
economics, and further research on health disparities.

$19 million for the Division of Oral Health at the Centers for Disease 
        Control and Prevention (CDC)
    The CDC Division of Oral Health expands the coverage of effective 
prevention programs. The program increases the basic capacity of State 
oral health programs to accurately assess the needs of the State, 
organize and evaluate prevention programs, develop coalitions, address 
oral health in State health plans, and effectively allocate resources 
to the programs. This strong public health response is needed to meet 
the challenges of oral disease affecting children and vulnerable 
populations.
    The level in fiscal year 2013 and the request for fiscal year 2014 
are below the level needed to adequately sustain an appropriately 
staffed State dental program, provide a robust surveillance system to 
monitor and report disease, and support State efforts with other 
governmental, non-profit, and corporate partners. We look forward to 
sharing information with the committee in the coming weeks about the 
impact that the current path of funding will have on the overall health 
and preparedness of the Nation's States and communities.
    Thank you for your consideration of this request. ADEA looks 
forward to working with you to ensure the continuation of congressional 
support for these critical programs. Please feel free to use us as a 
resource on any issue affecting dental education. Please contact Yvonne 
Knight, J.D., Senior Vice President for Advocacy and Governmental 
Relations at [email protected].
    We look forward to working with you on the many issues of mutual 
concern.
                                 ______
                                 
   Prepared Statement of the American Dental Hygienists' Association

    On behalf of the American Dental Hygienists' Association (ADHA), 
thank you for the opportunity to submit testimony regarding 
appropriations for fiscal year 2014. ADHA appreciates the 
subcommittee's past support of programs that seek to improve the oral 
health of Americans and to bolster the oral health workforce. Oral 
health is a part of total health and authorized oral health care 
programs require appropriations support in order to increase the 
accessibility of oral health services, particularly for the 
underserved. ADHA urges $32 million for Title VII Program Grants to 
expand and educate the dental workforce; ADHA urges that the block on 
funding for Section 340G-1 of the Public Health Service Act--a much-
needed dental workforce demonstration program--be lifted and that $10 
million be appropriated; ADHA joins other oral health organizations in 
support for continued funding of the Dental Reimbursement Program (DRP) 
and the Community-Based Dental Partnerships Program established under 
the Ryan White HIV/AIDS Treatment and Modernization Act ($14 million 
for fiscal year 2014) as well as block grants offered by HRSA's 
Maternal Child Health Bureau ($8 million for fiscal year 2014). ADHA 
also supports full funding for community health centers, and urges HRSA 
be directed to further bolster the delivery of oral health services at 
community health centers, including through the use of new types of 
dental providers. ADHA urges $5 million for the CDC Oral Health 
Prevention and Education Campaign; ADHA urges funding sufficient so 
that all States have a school-based sealant program; ADHA urges at 
least $25 million for oral health programming at CDC; ADHA urges $20 
million for Dental Health Improvement Grants. ADHA also urges funding 
of $450 million for NIDCR.
    ADHA is the largest national organization representing the 
professional interests of more than 150,000 licensed dental hygienists 
across the country. In order to become licensed as a dental hygienist, 
an individual must graduate from an accredited dental hygiene education 
program and successfully complete a national written and a State or 
regional clinical examination. Dental hygienists are primary care 
providers of oral health services and are licensed in each of the fifty 
States. Hygienists are committed to improving the Nation's oral health, 
a fundamental part of overall health and general well-being. In the 
past decade, the link between oral health and total health has become 
more apparent and the significant disparities in access to oral health 
care services have been well documented. At this time, when 130,000 
million Americans struggle to obtain the oral health care required to 
remain healthy, Congress has a great opportunity to support oral health 
prevention, infrastructure and workforce efforts that will make care 
more accessible and cost-effective. ADHA urges funding of all 
authorized oral health programs and describes some of the key oral 
health programs below:

HRSA--Title VII Program Grants to Expand and Educate the Dental 
        Workforce--
Fund at a level of $32 million in fiscal year 2014
    A number of existing grant programs offered under Title VII support 
health professions education programs, students, and faculty. ADHA is 
pleased dental hygienists are recognized as primary care providers of 
oral health services and are included as eligible to apply for several 
grants offered under the ``General, Pediatric, and Public Health 
Dentistry'' grants. With millions more Americans eligible for dental 
coverage in coming years, it is critical that the oral health workforce 
is bolstered. Dental and dental hygiene education programs currently 
struggle with significant shortages in faculty and there is a dearth of 
providers pursuing careers in public health dentistry and pediatric 
dentistry. Securing appropriations to expand the Title VII grant 
offerings to additional dental hygienists and dentists will provide 
much needed support to programs, faculty, and students in the future. 
ADHA recommends funding at a level of $32 million for fiscal year 2014.

HRSA--Alternative Dental Health Care Provider Demonstration Project 
        Grants--
Fund at a level of $10 million in fiscal year 2014
    Congress recognized the need to improve the oral health care 
delivery system when it authorized the Alternative Dental Health Care 
Provider Demonstration Grants, Section 340G-1 of the Public Health 
Service Act. The Alternative Dental Health Care Providers Demonstration 
Grants program is a Federal grant program that recognizes the need for 
innovations to be made in oral health care delivery to bring quality 
care to the underserved by pilot testing new models. Dental workforce 
expansion is one of many areas that need to be addressed as we move 
forward with efforts to increase access to oral health care services to 
those who are currently not able to obtain the care needed to maintain 
a healthy mouth and body. The authorizing statute makes clear that 
pilots must ``increase access to dental care services in rural and 
underserved communities'' and comply with State licensing requirements. 
Such new providers are already authorized in Minnesota and are under 
consideration in Connecticut, Vermont, Kansas, Maine, New Hampshire, 
Washington State and several other States. The fiscal year 2013 
appropriations bill currently funding the Department of Health and 
Human Services includes language designed to block funding for this 
important demonstration program. We seek your leadership in removing 
this unjustified prohibition on funding for the Alternative Dental 
Health Care Providers Demonstration Grants. ADHA, along with more than 
60 other oral health care organizations, advocated for funding of this 
important program. Without the appropriate supply, diversity and 
distribution of the oral health workforce, the current oral health 
access crisis will only be exacerbated. ADHA recommends funding at a 
level of $10 million for fiscal year 2014 to support these vital 
demonstration projects.

HRSA--Dental Health Improvement Grants--
Fund at a level of $20 million in fiscal year 2014
    HRSA administered dental health improvement grants are an important 
resource for States to have available to develop and carry out State 
oral health plans and related programs. Past grantees have used funds 
to better utilize the existing oral health workforce to achieve greater 
access to care. Previously awarded grants have funded efforts to 
increase diversity among oral health providers in Wisconsin, promote 
better utilization of the existing workforce including the extended 
care permit (ECP) dental hygienist in Kansas, and in Virginia implement 
a legislatively directed pilot program to allow patients to directly 
access dental hygiene services. ADHA supports funding of HRSA dental 
health improvement grants at a level of $20 million for fiscal year 
2014.

CDC--Oral Health Prevention and Education Campaign--
Fund at a level of $5 million in fiscal year 2014
    A targeted national campaign led by the Centers for Disease Control 
(CDC) to educate the public, particularly those who are underserved, 
about the benefits of oral health prevention could vastly improve oral 
health literacy in the country. While significant data has emerged over 
the past decade drawing the link between oral health and systemic 
diseases like diabetes, heart disease, and stroke, many remain unaware 
that neglected oral health can have serious ramifications to their 
overall health. Data is also emerging to highlight the role that poor 
oral health in pregnant women has on their children, including a link 
between periodontal disease and low-birth weight babies. ADHA is 
pleased that the CDC has begun the development of an oral health 
communication plan and ADHA advocates an allocation of $5 million in 
fiscal year 2014 to further a national oral health prevention and 
education campaign and to ensure that CDC's media center has the 
resources needed to make oral health education material readily 
available.

CDC--School-Based Sealant Programs--
Fund at a level sufficient to ensure school-based sealant programs in 
        all 50 States
    Sealants have long-proven to be low-cost and effective in 
preventing dental caries (cavities), particularly in children. Despite 
this proven prevention capacity, dental caries remains the most common 
childhood disease, five times more common than asthma, and more than 
half of all children age 5-9 have a cavity or filling. The CDC noted 
that data collected in evaluations of school-based sealant programs 
indicates the programs are effective in stopping and preventing dental 
decay. CDC data show that the 60 percent increase in the delivery of 
school-based sealants in those States with CDC funding saved an 
estimated $1 million in Medicaid dental expenditures. Significant 
progress has been made in developing best practices for school-based 
sealant programs, yet most States lack well developed programs as a 
result of funding shortfalls. ADHA encourages the transfer of funding 
from the Public Health and Prevention Fund sufficient to allow CDC to 
meaningfully fund school-based sealant programs in all 50 States in 
fiscal year 2014.

CMS--Oral Health Access--
Given the dearth of dentists, encourage CMS to continue its efforts to 
        improve access to pediatric oral health services provided by 
        non-dentists, including dental hygienists and mid-level dental 
        providers
    ADHA commends the Center for Medicare and Medicaid Services (CMS) 
for its work on the Department wide Oral Health Initiative and its 
continuing efforts to improve access to pediatric oral health services. 
These efforts are vital because, as the Center for Medicaid and CHIP 
Services noted in an April 18, 2013 Informational Bulletin, fewer than 
half of Medicaid-enrolled children nationally are receiving at least 
one preventive oral health service in a year, and there remains a wide 
variation across States. CMS noted in its fiscal year 2014 budget 
justification that, in response to report language in the fiscal year 
2013 appropriations bill, that it will issue a State Medicaid Director 
letter in late 2013 providing a general clarification of CMS policy 
allowing States to reimburse for services provided by dental hygienists 
outside of a dental office without a prior exam or pre-authorization by 
a dentist. This letter should also make clear that CMS does not require 
dentist supervision of dental hygienists.

CDC--Oral Health Programming--
Fund at a level of $25 million in fiscal year 2014
    ADHA joins with others in the dental community in urging $25 
million for oral health programming within the Centers for Disease 
Control. This funding level will enable CDC to continue its vital work 
to control and prevent oral disease, including vital work in community 
water fluoridation. Federal grants to facilitate improved oral health 
leadership at the State level, support the collection and synthesis of 
data regarding oral health coverage and access, promote the integrated 
delivery of oral health and other medical services, enable States to 
innovate new types of oral health programs and promote a data-driven 
approach to oral health programming. ADHA advocates for $25 million in 
funding for grants to improve and support oral health infrastructure 
and surveillance.

NIH--National Institute of Dental and Craniofacial Research--
Fund at a level of $450 million in fiscal year 2014
    The National Institute of Dental and Craniofacial Research (NIDCR) 
cultivates oral health research that has led to a greater understanding 
of oral diseases and their treatments and the link between oral health 
and overall health. Research breeds innovation and efficiency, both of 
which are vital to improving access to oral health care services and 
improved oral status of Americans in the future. ADHA joins with others 
in the oral health community to support NIDCR funding at a level of 
$450 million in fiscal year 2014.

                               CONCLUSION

    ADHA appreciates the difficult task Appropriators face in 
prioritizing and funding the many meritorious programs and grants 
offered by the Federal Government. In addition to the items listed, 
ADHA joins other oral health organizations in support for continued 
funding of the Dental Reimbursement Program (DRP) and the Community-
Based Dental Partnerships Program established under the Ryan White HIV/
AIDS Treatment and Modernization Act ($14 million for fiscal year 2014) 
as well as block grants offered by HRSA's Maternal Child Health Bureau 
($8 million for fiscal year 2014). ADHA also supports full funding for 
community health centers, and urges HRSA be directed to further bolster 
the delivery of oral health services at community health centers, 
including through the use of new types of dental providers. ADHA 
remains a committed partner in advocating for meaningful oral health 
programming that makes efficient use of the existing oral health 
workforce and delivers high quality, cost-effective care.
                                 ______
                                 
        Prepared Statement of the American Diabetes Association

    My name is John E. Anderson, M.D., President, Medicine and Science. 
Thank you for the opportunity to submit testimony on behalf of the 
American Diabetes Association (Association). As President of Medicine 
and Science for the Association, I represent the nearly 105 million 
American adults and children living with diabetes or prediabetes. 
Diabetes is a disabling, deadly, and growing epidemic. According to the 
CDC, one in three adults in our country--one in two among minority 
populations--will have diabetes in 2050 if present trends continue.
    This is an unacceptable future that our country cannot afford, but 
it is avoidable. For fiscal year 2014, the Association urges the 
subcommittee to make a substantial investment in research and 
prevention efforts to find a cure, and improve the lives of those 
living with, or at risk for, diabetes. We ask the subcommittee to 
provide $2.216 billion for the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK) at the National Institutes of 
Health (NIH), $86.3 million for the Division of Diabetes Translation 
(DDT) at Centers for Disease Control and Prevention (CDC), and $20 
million in funding for the National Diabetes Prevention Program at CDC.
    I care for patients with diabetes every day in my practice in 
Nashville, Tennessee, and I can testify to the tremendous need for a 
much deeper Federal investment in diabetes research and prevention 
programs. Nearly 26 million Americans have diabetes, and another 79 
million have prediabetes, a condition putting them at high risk for 
developing diabetes. Every 17 seconds, someone in this country is 
diagnosed with diabetes. Today, 230 Americans with diabetes will 
undergo an amputation, 120 will enter end-stage kidney disease 
programs, and 55 will go blind from diabetes. When I walked through the 
Intensive Care Unit at my hospital, I was struck that half of the 
patients there have diabetes. Diabetes robs us of our limbs, our sight 
and our lives. It should not be ignored by anyone, including Congress 
and the Administration. My patients, and individuals with, and at risk 
for diabetes everywhere in this country deserve a different and 
brighter future.
    In addition to the horrendous physical toll, diabetes is 
economically devastating to our country. A new report by the 
Association found the annual cost of diagnosed diabetes has skyrocketed 
by an astonishing 41 percent over the last 5 years--from $174 billion 
per year in 2007 to $245 billion in 2012. Approximately one out of 
every five health care dollars is spent caring for someone with 
diagnosed diabetes, while one in ten health care dollars is directly 
attributed to diabetes. An astonishing one of every three of Medicare 
dollars is associated with treating diabetes and its complications.
    As the Nation's leading non-profit health organization providing 
diabetes research, information and advocacy, the American Diabetes 
Association believes that the alarming state of our Nation's diabetes 
epidemic justifies the critical need for increased Federal funding for 
diabetes research and prevention programs. We acknowledge the 
challenging economic climate and support fiscal responsibility, but our 
country cannot afford the consequences of failing to adequately fight 
this growing epidemic. Sequestration has only heightened our concern 
about the future of key diabetes programs at NIDDK and DDT. If we hope 
to leave our children a physically and fiscally healthy Nation, we 
can't afford to turn our backs on promising research providing the keys 
to preventing diabetes, better managing the disease, and bringing us 
closer to a cure. The rising tide of diabetes in America is daunting, 
but not insurmountable. The Association is pressing forward by 
supporting research and expanding education and awareness efforts, but 
we cannot do it alone. Congress must immediately and significantly step 
up its response to this epidemic.

                               BACKGROUND

    Diabetes is a chronic disease that impairs the body's ability to 
utilize food. The hormone insulin, which is made in the pancreas, is 
needed for the body to change food into energy. In people with 
diabetes, either the pancreas does not create insulin, which is type 1 
diabetes, or the body does not create enough insulin and/or cells are 
resistant to insulin, which is type 2 diabetes. If left untreated, 
diabetes results in too much glucose in the blood stream. Blood glucose 
levels that are too high or too low (as a result of medication to treat 
diabetes) can be life threatening in the short term. In the long term, 
diabetes is the leading cause of kidney failure, new cases of adult-
onset blindness, and non-traumatic lower limb amputations--as well as a 
leading cause of heart disease and stroke. Additionally, an estimated 
18 percent of pregnancies are affected by gestational diabetes, a form 
of glucose intolerance diagnosed during pregnancy placing both mother 
and baby at risk. In those with prediabetes, blood glucose levels are 
higher than normal and reducing their risk of developing diabetes it is 
essential.

THE NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES AT 
                                  NIH

    NIDDK leads the way in supporting research across the country that 
moves us closer to a cure and better treatments for diabetes. Thanks to 
research supported by the NIDDK, people with diabetes now manage their 
disease with a variety of insulin formulations and regimens far 
superior to those used in decades past. For example, the continuous 
glucose monitor and insulin pumps many of my patients use allow them to 
better manage their blood glucose levels--and better pave the way to 
healthier futures.
    Examples of NIDDK-funded breakthroughs include: new drug therapies 
for type 2 diabetes; the advent of modern treatment regimens that have 
reduced the risk of costly complications like heart disease, stroke, 
amputation, blindness and kidney disease; and ongoing development of 
the artificial pancreas, a closed looped system combining continuous 
glucose monitoring with insulin delivery.
    While progress has been great, now is not the time to retreat from 
efforts that may bring new discoveries in the study of diabetes. 
Without increased funding, NIDDK will slow or halt promising research 
that would enable individuals with the disease to live healthier, more 
productive lives. The percentage of promising research proposals NIDDK 
was able to fund decreased last year and is expected to decrease again 
this year without additional funding. This is an ominous sign for the 
millions of American families affected by diabetes who continue to 
await the day when there are vastly improved treatments for diabetes 
and ultimately, a cure for the disease.
    Overall fiscal year 2014 funding of $2.216 billion would allow the 
NIDDK to support additional research to further improve prevention and 
treatment, and close in on a cure. For example, additional funding will 
support a new comparative effectiveness clinical trial testing 
different medications for type 2 diabetes. Additionally, NIDDK will be 
able to continue to support researchers studying how insulin-producing 
beta cells develop and function, with an ultimate goal of creating 
therapies for replacing damaged or destroyed beta cells in people with 
diabetes. Funding will also support a clinical trial testing therapies 
to prevent type 2 diabetes.

         THE DIVISION OF DIABETES TRANSLATION (DDT) AT THE CDC

    The prevalence of diabetes has increased dramatically in every 
State. The Federal Government's role in coordinating efforts to prevent 
diabetes and its serious complications has never been more essential. 
With this in mind, the Association remains very concerned that DDT's 
funding has not kept pace with the magnitude of the growing diabetes 
epidemic. We urge the Federal investment in DDT programs be 
substantially increased to a minimum of $86.3 million in fiscal year 
2014.
    Increased fiscal year 2014 funding is even more critical in light 
of the combined chronic disease grant application for State diabetes, 
heart disease, obesity, and school health programs, released by CDC in 
February 2013. While we think coordination across chronic disease 
programs at CDC is an important endeavor, Congress must ensure the 
needs of people with, and at risk for, diabetes are adequately 
addressed in this new funding process. Increased resources must be 
provided for this effort and delivery of primary, secondary, and 
tertiary diabetes prevention and performance measures must be a prime 
focus of combined grant activities in every State.
    The DDT works to eliminate the preventable burden of diabetes 
through proven educational programs, best practice guidelines, and 
applied research. It performs important work in primary prevention of 
diabetes and in preventing its complications. Funding for the DDT must 
focus on maintaining State-based Diabetes Prevention and Control 
Programs (DPCPs), supporting the National Diabetes Education Program, 
defining the diabetes burden through the use of public health 
surveillance, and translating research findings into clinical and 
public health practice. For example, the DPCPs, located in all 50 
States, the District of Columbia, and all U.S. territories, work to 
prevent diabetes, lower blood glucose and cholesterol levels, and 
reduce diabetes-related emergency room visits and hospitalizations. 
This work is designed to improve education and awareness of diabetes by 
engaging health providers, health systems and community-based 
organizations to ensure these outcomes are achieved. DDT funding also 
supports translational research like the SEARCH for Diabetes in Youth 
study, a joint NIDDK-DDT effort designed to determine the impact of 
type 2 diabetes in youth to improve prevention efforts aimed at young 
people.
    With additional fiscal year 2014 funding, the DDT will be able to 
expand the efforts of DPCPs to improve primary, secondary and tertiary 
prevention efforts at the State and local levels. Investing in DDT will 
also enable community-based organizations in urban and rural areas to 
reduce risk factors for diabetes in populations bearing a 
disproportionate burden of the disease through two valuable programs: 
the National Program to Eliminate Diabetes-Related Disparities in 
Vulnerable Populations and the Native Diabetes Wellness Program, which 
delivers effective health promotion activities tailored to American 
Indian/Native Alaskan communities. Increased funding for DDT will also 
allow it to expand its translational research to improve public health 
interventions, such as the Translating Research Into Action for 
Diabetes (TRIAD) study, a national, multicenter research effort to 
provide practical information on how to improve care of individuals 
with diabetes in managed-care settings.

             THE NATIONAL DIABETES PREVENTION PROGRAM (CDC)

    The Association is alarmed that 79 million Americans have 
prediabetes and are on the cusp of a type 2 diabetes diagnosis. 
Thankfully, the National Diabetes Prevention Program supports a 
national network of community-based sites where trained staff provides 
those at high risk for diabetes with cost-effective, group-based 
lifestyle intervention programs. We urge Congress to provide $20 
million for the National Diabetes Prevention Program in fiscal year 
2014 to continue its nationwide expansion. The program is a proven 
means of combating a growing epidemic, and research has shown it can 
reduce the risk of type 2 diabetes by 58 percent for individuals with 
prediabetes--at a cost of only about $300 per participant. Currently, 
there are over 200 CDC recognized programs and the largest program, run 
by the Y-USA, has 420 sites across the country. The National Diabetes 
Prevention Program began with a successful NIDDK study in a clinical 
setting. Additional translational research was then done by NIDDK and 
DDT, proving the program also works in the less-costly community 
setting. This is exactly the program we should be bringing to scale if 
we hope to conquer our country's diabetes epidemic.

                               CONCLUSION

    The Association is counting on Congress to significantly expand its 
investment at NIDDK and the DDT in fiscal year 2014, including the 
National Diabetes Prevention Program. We must change our country's 
future with regard to this devastating disease and hope, even in a 
difficult fiscal environment, the explosive growth in the financial and 
human tolls of diabetes will be reflected in your appropriations 
decisions. Thank you for the opportunity to submit this testimony. The 
Association looks forward to working with you to stop diabetes.
                                 ______
                                 
          Prepared Statement of the American Heart Association

    Although major progress has been made in the battle against 
cardiovascular disease (CVD) and stroke, CVD remains our Nation's No. 1 
and most costly killer of men and women, costing each year a projected 
$313 billion in medical expenses and lost productivity. Stroke, alone, 
is our No. 4 killer, costing an estimated $40 billion a year. Both 
remain major causes of disability.
    Today, an estimated 83 million U.S. adults suffer from CVD and a 
recent study projects that by the year 2030, more than 40 percent of 
U.S. adults will live with CVD at a cost exceeding $1 trillion 
annually. However, CVD and stroke research, prevention and treatment 
remain woefully underfunded and there is no steady stream of funding 
for the National Institutes of Health to mount a long-term, aggressive 
campaign against these terrible burdens on society.
    The current Federal budget dilemma makes a bad situation worse. The 
sequestration and funding the Government under a continuing resolution 
endanger the health of tens of millions of CVD sufferers and threaten 
to undermine our struggling economy and global competitiveness. It is 
imperative that Congress provide stable and sustained funding for CVD 
and stroke research, prevention and treatment programs. The Nation's 
physical and fiscal health are at stake.

     FUNDING RECOMMENDATIONS: INVESTING IN THE HEALTH OF OUR NATION

    Promising research that could stem the increase of heart disease 
and stroke risk factors remains unfunded. If Congress fails to 
capitalize on 50 years of progress, we will pay more in lives lost and 
health care costs. Our recommendations address the issues in a fiscally 
responsible way.

Capitalize on Investment for the National Institutes of Health (NIH)
    NIH research helps prevent and cure disease, creates economic 
growth, fosters innovation, and preserves U.S. leadership in 
pharmaceuticals and biotechnology, and has transformed patient care. 
NIH is the primary funder of basic research--the starting point for all 
medical progress and an essential function of the Federal Government 
that the private sector cannot fill.
    NIH produces major returns on investment by developing new 
technologies that create good-paying jobs. In fiscal year 2012, NIH 
created about 402,000 U.S. jobs and produced $57.8 billion in economic 
activity. Each dollar NIH distributes in a grant returns $2.21 in goods 
and services to the local community in just 1 year. Under 
sequestration, the NIH budget will be cut by 5 percent or $1.6 billion, 
reducing its budget to 2007 levels, with an expected loss of 2,300 
planned grants. Since NIH invests in every State and in 90 percent of 
congressional districts, 20,500 jobs will be lost and new economic 
activity will decline by $3 billion. These cuts will compromise NIH's 
role as the world leader in medical research, delay treatments and 
cures as scientists are on the verge of breakthroughs, and dishearten 
early career investigators who may not return to science.
    American Heart Association Advocates.--We ask Congress to 
appropriate $32 billion, same as our request last year, for NIH to 
restore sequester cuts, improve health, spur our economy and 
innovation, and promote heart and stroke research.

Enhance Funding for NIH Heart and Stroke Research: A Proven and Wise 
        Investment
    Declining death rates from CVD and stroke are directly related to 
NIH research, with scientists on the cusp of discoveries that could 
lead to revolutionary treatments and even cures. In addition to saving 
lives, NIH research is cost-effective. For example, the first NIH tPA 
drug trial resulted in a 10-year net $6.47 billion drop in stroke 
health care costs. Also, the Stroke Prevention in Atrial Fibrillation 
Trial 1 produced a 10-year net savings of $1.27 billion.

Cardiovascular Disease Research: National Heart, Lung, and Blood 
        Institute (NHLBI)
    Although heart disease death rates have sharply fallen, there is 
still no cure for CVD and demand will only increase to find better ways 
for people to live healthy and productive lives with CVD. Stable and 
sustained NHLBI funding is essential to capitalize on investments that 
have discovered a gene variant linked to aortic valve disease; 
developed a new computer tomography scanner that provides better heart 
images with far less radiation; used genetics to identify and treat 
those at greatest risk of CVD; hastened drug development to reduce 
cholesterol and blood pressure; and created tailored strategies to 
treat, slow or prevent heart failure. Sustained funding will permit 
aggressive implementation of priority initiatives in the CVD strategic 
plan.

Stroke Research: National Institute of Neurological Disorders and 
        Stroke (NINDS)
    An estimated 795,000 Americans will suffer a stroke this year, and 
more than 129,000 will die. Many of the 7 million survivors face severe 
physical and mental disabilities and emotional distress. In addition to 
the physical and emotional toll, stroke will cost a projected $40 
billion in medical expenses and lost productivity this year. And the 
future looks bleak. One study projects stroke prevalence will increase 
25 percent over the next 20 years, striking more than 10 million 
individuals with direct medical costs rising 238 percent over the same 
time.
    Stable and sustained NINDS funding is required to advance the nine 
top priorities in stroke prevention, treatment and recovery research. 
They include: accelerating translation of preclinical animal models 
into clinical studies; preventing vascular cognitive impairment; 
expediting comparative effectiveness research trials; developing 
imaging biomarkers; expanding and integrating stroke trial networks; 
improving clot-busting treatments; achieving robust brain protection; 
targeting early stroke recovery; and using neural interface devices.
    American Heart Association Advocates.--We recommend that NHLBI be 
funded at $3.2 billion and NINDS at $1.7 billion for fiscal year 2014.

Increase Funding for the Centers for Disease Control and Prevention 
        (CDC)
    Prevention is one of the strongest tools in the fight against CVD 
and stroke. In our summary of prevention cost-effectiveness and value, 
we found, for example, comprehensive worksite health programs have 
shown a $3.27 cut in medical costs for each dollar spent in the first 
12-18 months. Yet, proven prevention strategies are not being 
implemented due to scarce funds. In addition to conducting research and 
evaluation and developing a surveillance system, the Division for Heart 
Disease and Stroke Prevention manages Sodium Reduction Communities and 
the Paul Coverdell National Acute Stroke Registry. Also, DHDSP, with 
the Centers for Medicare and Medicaid Services, implements Million 
HeartsTM to prevent 1 million heart attacks and strokes in 5 
years.
    The DHDSP also manages WISEWOMAN that serves uninsured and under-
insured, low-income women ages 40 to 64. It helps them avoid heart 
disease and stroke by providing preventive health services, referrals 
to local health care providers--as needed--and lifestyle counseling and 
interventions tailored to risk factors to promote lasting behavior 
change.
    American Heart Association Advocates.--We join with the CDC 
Coalition in asking for $7.8 billion for CDC's ``core programs.'' AHA 
requests $75 million for the DHDSP and $37 million for WISEWOMAN. Also, 
we advocate for $35 million of the Prevention and Public Health Fund be 
allocated for Million HeartsTM to execute a national blood 
pressure educational campaign targeted at the 37 million Americans with 
uncontrolled blood pressure.

Restore Funding for Rural and Community Access to Emergency Devices 
        (AED) Program
    About 90 percent of cardiac arrest victims die outside of a 
hospital. Yet, prompt CPR and defibrillation with an automated external 
defibrillator (AED) can more than double the chances of survival. 
Communities with comprehensive AED programs have survival rates 
approaching 40 percent, compared to the current less than 10 percent. 
HRSA's Rural and Community AED Program provides competitive grants to 
States to buy AEDs, strategically place them, and train lay rescuers 
and first responders in their use. Due to this effort, almost 800 
patients were saved between August 1, 2009 and July 31, 2010. But 
limited resources allowed only 6 percent of applicants to be funded and 
only 8 States received funds in fiscal year 2012.
    American Heart Association Advocates.--We ask for a fiscal year 
2014 appropriation of $8.927 million to restore this life-saving AED 
program to fiscal year 2005 levels when 47 States were funded.

                               CONCLUSION

    Cardiovascular disease and stroke continue to inflict a deadly, 
disabling and costly toll on Americans. Our funding recommendations for 
NIH, CDC and HRSA will save lives and cut rising health care costs. We 
urge Congress to seriously consider our proposals that represent a wise 
investment for our Nation and for the health and well-being of this and 
future generations.
                                 ______
                                 
 Prepared Statement of the American Indian Higher Education Consortium

    This statement includes the fiscal year 2014 (fiscal year 2014) 
recommendations of the Nation's Tribal Colleges and Universities 
(TCUs), in two areas of the Department of Education: Office of 
Postsecondary Education and Office of Vocational Education.

    I. Higher Education Act Programs:
  --Strengthening Developing Institutions.--Titles III and V of the 
        Higher Education Act support institutions that enroll large 
        proportions of financially disadvantaged students and have low 
        per-student expenditures. TCUs, funded under Title III-A Sec. 
        316, which are truly developing institutions, are providing 
        quality higher education opportunities to some of the most 
        rural, impoverished, and historically underserved areas of the 
        country. The goal of HEA-Titles III/V programs is ``to improve 
        the academic quality, institutional management and fiscal 
        stability of eligible institutions, in order to increase their 
        self-sufficiency and strengthen their capacity to make a 
        substantial contribution to the higher education resources of 
        the Nation.'' The TCU Title III-A program is specifically 
        designed to address the critical, unmet needs of their American 
        Indian students and communities, in order to effectively 
        prepare them to succeed in a global, competitive workforce. 
        Yet, in fiscal year 2011 this critical program was cut by over 
        11 percent and by another 4 percent in fiscal year 2012. The 
        TCUs urge the subcommittee to appropriate $30 million in fiscal 
        year 2014 for HEA Title III-A Section 316.
  --TRIO.--Retention and support services are vital to achieving the 
        national goal of having the highest percentage of college 
        graduates globally by 2020. TRIO programs, such as Student 
        Support Services and Upward Bound were created out of 
        recognition that college access is not enough to ensure 
        advancement and that multiple factors work to prevent the 
        successful completion of higher education for many low-income 
        and first-generation students and students with disabilities. 
        Therefore, in addition to maintaining the maximum Pell Grant 
        award level, it is critical that Congress also sustains student 
        assistance programs such as Student Support Services and Upward 
        Bound so that low-income and minority students have the support 
        necessary to allow them to remain enrolled in and ultimately 
        complete their postsecondary courses of study.
    Pell Grants.--The importance of Pell Grants to TCU students cannot 
be overstated. A majority of TCU students receive Pell Grants, 
primarily because student income levels are so low and they have far 
less access to other sources of financial aid than students at State-
funded and other mainstream institutions. Within the TCU system, Pell 
Grants are doing exactly what they were intended to do--they are 
serving the needs of the lowest income students by helping them gain 
access to quality higher education, an essential step toward becoming 
active, productive members of the workforce. However, last summer the 
Department of Education changed its regulations limiting Pell 
eligibility from 18 to 12 full-time semesters, without consideration of 
those already in the process of attaining a postsecondary degree. This 
change in policy will impede many TCU students from completing a 
postsecondary degree, which is widely recognized as being critical for 
access to, and advancement in, today's highly technical workforce.
    Recent placement tests administered at TCUs to first-time entering 
students indicated that 64 percent required remedial math, 78 percent 
needed remedial writing, and 60 percent required remedial reading. 
These results clearly illustrate just how serious this new Pell Grant 
eligibility limit is to the success of TCU students in completing a 
postsecondary degree. Students requiring remediation can use as much as 
a full year of eligibility enhancing their math, and or reading/writing 
skills, thereby hampering their future postsecondary degree plans. A 
prior national goal was to provide access to quality higher education 
opportunities for all students regardless of economic means, at which 
TCUs have been extremely successful. While the new national goal is 
intending to produce graduates with postsecondary degrees by 2020, this 
policy does not advance that objective. On the contrary, the new 
regulations will cause many low-income students to once again abandon 
their dream of a postsecondary degree, as they will simply not have the 
means to pursue it. The goal of a well-trained technical workforce will 
be greatly compromised. This new policy evokes the adage ``penny wise--
pound foolish.'' The TCUs urge the subcommittee to continue to fund 
this essential program at the highest possible level, and to direct the 
Secretary of Education to implement a process to waive the very 
restrictive 12 semester Pell Grant eligibility for TCU students.

    II. Perkins Career and Technical Education Programs:
  --Tribally-Controlled Postsecondary Career and Technical 
        Institutions.--Section 117 of the Carl D. Perkins Career and 
        Technical Education Act provides a competitively awarded grant 
        opportunity for tribally chartered and controlled career and 
        technical institutions. AIHEC requests $8,200,000 to fund 
        grants under Sec. 117 of the Perkins Act.
  --Native American Career and Technical Education Program (NACTEP).--
        NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding 
        to support American Indian career and technical programs. The 
        TCUs strongly urge the subcommittee to continue to support 
        NACTEP, which is vital to the continuation of career and 
        technical education programs offered at TCUs that provide job 
        training and certifications to remote reservation communities.

    III. American Indian Adult and Basic Education (Office of 
Vocational and Adult Education): This program supports adult basic 
education programs for American Indians offered by State and local 
education agencies, Indian tribes, agencies, and TCUs. Despite the 
absence of funding, TCUs must find a way to continue to provide adult 
basic education classes for those American Indians that the present K-
12 Indian education system has failed. Before many individuals can even 
begin the course work needed to learn a productive skill, they first 
must earn a GED or, in some cases, even learn to read. There is an 
extensive need for adult basic educational programs, and TCUs must have 
adequate and stable funding to provide these essential activities. TCUs 
request that the subcommittee direct that $8 million of the funds 
appropriated annually for the Adult Education State Grants be made 
available to make competitive awards to TCUs to help meet the growing 
demand for adult basic education and remediation program services on 
their respective Reservations.

  JUSTIFICATIONS FOR FISCAL YEAR 2014 APPROPRIATIONS REQUESTS FOR TCUS

    Tribal colleges and our students are already being 
disproportionately impacted by ongoing efforts to reduce the Federal 
budget deficit and control Federal spending. The final fiscal year 2011 
Continuing Resolution eliminated all of the Department of Housing and 
Urban Development's Minority Serving Institutions (MSIs) community-
based programs, including a critical TCU-HUD facilities program. TCUs 
were able to maximize leveraging potential, often securing even greater 
non-Federal funding to construct and equip Head Start and early 
childhood centers; student and community computer laboratories and 
public libraries; and student and faculty housing in rural and remote 
communities where few or none of these facilities existed. Important 
STEM programs, operated by the National Science Foundation and NASA 
were cut, and for the first time since the NSF program was established 
in fiscal year 2001, no new TCU-STEM awards were made in fiscal year 
2011. Additionally, TCUs and their students suffer the realities of 
cuts to programs such as GEAR-UP, TRIO, SEOG, and as noted earlier, are 
seriously impacted by the new highly restrictive Pell Grant eligibility 
criteria more profoundly than mainstream institutions of higher 
education, which can realize economies of scale due to large 
endowments, alternative funding sources, including the ability to 
charge higher tuition rates and enroll more financially stable 
students, and access to affluent alumni. The loss of opportunity that 
cuts to DoEd, HUD, and NSF programs represent to TCUs, and to other 
MSIs, is magnified by cuts to workforce development programs within the 
Department of Labor, nursing and allied health professions tuition 
forgiveness and scholarship programs operated by the Department of 
Health and Human Services, and an important TCU-based nutrition 
education program planned by USDA. Combined, these cuts strike at the 
most economically disadvantaged and health-challenged Americans.
    We respectfully ask the members of the subcommittee for their 
continued investment in the Nation's TCUs and full consideration of our 
fiscal year 2014 appropriations needs and recommendations.
                                 ______
                                 
          Prepared Statement of the American Lung Association

------------------------------------------------------------------------
    Centers for Disease Control &        National Institutes of Health
 Prevention ------ Increase overall       ------ Increase overall NIH
      CDC funding--$7.8 billion              funding--$32 billion
------------------------------------------------------------------------
Healthy Communities Program--$52.8    National Heart, Lung and Blood
 million                               Institute--$3.214 billion
Office on Smoking and Health--        National Cancer Institute--$5.296
 $212.36 million                       billion
Asthma programs--$28.435 million      National Institute of Allergy and
Environment and Health Tracking        Infectious Diseases--$4.689
 Network--$35 million                  billion
Tuberculosis programs--$243 million   National Institute of
Influenza Planning and Response--      Environmental Health Sciences--
 $173.061 million                      $717.9 million
NIOSH--$292.588 million               National Institute of Nursing
 (discretionary)                       Research--$151.178 million
Prevention and Public Health Fund--   National Institute on Minority
 Please Protect the Fund               Health & Health Disparities--
                                       $288.678 million
                                      Fogarty International Center--
                                       $72.864 million
------------------------------------------------------------------------

    The American Lung Association is pleased to present our 
recommendations for fiscal year 2014 (fiscal year 2014) to the Senate 
Labor, Health and Human Services, and Education Appropriations 
Subcommittee. The public health and research programs funded by this 
committee will prevent lung disease and improve and extend the lives of 
millions of Americans. Founded in 1904 to fight tuberculosis, the 
American Lung Association is the oldest voluntary health organization 
in the United States. The American Lung Association is the leading 
organization working to save lives by improving lung health and 
preventing lung disease through education, advocacy and research.
The Public Health Infrastructure Cannot Support Further Cuts
    The American Lung Association acknowledges and thanks the Committee 
for its commitment to maintaining investments in public health. The 
Lung Association is very concerned about the impact of cuts in the last 
5 years to public health agencies, especially those resulting from 
sequestration.
    The President's Budget for fiscal year 2014 proposes further cuts 
to critical to the Nation's public health infrastructure. The 
President's Budget contains another 3.7 percent in cut in budget 
authority for the Centers for Disease Control and Prevention and an 8.4 
percent cut in program level (including the Prevention Fund and other 
categories) since fiscal year 2012. In the last four fiscal years, CDC 
budget authority has fallen by 14.8 percent and program level by 9.3 
percent--a truly frightening prospect when considering the future of 
our Nation's public health agency.
    Investments in prevention and wellness pay near- and long-term 
dividends for the health of the American people. A recent study on the 
California tobacco control program published in PLoS One showed this 
amazing result: for every dollar the State spent on the program, it 
saved $55 in healthcare costs. In order to save healthcare costs in the 
long-term, investments must be made in proven public health 
interventions including tobacco control, asthma programs and TB 
infrastructure, particularly in light of recent sequestration cuts.

Lung Disease
    Each year, close to 400,000 Americans die of lung disease. It is 
America's number three killer, responsible for one in every six deaths. 
More than 33 million Americans suffer from a chronic lung disease and 
it costs the economy an estimated $106 billion each year. Lung diseases 
include: lung cancer, asthma, chronic obstructive pulmonary disease 
(COPD), tuberculosis, pneumonia, influenza, sleep disordered breathing, 
pediatric lung disorders, occupational lung disease and sarcoidosis.

Improving Public Health and Maintaining Our Investment in Medical 
        Research
    The American Lung Association strongly supports increasing overall 
CDC funding to $7.8 billion in order for CDC to carry out its 
prevention mission and to assure an adequate translation of new 
research into effective State and local public health programs. 
Congress must also maintain its commitment to medical research by 
increasing overall NIH funding to $32 billion. While our focus is on 
lung disease research, we support increasing the investment in research 
across the entire NIH.

The Prevention and Public Health Fund
    The American Lung Association has repeatedly stated its support for 
the Public Health and Prevention Fund and our fierce opposition to any 
attempts to divert or use these dollars for any purposes other than 
what was originally intended in the Affordable Care Act--which in part 
is to prevent and better manage devastating chronic diseases. The 
Committee must oppose any attempts to divert or use the Fund for any 
purposes other than what it was originally intended. The Prevention 
Fund provides funding to critical public health initiatives, like 
community programs that help people quit smoking, support groups for 
lung cancer patients, and classes that teach people how to avoid asthma 
attacks.
    The Lung Association remains troubled that Prevention Fund dollars 
are being used to supplant public health funds rather than supplement 
them as originally intended. The intent of the Prevention Fund was to 
fund additional public health programs and initiatives--leading to 
additional health benefits--not to fund already existing ones. An 
example of this is the President's proposal to fund the Environmental 
and Health Tracking Network entirely with Prevention Fund dollars. This 
program was previously funded by budget authority. As the Prevention 
Fund dollars remain under threat and continue to be diverted for other 
purposes, added budget authority at CDC is even more important.
    One high profile example of successful use of Prevention Fund 
dollars is CDC's Tips from Former Smokers campaign. The first phase of 
the campaign, which began in March 2012, resulted in hundreds of 
thousands of additional calls to 1-800-QUIT NOW and visits to 
smokefree.gov by smokers seeking help in quitting. CDC began re-airing 
the Tips ads in March 2013, and calls to 1-800-QUIT-NOW doubled in a 
majority of States. In April, new and extremely powerful ads in the 
Tips series began to air. The response from smokers seeking help to 
quit is tangible evidence of the Fund having a positive impact.

Tobacco Use
    The American Lung Association recognizes the ongoing support of the 
Committee in investing in proven ways to reduce tobacco use. Tobacco 
use is the leading preventable cause of death in the United States, 
killing more than 443,000 people every year. Over 43 million adults and 
1.9 million youth in the U.S. smoke. Annual health care and lost 
productivity costs total $193 billion in the U.S. each year. Given the 
magnitude of the tobacco-caused disease burden and how much of it can 
be prevented, the CDC Office on Smoking and Health (OSH) should be much 
larger and better funded. Historically, Congress has failed to invest 
in tobacco control--even though public health interventions have been 
scientifically proven to reduce tobacco use. This neglect cannot 
continue if the Nation wants to prevent disease, promote wellness and 
reduce healthcare costs. The American Lung Association requests $212.36 
million be appropriated to OSH for fiscal year 2014.

Lung Cancer
    The American Lung Association thanks the Committee's support for 
and interest in the National Cancer Institute's Lung Cancer Screening 
Trial and its findings. Given the magnitude of lung cancer and the 
enormity of the death toll, the American Lung Association strongly 
recommends that the NIH and other Federal research programs commit 
additional resources to lung cancer. The National Lung Screening Trial 
showed promising results for a small segment of the population at high 
risk for developing lung cancer but more research must be done in order 
to see if others would similarly benefit.
    Over 370,000 Americans are living with lung cancer. During 2012, 
more than 226,000 new cases of lung cancer were diagnosed--roughly 14 
percent of all cancer diagnoses. It is the leading cause of cancer 
deaths, with a five year survival rate of only 16.3 percent. In 2009, 
there were 87,694 lung cancer deaths in men and 70,387 in women. 
Although the number of deaths among men has plateaued, the number is 
still rising among women. African Americans are more likely to develop 
and die from lung cancer than persons of any other racial group. We 
support a funding level of $5.296 billion for the NCI and strongly urge 
more attention and focus on lung cancer.

Chronic Obstructive Pulmonary Disease (COPD)
    COPD is the third leading cause of death in the U.S. It has been 
estimated that 13.1 million patients have been diagnosed with some form 
of COPD and as many as 24 million adults may suffer from its 
consequences. In 2009, 133,965 people in the U.S. died of COPD. The 
annual cost to the Nation for COPD in 2010 was projected to be $49.9 
billion. We strongly support funding the NHLBI and its lifesaving lung 
disease research program at $3.214 billion. The American Lung 
Association also asks the Committee continue its support of the NHLBI 
working with the CDC and other appropriate agencies address COPD, 
including ongoing Federal efforts to better coordinate and implement 
Federal activities regarding COPD.

Asthma
    Asthma is highly prevalent and expensive. More than 25 million 
Americans currently have asthma, of whom 7 million are children. Asthma 
prevalence rates are over 37 percent higher among African Americans 
than whites. Asthma is also the third leading cause of hospitalization 
among children under the age of 15 and is a leading cause of school 
absences from chronic disease. Asthma costs our healthcare system over 
$50.1 billion annually and indirect costs from lost productivity add 
another $5.9 billion, for a total of $56 billion dollars annually. But 
teaching children and adults how to manage their asthma saves money. A 
study that appeared in the American Journal of Respiratory Critical 
Care found that for every dollar invested in asthma interventions, 
there was a $35 benefit in healthcare cost savings and workdays lost.
    The Lung Association was pleased to see that the President's fiscal 
year 2014 budget request did not again propose to merge the CDC's 
National Asthma Control Program with the Healthy Homes Program and 
slash its funding. The Lung Association thanks this Committee for its 
support of the National Asthma Control Program and asks for an 
appropriation of $28.435 million ($25.3 million for programmatic and 
$3.1 million for the working capital fund) in fiscal year 2014. In 
addition, we recommend that the NHLBI receive $3.214 billion and the 
NIAID receive $4.689 billion, and that both agencies continue their 
research investments in cures and treatments for asthma.

Influenza
    Public health experts warn that 209,000 Americans could die and 
865,000 would be hospitalized if a moderate flu epidemic hits the U.S., 
which may be made worse because of sequestration. Current threats of 
the latest strain of ``bird flu'' in China are a good example of our 
needs in this area. According to the World Health Organization, the 
H7N9 virus has sickened 108 people and killed 22. Public health 
officials are tracking the victims closely to determine whether there 
is evidence of human-to-human transmission, which would be the 
precursor of a possible pandemic. This swift and thorough response 
would not be possible without public health infrastructure in place and 
ready to respond to threats. To prepare for a potential pandemic, the 
American Lung Association supports funding CDC's influenza planning and 
response efforts at $173.061 million.

Tuberculosis (TB)
    There are an estimated 10-15 million Americans who carry latent TB 
infection, and it is estimated that 10 percent of these individuals 
will develop active TB disease. In 2011, there were 10,528 cases of 
active TB reported in the U.S. While declining overall TB rates are 
good news, the emergence and spread of multi-drug resistant TB and 
totally-drug resistant TB also poses a significant public health 
threat. We request that Congress increase funding for tuberculosis 
programs at CDC to $243 million for fiscal year 2014.

Additional Priorities
    We strongly encourage improved disease surveillance and health 
tracking to better understand diseases like asthma. We support an 
appropriations level of $35 million for the Environment and Health 
Outcome Tracking Network from budget authority instead of Prevention 
Fund dollars. We also strongly recommend at least $52.8 million in 
funding for CDC's Healthy Communities Program. This program supports 
investments in communities to identify and improve policies and 
environmental factors influencing health and reduce the burden of 
chronic diseases.

                               CONCLUSION

    Lung disease is a continuing, growing problem in the United States. 
It is America's number three killer, responsible for one in six deaths. 
Progress against lung disease is not keeping pace with progress against 
other major causes of death and more must be done. The level of support 
this committee approves for lung disease programs should reflect the 
urgency illustrated by the impact of lung disease.
                                 ______
                                 
         Prepared Statement of the American National Red Cross

    Chairman Tom Harkin, Ranking Member Jerry Moran, and members of the 
subcommittee, the American Red Cross and the United Nations Foundation 
appreciate the opportunity to submit testimony in support of measles 
control activities of the U.S. Centers for Disease Control and 
Prevention (CDC). The American Red Cross and the United Nations 
Foundation recognize the leadership that Congress has shown in funding 
CDC for these essential activities. We sincerely hope that Congress 
will continue to support the CDC during this critical period in measles 
control.
    In 2001, CDC--along with the American Red Cross, the United Nations 
Foundation, the World Health Organization, and UNICEF--founded the 
Measles Initiative, a partnership committed to reducing measles deaths 
globally. In 2012, the Initiative expanded to include rubella control 
and adopted a new name, the Measles & Rubella Initiative (the 
Initiative). The Initiative aims to reach elimination goals for 
measles, rubella and congenital rubella syndrome. The current UN goal 
is to reduce global measles deaths by 95 percent by 2015 compared to 
2000 estimates, and three of six WHO regions have set rubella control 
or elimination targets. The Initiative is committed to reaching these 
goals by providing technical and financial support to governments and 
communities worldwide.
    The Measles & Rubella Initiative has achieved ``spectacular'' \1\ 
results by supporting the vaccination of more than 1.1 billion 
children. Largely due to the Measles & Rubella Initiative, global 
measles mortality dropped 71 percent, from an estimated 548,000 deaths 
in 2000 to 158,000 in 2011 (the latest year for which data is 
available). During this same period, measles deaths in Africa fell by 
84 percent. About 430 children still die from measles each day from a 
virus that can be countered with an effective, inexpensive vaccine; and 
each year more than 110,000 children are born with congenital rubella 
syndrome. In May 2012, the 194 member States of the World Health 
Assembly resolved to endorse the Global Vaccine Action Plan, which 
affirmed the elimination of measles and rubella by 2020 in at least 
five of six WHO regions as global goals.

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


    Working closely with host governments, the Measles & Rubella 
Initiative has been the main international supporter of mass measles 
immunization campaigns since 2001. The Initiative mobilized more than 
$1 billion and provided technical support in more than 80 developing 
countries on vaccination campaigns, surveillance and improving routine 
immunization services. From 2000 to 2011, an estimated 10 million 
measles deaths were averted as a result of these accelerated measles 
control activities at a donor cost of less than $200/death averted, 
making measles mortality reduction one of the most cost-effective 
public health interventions.
    Nearly all the measles vaccination campaigns have been able to 
reach more than 90 percent of their target populations. Countries 
recognize the opportunity that measles vaccination campaigns provide in 
accessing mothers and young children, and ``integrating'' the campaigns 
with other life-saving health interventions has become the norm. In 
addition to measles vaccine, vitamin A (crucial for preventing 
blindness in under nourished children), de-worming medicine (reduces 
malnutrition), and insecticide-treated bed nets (ITNs) for malaria 
prevention are distributed during vaccination campaigns. The scale of 
these distributions is immense. The Initiative and its partners have 
supported the distribution of more than 245 million doses of vitamin A, 
113 million doses of de-worming medicine, 41 million insecticide-
treated bed nets, and 137 million doses of polio vaccine. Doses of oral 
polio vaccines are frequently distributed during measles campaigns in 
polio endemic and high risk countries. The delivery of polio vaccines 
in conjunction with measles vaccines in these campaigns strengthens the 
reach of elimination and eradication efforts of these diseases. The 
delivery of multiple child health interventions during a single 
campaign is far less expensive than delivering the interventions 
separately, and this strategy increases the potential positive impact 
on children's health from a single campaign.
    The extraordinary reduction in global measles deaths contributed 
nearly 25 percent of the progress to date toward Millennium Development 
Goal #4 (reducing under-five child mortality). However, large outbreaks 
in several African, European and Asian countries in 2011 and 2012 have 
put the 2015 measles elimination goals at risk. These outbreaks 
highlight the fragility of the last decade's progress. If mass 
immunization campaigns are not continued, measles deaths will increase 
rapidly with more than half a million deaths estimated for 2013 alone.
    To achieve the 2015 goal and avoid a resurgence of measles the 
following actions are required:
  --Fully implementing activities, both campaigns and strengthening 
        routine measles coverage, in India since it is the greatest 
        contributor to the global burden of measles.
  --Sustaining the gains in reduced measles deaths, especially in 
        Africa, by strengthening immunization programs to ensure that 
        more than 90 percent of infants are vaccinated against measles 
        through routine health services before their first birthday as 
        well as conducting timely, high quality mass immunization 
        campaigns.
  --Accelerating the introduction of a second dose of measles 
        containing vaccine into the routine immunization program of 
        eligible countries with support from the GAVI Alliance.
  --Securing sufficient funding for measles and rubella-control 
        activities both globally and nationally. The Measles & Rubella 
        Initiative faces a funding shortfall of an estimated U.S. $171 
        million for 2013-2015. Implementation of timely measles 
        campaigns is increasingly dependent upon countries funding 
        these activities locally. The decrease in donor funds available 
        at a global level to support measles elimination activities 
        makes increased political commitment and country ownership of 
        the activities critical for achieving and sustaining the goal 
        of reducing measles mortality by 95 percent.
    If these challenges are not addressed, the remarkable gains made 
since 2000 will be lost and a major resurgence in measles deaths will 
occur.
    By controlling measles and rubella cases in other countries, U.S. 
children are also being protected from the diseases. Measles can cause 
severe complications and death. A resurgence of measles occurred in the 
United States between 1989 and 1991, with more than 55,000 cases 
reported. This resurgence was particularly severe, accounting for more 
than 11,000 hospitalizations and 123 deaths. Since then, measles 
control measures in the United States have been strengthened and 
endemic transmission of measles cases have been eliminated here since 
2000. However, importations of measles cases into this country continue 
to occur each year, particularly from Europe. The costs of these cases 
and outbreaks are substantial, both in terms of the costs to public 
health departments and in terms of productivity losses among people 
with measles and parents of sick children. Studies show that a single 
case of measles in the United States can cost between $100,000 and 
$200,000 to control. The U.S. had 222 measles cases in 2011, the 
highest in 15 years and Canada experienced a large outbreak of over 800 
cases.

The Role of CDC in Global Measles Mortality Reduction
    Since fiscal year 2001 and until 2013, Congress has provided 
between $43.6 and $49.3 million annually in funding to CDC for global 
measles control activities. These funds were used toward the purchase 
of measles vaccine for use in large-scale measles vaccination campaigns 
in more than 80 countries in Africa and Asia, and for the provision of 
technical support to Ministries of Health. Specifically, this technical 
support includes:
  --Planning, monitoring, and evaluating large-scale measles 
        vaccination campaigns;
  --Conducting epidemiological investigations and laboratory 
        surveillance of measles outbreaks; and
  --Conducting operations research to guide cost-effective and high 
        quality measles control programs.
    In addition, CDC epidemiologists and public health specialists have 
worked closely with WHO, UNICEF, the United Nations Foundation, and the 
American Red Cross to strengthen measles control programs at global and 
regional levels, and will continue to work with these and other 
partners in implementing and strengthening rubella control programs. 
While it is not possible to precisely quantify the impact of CDC's 
financial and technical support to the Measles & Rubella Initiative, 
there is no doubt that CDC's support--made possible by the funding 
appropriated by Congress--was essential in helping achieve the sharp 
reduction in measles deaths in just eleven years.
    The American Red Cross and the United Nations Foundation would like 
to acknowledge the leadership and work provided by CDC and recognize 
that CDC brings much more to the table than just financial resources. 
The Measles & Rubella Initiative is fortunate in having a partner that 
provides critical personnel and technical support for vaccination 
campaigns and in response to disease outbreaks. CDC personnel have 
routinely demonstrated their ability to work well with other 
organizations and provide solutions to complex problems that help 
critical work get done faster and more efficiently.
    In fiscal year 2011 and fiscal year 2012, Congress appropriated 
approximately $49 million each year to fund CDC for global measles 
control activities. This amount represents a $2.7 million decrease from 
2010. The American Red Cross and the United Nations Foundation 
respectfully request a return to fiscal year 2010 funding levels ($52 
million) for fiscal year 2014 for CDC's measles and rubella control 
activities to protect the investment of the last decade, and prevent a 
global resurgence of measles and a loss of progress toward Millennium 
Development Goal #4.
    Your commitment has brought us unprecedented victories in reducing 
measles mortality around the world. In addition, your continued support 
for this initiative helps prevent children from suffering from this 
preventable disease both abroad and in the United States.
    Thank you for the opportunity to submit testimony.
---------------------------------------------------------------------------
    \1\ Unpublished data from Measles & Rubella, Annual Report 2012, 
page 11 (April 2013).
---------------------------------------------------------------------------
                                 ______
                                 
         Prepared Statement of the American Nurses Association

    The American Nurses Association (ANA) appreciates the opportunity 
to comment on fiscal year 2014 appropriations for the Title VIII 
Nursing Workforce Development Programs and Nurse-Managed Health 
Clinics. Founded in 1896, ANA is the only full-service professional 
association representing the interests of the Nation's 3.2 million 
registered nurses (RNs) and advanced practice registered nurses (APRNs-
including certified nurse-midwives, nurse practitioners, clinical nurse 
specialists, and certified registered nurse anesthetists) through its 
State nurses associations, and organizational affiliates. The ANA 
advances the nursing profession by fostering high standards of nursing 
practice, promoting the rights of nurses in the workplace, and 
projecting a positive and realistic view of nursing.
    As the largest single group of clinical health care professionals 
within the health system, licensed registered nurses are educated and 
practice within a holistic framework that views the individual, family 
and community as an interconnected system that can keep us well and 
help us heal. As the Nation works towards restructuring the healthcare 
system by focusing on expanding access, decreasing cost, and improving 
quality; a significant investment must be made in strengthening the 
nursing workforce.
    We are grateful to the subcommittee for your past commitment to 
Title VIII funding, and we understand the immense fiscal pressures the 
subcommittee is facing. However, ANA respectfully requests your support 
of $251 million for the Nursing Workforce Development programs 
authorized under Title VIII of the Public Health Service Act in fiscal 
year 2014. Additionally, we respectfully request $20 million for the 
Nurse-Managed Health Clinics authorized under Title III of the Public 
Health Service Act in fiscal year 2014. While we recognize the reality 
of the sequester and the need to continue to cut the Federal deficit, 
we also firmly believe this request is necessary given the demand for 
nursing services is steadily on the rise.

                  DEMAND FOR NURSES CONTINUES TO GROW

    A sufficient supply of nurses is critical in providing our Nation's 
population with quality health care now and into the future. Registered 
Nurses (RNs) and Advanced Practice Registered Nurses (APRNs) are the 
backbone of hospitals, community clinics, school health programs, home 
health and long-term care programs, and serve patients in many other 
roles and settings. The Bureau of Labor Statistics' (BLS) Employment 
Projections for 2010-2020 state the expected number of practicing 
nurses will grow from 2.74 million in 2010 to 3.45 million in 2020, an 
increase of 712,000 or 26 percent.
    Contrary to the good news that there are a growing number of 
nurses, the current nurse workforce is aging. According to the 2008 
National Sample Survey of Registered Nurses, over one million of the 
Nation's 2.6 million practicing RNs are over the age of 50. Within this 
population, more than 275,000 nurses are over the age of 60. As the 
economy continues to rebound, many of these nurses will seek 
retirement, leaving behind a significant deficit in the number of 
experienced nurses in the workforce. According to Douglas Staiger, 
author of a New England Journal of Medicine study, the nursing shortage 
will ``re-emerge'' from 2010 and 2015 as 118,000 nurses will stop 
working full time as the economy grows.
    Furthermore, as of January 1, 2011 Baby Boomers began turning 65 at 
the rate of 10,000 a day. With this aging population, the healthcare 
workforce will need to grow as there is an increase in demand for 
nursing care in traditional acute care settings as well as the 
expansion of non-hospital settings such as home care and long-term 
care.
    The BLS projections explain a need for 495,500 replacements in the 
nursing workforce, bringing the total number of job openings for nurses 
due to growth and replacements to 1.2 million by 2020. A shortage of 
this magnitude would be twice as large as any shortage experienced by 
this country since the 1960s. Cuts to Title VIII funding would be 
detrimental to the health care system and the patients we serve.

           TITLE VIII: NURSING WORKFORCE DEVELOPMENT PROGRAMS

    The Nursing Workforce Development programs, authorized under Title 
VIII of the Public Health Service Act (42 U.S.C. 296 et seq.), includes 
programs such as Nursing Loan Repayment Program and Scholarships 
Program, (Sec. 846, Title VIII, PHSA); Advanced Nursing Education (ANE) 
Grants; (Sec. 811), Advanced Education Nursing Traineeships, (AENT); 
Nurse Anesthetist Traineeships (NAT): Comprehensive Geriatric Education 
Grants, (Sec. 855, Title VIII, PHSA); Nurse Faculty Loan Program, (Sec. 
846 A, Title VIII, PHSA); and Nursing Workforce Diversity Grants, (Sec. 
821). These programs support the supply and distribution of qualified 
nurses to meet our Nation's healthcare needs.
    Without support for Title VIII funding and nursing education; there 
will be a shortage of nurse educators. With a shortage of nurse 
educators, schools will have to turn away nursing students. With less 
financial assistance to deserving nursing students; there will be fewer 
nursing students. With fewer nursing students, there will be fewer 
nurses. As noted above, the nursing shortage will have a detrimental 
impact on the entire health care system.
    Numerous studies have shown that nursing shortages contribute to 
medical errors, poor patient outcomes, and increased mortality rates. A 
study published in the March 17, 2011 issue of the New England Journal 
of Medicine shows that inadequate staffing is tied to higher patient 
mortality rates. The study supports findings of previous studies and 
finds that higher than typical rates of patient admissions, discharges, 
and transfers during a shift were associated with increased mortality--
an indication of the important time and attention needed by RNs to 
ensure effective coordination of care for patients at critical 
transition periods.
    Over the last 48 years, Title VIII programs have provided the 
largest source of Federal funding for nursing education; offering 
financial support for nursing education programs, individual students, 
and nurse educators. These programs bolster nursing education at all 
levels, from entry-level preparation through graduate study and in many 
areas including rural and medically underserved communities.
    The American Association of Colleges of Nursing's (AACN) Title VIII 
Student Recipient Survey gathers information about Title VIII dollars 
and its impact on nursing students. The 2011-2012 survey, which 
included responses from over 1,600 students, stated that Title VIII 
programs played a critical role in funding their nursing education. The 
survey showed that 68 percent of the students receiving Title VIII 
funding are attending school full-time. Between fiscal year 2005 and 
2010 alone, the Title VIII programs supported over 400,000 nurses and 
nursing students as well as numerous academic nursing institutions, and 
healthcare facilities.
    However, current funding levels are falling short of the growing 
need. In fiscal year 2008 (most recent year statistics are available), 
the Health Resources and Services Administration (HRSA) was forced to 
turn away 92.8 percent of the eligible applicants for the Nurse 
Education Loan Repayment Program (NELRP), and 53 percent of the 
eligible applicants for the Nursing Scholarship program due to a lack 
of adequate funding. These programs are used to direct RNs into areas 
with the greatest need--including community health centers, departments 
of public health, and disproportionate share hospitals. Additionally 
according to the AACN Title VIII Student Recipient Survey, a record 
58,327 qualified applicants were turned away due to insufficient 
clinical teaching sites, a lack of faculty, limited classroom space, 
insufficient preceptors and budget cuts.
    Monies you appropriate for these programs help move nurses into the 
workforce without delay. Your investment in programs, and the nurses 
that participate, is returned by more students entering into the 
profession and serving in rural and underserved areas; by nurses 
continuing with their education and studying to be nurse practitioners, 
thereby addressing our Nation's growing need for primary care 
providers; or by going on to become a nurse faculty member and teaching 
the next generation of nurses.
    While ANA appreciates the continued support of this subcommittee, 
we are concerned that Title VIII funding levels have not been 
sufficient to address the growing nursing shortage. Registered Nurses 
(RNs) and Advanced Practice Nurses (APRNs) are key providers whose care 
is linked directly to the availability, cost, and quality of healthcare 
services. For these reasons and many more, we again respectfully 
request you appropriate $251 million for the Nursing Workforce 
Development programs authorized under Title VIII of the Public Health 
Service Act in fiscal year 2014.

                      NURSE-MANAGED HEALTH CLINICS

    A health care system must value primary care and prevention to 
achieve an improved health status of individuals, families and the 
community. Nurses are strong supporters of community and home-based 
models of care. We believe that the foundation for a wellness-based 
health care system is built in these settings and reduces the amount of 
both financial expenditures and human suffering. ANA supports the 
renewed focus on new and existing community-based programs such as 
Nurse Managed Health Clinics (NMHCs).
    Currently, there are more than 200 Nurse Managed Health Clinics 
(NMHCs) in the United States which have provided care to over 2 million 
patients annually. ANA believes that Nurse Managed Health Clinics 
(NMHCs) are an efficient, cost-effective way to deliver primary health 
care services. NMHCs are effective in disease prevention and early 
detection, management of chronic conditions, treatment of acute 
illnesses, health promotion, and more. These clinics are also used as 
clinical sites for nursing education.
    We respectfully request the committee provide $20 million for the 
Nurse-Managed Health Clinics authorized under Title VIII of the Public 
Health Service Act in fiscal year 2014.
    Thank you for your time and your attention to this matter.
                                 ______
                                 
      Prepared Statement of the American Psychological Association

    The American Psychological Association (APA) is the largest 
scientific and professional organization representing psychology in the 
U.S.: Membership includes more than 137,000 researchers, educators, 
clinicians, consultants and students. Through its divisions in 54 
subfields of psychology and affiliations with 60 State, territorial and 
Canadian provincial associations, APA works to advance the creation, 
communication and application of psychological knowledge to benefit 
society and improve people's lives.
    APA is very concerned that deficit reduction efforts to date--both 
actual and those under consideration--have relied almost exclusively on 
cuts to public health, health research, and other discretionary 
programs. Public health and health research programs have experienced 
three consecutive years of cuts. Under sequestration, these cuts will 
be even deeper. We urge this Committee to consider the critical role of 
the Public Health Service agencies in our Nation's security, 
infrastructure and economic growth when making funding decisions.
    As a member of the Centers for Disease Control and Prevention (CDC) 
Coalition, APA supports at least $7.8 billion for CDC core programs in 
fiscal year 2014. CDC programs play a key role in protecting Americans 
from public health threats and emergencies, and in reducing healthcare 
costs and strengthening the Nation's health system. In addition to the 
significant overall funding cuts that the CDC has seen in recent years, 
funding for the agency has increasingly relied heavily on the 
Prevention and Public Health Fund and other fund transfers, so that the 
agency has seen deep cuts to its budget authority. The Prevention and 
Public Health Fund was intended to supplement and not supplant the base 
funding of our public health agencies and programs. APA urges the 
Committee to restore CDC's budget authority.
    As a member of the Friends of the National Center for Health 
Statistics (NCHS), APA recommends $181.5 million for the center in 
fiscal year 2014, consistent with the President's request. The data 
collected by NCHS on chronic disease prevalence, health care 
disparities, emergency room use, teen pregnancy, infant mortality, 
causes of death, and rates of insurance, to name a few, are essential 
to the Nation's statistical and public health infrastructure. The 
Committee's leadership in securing stable funding has helped NCHS 
rebuild after years of underinvestment and stabilize the collection of 
essential health data.
    APA applauds the NCHS's progress including questions related to 
sexual orientation in the National Health Interview Survey (NHIS), and 
urges that other Federal surveys to follow suit. Still, there is slower 
progress toward inclusion of gender identity questions. APA urges the 
Committee to ensure that milestones established in the July, 2011 
national data progression plan are met.
    APA is pleased that the Committee has continued to designate 
specific funding for the CDC's Prevention Research Centers (PRC) 
program, and urges the Committee to restore funding for the program to 
at least $28 million in fiscal year 2014, consistent with fiscal year 
2011 funding levels. The PRC network of community, academic, and public 
health partners makes significant research contributions that are 
essential to the focus on prevention that is critically needed to 
improve health in America.
    APA asks the Committee to encourage the National Center on Injury 
Prevention and Control to increase research on the psychological impact 
of intimate partner and sexual violence in order to increase and 
improve evidence based interventions to support the recovery of women 
from the trauma of violence.
    Finally, APA strongly supports the President's request for $10 
million for gun violence prevention research and for $20 million for 
expansion of the CDC's National Violent Death Reporting System. The 
freeze on Federal funding for gun violence research has significantly 
hampered psychological scientists' ability to systematically assess 
risks and to determine the effectiveness of various preventive 
measures. A new IOM committee on priorities for a public health 
research agenda to reduce the threat of firearm-related violence 
recently hosted a workshop where scientists from a range of fields, 
including psychology, presented on very promising topics for future and 
continued research, necessary for closing the gaps in knowledge about 
this devastating problem that faces our Nation and for determining 
effective solutions.
    APA supports at least $32 billion for the National Institutes of 
Health in fiscal year 2014. This represents the minimum investment 
necessary to avoid further loss of promising research, and at the same 
time allows the NIH's budget to keep pace with biomedical inflation. 
NIH drives scientific innovation and develops new and better 
diagnostics, improved prevention strategies, and more effective 
treatments. NIH supports critical behavioral research on aging, memory, 
learning, child development, behavior change and maintenance, and 
prevention and treatment of many chronic and acute conditions. Just a 
few highlights:
  --NIMH-supported research has shown that biomedical approaches to HIV 
        prevention are most effective when they are combined with 
        behavioral approaches. Behavioral research is needed more than 
        ever to bolster medication adherence and treatment uptake, to 
        document real-world decision- making processes associated with 
        biomedical interventions, and to better understand potential 
        unintended and/or undesired consequences of biomedical 
        interventions.
  --NICHD-supported research is examining the critical impact of stress 
        in altering a child's developmental trajectories. Investment in 
        additional longitudinal research is needed to understand the 
        long-term impact of stress on mental health outcomes, 
        cognitive, emotional and social development, including self-
        control, inhibitory response, executive functioning, attention, 
        memory and learning skills and how those variables impact later 
        adolescent health behaviors, childhood obesity and academic 
        achievement.
  --NIA-supported research is focusing on the feasibility of reversing 
        childhood disadvantage in later life.
  --NIDDK-supported research is exploring ways in which basic 
        behavioral research can be applied to the problem of obesity.
  --APA commends NIH for addressing the need for a more diverse 
        biomedical and behavioral research workforce and is encouraged 
        that NIH is examining the factors contributing to this 
        disparity in funding success, including the role of bias in the 
        peer review process, the process by which funding decisions are 
        made, and training/mentoring and support programs for under-
        represented investigators across the pipeline and at critical 
        career decision points. APA encourages the Committee to 
        continue to press NIH to improve common data collected and 
        measured across the biomedical and behavioral workforce, 
        including those programs that track underrepresented students 
        and investigators. Such efforts will provide the much needed 
        information and direction regarding what programs and 
        initiatives are most successful at enhancing the diversity of 
        the scientific workforce.
    Turning to the Center for Mental Health Services, APA is concerned 
that while minorities represent 30 percent of the population and are 
projected to increase to 40 percent by 2025, only 23 percent of recent 
doctorates in psychology, social work and nursing were awarded to 
minorities. We encourage the Committee to increase funding for the 
Minority Fellowship Program by $4.4 million as requested in the 
President's fiscal year 2014 budget proposal. The increase reflects the 
need to continually grow the pool of culturally competent mental health 
professionals.
    APA strongly supports the work of SAMHSA's National Child Traumatic 
Stress Network (NCTSN) program and recommends increased support for the 
Network and its efforts on behalf of the recovery of children, 
families, and communities affected by physical and sexual abuse, school 
and community violence, natural disasters, sudden death of a loved one, 
the impact of war on military families, and other sources of trauma.
    Given that approximately 20-25 percent of older adults have a 
mental or behavioral health problem, and older white males (age 85 and 
over) currently have the highest rates of suicide of any group in the 
U.S. APA supports an expanded effort to address the mental and 
behavioral health needs of older adults including implementation of the 
mental and behavioral health provisions in the Older Americans Act 
Amendments of 2006, grants to States for the delivery of mental health 
screening, and treatment services for older individuals and programs to 
increase public awareness and reduce the stigma associated with mental 
disorders in older individuals.
    APA also recommends continued support of the HHS's Lifespan Respite 
Program. Respite care can provide family caregivers with relief 
necessary to maintain their own health, bolster family stability and 
well-being, and avoid or delay more costly nursing home or foster care 
placements.
    In an effort to efficiently and effectively address the mental 
health issues facing our Nation, APA strongly urges the Committee to 
invest in programs already established and currently serving the 
Nation's needs to increase access to mental and behavioral health 
services and to increase the number of psychologists trained to provide 
those documented and needed mental and behavioral health services to 
those who need it throughout the country. APA urges Congress to fund 
the Health Resources and Services Administration`s Graduate Psychology 
Education program (GPE) at $4.5 million. This level represents a 
restoration to previously funded level for fiscal year 2003-2005 and 
would allow for 35-40 grants nationwide with over 900 eligible 
universities and hospitals. According to the President's Budget for 
fiscal year 2010-2011 in that year alone the GPE Program enabled the 
addition of 620 doctoral level trainees to be trained through an 
interdisciplinary approach to provide mental and behavioral health 
services to approximately 46,000 underserved children, older adults, 
chronically ill persons, and victims of abuse and trauma including 
veterans and their families.
    In addition, APA urges support of the programs funded under the 
Garrett Lee Smith Memorial Act at least at current appropriated levels. 
The suicide prevention programs authorized under the GLSMA and 
administered by the Substance Abuse and Mental Health Services 
Administration--State/Tribal, Campus, and the Technical Assistance 
Center--provide critical services to our youth population. Mental 
disorders account for nearly one-half of the disease burden for young 
adults in the United States, according to the Journal of Adolescent 
Health's January 2010 article, Mental Health Problems and Help-Seeking 
Behavior among College Students. Further, suicide is the second-leading 
cause of death for adolescents and young adults between the ages of 10 
and 24 and results in 4,850 lives lost each year, according to the 
Centers for Disease Control and Prevention. Any Federal efforts to 
provide needed services to this population should be supported by 
investing in the GLSMA programs.
    APA appreciates the Committee's efforts to support these programs 
which benefit all Americans.
                                 ______
                                 
      Prepared Statement of the American Public Health Association

    The American Public Health Association is the collective voice 
advocating for the public's health. As a diverse community of public 
health professionals, we've championed the health of all people and 
communities around the world for more than 140 years. We are pleased to 
submit our views regarding the fiscal year 2014 budgets of the Centers 
for Disease Control and Prevention and the Health Resources and 
Services Administration. We urge you to take our recommendations into 
consideration as you move forward with writing the fiscal year 2014 
Labor-HHS-Education Appropriations bill.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

    APHA believes that that Congress should support CDC as an agency--
not just the individual programs that it funds. Given the challenges 
and burdens of chronic disease, the ongoing threat of an influenza 
pandemic, constant public health emergencies, new and reemerging 
infectious diseases and our many unmet public health needs and missed 
prevention opportunities--we urge a funding level of $7.8 billion for 
CDC's programs in fiscal year 2014. Unfortunately, the President's 
fiscal year 2014 budget request for CDC represents a nearly $277 
million reduction when compared with fiscal year 2012. These proposed 
cuts come on top of the $577 million reduction to CDC in fiscal year 
2013 due to the sequester and reduction in Prevention and Public Health 
Fund resources. After these cuts, CDC's budget authority is now lower 
than 2003 levels.
    At the same time State and local health departments are operating 
on tight budgets and with a smaller workforce. Since 2008, more than 
46,000 State and local public health jobs have been lost. These cuts 
are simply not sustainable and will reduce the ability of CDC and its 
State and local grantees to investigate and respond to public health 
emergencies as well as food borne and infectious disease outbreaks.
    By translating research findings into effective intervention 
efforts, CDC is a critical source of funding for many of our State and 
local programs that aim to improve the health of communities. Perhaps 
more importantly, Federal funding through CDC provides the foundation 
for our State and local public health departments, supporting a trained 
workforce, laboratory capacity and public health education 
communications systems.
    CDC also serves as the command center for our Nation's public 
health defense system against emerging and reemerging infectious 
diseases. With the potential onset of a worldwide influenza pandemic 
and the many other natural and man-made threats that exist in the 
modern world, CDC has become the Nation's--and the world's--expert 
resource and response center, coordinating communications and action 
and serving as the laboratory reference center. States and communities 
rely on CDC for accurate information and direction in a crisis or 
outbreak.
    CDC serves as the lead agency for bioterrorism and other public 
health emergency preparedness and response programs and must receive 
sustained support for its preparedness programs in order for our Nation 
to meet future challenges. Given the challenges of terrorism and 
disaster preparedness, and our many unmet public health needs and 
missed prevention opportunities we urge you to provide adequate funding 
for State and local capacity grants. Unfortunately, this is not a 
threat that is going away.
    CDC plays a significant role in addressing chronic diseases such as 
heart disease, stroke, cancer, diabetes and arthritis that continue to 
be the leading causes of death and disability in the United States. 
These diseases, many of which are preventable, are also among the most 
costly to our health system. CDC's National Center for Chronic Disease 
Prevention and Health Promotion provides critical funding for State 
programs to prevent chronic disease, conducts surveillance to collect 
data on disease prevalence and monitor intervention efforts and 
translates scientific findings into public health practice in our 
communities.
    CDC's National Center for Environmental Health is essential to 
protecting and ensuring the health and well being of the American 
public by helping to control asthma, protecting from threats associated 
with natural disasters and climate change and reducing exposure to lead 
and other environmental hazards. We encourage the subcommittee to 
provide adequate funding for NCEH programs which has been significantly 
cut in recent years.

              HEALTH RESOURCES AND SERVICES ADMINISTRATION

    HRSA operates programs in every State and U.S. territory and is a 
national leader in providing health services for individuals and 
families. Roughly 55 million Americans are currently uninsured and more 
than 60 million live in rural communities where primary health care 
services are scarce--the agency serves as a health safety net for the 
medically underserved and works to improve their health. To respond to 
these challenges, APHA believes that the agency will require funding of 
$7.0 billion for discretionary HRSA programs in fiscal year 2014.
    The recommended funding level takes into account the need to reduce 
the Nation's deficit while prioritizing the immediate and long-term 
health needs of Americans. We are deeply concerned with the failure to 
avert the sequester that will cut over $311 million from HRSA's fiscal 
year 2013 discretionary funding. These cuts come on top of the 17 
percent or more than $1.2 billion reduction to HRSA's budget authority 
since fiscal year 2010. Unfortunately, the President's fiscal year 2014 
budget request for HRSA proposes a more than $193 million reduction 
when compared with fiscal year 2012. HRSA's ability to prevent 
sickness, keep people healthy and treat illness or injury for millions 
of Americans will be severely compromised, by across-the-board cuts if 
the sequester is not reversed and the cuts restored. Our recommended 
funding level is necessary to ensure HRSA is able to implement 
essential public health programs, including training for public health 
and health care professionals, providing primary care services through 
health centers, improving access to care for rural communities, 
supporting maternal and child health care programs and providing health 
care to people living with HIV/AIDS. In addition to delivering much 
needed services, the programs provide an important source of local 
employment and economic growth in many low-income communities.
    Our recommendation is based on the need to continue improving the 
health of Americans by supporting critical HRSA programs, including:
  --Health Professions programs support the education and training of 
        primary care physicians, nurses, dentists, optometrists, 
        physician assistants, mental and behavioral health 
        professionals and other allied health providers. With a focus 
        on primary care and training in interdisciplinary, community-
        based settings, these are the only Federal programs focused on 
        filling the gaps in the supply of health professionals, as well 
        as improving the distribution and diversity of the workforce so 
        health professionals are well-equipped to care for the Nation's 
        growing, aging and increasingly diverse population.
  --Primary Care programs support nearly 8,900 community health centers 
        and clinics in every State and U.S. territory, improving access 
        to care for more than 20 million patients in geographically 
        isolated and economically distressed communities. Close to half 
        of these health centers serve rural populations. In addition, 
        health centers target populations with special needs, including 
        migrant and seasonal farm workers, homeless individuals and 
        families and those living in public housing.
  --Maternal and Child Health programs, including the Title V Maternal 
        and Child Health Block Grant, Healthy Start and others support 
        a myriad of initiatives designed to promote optimal health, 
        reduce disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality health care for more 
        than 40 million women and children, including children with 
        special health care needs.
  --HIV/AIDS programs provide assistance to States and communities most 
        severely affected by HIV/AIDS. The programs deliver 
        comprehensive care, prescription drug assistance and support 
        services for more than half a million low-income people 
        impacted by HIV/AIDS, which accounts for roughly half of the 
        total population living with the disease in the U.S. 
        Additionally, the programs provide education and training for 
        health professionals treating people with HIV/AIDS and work 
        toward addressing the disproportionate impact of HIV/AIDS on 
        racial and ethnic minorities.
  --Family Planning Title X services ensure access to a broad range of 
        reproductive, sexual and related preventive healthcare for over 
        5 million poor and low-income women, men and adolescents at 
        nearly 4,400 health centers nationwide. This program helps 
        improve maternal and child health outcomes and promotes healthy 
        families.
  --Rural Health programs improve access to care for people living in 
        rural areas where there is a shortage of health care services. 
        These programs are designed to support community-based disease 
        prevention and health promotion projects, help rural hospitals 
        and clinics implement new technologies and strategies and build 
        health system capacity in rural and frontier areas.

                   PREVENTION AND PUBLIC HEALTH FUND

    We are deeply disappointed with the diversion of more than $450 
million from the Prevention and Public Health Fund in fiscal year 2013 
to pay for implementing the health exchanges through the Affordable 
Care Act. Between the reduction due to sequestration (-$51 million) and 
the net diversion of resources for implementation of health exchanges 
(-$332 million), programs currently supported by the fund are faced 
with a more than 38 percent cut from fiscal year 2012. While the HHS 
Secretary Sebelius was able to transfer some additional discretionary 
funding to blunt some of the cuts to agencies such as CDC, we urge you 
to oppose any future efforts to divert this funding and to instead 
appropriate adequate funding for ACA implementation in fiscal year 
2014. We are pleased that the President's fiscal year 2014 budget 
proposal restores the use of the fund to its original intent. We urge 
the Senate Appropriations Committee to work with the administration to 
ensure this funding goes toward supporting State, local, tribal and 
community-based activities in all 50 States for community prevention, 
tobacco use prevention, obesity prevention and fitness, and clinical 
prevention.

                               CONCLUSION

    In closing, we emphasize that the public health system requires 
stronger financial investments at every stage. This funding makes up 
only a fraction of Federal spending and continued cuts to public health 
and prevention programs will not balance our budget, it will only lead 
to increased costs to our health care system. Successes in biomedical 
research must be translated into tangible prevention opportunities, 
screening programs, lifestyle and behavior changes and other 
population-based interventions that are effective and available for 
everyone. Without a robust and sustained investment in our public 
health agencies, we will fail to meet the mounting health challenges 
facing our Nation.
                                 ______
                                 
      Prepared Statement of the American Society for Microbiology

    The American Society for Microbiology (ASM) is pleased to submit 
the following statement on the fiscal year 2014 appropriation for the 
Centers for Disease Control and Prevention (CDC). The ASM is the 
largest single life science organization in the world with 
approximately 37,000 members.
    The CDC is the lead Federal agency to prevent disease, injury, and 
disability and it must be adequately resourced for known and new public 
health threats. CDC partners with State and local health departments 
and global organizations and CDC medical personnel, scientists and 
other public health professionals respond to public health events 24/7 
wherever needed. CDC experts react quickly to events here and abroad, 
ranging from foodborne illness outbreaks or previously unknown 
infectious pathogens, to the health crises following earthquakes or 
typhoons.
    The ASM is very concerned that budgetary cuts are seriously eroding 
CDC's capabilities in key areas like surveillance, laboratory 
diagnosis, and control and prevention strategies. The budget 
constraints now in effect will prove deleterious to our Nation's public 
health system. Sequestration mandated cuts will certainly weaken or 
even eliminate important CDC activities. CDC officials have already 
announced probable decreases in grant award amounts and in numbers of 
new awards. Sequestration is expected to cut CDC support to States by 
more than $200 million, which will unquestionably affect responses to 
disease outbreaks and other urgent public health problems.
    Recent outbreak investigations point to the CDC's unique and 
multifaceted capabilities that are at risk under budget shortages. Last 
year, CDC personnel tracked the fungal meningitis linked to 
contaminated steroid injections, with over 700 cases and almost 50 
deaths across 20 States. CDC's epidemiologists and laboratories 
investigated hantavirus infection among visitors to Yosemite National 
Park, bacterial infections in pediatric oncology patients in Colorado, 
the unprecedented outbreak of West Nile encephalitis in the Dallas/Fort 
Worth area. CDC also supported international efforts against infectious 
diseases, investigating cholera in Sierra Leone, anthrax in the 
Republic of Georgia, Marburg hemorrhagic fever in Uganda, and other 
outbreaks elsewhere. CDC funding is critical to building and 
maintaining the expertise necessary to sustain CDC's rapid responses to 
public health threats in the U.S. and worldwide.
    As the Nation's public health agency, CDC continually faces 
challenges like microbial agents of infectious disease and other 
illnesses. One in six Americans gets sick each year from eating 
contaminated food; more than 1,000 foodborne outbreaks are reported to 
CDC officials annually. The CDC estimates that, each year in the United 
States, there are nearly 20 million new sexually transmitted diseases 
(STD) infections incurring lifetime medical costs of $15.6 billion. 
Despite progress in treating HIV infection, significant challenges 
remain (e.g., in 2010, an estimated 12,200 new infections in people in 
the U.S. aged 13-24; in 2011, 2.5 million people newly infected 
worldwide). Nearly 900,000 children in other countries still die each 
year from vaccine preventable diseases like rotavirus, hepatitis B, 
pneumococcal pneumonia, and meningitis. The U.S. has also witnessed a 
recent upsurge in vaccine-preventable diseases, with over 42,000 cases 
of pertussis (whooping cough) reported in 2012 alone and declared 
epidemics in several States. Globalization has meant fewer barriers to 
the spread of infectious diseases, making CDC's multi-talented programs 
even more essential. Human migration contributes considerably to the 
spread of disease: Each year, about 214 million people move across 
national borders, three quarter billion within their own countries, and 
nearly 3 billion travel by plane.

CDC Funding Provides Rapid Response, Surveillance
    CDC has more than 15,000 employees and has personnel deployed to 
over 50 countries, trained to protect through health promotion, 
prevention of disease and disability, and preparedness. Such 
widespread, diverse expertise gives CDC its agility to detect and 
define an expansive array of threats and to respond quickly. The 2012-
2017 strategic plan of CDC's National Center for Emerging and Zoonotic 
Infectious Diseases (NCEZID) underscores the complexities involved--one 
overall strategy, intended to ``strengthen public health 
fundamentals,'' directs CDC personnel to ``advance and increase 
effectiveness of infectious disease laboratory science, surveillance, 
epidemiology, information technology, communications, and strategic 
partnerships.'' The CDC budget directly support extensive surveillance, 
science based epidemiology, and other tools effective in combating 
disease.
    CDC investigations vary from behind the scenes lab support for 
localized incidents to frontline responses in highly visible outbreaks. 
An example is CDC's current collaboration with the World Health 
Organization (WHO) to better understand a previously unknown 
respiratory virus, related to the SARS virus that emerged in China in 
2002 and rapidly infected 8,000 worldwide. The new coronavirus, thus 
far called NCoV for novel coronavirus, causes severe lower respiratory 
disease. As of March 7, there were only 14 confirmed cases reported to 
WHO, with eight deaths, all among patients with ties to the Middle 
East, and thus far no cases have been identified in the United States. 
But CDC and other health organizations that have already faced fast 
moving outbreaks like SARS are concerned by similar evidence of human-
to-human transmission and spread of the virus to other countries, 
especially given the conflicts and volatility currently engulfing the 
Middle East. CDC laboratories also are conducting tests on patient 
specimens to isolate the new virus, as public health officials prepare 
to engage yet another communicable disease.
    CDC regularly applies its scientific expertise and laboratory 
capabilities to investigate outbreaks both large and limited in scope, 
including these recent examples:
  --CDC investigated more than 300 cases of swine-origin variant 
        influenza virus that occurred last summer and fall across 9 
        midwestern and mid-Atlantic States. Most cases were in children 
        who attended or exhibited swine at agricultural fairs, and a 
        number of hospitalizations and one death occurred. This virus 
        has acquired genetic material from the 2009 pandemic H1N1 
        virus, raising concerns about its pandemic potential. CDC and 
        States have been working with 4-H clubs, USDA, and State 
        agriculture agencies to address this emerging public health 
        concern and reduce the risk for the upcoming fair season.
  --CDC is collaborating with the U.S. Department of Agriculture's 
        Animal and Plant Health Inspection Service and State health 
        departments to follow an outbreak of human Salmonella 
        typhimurium infections linked to contact with pet hedgehogs. 
        The outbreak strain had been rare, with only one to two cases 
        reported via PulseNet (the national network for foodborne 
        disease surveillance) annually since 2002. Since 2011, an 
        increasing number of cases have been detected, with 14 in 2011, 
        18 in 2012, and two thus far in 2013.
  --In August, CDC investigators and the FDA linked a multi-State 
        outbreak of salmonellosis to contaminated cantaloupes from an 
        individual farm, using pulsed field gel electrophoresis 
        analysis of patient samples. There are over 2,700 serotypes of 
        foodborne Salmonella bacteria, and advanced diagnostic tests 
        used by CDC are essential in accurately pinpointing sources.
  --In January, CDC summarized its foodborne surveillance for 2009-
        2010: 1,527 foodborne disease outbreaks reported, involving 
        29,444 cases of illness. Among the 790 events with a single 
        confirmed pathogen, 42 percent were caused by norovirus, 30 
        percent by Salmonella.
    CDC must also address the alarming rise of drug resistant 
pathogens, including Carbapenem Resistant Enterobacteriaceae (CRE). 
Multiple CDC networks, with input from State health departments, have 
detected increased cases over the past decade, warning of a potential 
``nightmare'' scenario. CDC officials just released strongly worded 
reports on the pathogen's ``triple threat'': (1) resistant to all, or 
nearly all, available antibiotics; (2) causes a high mortality rate 
(40-50 percent); and (3) can transfer antibiotic resistance to certain 
other bacteria, even those normally benign. This is yet another example 
of the continuing threat of health care associated infections (HAIs).
    Surveillance networks hosted by CDC collect data on a long list of 
diseases, using powerful computing and two way communication with 
thousands of public health partners. These help guide CDC strategy, 
providing another weapon against both emerging threats, like 
chikungunya virus or multidrug resistant tuberculosis, and longtime 
problems like foodborne illnesses. Last year, for instance, CDC 
surveillance identified a resurgence of WNV infections: By mid-
December, there had been nearly 5,390 U.S. cases reported from 48 
States, the highest number since 2003. Since 1999, when WNV was first 
identified in the United States, CDC has tabulated more than 30,000 
cases. With transfusion associated cases first reported in 2002, CDC 
and its partners implemented WNV screening of the U.S. blood supply in 
2003, preventing an estimated 3,000 to 9,000 transfusion related 
infections.

CDC Funding Protects, Promotes Public Health
    Using surveillance data, public education, and tools like vaccines, 
CDC strives to prevent illness and injury, being proactive well beyond 
reacting to disease outbreaks. To illustrate, although CRE is still 
limited in the United States, it is typically acquired within 
healthcare settings. This has prompted CDC to develop a CRE action 
plan, part of its ongoing education campaigns to both minimize drug 
resistance among pathogens and prevent costly healthcare associated 
infections (HAIs). In its latest progress report (February 2013), CDC 
listed successes against some types of HAIs using stringent infection 
control measures; for example, a 41 percent reduction in central line 
associated bloodstream infections since 2008. These CDC efforts embody 
the obvious: that prevention quite literally is more cost effective 
than finding a cure.
    There are few public health measures as historically effective as 
immunization against communicable diseases. Both in the United States 
and elsewhere, CDC has been a major contributor, of personnel, 
vaccines, expert support systems, to national and global immunization 
campaigns like those against smallpox and polio. As of 2010, 85 percent 
of children aged 12-23 months were immunized against measles worldwide. 
Over the previous decade, measles deaths had been cut by 74 percent. In 
this country, CDC vigorously promotes vaccination against childhood 
infectious diseases, influenza, hepatitis, and more. It also evaluates 
new candidate vaccines through collaborations with medical schools and 
other Federal agencies. Yet last year's outbreak of whooping cough, a 
vaccine preventable disease, is a reminder that U.S. vaccination 
coverage is incomplete and that CDC education efforts must continue.
    The ASM strongly urges that Congress increase the CDC budget in 
fiscal year 2013 and fiscal year 2014 and fund the CDC at the highest 
possible level.
                                 ______
                                 
      Prepared Statement of the American Society for Microbiology

    The American Society for Microbiology (ASM) is pleased to submit 
the following statement on the fiscal year 2014 appropriation for the 
National Institutes of Health (NIH). The ASM is the largest single life 
science organization in the world with more than 37,000 members.
    The NIH supports research programs essential to public health and 
to stimulating valuable economic sectors in health care and biomedical 
sciences, and creating our future scientific workforce. The current 
fiscal impasse is alarming to the biomedical research community. NIH 
appropriations already had fallen short in recent years, with the 
Agency losing one-fifth of its purchasing power over the past decade. 
The budget sequestration now in effect would further cut NIH funding by 
over 5 percent in the current fiscal year, which actually would equal 
nearly 9 percent over the remaining fiscal year 2013 period.
    The ASM is very concerned by the probable fallout from this 
additional approximately $1.6 billion decrease in NIH's fiscal year 
2013 funding, particularly when biomedical research should receive 
more, not less, Federal support. NIH recently informed the scientific 
community that all grant awards currently being funded likely would 
receive less than their full fiscal year 2013 commitment levels. Under 
sequestration, the Agency also will distribute fewer new awards. The 
most recent success rate of grant applications was already at a low 18 
percent compared with 30 percent in 2003. In February, analysis by 
United for Medical Research (UMR) projected that sequestration of NIH 
funding could force the loss of 20,500 U.S. jobs and $3 billion in 
economic output. Sequestration decreases foreshadow the already grim 
scenario of an estimated $900 billion in NIH spending cuts over the 
next 10 years mandated under the Budget Control Act.
    NIH funding jeopardizes the Nation's competitive edge in 
biomedicine and thus our economic success in the innovation dependent 
global marketplace. Budget cuts also will have a chilling effect on 
whether young Americans choose research careers, if those careers 
appear to lack professional and financial stability. It is generally 
agreed that the United States must attract and inspire, not discourage, 
the next generation of scientists. We urge Congress to also recognize 
that inadequate NIH funding would fail a national public health system 
faced with rising healthcare costs, as well as an aging and 
increasingly diverse population. In 2011, national health spending 
reached an estimated $2.7 trillion (17.9 percent of the GDP), a 
startling argument for those effective disease treatment and prevention 
approaches discovered through NIH funding.
    The ASM strongly urges Congress to add additional funding for the 
NIH in fiscal year 2013 and fiscal year 2014 and fund the NIH at the 
highest possible level of funding.

NIH Funding of Biomedical Research is Essential to the Fight against 
        Infectious Diseases
    Biomedical advances extend life expectancy and steadily improve our 
quality of life. Examples include HIV/AIDS studies transforming a fatal 
disease into a chronic condition through treatment, and the vaccine 
development responsible for dramatic global declines in diphtheria, 
polio, yellow fever, tetanus, and smallpox. Each year, three NIAID 
supported vaccines are now saving numerous children worldwide: 
pneumococcal vaccine, 826,000; Haemophilus influenzae type b vaccine, 
386,000; and rotavirus vaccine, 435,000.
    Despite lower mortality from communicable causes, infectious 
diseases persist as significant threats to public health. Detecting, 
preventing, and treating infectious diseases is a critical part of 
NIH's portfolio. In allocating resources, it is important to remember 
that NIH is the Nation's primary Federal supporter of basic, clinical, 
and translational research in medicine, generating diagnostics, 
therapeutics, prevention strategies, and surveillance tools that help 
lift the burden of infectious disease.
    Health agencies in the United States periodically confront 
infectious diseases variously classified as newly emerging, reemerging/
resurging, or deliberately emerging (bioterrorism), as well as 
pathogens increasingly resistant to drug therapy. In recent years, 
these so called emerging infectious diseases (EID) have included those 
caused by hantavirus, HIV, and highly virulent strains of E. coli and 
influenza viruses; rising numbers of dengue, listeriosis, and West 
Nile; and drug resistant forms of Staphylococcus aureus. In 2012 alone, 
emerging examples included a novel disease causing coronavirus 
initially reported in the Middle East and a variant influenza virus 
(H3N2v) that spread from swine to people in U.S. farm communities. The 
media report this month (March) of a man infected with a deadly form of 
the tuberculosis pathogen, one considered to be ``extensively drug-
resistant'' (XDR TB), is just the most recent reminder that we cannot 
afford to fall behind in our understanding of, and science based 
responses to, microbial pathogens and their host interactions. U.S. 
health officials found his TB strain to be resistant to at least eight 
of the available standard drugs. Before being stopped at the U.S.-
Mexico border and placed in medical isolation, he had traveled through 
13 countries over 3 months. XDR poses a major threat due to its 
frightening drug resistance.
    Scientists funded by the NIAID consistently achieve advances 
against HIV/AIDS, malaria, tuberculosis, influenza, and other diseases 
significant to our health and economy. To illustrate their importance, 
NIAID supported these examples from the past year:
  --Genetic changes in the salivary glands of mosquitoes infected with 
        dengue virus might increase virus transmission, elucidating 
        viral biology that must be understood to develop 
        countermeasures. There currently is no vaccine or drug 
        treatment for dengue, which globally infects about 50 million 
        to 100 million each year and has been reported in parts of the 
        United States.
  --Discovery of a toxin transport system in S. aureus suggests a new 
        approach to drugs against a pathogen notorious for its ability 
        to resist traditional antibiotics. Methicillin resistant staph 
        (MRSA) is a leading cause of U.S. hospital acquired infections, 
        causing an estimated 18,000 deaths in 2005. In other research, 
        genome sequencing of multiple strains of vancomycin resistant 
        S. aureus gives scientific insight into pathogens resistant to 
        an antibiotic of last resort.
  --Universal flu vaccines against a wide range of virus strains are 
        moving closer to reality with results from studies like those 
        of human immune cells producing broadly neutralizing antibodies 
        against flu viruses and those showing that a prime boost 
        vaccine regimen can elicit ``universal'' antibody production. 
        Several clinical trials of first generation universal vaccines 
        are either under way or planned at NIAID's Vaccine Research 
        Center.
  --Clinical trials demonstrated the most effective antiretroviral drug 
        regimens to prevent HIV infection (pre-exposure prophylaxis, or 
        PrEP); other research helped shape antiretroviral treatment for 
        HIV infected individuals. Last August, NIAID awarded $7.8 
        million in first year funding to universities and medical 
        centers for basic research to identify new approaches in HIV 
        vaccine design, part of a much larger HIV vaccine discovery 
        effort.
    The NIGMS has funded basic research on the structure and function 
of HIV, in search of new treatments, for more than 25 years. It is a 
partner with the National Science Foundation, the U.S. Department of 
Agriculture and others in the Ecology and Evolution of Infectious 
Diseases (EEID) program, contributing expertise in basic research. Last 
year, NIGMS supported scientists developed a new improved CH-activation 
technique to add molecules to existing compounds, making it easier to 
tailor make new drugs; others reported on how iron uptake plays a role 
in bacterial invasion of host tissues.
    We invest in NIH each year to expand our vital scientific 
knowledge, but also to create real world products that protect our 
communities. In February, for example, researchers launched early-stage 
clinical trials of two candidate vaccines against Shigella infection, 
which each year causes about 90 million cases of severe diarrheal 
illness and 108,000 deaths worldwide. Others are working toward broad 
spectrum antivirals effective against groups of pathogens, like that 
being developed against all enveloped viruses, including the Nipah, 
Ebola, HIV, influenza, and Rift Valley fever viruses. NIH also is 
supporting development of new technologies like nanoscience techniques 
to detect pathogens hidden deep in human tissue and genome sequencing 
to better track infectious disease outbreaks.

NIH Funding Stimulates Economic Sector, Workforce Expansion
    Biomedicine is big business--the U.S. medical innovation sector 
employs 1 million U.S. citizens, generates $84 billion in wages and 
salaries, and exports $90 billion in goods and services. Yet U.S. 
industry performs only 17 percent of basic research, leaving most of 
the biomedical ``foundation building'' to Federal responsibility. NIH 
is the largest funder of biomedical research in the world, including 
the research of 138 Nobel Prize winners. It contributes more than 80 
percent of Federal biomedical research funding in the United States. 
The NIH extramural program supports about 50,000 competitive research 
grants and 300,000 scientists and research personnel at more than 2,500 
medical schools, universities, and other institutions throughout the 
country. Annual appropriations also support nearly 6,000 scientists 
working at the 27 NIH institutes and centers. The UMR analysis released 
in February reinforced the agency's importance as an economic motive 
force. In 2012 alone, the NIH financed more than 402,000 jobs and $57.8 
billion in economic output nationwide.
    Investment in NIH clearly reaps rewards well beyond improved public 
health. Since 2000, for example, NIGMS supported research has received 
18 Nobel Prizes either in Chemistry or in Physiology or Medicine. In 
December, NIH proposed multiple initiatives to help strengthen both the 
U.S. biomedical research enterprise and the Nation's global 
competitiveness, designed ''to support a research ecosystem that 
leverages the flood of biomedical data, strengthens the research 
workforce through diversity, and attracts the next generation of 
researchers.'' To be successful, initiative strategies like enhanced 
training of graduate students and better management of ``big data'' 
through high performance computing will require sufficient funding 
increases.
    NIH support for university research has long been a major factor in 
scientific and technological innovation in medicine. Unfortunately, the 
current fiscal scenario will force reductions in existing grants and 
likely fewer new awards going forward. Scientists at U.S. universities 
are already reporting sequestration related setbacks to their planned 
research, casting doubt on both potential breakthroughs and student 
training programs. Stakeholders in biomedical research are concerned 
that among the research jobs at risk, younger scientists will be 
particularly affected. Undermining a future workforce generation is 
shortsighted, and the ASM fears subsequent negative impacts on new R&D 
discoveries, public health, and U.S. global competitiveness.
    The ASM urgently requests the Congress increase funding for the NIH 
and biomedical research.
                                 ______
                                 
        Prepared Statement of the American Society for Nutrition

    Dear Chairman Harkin and Ranking Member Moran: The American Society 
for Nutrition (ASN) respectfully requests $32 billion for the National 
Institutes of Health (NIH) and $162 million for the Centers for Disease 
Control and Prevention/National Center for Health Statistics (CDC/NCHS) 
in fiscal year 2014. ASN is dedicated to bringing together the world's 
top researchers to advance our knowledge and application of nutrition. 
ASN has nearly 5,000 members working throughout academia, clinical 
practice, Government, and industry, who conduct research to help all 
Americans live healthier, more productive lives.

                     NATIONAL INSTITUTES OF HEALTH

    The National Institutes of Health (NIH) is the Nation's premier 
sponsor of biomedical research and is the agency responsible for 
conducting and supporting 86 percent (approximately $1.4 billion) of 
federally-funded basic and clinical nutrition research. Nutrition 
research, which makes up about 4 percent of the NIH budget, is truly a 
trans-NIH endeavor, being conducted and funded across multiple 
Institutes and Centers. Some of the most promising nutrition-related 
research discoveries have been made possible by NIH support. In order 
to fulfill the full potential of biomedical research, including 
nutrition research, ASN recommends an fiscal year 2014 funding level of 
$32 billion for the NIH, a modest increase over the current funding 
level of $30.64 billion.
    The modest increase we recommend is necessary to maintain both the 
existing and future scientific infrastructure. The discovery process--
while it produces tremendous value--often takes a lengthy and 
unpredictable path. Economic stagnation is disruptive to training, 
careers, long range projects and ultimately to progress. NIH needs 
sustainable and predictable budget growth to achieve the full promise 
of medical research and to improve the health of all Americans. It is 
imperative that we continue our commitment to biomedical research and 
continue our Nation's dominance in this area by making the NIH a 
national priority.
    Over the past 50 years, NIH and its grantees have played a major 
role in the growth of knowledge that has transformed our understanding 
of human health, and how to prevent and treat human disease. Because of 
the unprecedented number of breakthroughs and discoveries made possible 
by NIH funding, scientists are helping Americans to live healthier and 
more productive lives. Many of these discoveries are nutrition-related 
and have impacted the way clinicians prevent and treat heart disease, 
cancer, diabetes and other chronic diseases. By 2030, the number of 
Americans age 65 and older is expected to grow to 72 million, and the 
incidence of chronic disease will also grow. Sustained support for 
basic and clinical research is required if we are to successfully 
confront the health care challenges associated with an older, and 
potentially sicker, population.

               CDC NATIONAL CENTER FOR HEALTH STATISTICS

    The National Center for Health Statistics (NCHS), housed within the 
Centers for Disease Control and Prevention, is the Nation's principal 
health statistics agency. The NCHS provides critical data on all 
aspects of our health care system, and it is responsible for monitoring 
the Nation's health and nutrition status through surveys such as the 
National Health and Nutrition Examination Survey (NHANES), that serve 
as a gold standard for data collection around the world. Nutrition and 
health data, largely collected through NHANES, are essential for 
tracking the nutrition, health and well-being of the American 
population, and are especially important for observing nutritional and 
health trends in our Nation's children.
    Nutrition monitoring conducted by the Department of Health and 
Human Services in partnership with the U.S. Department of Agriculture/
Agricultural Research Service is a unique and critically important 
surveillance function in which dietary intake, nutritional status, and 
health status are evaluated in a rigorous and standardized manner. 
Nutrition monitoring is an inherently governmental function and 
findings are essential for multiple Government agencies, as well as the 
public and private sector. Nutrition monitoring is essential to track 
what Americans are eating, inform nutrition and dietary guidance 
policy, evaluate the effectiveness and efficiency of nutrition 
assistance programs, and study nutrition-related disease outcomes. 
Funds are needed to ensure the continuation of this critical 
surveillance of the Nation's nutritional status and the many benefits 
it provides.
    Through learning both what Americans eat and how their diets 
directly affect their health, the NCHS is able to monitor the 
prevalence of obesity and other chronic diseases in the U.S. and track 
the performance of preventive interventions, as well as assess 
`nutrients of concern' such as calcium, which are consumed in 
inadequate amounts by many subsets of our population. Data such as 
these are critical to guide policy development in the area of health 
and nutrition, including food safety, food labeling, food assistance, 
military rations and dietary guidance. For example, NHANES data are 
used to determine funding levels for programs such as the Supplemental 
Nutrition Assistance Program (SNAP) and the Women, Infants, and 
Children (WIC) clinics, which provide nourishment to low-income women 
and children.
    To continue support for the agency and its important mission, ASN 
recommends an fiscal year 2014 funding level of $162 million for NCHS. 
Sustained funding for NCHS can help to ensure uninterrupted collection 
of vital health and nutrition statistics, and will help to cover the 
costs needed for technology and information security upgrades that are 
necessary to replace aging survey infrastructure.
    Thank you for the opportunity to submit testimony regarding fiscal 
year 2014 appropriations for the National Institutes of Health and the 
CDC/National Center for Health Statistics. Please contact John E. 
Courtney, Ph.D., Executive Officer, if ASN may provide further 
assistance. He can be reached at 9650 Rockville Pike, Bethesda, 
Maryland 20814; or [email protected].
                                 ______
                                 
     Prepared Statement of the American Society for Pharmacology & 
                       Experimental Therapeutics

    The American Society for Pharmacology and Experimental Therapeutics 
(ASPET) is pleased to submit written testimony in support of the 
National Institutes of Health (NIH) fiscal year 2014 budget. ASPET 
recommends a budget of at least $32 billion for the NIH in fiscal year 
2014.
    Sustained growth for the NIH should be an urgent national priority. 
Research funded by the NIH improves public health, stimulates our 
economy and improves global competitiveness. Several years of flat 
funding and mandatory budget cuts required by sequestration in the 
current fiscal year prevents and delays advances in medical research, 
jeopardizes potential cures and eliminates jobs. Additionally, the 
Nation will lose a generation of young scientists who see no prospects 
for careers in biomedical research, creating a ``brain drain'' as many 
graduate students, post-doctoral researchers, and early career 
scientists leave the research enterprise or look for employment in 
foreign countries.
    The 5 percent sequestration cut further diminishes NIH's research 
capacity that has already fallen 20 percent since 2003 as a result of 
flat funding and inflation. With sequestration, NIH's purchasing power 
will be reduced by nearly 25 percent since 2003. Continued erosion of 
NIH's research capacity will accelerate further the diminishment of 
American leadership and innovation in biomedical research. Without a 
commitment to sustained funding for the NIH, the Nation's biomedical 
research capacity will erode further.
    A $32 billion budget for the NIH in fiscal year 2014 is a start to 
help restore NIH's biomedical research capacity. Currently, the NIH 
only can fund one in six grant applications, the lowest rate in the 
agency's history. Furthermore, the number of research project grants 
funded by NIH has declined every year since 2004.
    A budget of at least $32 billion in fiscal year 2014 will help the 
agency manage its research portfolio effectively without having to 
withhold funding for existing grants to researchers throughout the 
country. Scientific research takes time. Only through steady, sustained 
and predictable funding increases can NIH continue to fund the highest 
quality biomedical research to help improve the health of all Americans 
and continue to make significant economic impact in many communities 
across the country.
    There is no substitute for a steady, sustained Federal investment 
in biomedical research. Industry, venture capital, and private 
philanthropy can supplement research but cannot replace the investment 
in basic, fundamental biomedical research provided by NIH. Industry and 
venture capital both face their own economic challenges and venture 
capital investment in biomedicine has declined since 2007. Neither the 
private sector nor industry will be able to fill a void for NIH funded 
basic biomedical research. Much of industry support is applied research 
that builds upon the discoveries generated from NIH-funded projects. 
The majority of the investment in basic biomedical research that NIH 
provides is broad and long-term providing a continuous development 
platform for industry, which would not typically invest in research 
that may be of higher risk and require several years to fully mature. 
In addition to this long term view, NIH also has mechanisms in place to 
rapidly build upon key technologies and discoveries that have the 
ability to have significant impact on the health and well being of our 
citizens. Further, industry research is focused on developing drugs 
that are protected by patents and often does not make their data 
publicly available.
    Many of the basic science initiatives supported by NIH have led to 
totally unexpected discoveries and insight that have transformed our 
mechanistic understanding of and our ability to treat a wide range of 
diseases

Diminished Support for NIH will Negatively Impact Human Health
    Continued diminishment of funding for NIH will mean a loss of 
scientific opportunities to discover new therapeutic targets. Without a 
steady, sustained Federal investment in fundamental biomedical 
research, scientific progress will be slower and potentially helpful 
therapies or cures will not be developed. For example, more research is 
needed on Parkinson's disease to help identify the causes of the 
disease and help develop better therapies; discovery of gene variations 
in age-related macular degeneration could result in new screening tests 
and preventive therapies; more basic research is needed to focus on new 
molecular targets to improve treatment for Alzheimer's disease; and 
diminished support for NIH will prevent new and ongoing investigations 
into rare diseases that FDA estimates almost 90 percent are serious or 
life-threatening.
    Historically, our past investment in basic biological research has 
led to many innovative medicines. The National Research Council 
reported that of the 21 drugs with the highest therapeutic impact, only 
five were developed without input from the public sector. The 
significant past investment in the NIH has provided major gains in our 
knowledge of the human genome, resulting in the promise of 
pharmacogenomics and a reduction in adverse drug reactions that 
currently represent a major worldwide health concern. Several completed 
human genome sequence analyses have pinpointed disease-causing variants 
that have led to improved therapy and cures but further advances and 
improvements in technology will be delayed or obstructed with 
inadequate NIH funding.

Investing in NIH Helps America Compete Economically
    A $32 billion budget in fiscal year 2013 will also help the NIH 
train the next generation of scientists and provide a platform for 
broader workforce development that is so critical to our Nation's 
growth. Many individuals trained in the sciences via NIH support become 
educators in high schools and colleges. These individuals also enter 
into other aspects of technology development and evaluation in public 
and private sectors to further enrich the community and accelerate 
economic development.
    This investment will help to create jobs and promote economic 
growth. Limiting or cutting the NIH budget will mean forfeiting future 
discoveries and jobs to other countries.
    The U.S. share of global research and development investment from 
1999-2009 is now only 31 percent, a decline of 18 percent. In contrast, 
other nations continue to invest aggressively in science. China has 
grown its science portfolio with annual increases to the research and 
development budget averaging over 23 percent annually since 2000, 
including a 26 percent increase in 2012. Russia plans to increase 
support for research by 65 percent over the next 5 years. And while 
Great Britain 2 years ago also imposed strict austerity measures to 
address that Nation's debt problems, that Nation had the foresight to 
keep its strategic investments in science at current levels. The 
European Union, despite great economic distress and the severe debt 
problems of its member nations, has proposed to increase spending on 
research and innovation by 45 percent between 2014 and 2020.
    NIH research funding catalyzes private sector growth. More than 83 
percent of NIH funding is awarded to over 3,000 universities, medical 
schools, teaching hospitals and other research institutions in every 
State. One national study by an economic consulting firm found that 
Federal (and State) funded research at the Nation's medical schools and 
hospitals supported almost 300,000 jobs and added nearly $45 billion to 
the U.S. economy. NIH funding also provides the most significant 
scientific innovations of the pharmaceutical and biotechnology 
industries.

                               CONCLUSION

    ASPET appreciates the many competing and important spending 
decisions the subcommittee must make. The Nation's deficit and debt 
problems are great. However, NIH and the biomedical research enterprise 
face a critical moment. The agency's contribution to the Nation's 
economic and physical well being should make it one of the Nation's top 
priorities. With enhanced and sustained funding, NIH can begin to 
reverse its decline and help meet its potential to address many of the 
more promising scientific opportunities that currently challenge 
medicine. A budget of at least $32 billion in fiscal year 2014 will 
allow the agency to begin moving forward to full program capacity, 
exploiting more scientific opportunities for investigation, and 
increasing investigator's chances of discoveries that prevent, diagnose 
and treat disease. NIH should be restored to its role as a national 
treasure, one that attracts and retains the best and brightest to 
biomedical research and provides hope to millions of individuals 
afflicted with illness and disease.
    ASPET is a 5,100 member professional society whose members conduct 
basic, translational, and clinical pharmacological research within the 
academic, industrial and Government sectors. Our members discover and 
develop new medicines and therapeutic agents that fight existing and 
emerging diseases, as well as increase our knowledge regarding how 
therapeutics affects humans.
                                 ______
                                 
        Prepared Statement of the American Society of Hematology

    The American Society of Hematology (ASH) thanks the subcommittee 
for the opportunity to submit written testimony on the fiscal year 2014 
Departments of Labor, Health and Human Services, and Education 
Appropriations bill.
    ASH represents approximately 14,000 clinicians and scientists 
committed to the study and treatment of blood and blood-related 
diseases. These diseases encompass malignant disorders such as 
leukemia, lymphoma, and myeloma; life-threatening conditions, including 
thrombosis and bleeding disorders; and congenital diseases such as 
sickle cell anemia, thalassemia, and hemophilia. In addition, 
hematologists have been pioneers in the fields of bone marrow 
transplantation, stem cell biology and regenerative medicine, gene 
therapy, and the development of many drugs for the prevention and 
treatment of heart attacks and strokes.

Funding for Hematology Research: An Investment in the Nation's Health
    Over the past 60 years, American biomedical research has led the 
world in probing the nature of human disease. This research has led to 
new medical treatments, saved innumerable lives, reduced human 
suffering, and spawned entire new industries. This research would not 
have been possible without support from the National Institutes of 
Health (NIH). NIH-funded research drives medical innovation that 
improves health and quality of life through new and better diagnostics, 
improved prevention strategies, and more effective treatments. Federal 
funding of basic biomedical research through the NIH is crucial, as 
most of this discovery-based research is not supported by philanthropy 
or private industry. Discoveries gained through basic research yield 
the medical advances that improve the fiscal and physical health of the 
country.
    Funding for hematology research has been an important component of 
this investment in the Nation's health. Most of the research that 
produced cures and treatments for hematologic diseases has been funded 
by the NIH. The study of blood and its disorders is a trans-NIH issue 
involving many institutes at the NIH, including the National Heart, 
Lung and Blood Institute (NHLBI), the National Cancer Institute (NCI), 
the National Institute of Diabetes, Digestive and Kidney Diseases 
(NIDDK), and the National Institute on Aging (NIA).
    With the advances gained through an increasingly sophisticated 
understanding of how the blood system functions, hematologists have 
changed the face of medicine through their dedication to improving the 
lives of patients. As a result, children are routinely cured of acute 
lymphoblastic leukemia (ALL); more than 90 percent of patients with 
acute promyelocytic leukemia (APL) are cured with a drug derived from 
vitamin A; older patients suffering from previously lethal chronic 
myeloid leukemia (CML) are now effectively treated with well-tolerated 
pills; and patients with multiple myeloma are treated with new classes 
of drugs.
    Hematology advances also help patients with other types of cancers, 
heart disease, and stroke. Blood thinners effectively treat or prevent 
blood clots, pulmonary embolism, and strokes. Death rates from heart 
attacks are reduced by new forms of anticoagulation drugs. Stem cell 
transplantation can cure not only blood diseases but also inherited 
metabolic disorders, while gene therapy holds the promise of 
effectively treating even more genetic diseases. Even modest 
investments in hematology research have yielded large dividends for 
other disciplines.

The Future Promise of Hematology Research
    The era of precision medicine has arrived. Insights into new 
genetic and biologic markers can be used to understand what causes a 
disease, the risk factors that predispose to disease, and how patients 
will respond to a particular treatment. Translating these new 
discoveries and technologies into personalized patient care offers the 
possibility of better survival, less toxicity, disease prevention, 
improved quality of life, and lower health-care costs. However, many 
patients still lack effective therapy for malignant and non-malignant 
hematologic diseases.
    Research funding must increase to allow the major advances in 
understanding the molecular defects behind hematologic diseases to be 
translated into novel diagnostics and targeted therapeutics. Support 
for research in the areas listed below will be important for future 
progress:
  --Stem Cells and Regenerative Medicine: Turn iPS cells into cures for 
        human diseases
  --Myelodysplastic Syndrome and Acute Myeloid Leukemia: Find an 
        effective and personalized treatment for the elderly
  --Hematopoietic Stem Cell Transplantation: Increase success rates by 
        improving management of graft-versus-host disease
  --Sickle Cell Disease: Reduce the barriers to care, burden of pain, 
        end-organ injury, and premature death
  --Deep-Vein Thrombosis and Venous Thromboembolism: Understand the 
        risk factors and develop targeted therapies
  --Childhood Leukemia: Improve cure rates by performing coordinated 
        research that includes discovery and preclinical and clinical 
        testing of novel targeted therapies
  --Translating Laboratory Advances into the Clinic: Use novel genomic 
        technologies to improve treatment of hematologic diseases
Sequestration Threatens Scientific Momentum
    ASH is particularly concerned about the impact of continued cuts on 
biomedical research supported by the NIH. At a time when we should be 
investing more in research to save more lives, research funding is in 
serious jeopardy.
    After a decade of flat funding, the NIH budget after inflation is 
about 20 percent lower than it was in 2003. ASH is deeply disturbed 
about the impact that this effective ``un-doubling'' of the NIH budget, 
combined with the more than 5 percent cut in NIH funding under 
sequestration in the current fiscal year and additional planned cuts in 
future fiscal years, will have on the ability to sustain the scientific 
momentum that has contributed so greatly to our Nation's health and our 
economic vitality. NIH's ability to continue current research capacity 
and encourage promising new areas of science is, and will be, 
significantly limited. Sequestration will result in cuts in extramural 
grants and slowing momentum for the development of new treatments, or 
even cures, for seriously ill patients with deadly diseases.
    Additionally, perhaps one of the greatest concerns is the obstacle 
these continued cuts will present to the next generation of scientists, 
who will see training funds slashed and the possibility of sustaining a 
career in research diminished. NIH also plays a significant role in 
supporting the next generation of innovators, the young and talented 
scientists and physicians who will be responsible for the breakthroughs 
of tomorrow. The Society is especially concerned about the number of 
scientists who have abandoned research careers; continued cuts will 
exacerbate this exodus, forcing researchers to abandon potentially 
life-enhancing research, negatively affecting job creation, and 
seriously jeopardizing America's leadership in medical research 
throughout the world.

Fiscal Year 2014 NIH Funding Request
    ASH supports the recommendation of the Ad Hoc Group for Medical 
Research that the subcommittee recognize NIH as a critical national 
priority by providing at least $32 billion in funding in the fiscal 
year 2014 Labor-HHS-Education Appropriations bill. This funding 
recommendation represents the minimum investment necessary to avoid 
further loss of promising research and at the same time allows the 
NIH's budget to keep pace with biomedical inflation.
    Hematology research offers enormous potential to better understand, 
prevent, treat, and cure a number of blood-related and other 
conditions. Recent investments have created dramatic new research 
opportunities, spurring advancements and precipitating the promise of 
personalized medicine that will yield far-reaching health and economic 
benefits. Trials to find new therapies and cures for millions of 
Americans with blood cancers, bleeding disorders, clotting problems, 
and genetic diseases are just a few of the important projects that 
could be delayed unless NIH continues to receive predictable and 
sustained funding.
    It is critically important that our country continues to capitalize 
on the momentum of previous investments to drive research progress to 
develop new treatments for serious disorders, train the next generation 
of scientists, create jobs, and promote economic growth and innovation. 
Adequate funding is necessary for NIH to sustain current research 
capacity and encourage promising new areas of science and cures.
    While ASH recognizes the deficit and the increasing debt the 
country faces will require difficult decisions, it is also important to 
understand that Federal investment in research and public health 
programs saves lives, reduces health costs and strengthens the Nation. 
Funding for hematology research is an investment in the Nation's 
health. Research funding must increase to allow the major advances in 
understanding the molecular defects behind hematologic diseases to be 
translated into novel diagnostics and targeted therapeutics not only 
for blood disorders, but other life-threatening diseases. ASH urges the 
subcommittee to continue to be a champion for research and support at 
least $32 billion in funding for NIH in fiscal year 2014. The American 
people are depending on you to ensure the Nation does not lose the 
health and economic benefits of our extraordinary commitment to 
biomedical research.

Centers for Disease Control and Prevention (CDC) Public Health Response 
        for Blood Disorders
    The Society also recognizes the important role of the Centers for 
Disease Control and Prevention (CDC) in preventing and controlling 
clotting, bleeding, and other hematologic disorders. Blood disorders--
such as sickle cell disease, anemia, blood clots, and hemophilia--are a 
serious public health problem and affect millions of people each year 
in the United States, cutting across the boundaries of age, race, sex, 
and socioeconomic status. Men, women, and children of all backgrounds 
live with the complications associated with these conditions, many of 
which are painful and potentially life-threatening.
    Through the Division of Blood Disorders in the Center on Birth 
Defects and Developmental Disabilities (NCBDDD), CDC is working toward 
developing a comprehensive public health agenda to promote and improve 
the health of people with blood disorders. As a key component of this 
public health approach, CDC staff invest in identifying, monitoring, 
diagnosing, and investigating blood disorders to understand the 
prevalence and effect of these disorders. Charting the characteristics 
and outcomes of a disease population, such as those with sickle cell 
disease or hemophilia, can provide insight into these questions, as 
well as help identify the quality and cost of care issues that people 
who are affected face. Additionally, population-based studies can 
increase our understanding of risk factors that can result in severe 
complications for people with blood disorders.
    CDC is uniquely positioned to reduce the public health burden 
resulting from blood disorders by contributing to a better 
understanding of these conditions and their complications; ensuring 
that prevention programs are developed, implemented, and evaluated; 
ensuring that information is accessible to consumers and health care 
providers; and encouraging action to improve the quality of life for 
people living with or affected by these conditions. The Society is 
supportive of maintaining the programs funded by the Division of Blood 
Disorders and supports the requested budget authority of $20,672,000 
for the Public Health Approach to Blood Disorders in the President's 
fiscal year 2014 budget request. This funding will allow CDC to improve 
health outcomes and limit complications to those who are risk or 
currently have blood disorders, by promoting a comprehensive care 
model; identifying and evaluating effective prevention strategies; and 
increasing public and healthcare provider awareness of bleeding and 
clotting disorders such as such as hemophilia and thrombosis, and 
hemoglobinopathies, including sickle cell disease and thalassemia.
    Thank you again for the opportunity to submit testimony. Please 
contact Tracy Roades, ASH Legislative Advocacy Manager, at 
[email protected], if you have any questions or need further 
information concerning hematology research or ASH's fiscal year 2014 
funding request.
                                 ______
                                 
        Prepared Statement of the American Society of Nephrology

                           EXECUTIVE SUMMARY

    The American Society of Nephrology (ASN) requests $32 billion in 
funding for the National Institutes of Health (NIH) and $2 billion in 
funding for NIH's National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK) in the fiscal year 2014 Labor-HHS-Education 
Appropriations bill.
    ASN is dedicated to the study, prevention, and treatment of kidney 
disease, and the society's 14,000 plus members greatly respect your 
leadership and commitment to preventing illness, treating disease, and 
maintaining fiscal responsibility. Chronic kidney disease (CKD) 
currently affects more than 20 million Americans, and more than 570,000 
of them have irreversible kidney failure requiring life-sustaining 
treatment with regular dialysis therapies.
    The vast majority of research leading to advances in the care and 
treatment of adults and children afflicted with kidney disease is 
funded by the National Institutes of Health (NIH) broadly and the 
National Institute of Diabetes and Digestive and Kidney Diseases 
(NIDDK) specifically. Any reduction in this funding would seriously 
reduce our ability to contain and reverse this disease, which costs 
Americans enormous suffering, lost productivity, and foreshortened 
spans of life.
    Examples of critical discoveries arising from NIH-funded research 
are numerous. For instance, investigative studies supported by NIH and 
NIDDK led to a groundbreaking discovery that helps explain racial/
ethnic disparities that increase risks for kidney disease, which can 
lead to earlier detection and treatment. The recent finding that 
African Americans with two variants of the APOL1 gene are likely to 
experience faster decline in kidney function, and earlier initiation of 
hemodialysis than their peers without the gene, is a crucial step in 
understanding differences in kidney disease progression across 
different populations and how early interventions may improve their 
outcomes.
    Scientists supported by NIH and NIDDK also identified mutations in 
two genes that help regulate blood pressure and salt balance in a rare, 
heritable disease that causes high blood pressure, or hypertension. 
Hypertension is a leading contributor to the development of kidney 
failure, so this finding may improve hypertension management in 
patients with kidney disease--possibly preventing kidney failure--and 
could lead to better therapies for controlling high blood pressure in 
the general patient population.
    Moreover, funding from NIH and NIDDK enabled research that found 
that people with antibodies that target a protein [the phospholipase A2 
receptor called PLAR2] on a specific kidney cell develop a kidney 
disorder, known as nephrotic syndrome that results in a harmful excess 
protein in urine. Future therapies that reduce PLAR2 antibody levels 
may help prevent people with nephrotic syndrome from progressing to 
kidney failure.
    Dialysis is covered by Medicare regardless of a patient's age or 
disability status. Consequently, preventing kidney disease and 
advancing the effectiveness of therapies for kidney failure--starting 
with innovative research at NIDDK--would have a great impact at the 
highest level of costs within the Centers for Medicare and Medicaid 
Services. Perhaps most important, in human terms, the applied research 
will help prevent greater suffering among those who would otherwise 
progress to an even greater level of illness.
    Sustained, predictable investment in research is the only way that 
scientific investigations can be effective and lead to new discoveries. 
With funding from NIH and NIDDK, scientists have been able to pursue 
cutting-edge basic, clinical, and translational research. While ASN 
fully understands the difficult economic environment and the intense 
pressure you are under as an elected official to guide America forward 
during these tough times, the society firmly believes that funding NIH 
and NIDDK is a good investment to create jobs, support the next 
generation of investigators, and ultimately improve the public health 
of Americans.
    Several recent studies have concluded that Federal support for 
medical research is a major force in the economic health of communities 
across the Nation.
    It is critically important that the Nation continue to capitalize 
on previous investments to drive research progress, train the next 
generation of scientists, create new jobs, promote economic growth, and 
maintain leadership in the global innovation economy--particularly as 
other countries increase their investments in scientific research. Most 
important, a failure to maintain and strengthen NIH and NIDDK's ability 
to support the groundbreaking work of researchers across the country 
carries a palpable human toll, denying hope to the millions of patients 
awaiting the possibility of a healthier tomorrow.
    ASN strongly recommends that the fiscal year 2014 Labor-HHS-
Education Appropriations bill uphold its longstanding legacy of 
bipartisan support for biomedical research.
    Should you have any questions or wish to discuss NIH, NIDDK, or 
kidney disease research in more detail, please contact ASN Manager of 
Policy and Government Affairs Rachel Shaffer at [email protected].

                               ABOUT ASN

    The American Society of Nephrology (ASN) is a 501(c)(3) non-profit, 
tax-exempt organization that leads the fight against kidney disease by 
educating the society's more than 14,000 physicians, scientists, and 
other healthcare professionals, sharing new knowledge, advancing 
research, and advocating the highest quality care for patients. For 
more information, visit ASN's website at www.asn-online.org.
                                 ______
                                 
   Prepared Statement of the American Society of Pediatric Nephrology

    I am Dr. Joseph Flynn, President of the American Society of 
Pediatric Nephrology (ASPN). I am pleased to submit written testimony 
on behalf of the ASPN in support of Federal funding for the National 
Institutes of Health, including the National Institutes for Diabetes, 
Digestive and Kidney Diseases (NIDDK) and Eunice Kennedy Shriver 
National Institute for Child Health and Human Development (NICHD). In 
fiscal year 2014 we urge you to support an appropriation of $32 billion 
for the NIH, including at least $2.03 billion for NIDDK and $1.37 
billion for NICHD.
    Founded in 1969, the American Society for Pediatric Nephrology 
(ASPN) is a professional society composed of pediatric nephrologists 
whose goal is to promote optimal care for children with kidney disease 
and to disseminate advances in the clinical practice and basic science 
of pediatric nephrology. The ASPN currently has over 700 members, 
making it the primary representative of the pediatric nephrology 
community in North America.
    The mission of the National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK) is to support and conduct research to combat 
diabetes and other endocrine and metabolic diseases, liver and other 
digestive diseases, nutritional disorders, obesity, and kidney, 
urologic, and hematologic diseases. The NIDDK's broad mission covers 
chronic, common and costly diseases that have very tangible monetary 
consequences for our Nation. For example, estimates of chronic kidney 
disease (CKD) show that more than 23 million Americans are affected, 
and over 550,000 have irreversible end-stage renal disease (ESRD). 
ESRD's cost to our bottom line is also felt at the Centers for Medicare 
and Medicaid Services, as ESRD is covered by Medicare regardless of a 
patient's age. NIDDK-funded investigations intended to prevent this 
disease would have a significant impact on many Americans.
    Without research funded by the NIH and NIDDK, advances in the care 
and treatment of adults and children afflicted with kidney disease 
would not have been accomplished. For instance, hereditary diseases 
such as cystinosis--a metabolic disorder that affects the kidneys, 
eyes, thyroid, pancreas, and brain--can now be treated so as to prevent 
or delay its worst effects on children. The NIDDK supports a wide range 
of medical research through grants to universities and other medical 
research institutions across the country. The Institute also supports 
Government scientists who conduct basic, translational, and clinical 
research across a broad spectrum of research topics and serious, 
chronic diseases and conditions related to the Institute's mission. In 
addition, the NIDDK supports research training for students and 
scientists at various stages of their careers and a range of education 
and outreach programs to bring science-based information to patients 
and their families, health care professionals, and the public. 
Developing the next generation of researchers through grant support 
will solidify future novel therapeutics and improved outcomes for 
children with kidney disease.
    Established in 1963, the NICHD was initially founded to support the 
world's best minds in investigating human development throughout the 
entire lifespan, focusing on understanding developmental disabilities, 
including intellectual and developmental disabilities, and illuminating 
important events that occur during pregnancy. Since then, the NICHD has 
achieved an impressive array of scientific advances in its pursuit to 
enhance lives throughout all stages of human development, from 
preconception through adulthood, improving the health of children, 
adults, families, communities, and populations. Recent efforts by the 
NICHD to improve the availability and safety of drugs for children will 
have significant impact on pediatric therapeutics. Research supported 
and conducted by the NICHD has helped to explain the unique health 
needs of many, and has brought about novel and effective ways to 
fulfill them. An estimated 150,000 children and adolescents currently 
suffer from kidney disease; about 10,000 of them suffer from ESRD and 
receive chronic dialysis or have a kidney transplant. Children and 
adolescents undergoing dialysis or transplants are different from 
adults, with different underlying diseases, dependence on adult 
caregivers, and ongoing growth and development. Renal transplantation 
is the best treatment for children who reach ESRD, as transplant allows 
better growth and school attendance and a more normal life for affected 
children and families. The ASPN works to educate the public, Members of 
Congress and their staffs, and the medical community about these unique 
needs of pediatric patients with kidney disease. Nonetheless, without 
adequate funding from the NIH, pediatric nephrologists are unable to 
focus on this challenging pediatric population.
    The ASPN supports improving the quality of life for pediatric 
kidney patients, especially those with kidney transplants, through the 
following initiatives:
    Increased research focused on the prevention and early 
identification of pediatric kidney disease to decrease the growing need 
for renal transplantation.--The dramatic increase in childhood obesity 
puts more than 15 percent of America's children at risk for Type 2 
diabetes, hypertension, and chronic kidney disease later in life. The 
fastest growing segment of patients waiting for a kidney transplant 
today have ESRD related to complications of diabetes and hypertension, 
making it ever more difficult to keep up with the demand for kidney 
transplants. The ASPN advocates for more research to address ways to 
keep children with Type 2 diabetes and hypertension from becoming 
adolescents and young adults with ESRD. We also advocate for additional 
research to investigate the common causes of CKD and ESRD including 
progressive glomerular diseases and congenital anomalies of the kidney 
and urinary tract. Furthermore, we strongly support investigations into 
common sequelae of CKD and ESRD such as acidosis and kidney stones as 
well as those that can accelerate the progression from CKD to ESRD such 
as urinary tract infections, toxins, and acute kidney injury.
    Improved transition of patients from pediatric to adult medical 
care.--The ASPN collaborates with pediatric and adult nephrology 
professionals to improve the transition of adolescents to adult care. 
The ASPN advocates for better access to medical insurance coverage and 
anti-rejection medications for transitioning patients to help reduce 
the high incidence of loss of transplant function in adolescents and 
young adults. Kidney disease continues to be a major cause of illness 
and death among the most vulnerable segment of the population--our 
children--and research being conducted at the NIH will allow us to 
better understand how to reduce its impact. An estimated 150,000 
children and adolescents currently suffer from kidney diseases for 
which a cure or treatment does not exist; about 10,000 of them suffer 
from ESRD and are on dialysis or have a kidney transplant. With 
adequate funding for NIH, scientists will work to find cures or more 
effective treatments.
    We urge you to support the work conducted by NIDDK for research 
focused on pediatric kidney disease. ASPN is enthusiastic and 
encouraged by the discoveries made by such research. Because many adult 
kidney diseases originate prenatally or during childhood, we hope you 
can support NIDDK efforts to assign a higher priority to research that 
explores pediatric renal disease, focusing on the causes, outcomes and 
consequences of such diseases. Due to the unique challenges of 
recruiting children into clinical trials, NIDDK should fund research 
endeavors that include support for infrastructure and the enhancement 
of collaborative and comparative multicenter pediatric prospective 
clinical/translational trials that aim to improve patient outcomes.
    Additionally, normal child development is essential for promoting a 
healthy adult society. Diseases that pose a substantial burden in 
adults, such as hypertension and chronic kidney disease, may have their 
origins during childhood years or may be patterned in early fetal life. 
Cognitive development and cardiovascular health in children, which 
depend upon normal physiology, are essential for healthy, productive 
adult outcomes. Yet the importance of normal kidneys to normal 
intrauterine and childhood growth, and its impact on the risk of 
subsequent disease later in life, has not been well studied. We urge 
you to support collaboration between NICHD and NIDDK to undertake 
efforts to examine the role of normal kidney development and/or 
function in neonatal and child health. Specific opportunities to be 
addressed include: kidney function in low-birth weight infants; how 
chronic acidosis, untreated hypertension or recurrent urinary tract 
infections affect child development; the impact of childhood onset 
hypertension on adult cardiovascular health; and identification of 
genetic factors that may result in kidney injury and progression of 
hypertension and chronic kidney disease.
    Thank you for the opportunity to provide testimony in support of 
these vital programs. We look forward to continuing to work with you in 
the future on these important issues.
                                 ______
                                 
     Prepared Statement of the American Society of Plant Biologists

    On behalf of the American Society of Plant Biologists (ASPB), we 
would like to thank the subcommittee for its support of the National 
Institutes of Health (NIH). ASPB and its members strongly believe that 
sustained investments in scientific research will be a critical step 
toward economic recovery and job creation in our Nation. ASPB asks that 
the subcommittee Members encourage increased support for plant-related 
research within NIH; 25 percent of our medicines originate from 
discoveries related to plant natural products, and such research has 
contributed in innumerable ways to improving the lives and health of 
Americans and people throughout the world.
    ASPB is an organization of some 4,500 professional plant biology 
researchers, educators, students, and postdoctoral scientists with 
members across the Nation and throughout the world. A strong voice for 
the global plant science community, our mission--achieved through work 
in the realms of research, education, and public policy--is to promote 
the growth and development of plant biology, to encourage and 
communicate research in plant biology, and to promote the interests and 
growth of plant scientists in general.

Plant Biology Research and America's Future
    Among many other functions, plants form much of the base of the 
food chain upon which all life depends. Importantly, plant research is 
also helping make many fundamental contributions in the area of human 
health, including that of a sustainable supply and discovery of plant-
derived pharmaceuticals, nutriceuticals, and alternative medicines. 
Plant research also contributes to the continued, sustainable, 
development of better and more nutritious foods and the understanding 
of basic biological principles that underpin improvements in the health 
and nutrition of all Americans.

Plant Biology and the National Institutes of Health
    Plant science and many of our ASPB member research activities have 
enormous positive impacts on the NIH mission to pursue ``fundamental 
knowledge about the nature and behavior of living systems and the 
application of that knowledge to extend healthy life and reduce the 
burdens of illness and disability.'' In general, plant research aims to 
improve the overall human condition--be it food, nutrition, medicine or 
agriculture--and the benefits of plant science research readily extend 
across disciplines. In fact, plants are often the ideal model systems 
to advance our ``fundamental knowledge about the nature and behavior of 
living systems'' as they provide the context of multi-cellularity while 
affording ease of genetic manipulation, a lesser regulatory burden, and 
maintenance requirements that are less expensive than those required 
for the use of animal systems.
    Many fundamental biological components and mechanisms (e.g., cell 
division, viral and bacterial invasion, polar growth, DNA methylation 
and repair, innate immunity signaling and circadian rhythms) are shared 
by both plants and animals. For example, a process known as RNA 
interference, which has potential application in the treatment of human 
disease, was first discovered in plants. Subsequent research eventually 
led to two American scientists, Andrew Fire and Craig Mello, earning 
the 2006 Nobel Prize in Physiology or Medicine. More recently 
scientists engineered a class of proteins called TALENs capable of 
precisely editing genomes to potentially correct mutations that lead to 
disease. That these therapeutic proteins are derived from others 
initially discovered in a plant pathogen exemplifies the application of 
plant biology research to improving human health. These important 
discoveries again reflect the fact that some of the most important 
biological discoveries applicable to human physiology and medicine can 
find their origins in plant-related research endeavors.
    Health and Nutrition.--Plant biology research is also central to 
the application of basic knowledge to ``extend healthy life and reduce 
the burdens of illness and disability.'' Without good nutrition, there 
cannot be good health. Indeed, a World Health Organization study on 
childhood nutrition in developing countries concluded that over 50 
percent of child deaths under the age of five could be attributed to 
malnutrition's effects in weakening the immune system and exacerbating 
common illnesses such as respiratory infections and diarrhea. 
Strikingly, most of these deaths were not linked to severe 
malnutrition, but chronic nutritional deficiencies brought about by 
overreliance on single crops for primary staples. Plant researchers are 
working today to address the root cause of this problem by balancing 
the nutritional content of major crop plants to provide the full range 
of essential micronutrients in plant-based diets.
    By contrast to developing countries, obesity, cardiac disease, and 
cancer take a striking toll in the developed world. Research to improve 
and optimize concentrations of plant compounds known to have, for 
example, anti-carcinogenic properties, will hopefully help in reducing 
disease incidence rates. Ongoing development of crop varieties with 
tailored nutraceutical content is an important contribution that plant 
biologists can and are making toward realizing the long-awaited goal of 
personalized medicine, especially for preventative medicine.
    Drug Discovery.--Plants are also fundamentally important as sources 
of both extant drugs and drug discovery leads. In fact, 60 percent of 
anti-cancer drugs in use within the last decade are of natural product 
origin--plants being a significant source. An excellent example of the 
importance of plant-based pharmaceuticals is the anti-cancer drug 
taxol, which was discovered as an anti-carcinogenic compound from the 
bark of the Pacific yew tree through collaborative work involving 
scientists at the NIH National Cancer Institute and plant natural 
product chemists. Taxol is just one example of the many plant compounds 
that will continue to provide a fruitful source of new drug leads.
    While the pharmaceutical industry has largely neglected natural 
products-based drug discovery in recent years, research support from 
NIH offers yet another paradigm. Multidisciplinary teams of plant 
biologists, bioinformaticians, and synthetic biologists are being 
assembled to develop new tools and methods for natural products 
discovery and creation of new pharmaceuticals. We appreciate NIH's 
current investment into understanding the biosynthesis of natural 
products through transcriptomics and metabolomics of medicinal plants. 
The recently released ``Genomes to Natural Products'' funding 
opportunity is also to be applauded as a potential avenue for new 
plant-related medicinal research, and we strongly encourage the 
continuation of these types of investments and other plant-related 
initiatives which can help further achievement of the NIH mission.

Conclusion
    Although NIH does recognize that plants serve many important roles, 
the boundaries of plant-related research are expansive and integrate 
seamlessly and synergistically with many different disciplines that are 
also highly relevant to NIH. As such, ASPB asks the subcommittee to 
provide direction to NIH to support additional plant research in order 
to continue to pioneer new discoveries and new methods with 
applicability and relevance in biomedical research.
    Thank you for your consideration of our testimony on behalf of the 
American Society of Plant Biologists. For more information about ASPB, 
please see www.aspb.org.
                                 ______
                                 
  Prepared Statement of the American Society of Tropical Medicine and 
                                Hygiene

    The American Society of Tropical Medicine and Hygiene (ASTMH)--the 
principal professional membership organization representing, educating, 
and supporting scientists, physicians, clinicians, researchers, 
epidemiologists, and other health professionals dedicated to the 
prevention and control of tropical diseases--appreciates the 
opportunity to submit testimony to the House Labor, Health and Human 
Services, and Education Appropriations Subcommittee. The benefits of 
U.S. investment in tropical diseases are both humanitarian and 
diplomatic. With this in mind, we respectfully request that the 
subcommittee fully fund the NIH and CDC in the fiscal year 2014 LHHS 
appropriations bill in order to ensure a continued U.S. investment in 
global health and tropical medicine research and development, 
specifically:

National Institutes of Health:
  --Malaria and neglected tropical disease (NTD) treatment, control, 
        and research and development efforts within the National 
        Institute of Allergy and Infectious Diseases (NIAID);
  --Expanded focus on diarrheal disease within the NIH;
  --Research capacity development in countries where populations are at 
        heightened risk for malaria, NTDs, and diarrheal diseases 
        through the Fogarty International Center (FIC); and
  --Research on infectious diseases transmitted by ticks, fleas, and 
        mosquitoes that occur within the borders of the U.S. as well as 
        in tropical and subtropical regions abroad.
The Centers for Disease Control and Prevention:
  --The Center for Global Health, which includes CDC's work in malaria 
        and NTDs; and
  --The National Center for Emerging & Zoonotic Infectious Diseases, 
        which is responsible for protecting the U.S. from new and 
        emerging infections spread by mosquitoes and ticks.
              return on investment of u.s.-funded research
    CDC and NIH play essential roles in R&D for tropical medicine and 
global health. Both agencies are at the forefront of the new science 
that leads to tools to combat malaria and NTDs. This research provides 
jobs for American researchers and an opportunity for the U.S. to be a 
leader in the fight against global disease, in addition to creating 
lifesaving new drugs and diagnostics to some of the poorest, most at-
risk people in the world.

                            TROPICAL DISEASE

    Malaria and Parasitic Disease.--Malaria remains a global emergency 
affecting mostly poor women and children; it is an acute, sometimes 
fatal disease. Despite being treatable and preventable, malaria is one 
of the leading causes of death and disease worldwide. Approximately 
every 30 seconds, a child dies of malaria--a total of about 800,000 
under the age of 5 every year. The World Health Organization (WHO) 
estimates that one half of the world's people are at risk for malaria 
and that there are 108 malaria-endemic countries.
    Neglected Tropical Diseases.--NTDs are a group of chronic parasitic 
diseases, which represent the most common infections of the world's 
poorest people. These infections have been revealed as the stealth 
reason why the ``bottom billion''--the 1.4 billion poorest people 
living below the poverty line--cannot escape poverty, because of the 
effects of these diseases on reducing child growth, cognition and 
intellect, and worker productivity.
    Diarrheal Disease.--The child death toll due to diarrheal illnesses 
exceeds that of AIDS, tuberculosis, and malaria combined. In poor 
countries, diarrheal disease is second only to pneumonia as the cause 
of death among children under 5 years old. Every week, 31,000 children 
in low-income countries die from diarrheal diseases.
    The United States has a long history of leading the fight against 
tropical diseases that cause human suffering and pose financial burden 
that can negatively impact a country's economic and political 
stability. Tropical diseases, many of them neglected for decades, 
impact U.S. citizens working or traveling overseas, as well as our 
military personnel. Additionally, some diseases such as dengue fever 
have been found in the U.S.

                     NATIONAL INSTITUTES OF HEALTH

    National Institute of Allergy and Infectious Diseases.--A long-term 
investment is critical to achieve the drugs, diagnostics, and research 
capacity needed to control malaria and NTDs. NIAID is the lead 
institute for malaria and NTD research.
ASTMH encourages the subcommittee to:
  --Increase funding for NIH to expand the agency's investment in 
        malaria, NTDs, tick-borne infections, and diarrheal disease 
        research and coordinate with other agencies to maximize 
        resources and ensure development of basic discoveries into 
        usable solutions;
  --Specifically invest in NIAID to support its role at the forefront 
        of these efforts to developing the next generation of drugs, 
        vaccines, and other interventions; and
  --Urge NIH to include enteric infections and neglected diseases in 
        its RCDC process on the RePORT website to outline the work that 
        is being done in these important research areas.
    Fogarty International Center.--Biomedical research has provided 
major advances in the treatment and prevention of malaria, NTDs, and 
other infectious diseases. These benefits, however, are often slow to 
reach the people who need them most. FIC works to strengthen research 
capacity in countries where populations are particularly vulnerable to 
threats posed by malaria, NTDs, and other infectious diseases. This 
maximizes the impact of U.S. investments and is critical to fighting 
malaria and other tropical diseases.

ASTMH encourages the subcommittee to:
  --Allocate sufficient resources to FIC in fiscal year 2014 to 
        increase these efforts, particularly as they address the 
        control and treatment of malaria, NTDs, and diarrheal disease.
             the centers for disease control and prevention
    Malaria and Parasitic Disease.--Malaria has been eliminated as an 
endemic threat in the United States for over fifty years, and CDC 
remains on the cutting edge of global efforts to reduce the toll of 
this deadly disease. CDC efforts on malaria and parasitic disease fall 
into three broad categories: prevention, treatment, and monitoring/
evaluation of efforts. The agency performs a wide range of basic 
research within these categories, such as:
  --Conducting research on antimalarial drug resistance to inform new 
        strategies and prevention approaches;
  --Assessing new monitoring, evaluation, and surveillance strategies;
  --Conducting additional research on malaria vaccines, including field 
        evaluations; and
  --Developing innovative public health strategies for improving access 
        to antimalarial treatment and delaying the appearance of 
        antimalarial drug resistance.

ASTMH encourages the subcommittee to:
  --Fund a comprehensive approach to effective and efficient malaria 
        and parasitic disease, including adequately funding the 
        important contributions of CDC in malaria and parasitic disease 
        at no less than $18 million.
    Neglected Topical Diseases.--CDC currently receives zero dollars 
directly for NTD work outside of parasitic diseases; however, this 
should be changed to allow for more comprehensive work to be done on 
NTDs at CDC. CDC has a long history of working on NTDs and has provided 
much of the science that underlies the global policies and programs in 
existence today.

ASTMH encourages the subcommittee to:
  --Provide direct funding to CDC to continue its work on NTDs, 
        including but not limited to parasitic diseases; and
  --Urge CDC to continue its monitoring, evaluation, and technical 
        assistance in these areas as an underpinning of efforts to 
        control and eliminate these diseases.
    Vector-Borne Disease Program (VBDP).--Through the VBDP, researchers 
are able to practice essential surveillance and monitoring activities 
that protect the U.S. from deadly infections before they reach our 
borders and to address problems of tick- and flea-transmitted 
infections such as Lyme disease and a dozen other infections, some of 
which are life-threatening within the U.S. The world is becoming 
increasingly smaller as international travel increases and new 
pathogens are introduced quickly into new environments. We have seen 
this with SARS, avian influenza, and now, dengue fever, in the United 
States. Arboviruses like dengue, and others, such as chikungunya, are a 
constant threat to travelers, and to Americans generally.
ASTMH encourages the subcommittee to:
  --Ensure that CDC maintain these activities by continuing CDC funding 
        for VBDP activities through the National Center for Emerging 
        and Infectious Zoonotic Diseases.

                               CONCLUSION

    Thank you for your attention to these important U.S. and global 
health matters. We know Congress and the American people face many 
challenges in choosing funding priorities, and we hope you will provide 
the requested fiscal year 2014 resources to those programs identified 
above that meet critical needs for Americans and people around the 
world. ASTMH appreciates the opportunity to share its expertise, and we 
thank you for your consideration of these requests that will help 
improve the lives of Americans and the global poor.
                                 ______
                                 
          Prepared Statement of the American Thoracic Society

                    SUMMARY: FUNDING RECOMMENDATIONS
                             [In millions $]
------------------------------------------------------------------------
 
------------------------------------------------------------------
National Institutes of Health......................      32,000
    National Heart, Lung & Blood Institute.........       3,214
    National Institute of Allergy & Infectious            4,701
     Disease.......................................
    National Institute of Environmental Health              717.7
     Sciences......................................
    Fogarty International Center...................          72.7
    National Institute of Nursing Research.........         151
Centers for Disease Control and Prevention.........       7,800
    National Institute for Occupational Safety &            293.6
     Health........................................
    Asthma Programs................................          25.3
    Div. of Tuberculosis Elimination...............         243
    Office on Smoking and Health...................         197.1
    National Sleep Awareness Roundtable (NSART)....           1
------------------------------------------------------------------------

    The American Thoracic Society (ATS) is pleased to submit our 
recommendations for programs in the Labor Health and Human Services and 
Education Appropriations Subcommittee purview. Founded in 1905, the ATS 
is an international education and scientific society of 15,000 members 
that focuses on respiratory and critical care medicine. ATS members 
help prevent and fight respiratory disease through research, education, 
patient care and advocacy.

Lung Disease in America
    Diseases of breathing constitute the third leading cause of death 
in the U.S., responsible for one of every seven deaths. Diseases 
affecting the respiratory (breathing) system include chronic 
obstructive pulmonary disease (COPD), lung cancer, tuberculosis, 
influenza, sleep disordered breathing, pediatric lung disorders, 
occupational lung disease, asthma, and critical illness. The death rate 
due to COPD has doubled within the last 30 years and is still 
increasing, while the rates for the other three top causes of death 
(heart disease, cancer and stroke) have decreased by over 50 percent. 
The number of people with asthma in the U.S. has surged over 150 
percent since 1980 and the root causes of the disease are still not 
fully known. Research into the diagnosis, treatment and prevention of 
lung diseases should be expanded to meet the increasing public health 
burden of these diseases.

National Institutes of Health
    The NIH is the world's leader in groundbreaking biomedical health 
research into the prevention, treatment and cure of diseases such as 
lung cancer, COPD and tuberculosis. But due to eroded funding, the 
success rate for NIH research grants has plummeted to below 13 percent, 
which means that more than 85 percent of meritorious research is not 
being funded. The implementation of budget sequestration in fiscal year 
2013 will cut NIH by an additional $1.5 billion, which will result in 
the elimination of at least 1,000 grant opportunities and cuts of up to 
10 percent for continuing grants. These cuts will result in the halting 
of vital research into diseases affecting millions around the world. We 
ask the subcommittee to provide $32 billion in funding for the NIH in 
fiscal year 2014.
    Despite the rising lung disease burden, lung disease research is 
underfunded. In fiscal year 2012, lung disease research represented 
just 23.2 percent of the National Heart Lung and Blood Institute's 
(NHLBI) budget. Although lung disease is the third leading cause of 
death in the U.S., research funding for the disease is a small fraction 
of the money invested for the other three leading causes of death. In 
order to stem the devastating effects of lung disease, research funding 
must continue to grow.

Centers for Disease Control and Prevention
    In order to ensure that health promotion and chronic disease 
prevention are given top priority in Federal funding, the ATS supports 
a funding level for the Centers for Disease Control and Prevention 
(CDC) that enables it to carry out its prevention mission, and ensure a 
translation of new research into effective State and local public 
health programs. We ask that the CDC budget be adjusted to reflect 
increased needs in chronic disease prevention, infectious disease 
control, including TB control and occupational safety and health 
research and training. The ATS recommends a funding level of $7.8 
billion for the CDC in fiscal year 2014.

COPD
    COPD is the third leading cause of death in the United States and 
the third leading cause of death worldwide. CDC estimates that 12 
million patients have COPD; an additional 12 million Americans are 
unaware that they have this life threatening disease. In 2010, the 
estimated economic cost of lung disease in the U.S. was $186 billion, 
including $117 billion in direct health expenditures and $69 billion in 
indirect morbidity and mortality costs.
    Despite the growing burden of COPD, the U.S. does not have a public 
health action plan on the disease. The ATS is pleased that the NHLBI is 
developing a national action plan, in coordination with the Centers for 
Disease Control and Prevention (CDC) to expand COPD surveillance, 
develop public health interventions and expand research public 
awareness of the disease. The NHLBI has shown successful leadership in 
educating the public about COPD through the COPD Education and 
Prevention Program.
    CDC has an additional role to play in this work. We urge CDC to 
include COPD-based questions to future CDC health surveys, including 
the National Health and Nutrition Evaluation Survey (NHANES) and the 
National Health Information Survey (NHIS).

Tobacco Control
    Cigarette smoking is the leading preventable cause of death in the 
U.S., responsible for one in five deaths annually. The ATS is pleased 
that the Department of Health and Human Services has made tobacco use 
prevention a key priority. The CDC's Office of Smoking and Health 
coordinates public health efforts to reduce tobacco use. In order to 
significantly reduce tobacco use within 5 years, as recommended by the 
subcommittee in fiscal year 2010, the ATS recommends a total funding 
level of $197 million for the Office of Smoking and Health in fiscal 
year 2014.

Asthma
    Asthma is a significant public health problem in the United States. 
Approximately 25 million Americans currently have asthma. In 2010, 
3,388 Americans died as a result of asthma exacerbations. Asthma is the 
third leading cause of hospitalization among children under the age of 
15 and is a leading cause of school absences from chronic disease. The 
disease costs our healthcare system over $50.1 billion per year. 
African Americans have the highest asthma prevalence of any racial/
ethnic group and the age-adjusted death rate for asthma in this 
population is three times the rate in whites. One of the keys to 
reducing asthma exacerbations and the associated healthcare costs is 
through patient education on asthma management. A study published in 
the American Journal of Respiratory Critical Care in 2012 found that 
for every dollar invested in asthma interventions, there was a $36 
benefit. We ask that the subcommittee's appropriations request for 
fiscal year 2014 that funding for CDC's National Asthma Control Program 
be maintained at a funding level of at least $25.3 million and that the 
National Asthma Control Program remain as a distinct, stand-alone 
program.

Sleep
    Several research studies demonstrate that sleep-disordered 
breathing and sleep-related illnesses affect an estimated 50-70 million 
Americans. The public health impact of sleep illnesses and sleep 
disordered breathing is still being determined, but is known to include 
increased mortality, traffic accidents, cardiovascular disease, 
obesity, mental health disorders, and other sleep-related 
comorbidities. Despite the increased need for study in this area, 
research on sleep and sleep-related disorders has been underfunded. The 
ATS recommends a funding level of $1 million in fiscal year 2014 to 
support activities related to sleep and sleep disorders at the CDC, 
including for the National Sleep Awareness Roundtable (NSART), 
surveillance activities, and public educational activities. The ATS 
also recommends an increase of funding for research on sleep disorders 
at the Nation Center for Sleep Disordered Research (NCSDR) at the 
NHLBI.

Tuberculosis
    Tuberculosis (TB) is the second leading global infectious disease 
killer, claiming 1.4 million lives each year. In the U.S., every State 
reports cases of TB annually. Drug-resistant TB poses a particular 
challenge to domestic TB control due to the high costs of treatment and 
intensive health care resources required. Treatment costs for 
multidrug-resistant (MDR) TB range from $100,000 to $300,000. The 
global TB pandemic and spread of drug resistant TB present a persistent 
public health threat to the U.S.
    Despite declining rates, persistent challenges to TB control in the 
U.S. remain. Specifically: (1) racial and ethnic minorities continue to 
suffer from TB more than majority populations; (2) foreign-born persons 
are adversely impacted; (3) sporadic outbreaks occur, outstripping 
local capacity; (4) drug resistant TB cases are on the rise; and (5) 
there are critical needs for new diagnostics, treatment and prevention 
tools.
    The Comprehensive Tuberculosis Elimination Act (CTEA, Public Law 
110-392), enacted in 2008, reauthorized programs at CDC with the goal 
of putting the U.S. back on the path to eliminating TB. The ATS, 
recommends a funding level of $243 million in fiscal year 2014 for 
CDC's Division of TB Elimination, as authorized under the CTEA, and 
encourages the NIH to expand efforts to develop new tools to reduce the 
rising global TB burden.

Critical Illness
    The burden associated with the provision of care to critically ill 
patients is enormous, and is anticipated to increase significantly as 
the population ages. Approximately 200,000 people in the United States 
require hospitalization in an intensive care unit because they develop 
a form of pulmonary disease called Acute Lung Injury. Despite the best 
available treatments, 75,000 of these individuals die each year from 
this disease. This is the approximately the same number of deaths each 
year due to breast cancer, colon cancer, and prostate cancer combined. 
Investigation into diagnosis, treatment and outcomes in critically ill 
patients should be a priority, and the NIH should be encouraged and 
funded to coordinate investigation in this area in order to meet this 
growing national imperative.

Pediatric Lung Disease
    The ATS is pleased to report that infant death rates for various 
lung diseases have declined for the past 10 years. In 2009, of the 10 
leading causes of infant mortality, 4 were lung diseases or had a lung 
disease component. Many of the precursors of adult respiratory disease 
start in childhood. Many children with respiratory illness grow into 
adults with COPD. It is estimated that 7.1 million children suffer from 
asthma. While some children appear to outgrow their asthma when they 
reach adulthood, 75 percent will require life-long treatment and 
monitoring of their condition. The ATS encourages the NHLBI to continue 
with its research efforts to study lung development and pediatric lung 
diseases.

Fogarty International Center
    The Fogarty International Center (FIC) provides training grants to 
U.S. universities to teach AIDS treatment and research techniques to 
international physicians and researchers. Because of the link between 
AIDS and TB infection, FIC has created supplemental TB training grants 
for these institutions to train international health professionals in 
TB treatment and research. The ATS recommends Congress provide $72.8 
million for FIC in fiscal year 2014, to allow expansion of the TB 
training grant program from a supplemental grant to an open competition 
grant.

Researching and Preventing Occupational Lung Disease
    The ATS urges the subcommittee to provide at least level funding 
for the National Institute for Occupational Safety and Health (NIOSH). 
NIOSH, within the Centers for Disease Control and Prevention (CDC), is 
the primary Federal agency responsible for conducting research and 
making recommendations for the prevention of work-related illness and 
injury. NIOSH provides national and world leadership to avert workplace 
illness, injury, disability, and death by gathering information, 
conducting scientific research, and translating this knowledge into 
products and services. NIOSH supports programs in every State to 
improve the health and safety of workers.
    The ATS appreciates the opportunity to submit this statement to the 
subcommittee.
                                 ______
                                 
 Prepared Statement of the Americans for Nursing Shortage Relief (ANSR)

    The organizations of the ANSR Alliance greatly appreciate the 
opportunity to submit written testimony recommending $251 million for 
the Title VIII Nursing Workforce Development Programs at the Health 
Resources and Services Administration (HRSA) and $20 million for the 
Nurse Managed Health Clinics as authorized under Title III of the 
Public Health Service Act. We represent a diverse cross-section of 
health care and other related organizations, health care providers, and 
supporters of nursing issues (http://www.ansralliance.org/Members.html) 
that have united to address the national nursing shortage. ANSR stands 
ready to work with Congress to advance programs and policy that will 
ensure our Nation has a sufficient and adequately prepared nursing 
workforce to provide quality care to all well into the 21st century.

The Nursing Shortage
    Nursing is the largest health care profession in the United States. 
Nurses work in a variety of settings, including primary care, public 
health, long-term care, surgical care facilities, schools, and 
hospitals. The March 2008 study, The Future of the Nursing Workforce in 
the United States: Data, Trends, and Implications, calculates a 
projected demand of 500,000 full-time equivalent registered nurses by 
2025. According to the U.S. Bureau of Labor Statistics, due to the 
country's gaining population and increasing health needs, employment of 
registered nurses is expected to grow by 26 percent from 2010 to 2020 
resulting in 711,900 new jobs. The Title VIII Nursing Workforce 
Education Programs will help fill these vacancies by supporting 
training programs designed to meet these health care needs.
    The Title VIII Nursing Workforce and Education programs provide 
training for entry-level and advanced degree nurses to improve the 
access to, and the quality of, health care in underserved areas. These 
programs provide the largest source of Federal funding for nursing 
education, providing loans, scholarships, traineeships, and 
programmatic support that, between fiscal year 2005 and 2010, supported 
over 400,000 nurses and nursing students as well as numerous academic 
nursing institutions and health care facilities.

The Desperate Need for Nurse Faculty
    Nursing vacancies exist throughout the entire health care system, 
including long-term care, home care and public health. Government 
estimates indicate that this situation only promises to worsen due to 
an insufficient supply of individuals matriculating in nursing schools, 
an aging existing workforce, and the inadequate availability of nursing 
faculty to educate and train the next generation of nurses. At the 
exact same time that the nursing shortage is expected to worsen, the 
baby boom generation is aging and the number of individuals with 
serious, life-threatening, and chronic conditions requiring nursing 
care will increase.
    Each year, nursing schools turn away tens of thousands of qualified 
applications at all degree levels due to an insufficient number of 
faculty, clinical sites, classroom space, clinical preceptors, and 
budget constraints. Securing and retaining adequate numbers of faculty 
is essential to ensure that all individuals interested in--and 
qualified for--nursing school can matriculate in the year that they are 
accepted.
    ANSR supports the need for sustained attention on the efficacy and 
performance of existing and proposed programs to improve nursing 
practices and strengthen the nursing workforce. The support of research 
and evaluation studies that test models of nursing practice and 
workforce development is integral to advancing health care for all in 
America. Investments in research and evaluation studies have a direct 
effect on the caliber of nursing care. Our collective goal of improving 
the quality of patient care, reducing costs, and efficiently delivering 
appropriate health care to those in need is served best by aggressive 
nursing research and performance and impact evaluation at the program 
level.

The Nursing Supply Impacts the Nation's Health and Economic Safety
    The demand for primary care services in the U.S. is expected to 
increase over the next few years, particularly with the aging and 
growth of the population. One study projects that by the year 2019, the 
demand for primary care in the United States will increase by between 
15 million and 25 million visits per year. HRSA estimates that more 
than 35.2 million people living within the 5,870 Health Professional 
Shortage Areas nationwide do not currently receive adequate primary 
care services. Research suggests that nurses and other health 
professionals are trained to and already do deliver many primary care 
services and may therefore be able to help increase access to primary 
care, particularly in underserved areas.
    ANSR applauds the subcommittee's bipartisan efforts to recognize 
that a strong nursing workforce is essential to a health policy that 
provides high-value care for every dollar invested in capacity building 
for a 21st century nurse workforce. For nearly 50 years, the Title VIII 
Nursing Workforce Development Programs have responded to the Nation's 
evolving workforce needs by providing education and training 
opportunities to nurses. These programs are the only Federal programs 
focused on filling gaps in the supply of nurses not met by traditional 
market forces, as well as producing a workforce prepared to care for 
the Nation's increasingly diverse and aging population. Numerous 
studies have demonstrated that the Title VIII programs graduate more 
minority and disadvantaged students more likely to serve in community 
health centers as well as rural and underserved areas. In a difficult 
economy, the Title VIII Nursing Workforce Education Programs help 
schools offer scholarships and affordable loans to nursing students, 
making such educational opportunities available to aspiring nurses of 
all backgrounds. By guiding job seekers to high-demand nursing jobs, 
the programs fulfill both their individual career goals and a 
community's health needs.

Summary
    HRSA's Title VIII Nursing Workforce Education programs contribute 
to a sufficient nursing workforce to meet the demands of a highly 
diverse and aging population is an essential component to improving the 
health status of the Nation and reducing health care costs. While the 
ANSR Alliance understands the immense fiscal pressures facing the 
Nation, we respectfully urge support for $251 million in funding for 
Nursing Workforce Development Programs under Title VIII of the Public 
Health Service Act at HRSA and $20 million for the Nurse Managed Health 
Clinics under Title III of the Public Health Service Act in fiscal year 
2013. We look forward to working with the subcommittee to prioritize 
the Title VIII programs in fiscal year 2014 and the future.

                   LIST OF ANSR MEMBER ORGANIZATIONS

Academy of Medical-Surgical Nurses
American Academy of Ambulatory Care Nursing
American Academy of Nurse Practitioners
American Academy of Nursing
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordination
American Association of Occupational Health Nurses
American College of Nurse-Midwives
American Organization of Nurse Executives
American Psychiatric Nurses Association
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
American Society of Plastic Surgical Nurses
Association for Radiologic & Imaging Nursing
Association of Pediatric Hematology/Oncology Nurses
Association of State and Territorial Directors of Nursing
Association of Women's Health, Obstetric & Neonatal Nurses
Citizen Advocacy Center
Dermatology Nurses' Association
Developmental Disabilities Nurses Association
Emergency Nurses Association
Infusion Nurses Society
International Association of Forensic Nurses
International Nurses Society on Addictions
International Society of Nurses in Genetics, Inc.
Legislative Coalition of Virginia Nurses
National Association of Clinical Nurse Specialists
National Association of Hispanic Nurses
National Association of Neonatal Nurses
National Association of Neonatal Nurse Practitioners
National Association of Nurse Massage Therapists
National Association of Nurse Practitioners in Women's Health
National Association of Orthopedic Nurses
National Association of Registered Nurse First Assistants
National Association of School Nurses
National Black Nurses Association
National Council of State Boards of Nursing
National Council of Women's Organizations
National Gerontological Nursing Association
National League for Nursing
National Nursing Centers Consortium
National Nursing Staff Development Organization
National Organization for Associate Degree Nursing
National Student Nurses' Association, Inc.
Nurses Organization of Veterans Affairs
Pediatric Endocrinology Nursing Society
Preventive Cardiovascular Nurses Association
RN First Assistants Policy & Advocacy Coalition
Society of Gastroenterology Nurses and Associates, Inc.
Society of Pediatric Nurses
Society of Trauma Nurses
Women's Research & Education Institute
Wound, Ostomy and Continence Nurses Society
      
                                 ______
                                 
             Prepared Statement of the Arthritis Foundation

                             SUMMARY REQUEST
------------------------------------------------------------------------
 
------------------------------------------------------------------------
National Institutes of Health overall funding.........   $32,000,000,000
    NIH: National Institute of Arthritis and                 525,000,000
     Musculoskeletal and Skin Diseases (NIAMS)........
Health Resources and Services Administration
    Pediatric Subspecialty Loan Repayment Program.....         5,000,000
Centers for Disease Control
    CDC Arthritis Program.............................        15,000,000
------------------------------------------------------------------------

    The Arthritis Foundation is committed to raising awareness and 
reducing the unacceptable impact of arthritis, which strikes one in 
every five adults and 300,000 children, and is the Nation's leading 
cause of disability. The Arthritis Foundation would like to provide 
recommendations for the Labor Health and Human Services (Labor HHS) 
Budget for fiscal year 2014.
    Specifically, we would like to comment on three specific agencies 
of jurisdiction of the Labor HHS Appropriations Subcommittee: the 
National Institutes of Health (NIH) and in particular the National 
Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), 
the Health Services Resources Administration (HRSA) and the Centers for 
Disease Control (CDC).

 ARTHRITIS RELATED RESEARCH INVESTMENTS AT THE NATIONAL INSTITUTES OF 
   HEALTH (NIH): FUNDING FOR THE NATIONAL INSTTUTE OF ARTHRITIS AND 
               MUSCULOSKELETAL AND SKIN DISEASES (NIAMS)

    Research holds the key to preventing, controlling, and curing 
arthritis, the Nation's leading cause of disability. The prevalence, 
impact and disabling pain continues to increase. 50 million Americans--
one in five adults--have arthritis now. Within 20 years, the Centers 
for Disease Control and Prevention (CDC) estimates that 67 million 
adults or 25 percent of the population will have arthritis. Arthritis 
limits the daily activities of 21 million Americans and accounts for 
$128 billion annually in economic costs. The National Institute of 
Arthritis and Musculoskeletal and Skin Diseases (NIAMS) supports 
research into the causes, treatment, and prevention of arthritis and 
musculoskeletal and skin diseases. The critical research done at NIAMS 
improves the quality of life for people with arthritis and decreases 
the overall burden of the disease. NIH funding should be allocated $32 
billion for fiscal year 2014 and NIAMS should be funded at $559 million 
to fund critical research on arthritis and other related diseases at 
the Institute. Our NIH recommendations reflect , the minimum needed to 
sustain the current level of research and account for inflation.

          HRSA PEDIATRIC SUBSPECIALITY LOAN REPAYMENT PROGRAM

    Juvenile arthritis is one of the most common childhood diseases, 
affecting more children than cystic fibrosis and muscular dystrophy. 
Currently, there are less than 250 board-certified practicing pediatric 
rheumatologists in the United States and about 90 percent of those are 
clustered in and around large cities. Pediatric rheumatology has one of 
the smallest numbers of doctors of any pediatric subspecialty. Of those 
children with juvenile arthritis, only one-fourth see a pediatric 
rheumatologist due to their scarcity. The other 75 percent of juvenile 
arthritis patients see either pediatricians (who tend not to be trained 
in how to care for juvenile arthritis) or adult rheumatologists, who 
aren't trained to deal with pediatric issues. Issues such as whether 
it's the stunted bone growth that can result from arthritis and its 
treatment, or the unwillingness of an adolescent to take his medicine. 
There are currently eleven States that do not have a single practicing, 
board-certified pediatric rheumatologist and seven States with only one 
practicing board-certified pediatric rheumatologist.
    The Pediatric Subspecialty Loan Repayment Program was authorized by 
Section 5203 of the Affordable Care Act (ACA) in March 2010. The 
program would incentivize training and practice in pediatric medical 
subspecialties, like pediatric rheumatology, in underserved areas 
across the United States. The program would offer up to $35,000 in loan 
forgiveness for each year of service for a maximum of 3 years. The 
program was authorized for $30 million for fiscal year 2010 through 
fiscal year 2014, but has yet to be appropriated any funding. President 
Obama's fiscal year 2014 budget requests $5 million to fund the 
Pediatric Subspecialty Loan Repayment Program. The Arthritis Foundation 
urges Congress to allocate $5 million dollars to fund the Pediatric 
Subspecialty Loan Repayment Program.

            CENTER FOR DISEASE CONTROL: CDC ARTHRITS PROGRAM

    The goal of the CDC Arthritis Program is to improve the quality of 
life for people affected by arthritis and other rheumatic conditions by 
working with States and other partners to (1) increase awareness about 
appropriate arthritis self-management activities, (2) expanding the 
reach of programs proven to improve the quality of life for people with 
arthritis and (3) decrease the overall burden of arthritis as well as 
its associated disability, work and activity limitations.
    The Arthritis Foundation requests that Congress provide a slight 
increase ($2 million) to expand the CDC Arthritis Program to $15 
million for fiscal year 2014. These additional funds would allow the 
Program to expand to two additional States. These State-based programs 
would (1) increase evidence based interventions, such as the Arthritis 
Foundation's Walk with Ease Program (WWE), into more communities; (2) 
reach diverse populations by funding partnership activities; and (3) 
support the OA Action Alliance, a coalition committed to elevating OA 
as a national priority. www.oaactionalliance.org.
    The Arthritis Foundation appreciates the opportunity to provide 
recommendations to the Senate Labor Health and Human Services Committee 
on recommendations for fiscal year 2014.
    If you have questions about these comments, please don't hesitate 
to contact the Arthritis Foundation. Questions about HRSA request--Kim 
Beer, Director, Advocacy, [email protected] or Maria Spencer, 
Director, Federal Affairs for NIH/CDC, [email protected].
                                 ______
                                 
   Prepared Statement of the Association for Research in Vision and 
                          Ophthalmology (ARVO)

                           EXECUTIVE SUMMARY

    ARVO is a community of more than 12,750 vision and ophthalmology 
researchers from 80 countries; we are the largest, most respected eye 
and vision research organization in the world. Our aim is to help cure 
and prevent blindness by encouraging and assisting research, training, 
publication and knowledge-sharing. In that regard, ARVO is pleased to 
make the following request regarding fiscal year 2014 appropriations:
    Congress fund the National Institutes of Health (NIH) at $32 
billion, which reflects a $1.38 billion, or 4.5 percent increase, over 
fiscal year 2012, which consists of biomedical inflation of 2.8 percent 
plus modest growth.
  --This recommendation reflects the minimum investment necessary to 
        make up for the 20 percent loss in purchasing power over the 
        last decade, as well as the impact of the sequester, which cut 
        5.1 percent or $1.6 billion from NIH's $30.8 billion budget.
  --NIH funding, especially in basic research, plays an essential role 
        that the private sector could not duplicate.
    Congress fund the National Eye Institute (NEI) at $730 million 
within the overall NIH funding increase. The President's budget 
proposes an fiscal year 2014 NEI funding cut of $2.1 million to a level 
$699 million, which is unacceptable because:
  --It cuts 35 competing grants. The $36 million cut in fiscal year 
        2013 NEI funding due to the sequester has already translated 
        into a loss of an estimated 90 grants--any one of which holds 
        the promise to save or restore vision.
  --The cut jeopardizes NEI's ability to fund new and compelling 
        scientific ideas to advance research, which were identified 
        through its Audacious Goals Initiative.
    In fiscal year 2012 and fiscal year 2013 funding, with the latter 
including the sequester, the vision research community has experienced 
the ``perfect storm''--cuts to new grants, no inflationary increases to 
existing grants, which may also be cut, and the reduction of the salary 
cap from Executive Level (EL) I to EL II--which, in totality, threaten 
the development of the next generation of vision scientists and the 
United States' leadership in vision research. Every researcher within 
our community has been impacted--seasoned researchers, new and young 
investigators, students-in-training, and clinician scientists--and each 
institution has been affected in terms of its ability to retain and 
attract trained personnel and to balance Federal funding cuts with 
bridge or philanthropic funding in an effort to maintain the momentum 
of past research.
    As a result, ARVO asks Congress to carefully consider every aspect 
of fiscal year 2014 NIH and NEI appropriations--the funding level, the 
impact on new and existing grants, and the salary cap, the past 
reduction of which to EL II has disproportionately affected clinician-
scientists who are critical to the translation of basic science. ARVO 
also asks Congress to fully consider the consequences for the current 
and future generation of scientists who are not only helping to 
understand the basis of disease, but developing treatments and 
therapies to save and restore vision as well as improve lives .

 ARVO REQUESTS THAT CONGRESS IMPROVE UPON THE PRESIDENT'S FISCAL YEAR 
      2014 REQUEST, WHICH CUTS NEI FUNDING AND THREATENS RESEARCH

    Despite the President's request increasing NIH funding by $471 
million, or 1.5 percent, over the fiscal year 2012 level of $30.6 
billion (net of transfers), it proposes to cut NEI by $2.1 million, or 
0.3 percent, below its fiscal year 2012 level of $701.3 million (net of 
transfers). Although the cut is primarily driven by an $8.9 million 
reduction due to the conclusion of the NEI-sponsored Ocular 
Complications of AIDS (SOCA) studies, which are funded by the NIH 
Office of AIDS Research, it is still a cut and drives NEI funding in 
the wrong direction. The President's proposed fiscal year 2014 NEI 
funding level of $699 million falls $8 million below the base fiscal 
year 2010 level of $707 million, the highest NEI funding level ever 
prior to the addition of American Recovery and Reinvestment Act (ARRA) 
funding.
    Most importantly, the President's proposed fiscal year 2014 NEI cut 
of $2.1 million comes after the fiscal year 2013 sequester cut of $36 
million. The President's fiscal year 2014 budget would cut 35 competing 
grants from NEI funding, which follows a $36 million reduction in NEI 
funding due to the sequester in fiscal year 2013 that has already 
translated into a loss of an estimated 90 grants--any one of which 
holds the promise of sight.
    The very health of the vision research community is at stake with a 
decrease in NEI funding. Not only will funding for new investigators 
and those in training be at risk, but also that of seasoned 
investigators, which threatens the continuity of research and the 
retention of trained staff, while making institutions more reliant on 
bridge and philanthropic funding. If an institution needs to let staff 
go, that could result in a highly-trained person leaving research 
altogether or moving to an institution in another country.
    This threatens the United States' leadership in vision research. 
Despite efforts in many ARVO members' home countries to increase 
medical and vision research funding, especially in China and India, 
they readily acknowledge that NEI-funded research still leads the 
world's efforts to save and restore vision. Since many of these members 
have also received their training in the U.S., they also value the 
importance of ongoing collaborations with U.S.-based investigators. 
NEI's leadership is essential to a global synergy that is resulting in 
the breakthroughs in vision research.
    ARVO also requests NEI funding at $730 million since our Nation's 
investment in vision health is an investment in overall health. NEI's 
breakthrough research is a cost-effective investment, since it is 
leading to treatments and therapies that can ultimately delay, save, 
and prevent health expenditures, especially those associated with the 
Medicare and Medicaid programs. It can also increase productivity, help 
individuals to maintain their independence, and generally improve the 
quality of life, especially since vision loss is associated with 
increased depression and accelerated mortality.
arvo requests fiscal year 2014 nei funding at $730 million to enable it 

 TO BUILD UPON ITS PAST RECORD OF BASIC AND TRANSLATIONAL RESEARCH AND 
           PURSUE THE MOST AUDACIOUS GOALS IN VISION RESEARCH

    The NEI is in the middle of a novel planning initiative to identify 
long-term, ten-year goals in vision research. Under the auspices of the 
National Advisory Eye Council, this expansion of NEI program planning 
is designed to engage and energize the vision research community and 
help the NEI establish the most compelling research priorities by 
identifying one or more ``audacious goals.'' Most recently, NEI hosted 
200 representatives from every sector of the vision community, as well 
as Government scientists and regulators from various disciplines at the 
NEI's Audacious Goals Development meeting. NIH Director Francis 
Collins, M.D., Ph.D. was very enthusiastic about this initiative and 
urged the attendees to have a ``bold vision for vision'' by describing 
NEI's long tradition of leadership in the biomedical research arena, 
including:
  --identifying more than 500 genes associated with vision loss, which 
        is one-quarter of all genes discovered to date; and
  --funding the successful human gene therapy trial for patients with 
        Leber Congenital Amaurosis, in which treated patients have 
        experienced vision improvement.
    The meeting's discussion topics were built around the 10 winning 
submissions from a pool of nearly 500 entries selected through NEI's 
Audacious Goals in Vision Research and Blindness Rehabilitation 
Challenge, a competition for bold and novel ideas to dramatically 
advance vision science. These ideas included restoring light 
sensitivity to the blind through gene-based therapies and visual 
prosthetics, pinpoint correction of defective genes, and growing 
healthy tissue from stem cells for ocular tissue transplants. 
Translating these and other research ideas into safe and effective 
treatments to save and restore vision requires adequate funding.
    NEI has always envisioned the future. Just a few short years ago, 
the ``bionic eye'' was just a fantasy. However, In February 2013, the 
Food and Drug Administration (FDA) approved an implanted retinal 
prosthesis to treat adult patients with advanced retinitis pigmentosa 
(RP), a rare genetic condition that damages the retina and leads to 
blindness. In this device, developed in part with NEI funding, a small 
video camera mounted on a pair of glasses sends images to a video 
processing unit that converts them to electronic data that is 
wirelessly transmitted to an array of electrodes implanted onto the 
retina. The device is enabling those who are otherwise completely blind 
to identify doors, crosswalks, and even utensils on a table. Funding 
must be adequate for NEI to successfully pursue its goal of saving and 
restoring vision.

   BLINDNESS AND VISION LOSS IS A GROWING PUBLIC HEALTH PROBLEM THAT 
        INDIVIDUALS FEAR AND WOULD TRADE YEARS OF LIFE TO AVOID

    NEI is already facing enormous challenges this decade: each day, 
from 2011 to 2029, 10,000 citizens will turn 65 and be at greatest risk 
for eye disease; the fast growing African American and Hispanic 
populations will experience a disproportionately higher incidence of 
eye disease; and the epidemic of obesity will significantly increase 
the incidence of diabetic retinopathy.
    The NEI estimates that more than 38 million Americans age 40 and 
older experience blindness, low vision, or an age-related eye disease 
such as age-related macular degeneration (AMD), glaucoma, diabetic 
retinopathy, or cataracts. This is expected to grow to more than 50 
million Americans by the year 2020. Although NEI estimates that the 
current annual cost of vision impairment and eye disease to the U.S. is 
$68 billion, this number does not fully quantify the impact of indirect 
healthcare costs, lost productivity, reduced independence, diminished 
quality of life, increased depression, and accelerated mortality. NEI's 
proposed fiscal year 2014 funding of $699 million reflects just a 
little more than 1 percent of this annual costs of eye disease. The 
continuum of vision loss presents a major public health problem, as 
well as a significant financial challenge to the public and private 
sectors.
    Vision loss also presents a real fear to most citizens. In public 
opinion polls over the past 40 years, Americans have consistently 
identified fear of vision loss as second only to fear of cancer. NEI's 
Survey of Public Knowledge, Attitudes, and Practices Related to Eye 
Health and Disease reported that 71 percent of respondents indicated 
that a loss of their eyesight would rate as a ``10'' on a scale of 1 to 
10, meaning that it would have the greatest impact on their day-to-day 
life. In patients with diabetes, going blind or experiencing vision 
loss rank among the top four concerns about the disease. These patients 
are so concerned about vision loss diminishing their quality of life 
that those with nearly perfect vision (20/20 to 20/25) would be willing 
to trade 15 percent of their remaining life for ``perfect vision,'' 
while those with moderate impairment (20/30 to 20/100) would be willing 
to trade 22 percent of their remaining life for perfect vision. 
Patients who are legally blind from diabetes (20/200 to 20/400) would 
be willing to trade 36 percent of their remaining life to regain 
perfect vision.
    ARVO urges Congress to fund NIH at $32 billion and NEI at $730 
million, in fiscal year 2014 to ensure the momentum of research, to 
retain trained personnel, and maintain U.S. leadership.
                                 ______
                                 
 Prepared Statement of the Association for Professionals in Infection 
Control and Epidemiology and the Society for Healthcare Epidemiology of 
                                America

    The Association for Professionals in Infection Control and 
Epidemiology (APIC) and the Society for Healthcare Epidemiology of 
America (SHEA) thank you for this opportunity to submit testimony on 
Federal efforts to detect dangerous infectious diseases and protect the 
American public from healthcare-associated infections (HAIs). We ask 
that the subcommittee support the following programs under 
appropriations for the Department of Health and Human Services.
    First, under the Centers for Disease Control and Prevention 
National Center for Emerging and Zoonotic Infectious Diseases: $31.5 
million for the National Healthcare Safety Network (NHSN) and the 
Prevention Epicenters Program; $40 million for the Advanced Molecular 
Detection and Response to Infectious Disease Outbreaks Program; and 
$226.7 million for Core Infectious Diseases to include funding for 
Healthcare-Associated Infections, Antimicrobial Resistance, and the 
Emerging Infections Program (EIP). Additionally, we request $34 million 
for the Agency for Healthcare Research and Quality (AHRQ) to reduce and 
prevent HAIs. This includes $12.6 million in HAI research grants and 
$21.4 million in HAI contracts including the Comprehensive Unit-based 
Safety Program (CUSP). These CDC requests include the agency's 
recommendations related to the Working Capital Fund. Finally, we 
request $500 million annually for the National Institutes of Health 
(NIH), National Institute of Allergy and Infectious Diseases' 
antibacterial and related diagnostics efforts by the end of fiscal year 
2014.
    HAIs are among the leading causes of preventable death in the 
United States. In hospitals alone, CDC estimates that one in 20 
hospitalized patients has an HAI, while over one million HAIs occur 
across healthcare settings annually.
    In addition to the substantial human suffering, HAIs contribute $28 
to $33 billion in excess healthcare costs each year. Fortunately 
several HAIs are on the decline as a result of recent advances in the 
understanding of how to prevent certain infections. In particular, 
bloodstream infections associated with indwelling central venous 
catheters, or ``central lines,'' are largely preventable when 
healthcare providers use the CDC infection prevention recommendations 
in the context of a performance improvement collaborative. CDC recently 
reported a 41 percent reduction in central line-associated bloodstream 
infections in 2011. The reduction in central line associated 
bloodstream infections over the last 4 years has saved 5,000 lives and 
averted an estimated $83 million in healthcare costs. Now we have the 
opportunity to continue this momentum and extend it to other 
infections.

            CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

    APIC and SHEA request $31.5 million for the National Healthcare 
Safety Network (NHSN) and the Prevention Epicenters Program. These 
programs provide critical funding to detect dangerous multidrug-
resistant organisms (MDROs) in order to protect patients and the public 
from disease and death associated with HAIs.
    APIC and SHEA are strongly supportive of the Prevention Epicenters 
Program, a collaboration of CDC's Division of Healthcare Quality 
Promotion (DHQP) and academic medical centers that conduct innovative 
infection control and prevention research to address important 
scientific gaps regarding the prevention of HAIs, antibiotic resistance 
and other adverse healthcare events.
    Consistent, high quality, scientifically sound and validated data 
are necessary to measure the true extent of the problem, develop 
evidence-based HAI prevention strategies, and to ensure that accurate 
data are available at the State and Federal level for public reporting.
    Funding for this program has been flat since fiscal year 2010, 
despite the system's importance in our Nation's efforts to monitor and 
prevent HAIs, and the increase in facilities reporting into the NHSN--
from 3,000 in 2010 to nearly 12,000 in 2013.
    APIC and SHEA request $226.7 million for Core Infectious Diseases 
to include funding for Healthcare-Associated Infections, Antimicrobial 
Resistance, and Emerging Infections Program.
    APIC and SHEA support the EIP as it helps States, localities and 
territories in detecting and protecting the public from known 
infectious disease threats in their communities while maintaining our 
Nation's capacity to identify new threats as they emerge.
    Further, ensuring the effectiveness of antibiotics well into the 
future is vital for the Nation's public health, particularly when our 
current therapeutic options are now dwindling and research and 
development of new antibiotics is lagging. As noted in the recently 
released CDC Vital Signs report related to carbapenem-resistant 
Enterobacteriaceae (CRE), microorganisms are becoming more resistant to 
antimicrobials. Such resistance is one of the most pressing challenges 
facing healthcare providers and patients in the coming decade, so it is 
essential that the CDC maintain the ability to monitor organism 
resistance.
    APIC and SHEA request $40 million for the Advanced Molecular 
Detection and Response to Infectious Disease Outbreaks Program (AMD). 
This program will improve urgently needed molecular and bioinformatics 
capacities for controlling infectious disease threats at the national 
and State level.
    Modernizing public health microbiology capacities through the AMD 
program will ensure CDC is able to meet its basic public health mission 
by keeping pace with major technologic advances in the diagnosis and 
characterization of infectious agents and reducing the burden of 
infectious diseases. AMD will allow for the efficient determination of 
the origin of emerging diseases, whether microorganisms are resistant 
to antimicrobials, and how microorganisms maneuver and alter through a 
population.

           AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)

    APIC and SHEA request $34 million for AHRQ in fiscal year 2014 to 
reduce and prevent HAIs. This total includes funding for HAI research 
grants to improve the prevention and management of HAIs, and HAI 
contracts including nationwide implementation of the Comprehensive 
Unit-based Safety Program (CUSP). Over the past decade, AHRQ has funded 
numerous projects targeting HAI prevention that have led to the 
successful reduction of central line-associated bloodstream infections 
(CLABSIs) in hospital intensive care units (ICUs) by 58 percent since 
2001, representing up to 27,000 lives saved. In spite of this notable 
progress, there is a great deal of work to be done toward the goal of 
HAI elimination. SHEA and APIC are very pleased that AHRQ is expanding 
the CUSP program to reach healthcare settings outside the ICU and to 
broaden the focus to address other types of infection.
national institutes of health (nih), national institute of allergy and 

                      INFECTIOUS DISEASES (NIAID)

    APIC and SHEA request that at least $500 million annually be 
provided for NIAID's antibacterial and related diagnostics efforts by 
the end of fiscal year 2014. As part of this effort, we believe NIAID 
should invest at least $100 million per year in the antibiotic 
resistance-focused clinical trials network that the Institute is 
currently establishing and should be operational by 2014. Although we 
applaud NIAID for establishing this new network, we believe the planned 
investment of $10 million per year over the next 10 years will be 
insufficient to undertake the critical studies needed to address what 
are quickly becoming untreatable infections. We thank you for the 
opportunity to submit testimony and greatly appreciate this 
subcommittee's assistance in providing the necessary funding for the 
Federal Government to have a leadership role in the effort to eliminate 
HAIs.
    About APIC.--APIC's mission is dedicated to creating a safer world 
through prevention of infection. The association's more than 14,000 
members direct and maintain infection prevention programs that prevent 
suffering, save lives and contribute to cost savings for hospitals and 
other healthcare facilities. APIC advances its mission through patient 
safety, implementation science, competencies and certification, 
advocacy, and data standardization.
    About SHEA.--Founded in 1980, SHEA works to achieve the highest 
quality of patient care and healthcare personnel safety in all 
healthcare settings by applying epidemiologic principles and prevention 
strategies to a wide range of quality-of-care issues. SHEA's membership 
of 2,000 represents all branches of medicine, public health, and 
healthcare epidemiology. SHEA members are committed to implementing 
evidence-based strategies to prevent HAIs and improve patient safety, 
and have scientific expertise in evaluating potential strategies to 
accomplish this goal.
                                 ______
                                 
  Prepared Statement of the Association of American Cancer Institutes

    The Association of American Cancer Institutes (AACI), representing 
95 of the Nation's premier academic and free-standing cancer centers, 
appreciates the opportunity to submit this statement for consideration 
by the United States Senate's Subcommittee on Labor, Health and Human 
Services, Education and Related Agencies, Committee on Appropriations.
    AACI thanks the President, Congress and the subcommittee for its 
long-standing commitment to ensuring quality care for cancer patients, 
as well as for providing researchers with the resources that they need 
to develop better cancer treatments and, ultimately, to cure this 
disease.
    The President's fiscal year 2014 budget requests $31.3 billion for 
the National Institutes of Health (NIH), an increase of $471 million 
(1.5 percent) over the fiscal year 2012 level. This amount includes 
$5.125 billion for the National Cancer Institute (NCI), a $63 million 
increase over fiscal year 2012 (1.2 percent). However, the President's 
budget request does not account for the cuts due to sequestration. 
Unless Congress acts to replace the sequester, the automatic spending 
cuts will reduce the NIH and NCI budgets further through 2021.
    AACI joins with our colleagues in the biomedical research community 
in recommending that the subcommittee recognize NIH as a critical 
national priority by providing at least $32 billion in funding in the 
fiscal year 2014 Labor-HHS-Education Appropriations bill, including an 
equivalent percentage increase in funding for NCI. This funding level 
represents the minimum investment necessary to avoid further loss of 
promising research.
    AACI cancer centers are at the front line in the national effort to 
eradicate cancer. The cancer centers that AACI represents house more 
than 20,000 scientific, clinical and public health investigators who 
work collaboratively to translate promising research findings into new 
approaches to prevent and treat cancer. Making progress against cancer 
is complex as it takes a significant amount of time to discovery new 
therapies and treatments for cancer patients. However, the pace of 
discovery and translation of novel basic research to new therapies 
could be faster if researchers could count on an appropriate and 
predictable investment in Federal cancer funding. Cuts to the NIH 
budget have a real impact on progress against cancer at cancer centers 
across the country. Continued progress in cancer research is dependent 
on the sustained efforts of highly skilled research teams working at 
cancer centers across the country and supported by the NCI. Failure to 
keep up with the rate of biomedical inflation diminishes many of the 
research teams working on new treatments and new cures.
    AACI and its members are profoundly aware of the country's fiscal 
environment. The vast majority of our cancer centers exist within 
universities that are absorbing severe budget reductions. Furthermore, 
because of the reduced funding pool for meritorious grant applications, 
many of our senior and most promising young investigators are now 
without NCI funding and require significant bridge funding from private 
sources. In recent years, however, it has become more challenging to 
raise philanthropic and other external funds. As a result, we continue 
to be highly dependent on Federal cancer center grants. The lack of 
funding for promising young scientists risks driving an entire 
generation of young cancer physicians and researchers either abroad, to 
seek opportunities to practice their craft and advance their careers, 
or out of the field altogether. These serious consequences for 
biomedical jobs and local economies mean that funding cuts will 
undermine U.S. competitiveness, at a time when other nations are 
aggressively boosting their investments in research and development.

Impact in the Lab and Beyond
    The negative effects of diminished biomedical research funding 
reach beyond the lab and into local communities, as chronicled by a 
number of AACI cancer center directors who were featured in newspaper 
editorials or interviews that highlighted the impact of NIH and NCI 
funding on people and local economies in their individual States.
    For example, AACI President Michelle M. Le Beau, PhD, director of 
the University of Chicago Comprehensive Cancer Center and AACI Vice-
President/President-Elect George Weiner, MD, director of the Holden 
Comprehensive Cancer Center at the University of Iowa noted that at 
their respective NCI-designated Comprehensive Cancer Centers alone, 
sequestration has begun to undermine innovative work being done to 
harness a patient's own immune system to fight cancer, genomic 
profiling of patients' cancers to personalize treatment, and the 
evaluation of more sensitive imaging technology for early detection of 
cancer.
    Nancy E. Davidson, MD, director of the University of Pittsburgh 
Cancer Institute, told a local newspaper that she has serious concerns 
about the cuts, which she said would affect the institute's work. She 
noted that budget cuts would force her to eliminate jobs, shut 
laboratories and halt promising experiments. She stated that she would 
not be able to hire faculty members and faces the possibility of 
shutting down programs.
    Roy A. Jensen, MD, director of the University of Kansas Cancer 
Center said, ``It's really come on top of a fairly extended period of 
flat funding, which has eroded the purchasing power of biomedical 
dollars. . . It's almost like the final push over the edge. I know a 
lot of labs are having to lay people off and not pursuing promising 
scientific leads.''
    Edward J. Benz, Jr., MD, director of the Dana-Farber Cancer 
Institute, affiliated with Harvard Medical School, stated, ``The cuts 
in Federal funding as they're being put into play are unraveling one of 
the greatest biomedical-research enterprises in the history of the 
world. . . These kinds of draconian, across-the-board cuts are really 
cutting into the meat of what we do.''
    Ralph de Vere White, MD, director of the UC Davis Comprehensive 
Cancer Center and associate dean for cancer programs at the UC Davis 
School of Medicine, wrote in an opinion piece that, ``Deterioration of 
the (funding) pipeline comes at a critical time. Although death rates 
from most types of cancer have fallen because we are finding and 
treating tumors earlier, advanced cancers have proved much more 
challenging. This Nation's investment in cancer research has allowed us 
to develop the tools to drastically cut that death rate. These tools 
are not simply costly new drugs. They are methods to interrogate tumors 
at the molecular level. They are tests to identify a tumor's genetic 
characteristics so we can choose appropriate treatments on a patient-
by-patient basis so we can spare patients therapies that cause side 
effects but offer no benefit.''
    Donald L. Trump, MD, President and CEO of Roswell Park Cancer 
Institute, in Buffalo, informed his colleagues that proposals within 
the institute, specifically a proposal for a study on the role specific 
genes play in metastasis of prostate cancer, the second leading cause 
of cancer death in American men, will suffer due to budget constraints. 
Roswell Park anticipated cutting three researchers from this effort--a 
33 percent workforce reduction.
    Walter J. Curran, Jr., MD, FACR, executive director of Winship 
Cancer Institute of Emory University, in Atlanta, testified on behalf 
of AACI before the Committee on Appropriations Subcommittee on Labor, 
Health and Human Services, Education and Related Agencies. He noted 
that Winship has an outstanding research team making real progress 
understanding how to target newly discovered mutations causing lung 
cancer, the type of cancer causing the most deaths in our country. 
Winship has observed an increase in the number of lung cancer patients 
who have little or no tobacco use history, and are just beginning to 
understand the genetic and genomic risk factors of such individuals for 
developing lung cancer, he said. Dr. Curran was adamant that any cut in 
funding support of this and other projects could delay finding new and 
effective therapies for thousands of patients by years.
    Recent studies have also concluded that Federal support for medical 
research is a major determinant in the economic health of communities 
across the country. In one report, United for Medical Research, a 
coalition of leading research institutions, patient and health 
advocates and private industry, estimated that NIH funding generated 
the greatest number of jobs in California (59,363), Massachusetts 
(34,031), New York (32,249), Texas (25,408) and North Carolina (18,779) 
and also supported more than 10,000 jobs each in Pennsylvania, 
Maryland, Washington, Illinois, Ohio, Florida, Michigan and Georgia. 
Fifty-five AACI cancer centers are located in those 13 States.
    Cancer centers are already challenged to provide infrastructure 
resources necessary to support funded researchers, and cuts in Federal 
cancer center grants will limit our members' ability to provide well-
functioning shared resources to investigators who depend on them to 
complete their research. For most academic cancer centers, the majority 
of NCI grant funds are used to sustain shared resources that are 
essential to basic, translational, clinical and population cancer 
research, or to provide matching dollars which allow departments to 
recruit new cancer researchers to a university and support them until 
they receive their first grants.
    Independent investigator research is a particularly valuable 
resource, especially in genomics and molecular epidemiology. Such 
research depends on state-of-the-art shared resources like tissue 
processing and banking, DNA sequencing, microRNA platforms, proteomics, 
biostatistics and biomedical informatics. This infrastructure is 
expensive and it is not clear where cancer centers would acquire 
alternative funding if NCI grants for these efforts were reduced.

Cancer Research is Improving America's Health
    The broad portfolio of research supported by NIH and NCI is 
essential for improving our basic understanding of diseases and it has 
paid off considerably in terms of improving Americans' health.
    The 5-year relative survival rate for all cancers diagnosed between 
2002 and 2008 is 68 percent, up from 49 percent in 1975-1977. The 
improvement in survival reflects both progress in diagnosing certain 
cancers at an earlier stage and improvements in treatment. Data has 
shown specifically that cancer death rates have dropped 11.4 percent 
among women and 19.2 percent among men over the past 15 years, due in 
large part to better detection and more effective treatments.\1\
    Despite that success, cancer remains the second leading cause of 
death in the U.S., with almost 1,600 deaths per day. More than 1.6 
million Americans are expected to be diagnosed with cancer in 2013, 
with an expected 580,350 people to die from the disease.\2\ NCI 
estimates that 41 percent of individuals born today will receive a 
cancer diagnosis at some point in their lifetime.\3\
    The network of cancer centers represented by AACI continues the 
fight against cancer by conducting the highest-quality cancer research 
in the world and provides exceptional patient care. In 2012, 86 percent 
of NCI's total budget was awarded extramurally to research 
institutions, including the AACI's member cancer centers.\4\ Because 
these centers are networked nationally, opportunities for 
collaborations are many--assuring wise and non-duplicative investment 
of scarce Federal dollars.

Conclusion
    NIH estimates that the overall costs of cancer in 2008 were $201.5 
billion: $77.4 billion for direct medical costs (total of all health 
expenditures) and $124.0 billion for indirect mortality costs (cost of 
lost productivity due to premature death).\5\ The cost of cancer 
continues to rise, but the investment in cancer research will one day 
eliminate such economic burdens on Americans and the cancer center 
researchers who work tirelessly to find a cure for this deadly disease.
    In the face of that economic burden, the Nation's financial support 
of NIH and NCI has paid dividends by introducing innovative therapies 
for cancers that years ago robbed countless Americans of their future. 
NIH's full support of NCI-designated centers and their programs remains 
a top priority for our Nation's cancer centers. We are on a clear path 
to dramatic breakthroughs at cancer centers across the country. It is 
through the power of collaborative innovation that we will continue to 
move toward a future without cancer, and Federal research funding is 
essential to achieving our goals.
---------------------------------------------------------------------------
    \1\ American Cancer Society. Facts and Figures, 2013. http://
www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/
document/acspc-036845.pdf.
    \2\ American Cancer Society. Facts and Figures, 2013.
    \3\ Cancer Trends Progress Report--2011/2012 Update, National 
Cancer Institute, NIH, DHHS, Bethesda, MD, August 2012, http://
progressreport.cancer.gov.
    \4\ U.S. Department of Health and Human Services, National 
Institutes of Health, National Cancer Institute 2012 Fact Book.
    \5\ American Cancer Society. Facts and Figures 2013. Please note: 
these figures are not comparable to those published in previous years 
because as of 2011, the NIH is calculating the estimates using a 
different data source: the Medical Expenditure Panel Survey (MEPS) of 
the Agency for Healthcare Research and Quality. The MEPS estimates are 
based on more current, nationally representative data and are used 
extensively in scientific publications. As a result, direct and 
indirect costs will no longer be projected to the current year, and 
estimates of indirect morbidity costs have been discontinued. For more 
information, please visit nhlbi.nih.gov/about/factpdf.htm.
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                                 ______
                                 
   Prepared Statement of the Association of American Medical Colleges

    The Association of American Medical Colleges (AAMC) is a not-for-
profit association representing all 141 accredited U.S. and 17 
accredited Canadian medical schools; nearly 400 major teaching 
hospitals and health systems; and nearly 90 academic and scientific 
societies. Through these institutions and organizations, the AAMC 
represents 128,000 faculty members, 75,000 medical students, and 
110,000 resident physicians. The association wishes to address four 
Federal priorities that play essential roles in assisting medical 
schools and teaching hospitals to fulfill their missions of education, 
research, and patient care: the National Institutes of Health (NIH); 
the Agency for Healthcare Research and Quality (AHRQ); health 
professions education funding through the Health Resources and Services 
Administration (HRSA)'s Bureau of Health Professions; and student aid 
through the Department of Education and HRSA's National Health Service 
Corps. The AAMC appreciates the subcommittee's longstanding, bipartisan 
efforts to strengthen these programs.
    National Institutes of Health.--The NIH is one of the Federal 
Government's greatest achievements. Congress's long-standing bipartisan 
support for medical research through the NIH has created a scientific 
enterprise that is the envy of the world and has contributed greatly to 
improving the health and well-being of all Americans. The foundation of 
scientific knowledge built through NIH-funded research drives medical 
innovation that improves health through new and better diagnostics, 
improved prevention strategies, and more effective treatments.
    Eighty-four percent of NIH research funding is awarded to more than 
2,500 research institutions in every State; at least half of this 
funding supports life-saving research at America's medical schools and 
teaching hospitals. This successful partnership not only lays the 
foundation for improved health and quality of life, but also 
strengthens the Nation's long-term economy.
    The AAMC supports the recommendation of the Ad Hoc Group for 
Medical Research to recognize NIH as an urgent national priority by 
providing at least $32 billion in its fiscal year 2014 Labor-HHS-
Education Appropriations bill. Strengthening our Nation's commitment to 
medical research, through robust funding of the NIH, is a critical 
element in ensuring the health and well-being of the American people 
and our economy.
    The AAMC notes past proposals by the House subcommittee to reduce 
the limit on salaries that can be drawn from NIH extramural awards to 
Executive Level III of the Federal Executive Pay Scale and thanks the 
Senate subcommittee for rejecting these efforts. These proposals come 
at a time when medical schools' and teaching hospitals' discretionary 
funds from clinical revenues and other sources have become increasingly 
constrained and less available to invest in research. As institutions 
and departments divert funds to compensate for the reduction in the 
salary limit, they will have less funding for critical activities such 
as bridge funding to investigators who may be between grants and seed 
grants and start-up packages for young investigators. The lower salary 
cap will disproportionately affect physician investigators, who will be 
forced to make up salaries from clinical revenues, thus leaving less 
time for research. This may serve as a deterrent to their recruitment 
into research careers. The AAMC urges the subcommittee to retain the 
limit at Executive Level II.
    Agency for Healthcare Research and Quality.--Complementing the 
medical research supported by NIH, AHRQ sponsors health services 
research designed to improve the quality of health care by translating 
research into measurable improvements in the health care system. The 
AAMC firmly believes in the value of health services research as the 
Nation continues to strive to provide high quality, efficient health 
care to all of its citizens. The AAMC joins the Friends of AHRQ in 
recommending $434 million for the agency in fiscal year 2014.
    As the lead Federal agency to improve health care quality, AHRQ's 
overall mission is to support research and disseminate information that 
improves the delivery of health care by identifying evidence-based 
medical practices and procedures. The Friends of AHRQ funding 
recommendation will allow AHRQ to continue to support the full spectrum 
of research portfolios at the agency, from patient safety to other 
valuable research initiatives. These research findings will better 
guide and enhance consumer and clinical decisionmaking, provide 
improved health care services, and promote efficiency in the 
organization of public and private systems of health care delivery.
    Health Professions Funding.--HRSA's Title VII health professions 
and Title VIII nursing education programs are the only Federal programs 
designed to improve the supply, distribution, and diversity of the 
Nation's health care workforce. Through loans, loan guarantees, and 
scholarships to students, and grants and contracts to academic 
institutions and non-profit organizations, the Title VII and Title VIII 
programs fill the gaps in the supply of health professionals not met by 
traditional market forces. The AAMC joins the Health Professions and 
Nursing Education Coalition (HPNEC) in recommending $520 million for 
these important workforce programs in fiscal year 2014.
    Throughout their 50-year history, the Title VII and Title VIII 
programs have helped the workforce adapt to meet the Nation's changing 
health care needs. Further, the programs advance timely priorities, 
such as strengthening education and training opportunities in 
geriatrics and working to close the gap in access to mental and 
behavioral health services. Therefore, continued support for the 
programs is essential to adequately prepare the next generation of 
health professionals to meet the changing needs of our Nation's 
growing, aging, and increasingly diverse population.
    AAMC is deeply troubled by the President's proposal to eliminate 
the Title VII Area Health Education Centers (AHEC) and the Title VII 
Health Careers Opportunity Program (HCOP). As described in the results 
of a recent AAMC survey, eliminating HCOP will impede programs to 
assist minority and disadvantaged students in becoming more competitive 
applicants for health professions training programs and will undermine 
the positive effects such pipeline programs have on their communities. 
Similarly, eliminating AHEC will threaten access to primary care for 
patients in rural and underserved settings by discontinuing support for 
educational opportunities in these environments. Indeed, failing to 
support the full range of health professions programs will be 
counterproductive, disrupting efforts to address some of the country's 
most pressing health care challenges.
    In addition to funding for Title VII and Title VIII, HRSA's Bureau 
of Health Professions also supports the Children's Hospitals Graduate 
Medical Education (CHGME) program. This program provides critical 
Federal graduate medical education support for children's hospitals to 
prepare the future primary care workforce for our Nation's children and 
for pediatric specialty care. At a time when the Nation faces a 
critical doctor shortage, the AAMC strongly objects to the President's 
fiscal year 2014 proposal to drastically reduce funding for CHGME. AAMC 
encourages the subcommittee to reject the President's proposal and 
fully fund the Children's Hospitals Graduate Medical Education program.
    Student Aid and the National Health Service Corps (NHSC).--The AAMC 
urges the committee to sustain student loan and repayment programs for 
graduate and professional students at the Department of Education. The 
average graduating debt of medical students is currently $170,000, and 
typical repayment can range from $321,000 to $476,000. The Budget 
Control Act (BCA, Public Law 112-25) adds another $10,000 to $20,000 to 
total repayment as a result of eliminating graduate and professional 
in-school subsidies, effective July 1, 2012.
    The AAMC opposes any rescissions from the National Health Service 
Corps (NHSC) Fund created under the Affordable Care Act (ACA, Public 
Law 111-142 and Public Law 111-152). The steady, sustained, and certain 
growth established by this mandatory funding for the NHSC has resulted 
in program expansion and innovative pilots such as the Student to 
Service (S2S) Loan Repayment Program that incentivizes fourth-year 
medical students to practice primary care in underserved areas after 
residency training. The AAMC further requests that any expansion of 
NHSC eligible disciplines or specialties be accompanied by a 
commensurate increase in NHSC appropriations so as to prevent a 
reduction of awards to current eligible health professions. 
Furthermore, the AAMC believes that such changes are best tested 
through the NHSC State Loan Repayment Program (SLRP), and that funds 
provided for this program should allow the States to define specialty 
and geographic shortages.
    Once again, the AAMC appreciates the opportunity to submit this 
statement for the record and looks forward to working with the 
subcommittee as it prepares its fiscal year 2014 spending bill.
                                 ______
                                 
     Prepared Statement of the Association of Independent Research 
                               Institutes

    The Association of Independent Research Institutes (AIRI) 
respectfully submits this written testimony for the record to the 
Senate Appropriations Subcommittee on Labor, Health and Human Services, 
Education and Related Agencies. AIRI appreciates the commitment the 
Members of this subcommittee have made to biomedical research through 
your strong support for the National Institutes of Health (NIH) and 
recommends providing at least $32 billion for NIH in fiscal year 2014. 
We believe this amount is the minimum level of funding needed to 
accommodate the rising costs of medical research and to help mitigate 
the effects of sequestration. AIRI also encourages the subcommittee to 
work to stop the sequestration cuts to research funding that squander 
invaluable scientific opportunities, threaten medical progress and 
continued improvements in our Nation's health, and jeopardize our 
economic vitality.
    AIRI is a national organization of 80 independent, non-profit 
research institutes that perform basic and clinical research in the 
biological and behavioral sciences. AIRI institutes vary in size, with 
budgets ranging from a few million to hundreds of millions of dollars. 
In addition, each AIRI member institution is governed by its own 
independent Board of Directors, which allows our members to focus on 
discovery-based research while remaining structurally nimble and 
capable of adjusting their research programs to emerging areas of 
inquiry. Researchers at independent research institutes consistently 
exceed the success rates of the overall NIH grantee pool, and they 
receive about 10 percent of NIH's peer-reviewed, competitively-awarded 
extramural grants.
    The reduction of Federal funds to support research, including the 5 
percent cut in NIH funding under sequestration, harms our Nation's 
ability to advance scientific discoveries that improve human health, 
bolster the economy, and help keep our Nation globally competitive. 
Furthermore, the impact of sequestration has been compounded by ongoing 
funding constraints caused by 10 years of flat NIH budgets, which have 
resulted in a loss of purchasing power and affected the ability of NIH-
funded scientists to pursue promising new avenues of research.
    At the same time that scientists are facing these funding 
challenges, they are poised like never before to capitalize on 
tremendous scientific opportunities and make paradigm-shifting 
discoveries to address our Nation's most pressing public health needs. 
Budget uncertainty is disruptive to training, careers, long-range 
projects, and ultimately, to research progress. To ensure the 
successful and efficient advancement of science, the research engine 
needs predictable, sustained funding that maximizes the Nation's return 
on investment.
    Not only is NIH research essential to advancing health, it also 
plays a key economic role in communities nationwide. Approximately 85 
percent of NIH funding is spent in communities across the Nation, 
creating jobs at more than 2,500 research institutes, universities, 
teaching hospitals, and other institutions. NIH research also supports 
long-term competitiveness for American workers, forming one of the key 
foundations for U.S. industries like biotechnology, medical device and 
pharmaceutical development, and more. AIRI member institutes are 
especially vulnerable to reductions in the NIH budget, as they do not 
have other reliable sources of revenue to make up the shortfall.
    In addition to concerns over funding, AIRI member institutes oppose 
legislative provisions--such as directives to reduce the salary limit 
for extramural researchers--which would harm the integrity of the 
research enterprise and disproportionately affect independent research 
institutes. Such prescriptive policies hinder AIRI members' research 
missions and their ability to recruit and retain talented researchers. 
AIRI also does not support legislative language limiting the 
flexibility of NIH to determine how to most effectively manage its 
resources while funding the best scientific ideas.
    Pursuing New Knowledge.--The NIH model for conducting biomedical 
research, which involves supporting scientists at universities, medical 
centers, and independent research institutes, provides an effective 
approach to making fundamental discoveries in the laboratory that can 
be translated into medical advances that save lives. AIRI member 
institutions are private, stand-alone research centers that set their 
sights on the vast frontiers of medical science. AIRI institutes are 
specifically focused on pursuing knowledge around the biology and 
behavior of living systems and applying that knowledge to improve human 
health and reduce the burdens of illness and disability. Additionally, 
AIRI member institutes have embraced technologies and research centers 
to collaborate on biological research for all diseases. Using shared 
resources--specifically, advanced technology platforms or ``cores,''--
as well as genomics, imaging, and other technologies, AIRI researchers 
advance therapeutics development and drug discovery.
    Translating Research into Treatments and Therapeutics.--As a 
network of efficient, flexible independent research institutes that 
have been conducting translational research for years, AIRI plays a key 
role in bringing research from the bench to the bedside. The following 
examples of AIRI members' translational research successes demonstrate 
the value NIH funding brings to human health:
    Scientists at the Fred Hutchinson Cancer Research Center (Seattle, 
WA) have pioneered a method to improve the use of umbilical cord blood 
for blood stem cell transplants, a technique that is bringing 
transplants and cures to many of the 16,000 leukemia patients each year 
who are unable to find a matching bone marrow donor. In related work, 
scientists have also developed a strategy to prevent many cases of 
infection with the virus known as cytomegalovirus, a leading cause of 
complications and death in cord blood transplant recipients.
    Starting with fundamental research on a genetic pathway that blunts 
the immune response to cancer, scientists at the Lankenau Institute for 
Medical Research pioneered a new type of drug therapy that destroys a 
key immune barrier and greatly heightens the efficacy of radiotherapy 
and chemotherapies used to treat most human cancers. On the basis of 
groundbreaking proof-of-concept studies at Lankenau, similar inhibitor 
programs have been started by several pharmaceutical companies. The 
resulting lead compound has been rated by an NCI workshop as one of the 
most promising immunotherapeutics in the field, now in Phase Ib/II 
trials.
    Providing Efficiency and Flexibility.--AIRI member institutes' 
flexibility and research-only missions provide an environment 
particularly conducive to creativity and innovation. Independent 
research institutes possess a unique versatility and culture that 
encourages them to share expertise, information, and equipment across 
research institutions, as well as neighboring universities. These 
collaborative activities help minimize bureaucracy and increase 
efficiency, allowing for fruitful partnerships in a variety of 
disciplines and industries. Also, unlike institutes of higher 
education, AIRI member institutes focus primarily on scientific inquiry 
and discovery, allowing them to respond quickly to the research needs 
of the country.
    Supporting Local Economies.--AIRI is unique from other biomedical 
research organizations in that our membership consists of institutions 
located in regions not traditionally associated with cutting-edge 
research. AIRI members are located in 25 States, including many smaller 
or less-populated States that do not have major academic research 
institutions. In many of these regions, independent research institutes 
are major employers and local economic engines, and they exemplify the 
positive impact of investing in research and science.
    Fostering the Next Generation Scientific Workforce.--The biomedical 
research community depends upon a knowledgeable, skilled, and diverse 
workforce to address current and future critical health research 
questions. While the primary function of AIRI member institutions is 
research, most are highly involved in training the next generation of 
biomedical researchers, ensuring that a pipeline of promising 
scientists is prepared to make significant and potentially 
transformative discoveries in a variety of areas. AIRI supports 
policies that promote the ability of the United States to maintain a 
competitive edge in biomedical science. Initiatives focusing on career 
development and recruitment of a diverse scientific workforce are 
important to innovation in biomedical research and public health.
    AIRI thanks the subcommittee for its important work dedicated to 
ensuring the health of the Nation, and we appreciate this opportunity 
to urge the subcommittee to provide at least $32 billion for NIH in the 
fiscal year 2014 appropriations bill. AIRI looks forward to working 
with Congress to support research that improves the health and quality 
of life of all Americans.
                                 ______
                                 
  Prepared Statement of the Association of Maternal and Child Health 
                                Programs

    The Association of Maternal and Child Health Programs (AMCHP) 
requests for $640 million in funding for fiscal year 2014 for the Title 
V Maternal and Child Health (MCH) Services Block Grant administered by 
the Health Resources and Services Administration Maternal and Child 
Health Bureau. This funding request represents a $90 million decrease 
from its highest level of $730 million in fiscal year 2003. Nondefense 
discretionary programs cannot continue to bear the brunt of efforts to 
reduce the Federal deficit. Specifically, sequestration combined with 
reductions throughout the past 10 years resulted in at least a $124 
million decrease bringing funding for the Title V MCH Block Grant to 
its lowest level since 1991. The Title V MCH block grant is the 
foundation upon which core public health programs dedicated to 
improving the lives of our families is built and we strongly urge you 
to halt the erosion of funding for this critical program.
    In 2011 the Title V MCH Block Grant provided support and services 
to 44 million American women, infants and children, including children 
with special health care needs. It has been proven a cost effective, 
accountable, and flexible funding source used to address the most 
critical, pressing and unique MCH needs of each State. States and 
jurisdictions use the Title V MCH Block Grant to design and implement a 
wide range of maternal and child health programs. Although specific 
initiatives may vary among the States and jurisdictions, all of them 
work with local, State, and national partners to accomplish the 
following:
  --Reduce infant mortality and incidence of disabling conditions among 
        children;
  --Increase the number of children appropriately immunized against 
        disease ;
  --Increase the number of children in low-income households who 
        receive assessments and follow-up diagnostic and treatment 
        services;
  --Provide and ensure access to comprehensive perinatal care for 
        women; preventative and child care services; comprehensive 
        care, including long-term care services, for children with 
        special health care needs; and rehabilitation services for 
        blind and disabled children and
  --Facilitate the development of comprehensive, family-centered, 
        community-based, culturally competent, coordinated systems of 
        care for children with special health care needs.
    In addition to providing services to over 40 million Americans, 
Title V MCH Block Grant programs save Federal and State governments' 
money by ensuring that people receive preventive services to avoid more 
costly chronic conditions later in life. Below are some examples of the 
cost effectiveness of maternal and child health interventions and the 
role of this program:
  --Total medical costs are lower for exclusively breastfed infants 
        than never-breastfed infants since breastfed infants typically 
        need fewer sick care visits, prescriptions and 
        hospitalizations. State MCH programs promote breastfeeding by 
        developing educational materials for new mothers on 
        breastfeeding practices and providing information on 
        breastfeeding to all residents of their States through 
        websites, toll free telephone lines and coordinating with other 
        local and State programs.
  --Studies demonstrate that every $1 spent on smoking cessation 
        counseling for pregnant women saves $3 in neonatal intensive 
        care costs. State MCH programs fund State-wide smoking 
        cessation or ``quit lines'' for pregnant women and provide 
        education within their State about the dangers of smoking 
        during pregnancy, helping moms and moms-to-be quit smoking and 
        reducing their risk of premature birth.
  --Every $1 spent on preconception care programs for women with 
        diabetes can reduce health costs by up to $5.19 by preventing 
        costly complications in both mothers and babies. Investing $10 
        per person per year in community based disease prevention could 
        save more than $16 billion annually within 5 years. State MCH 
        and chronic disease programs work together at the State and 
        community levels to educate women, children and families about 
        the importance of physical activity, nutrition and obesity 
        prevention throughout the lifespan.
  --Early detection of genetic and metabolic conditions can lead to 
        reductions in death and disability as well as saved costs. For 
        example, phenylketonuria (PKU) a rare metabolic disorder 
        affects approximately one of every 15,000 infants born in the 
        U.S. Studies have found that PKU screening and treatment 
        represent a net direct costs savings. State MCH programs are 
        responsible for assuring that newborn screening systems are in 
        place statewide and that clinicians are alerted when follow up 
        is required.
  --Early detection of physical and intellectual disabilities results 
        in more efficient and effective treatment and support for 
        children with special health care needs. High-quality programs 
        for children at risk produce strong economic returns ranging 
        from about $4 per dollar invested to over $10 per dollar 
        invested. State MCH programs administer the State and 
        territorial Early Childhood Comprehensive Systems Initiative to 
        support State and community efforts to strengthen, improve and 
        integrate early childhood service systems.
  --The injuries incurred by children and adolescents in 1 year create 
        total lifetime economic costs estimated at more than $50 
        billion in medical expenses and lost productivity. State MCH 
        programs examine data and translate it into information and 
        policy to positively impact the incidence of infant mortality 
        and other factors that may contribute to child deaths. State 
        MCH programs invest in injury prevention programs, including 
        State and local initiatives to promote the proper use of child 
        safety seats and helmets. Additionally State MCH programs 
        promote safe sleeping practices to prevent Sudden Infant Death 
        Syndrome (SIDS).
  --The total cost of adolescent health risk behaviors is estimated to 
        be $435.4 billion per year. Risky behaviors have impact on the 
        health and well being of adolescents included smoking, binge 
        drinking, substance abuse, suicide attempts and high risk 
        sexual behavior. State MCH programs and their partners address 
        access to health care, violence, mental health and substance 
        use, reproductive health and prevention of chronic disease 
        during adulthood. State MCH programs often support State 
        adolescent health coordinators who work to improve the health 
        of adolescents within their States and territories.
    Some Members of Congress contend that savings such as these will 
not be realized in the near future and therefore will not result in 
immediate savings in these tight fiscal times. But today we can 
highlight a real-time example of how the Title V MCH Block Grant has 
played a role in helping save millions in annual health care costs. In 
Ohio, Title V played a lead role in providing funding for the Ohio 
Perinatal Quality Collaborative (OPQC). The OPQC is charged with 
reducing preterm births and improving outcomes of preterm newborns. 
Using the Institute for Healthcare Improvement Breakthrough Series, 
OPQC worked with 20 maternity hospitals (47 percent of all births in 
the State) through a collaborative focused on several obstetric 
improvement projects. OPQC reports that as a result of their efforts 
over 9,000 births are full term and that approximately 250 NICU 
admissions have been avoided. OPQC estimates approximately $10 million 
in annual health care cost savings. Other States have similar 
initiatives and we are tracking their successes.
    Another key component of the Title V MCH Block Grant is the Special 
Projects of Regional and National Significance (SPRANS). SPRANS funding 
complements and helps ensure the success of State Title V, Medicaid and 
CHIP programs by driving innovation, training young professionals and 
building capacity to create integrated systems of care for mothers and 
children. Examples of innovative projects funded through SPRANS include 
guidelines for child health supervision from infancy through 
adolescence (i.e. Bright Futures); nutrition care during pregnancy and 
lactation; recommended standards for prenatal care; successful 
strategies for the prevention of childhood injuries; and health safety 
standards for out of home childcare facilities.
    Without a sustained Federal investment the aforementioned savings 
will not be realized, program capacity and supports will be diminished 
and our Nation's ability to address the most pressing needs of these 
vulnerable populations will not be possible. The Title V MCH Block 
Grant supports a system which treats a whole person, not by their 
specific disease and AMCHP strongly urges Congress to sustain this 
investment at $640 million in fiscal year 2014.
    In addition to the Title V MCH block grant AMCHP is extremely 
concerned about any future proposals to cut funding from other core 
programs designed to assure the health of our Nation's families. We 
strongly urge you to sustain funding for the Centers for Control and 
Prevention (CDC). It is short sighted and counterproductive to further 
cut discretionary funding for prevention in the interest of deficit 
reduction. CDC programs should be protected from further cuts that will 
have profound consequences on our capacity to address the needs of the 
most vulnerable.
                                 ______
                                 
 Prepared Statement of the Association of Minority Health Professions 
                                Schools

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS

_______________________________________________________________________

    1)  Title VII Health Professions Training Programs:
     -- $24.602 million for the Minority Centers Of Excellence.
     -- $22.133 million for the Health Careers Opportunity Program.
    2)  $32 billion for the National Institutes of Health:
     -- Provide proportional increased support for the National 
        Institute on Minority Health and Health Disparities.
     -- Provide proportional increased support for Research Centers for 
        Minority Institutions.
    3)  $65 million for the Department of Health and Human Services' 
Office of Minority Health.
    4)  $65 million for the Department of Education's Strengthening 
Historically Black Graduate Institutions Program.
_______________________________________________________________________

    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to present my views before you. I am Dr. Wayne J. Riley, 
Chairman of the Board of Directors of the Association of Minority 
Health Professions Schools (AMHPS) and the President and Chief 
Executive Officer of Meharry Medical College. AMHPS, established in 
1976, is a consortium of our Nation's twelve (12) historically black 
medical, dental, pharmacy, and veterinary medicine schools. The members 
are two dental schools at Howard University and Meharry Medical 
College; four colleges of medicine at The Charles Drew University, 
Howard University, Meharry Medical College, and Morehouse School of 
Medicine; five schools of pharmacy at Florida A&M University, Hampton 
University, Howard University, Texas Southern University, and Xavier 
University; and one college of veterinary medicine at Tuskegee 
University.. In all of these roles, I have seen firsthand the 
importance of minority health professions institutions and the Title 
VII Health Professions Training programs.
    Mr. Chairman, I speak for our institutions, when I say that the 
minority health professions institutions and the Title VII Health 
Professionals Training programs address a critical national need. 
Persistent and severe staffing shortages exist in a number of the 
health professions, and chronic shortages exist for all of the health 
professions in our Nation's most medically underserved communities. 
Furthermore, even after the landmark passage of health reform, it is 
important to note that our Nation's health professions workforce does 
not accurately reflect the racial composition of our population. For 
example while blacks represent approximately 15 percent of the U.S. 
population, only 2-3 percent of the Nation's health professions 
workforce is black. Mr. Chairman, I would like to share with you how 
your committee can help AMHPS continue our efforts to help provide 
quality health professionals and close our Nation's health disparity 
gap.
    There is a well established link between health disparities and a 
lack of access to competent healthcare in medically underserved areas. 
As a result, it is imperative that the Federal Government continue its 
commitment to minority health profession institutions and minority 
health professional training programs to continue to produce healthcare 
professionals committed to addressing this unmet need--even in austere 
financial times.
    An October 2006 study by the Health Resources and Services 
Administration (HRSA)--during the Bush Administration--entitled ``The 
Rationale for Diversity in the Health Professions: A Review of the 
Evidence'' found that minority health professionals serve minority and 
other medically underserved populations at higher rates than non-
minority professionals. The report also showed that; minority 
populations tend to receive better care from practitioners who 
represent their own race or ethnicity, and non-English speaking 
patients experience better care, greater comprehension, and greater 
likelihood of keeping follow-up appointments when they see a 
practitioner who speaks their language. Studies have also demonstrated 
that when minorities are trained in minority health profession 
institutions, they are significantly more likely to: 1) serve in rural 
and urban medically underserved areas, 2) provide care for minorities 
and 3) treat low-income patients.
    As you are aware, Title VII Health Professions Training programs 
are focused on improving the quality, geographic distribution and 
diversity of the healthcare workforce in order to continue eliminating 
disparities in our Nation's healthcare system. These programs provide 
training for students to practice in underserved areas, cultivate 
interactions with faculty role models who serve in underserved areas, 
and provide placement and recruitment services to encourage students to 
work in these areas. Health professionals who spend part of their 
training providing care for the underserved are up to 10 times more 
likely to practice in underserved areas after graduation or program 
completion.
    In fiscal year 2014, funding for the Title VII Health Professions 
Training programs must be robust, especially the funding for the 
Minority Centers of Excellence (COEs) and Health Careers Opportunity 
Program (HCOPs). In addition, the funding for the National Institutes 
of Health (NIH)'s National Institute on Minority Health and Health 
Disparities (NIMHD), as well as the Department of Health and Human 
Services (HHS)'s Office of Minority Health (OMH), should be preserved.
    Minority Centers of Excellence.--COEs focus on improving student 
recruitment and performance, improving curricula in cultural 
competence, facilitating research on minority health issues and 
training students to provide health services to minority individuals. 
COEs were first established in recognition of the contribution made by 
four historically black health professions institutions to the training 
of minorities in the health professions. Congress later went on to 
authorize the establishment of ``Hispanic'', ``Native American'' and 
``Other'' Historically black COEs. For fiscal year 2014, I recommend a 
funding level of $24.602 million for COEs.
    Health Careers Opportunity Program (HCOP).--HCOPs provide grants 
for minority and non-minority health profession institutions to support 
pipeline, preparatory and recruiting activities that encourage minority 
and economically disadvantaged students to pursue careers in the health 
professions. Many HCOPs partner with colleges, high schools, and even 
elementary schools in order to identify and nurture promising students 
who demonstrate that they have the talent and potential to become a 
health professional. For fiscal year 2014, I recommend a funding level 
of $22.133 million for HCOPs.

                     NATIONAL INSTITUTES OF HEALTH

    National Institute on Minority Health and Health Disparities.--The 
National Institute on Minority Health and Health Disparities (NIMHD) is 
charged with addressing the longstanding health status gap between 
minority and nonminority populations. The NIMHD helps health 
professions institutions to narrow the health status gap by improving 
research capabilities through the continued development of faculty, 
labs, and other learning resources. The NIMHD also supports biomedical 
research focused on eliminating health disparities and develops a 
comprehensive plan for research on minority health at the NIH. 
Furthermore, the NIMHD provides financial support to health professions 
institutions that have a history and mission of serving minority and 
medically underserved communities through its Centers of Excellence 
program. For fiscal year 2014, I recommend funded increases 
proportional with the funding of the overall NIH, with increased FTEs.
    Research Centers at Minority Institutions.--The Research Centers at 
Minority Institutions program (RCMI), newly moved to the National 
Institute on Minority Health and Health Disparities has a long and 
distinguished record of helping our institutions develop the research 
infrastructure necessary to be leaders in the area of health 
disparities research. Although NIH has received unprecedented budget 
increases in recent years, funding for the RCMI program has not 
increased by the same rate. Therefore, the funding for this important 
program grow at the same rate as NIH overall in fiscal year 2014.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Office of Minority Health.--Specific programs at OMH include: 
assisting medically underserved communities with the greatest need in 
solving health disparities and attracting and retaining health 
professionals; assisting minority institutions in acquiring real 
property to expand their campuses and increase their capacity to train 
minorities for medical careers; supporting conferences for high school 
and undergraduate students to interest them in health careers, and 
supporting cooperative agreements with minority institutions for the 
purpose of strengthening their capacity to train more minorities in the 
health professions.
    The OMH has the potential to play a critical role in addressing 
health disparities, however that role will be greatly diminished if 
this agency does not retain its grant-making authority. For fiscal year 
2014, I recommend a funding level of $65 million for the OMH.

                        DEPARTMENT OF EDUCATION

    Strengthening Historically Black Graduate Institutions.--The 
Department of Education's Strengthening Historically Black Graduate 
Institutions (HBGI) program (Title III, Part B, Section 326) is 
extremely important to AMHPS. The funding from this program is used to 
enhance educational capabilities, establish and strengthen program 
development offices, initiate endowment campaigns, and support numerous 
other institutional development activities. In fiscal year 2014, an 
appropriation of $65 million is suggested to continue the vital support 
that this program provides to historically black graduate institutions.
    Mr. Chairman, please allow me to express my appreciation to you and 
the members of this subcommittee. With your continued help and support, 
AMHPS' member institutions and the Title VII Health Professions 
Training programs and the historically black health professions schools 
can help this country to overcome health disparities. Congress must be 
careful not to eliminate, paralyze or stifle the institutions and 
programs that have been proven to work. The Association seeks to close 
the ever widening health disparity gap. If this subcommittee will give 
us the tools, we will continue to work towards the goal of eliminating 
that disparity everyday.
    Thank you, Mr. Chairman.
                                 ______
                                 
  Prepared Statement of the Association of Public Television Stations 
            (APTS) and the Public Broadcasting Service (PBS)

    On behalf of America's 361 public television stations, we 
appreciate the opportunity to submit testimony for the record on the 
importance of Federal funding for local public television stations and 
PBS. We urge the subcommittee to support level funding of $445 million 
in two-year advance funding for the Corporation for Public Broadcasting 
in fiscal year 2016, and level funding of $27.3 million for the Ready 
To Learn program at the Department of Education in fiscal year 2014.

Corporation for Public Broadcasting--fiscal year 2016 Request: $445 
        million, two-year advance funded
    More than 40 years after the inception of public broadcasting, 
local stations and PBS continue to serve as the treasured educational 
and cultural institutions envisioned by their founders, reaching 
America's local communities with unique, essential and unsurpassed 
programming and services.
    Local stations and PBS treat their audience as citizens rather than 
mere consumers, providing essential services to all Americans, not just 
the 18-49 year olds to whom advertisers hope to appeal to. We serve 
everyone, everywhere, every day, for free.
    Public broadcasting serves the public good--in education, public 
affairs, public safety, the preservation of the national memory and 
celebration of the American culture, and many other areas--and richly 
deserves public support. The overwhelming majority of Americans agree. 
In a recent bi-partisan poll conducted by Hart Research Associates/
American Viewpoint, nearly 70 percent of American voters, including 
majorities of self-identifying Republicans, Independents, and Democrats 
support continued Federal funding for public broadcasting. In addition, 
polls shows that Americans consider PBS to be the second most 
appropriate expenditure of public funds, behind only military defense.
    Federal support for CPB and local public television stations has 
resulted in a nationwide system of locally owned and controlled, 
trusted, community-driven and community responsive media entities that 
form an incredibly successful public-private partnership. At an annual 
cost of about $1.35 per year for each American, public broadcasting is 
a smart investment creating important economic activity while providing 
an essential educational and cultural service. Public media provides a 
6 to 1 return on investment for every Federal dollar. In addition, 
public broadcasting directly supports over 20,000 jobs, and the vast 
majority of them are in local public television and radio stations in 
hundreds of communities across America.
    We seek Federal funding for public broadcasting because we are part 
of the Nation's public service infrastructure, just like public 
libraries, public schools and public highways.
    Funding through CPB is absolutely essential to public television 
stations. Stations rely on the Federal investment to develop local 
programming, operate their facilities, pay their employees and provide 
community resources on-air, online and on-the-ground. This funding is 
particularly important to rural stations that struggle to raise local 
funds from individual donors due to the smaller and often economically 
strained population base. At the same time it is often more costly to 
serve rural areas due to the topography and distances between 
communities. As a result, public broadcasters, with their commitment to 
universal service, are often the only local broadcast source for these 
rural communities.
    More than 70 percent of funding appropriated to CPB reaches local 
stations in the form of Community Service Grants. On average, Federal 
spending makes up approximately 15 percent of local television 
station's budgets. However, for many smaller and rural stations, 
Federal funding represents more than 30-50 percent (and in a handful of 
instances, an even larger percentage) of their total budget. For all 
stations, this Federal funding is the ``lifeblood'' of public 
broadcasting, providing critical seed money to local stations that 
enables them to build additional support from State legislatures, 
private foundations and corporations, and ``viewers like you.''
    A 2007 GAO report concluded that these Federal Community Service 
Grants are an irreplaceable source of revenue, and that ``substantial 
growth of nonFederal funding appears unlikely.'' It also found that 
``cuts in Federal funding could lead to a reduction in staff, local 
programming or services.'' In addition, a June 2012 study requested by 
this subcommittee and conducted by an independent third party for CPB 
came to the same conclusion as the GAO: Federal funding for public 
broadcasting is irreplaceable.
    Federal support combined with the advent of digital technology has 
created enormous potential for stations, allowing them to bring content 
to Americans in new, innovative ways while retaining our fundamental 
public service mission. Americans streamed 229 million videos across 
PBS' web and mobile platforms in January 2013 alone and in December 
2012, 45 percent of all video minutes consumed on kids' Internet sites 
were on PBSKIDS.org. Further, public television stations are now 
utilizing a wide array of digital tools to expand their current roles 
as educators, local conveners and vital sources of trusted information 
at a time when their communities need them most.
    As the leading source of digital learning tools for America's 
preschool teachers and K-12 classrooms with resources to help build 
science, math and literacy skills, PBS and local stations make-up the 
Nation's largest classroom. Local stations provide free, cutting edge, 
educational content for all Americans so that regardless of their 
family's income, children have access to safe, non-commercial media 
that has helped prepare 90 million American kids for success in school 
and has been proven to help close the achievement gap.
    Stations are also responding to the needs of the 21st century 
classroom by expanding digital educational resources for teachers, 
students and parents alike. For example, stations and PBS are working 
together on PBS Learning Media, an online portal where educators can 
access standards-based, curriculum-aligned digital learning objects 
created from public television content as well as material from the 
Library of Congress, National Archives, and other contributors to the 
Department of Education's Learning Registry. Over 28,000 homeschooling 
families rely on PBS for instructive resources like PBS LearningMedia. 
Stations are also building homegrown learning platforms like Maryland 
Public Television's Thinkport online system, which the State 
superintendent of schools has credited with helping raise Maryland's 
students to the top of the student achievement rankings nationwide.
    In their role as community conveners, stations have been working to 
confront the dropout crisis in America's high schools. CPB developed 
the American Graduate initiative, a significant investment and 
partnership with local stations and their communities to address the 
daunting high school dropout problem. Stations are providing resources 
and services to raise awareness, coordinate action with community 
partners, and work directly with students, parents, teachers, mentors, 
volunteers and leaders to lower the drop-out rate in their respective 
communities.
    Local public television stations have also embraced the 
opportunities of digital technology as a way to help address emergency 
response and homeland security issues in their communities. Stations 
like Las Vegas PBS have integrated their digital technology with local 
public safety officials to provide enhanced emergency communications 
that better aid the responders and provide citizens with needed 
information during a crisis. Vegas PBS is also the largest job trainer 
in Nevada, and this manifold mission of service is being emulated by 
public television stations nationwide.
    Local public television stations serve as essential communications 
hubs in their communities providing unparalleled local coverage of 
news, current events, and State legislatures that encourages every 
American to become a more informed citizen. Public television is the 
place for real public affairs programming, real news, real history, 
real science, real art that makes us think, teaches us useful things, 
and inspires us to be a better, more sophisticated, more civilized, 
more successful people. We bring the wonders of the world--Broadway 
shows, the finest museums, the best professors and much more--to the 
most remote places in our country.
    In order for our stations to continue playing this vital role in 
their communities, APTS and PBS respectfully request $445 million for 
CPB, two-year advance funded for fiscal year 2016.
    Two-year advance funding is essential to the mission of public 
broadcasting. This longstanding practice, which was proposed by 
President Ford and embraced by Congress in 1976, establishes a firewall 
insulating programming decisions from political interference, enables 
the leveraging of funds to ensure a successful public-private 
partnership, and provides stations with the necessary lead time to plan 
in-depth programming.
    Public television's history of editorial independence has paid off 
in unprecedented levels of public trust--for the tenth consecutive 
year, the American people have ranked PBS as one of the most trusted 
national institutions. Advance funding and the firewall it provides is 
vital to maintaining this credibility among the American public.
    In addition, local public broadcasting stations are able to 
leverage the two-year advance funding to raise State, local and private 
funds, ensuring the continuation of this strong public-private 
partnership. These Federal funds act as essential seed money for 
fundraising efforts at every station, no matter its size.
    Finally, the two-year advance funding mechanism also gives stations 
and producers the critical lead time needed to plan and produce high-
quality programs. The signature series that demonstrate the depth and 
breadth of public television, like Ken Burns' The Civil War and Henry 
Hampton's Eyes on the Prize, take several years to produce. Ken Burns' 
documentary schedule is already planned through 2019, and it will 
educate the Nation on subjects ranging from the Vietnam War to the 
history of country music.
    The fact that stations know they will have funding to support 
projects like these in advance is critical for producers to be able to 
actively develop groundbreaking projects. In addition, two-year advance 
funding is essential to the creation of local programming over multiple 
fiscal years as stations convene the community to identify needs, 
recruit partners, conduct research, develop content and deliver 
services.
    The two-year advance funding is essential for stations as they 
continue to plan the production of the unparalleled programming and 
local services that educate, inspire, inform and entertain the American 
people in the unique way only public broadcasting can.

Ready To Learn--fiscal year 2014 Request: $27.3 million (Department of 
        Education)
    The Ready To Learn (RTL) competitive grant program uses the power 
of public television's on-air, online, mobile and on-the-ground 
educational content to build the math and reading skills of children 
between the ages of two and eight, especially those from low-income 
families. Federal support funds evidence-based television programs and 
digital content that teach key reading, math and STEM skills, 
effectively reaching our Nation's children.
    Together, CPB and PBS are collaborating with teams of math and 
literacy experts, technologists, education organizations, and 
producers, to design and test media that can help close the achievement 
gap. Numerous studies show that RTL content has a significant and 
positive effect on the educational lives of children who use it. For 
example, one study showed that children who watched the RTL-funded PBS 
series SUPER WHY! scored 46 percent higher on standardized tests than 
those who did not watch the show
    Pivoting off the success in literacy, public media has incorporated 
early math skills into RTL to help bridge the achievement gap by 
further innovating educational media content, educating kids inside and 
outside the classroom, and engaging local communities. Studies have 
already shown that using RTL content in low-income homes improves pre-
school age kids' numerical sense skills. In addition to the content, 
new tools will be provided including a sophisticated progress tracking 
system that equips parents and educators with the means to measure 
student progress, in real time. RTL will continue to be rigorously 
evaluated for its appeal and efficacy, so that the program can continue 
to offer America's youngest citizens the tools they need to succeed in 
school and in life.
    In addition to being research-based and teacher tested, the RTL 
Television program also provides excellent value for our Federal 
dollars. In the last five-year grant round, public broadcasting 
leveraged an additional $50 million in funding to augment the $73 
million investment by the Department of Education for content 
production. Without the investment of the Federal Government, this 
supplemental funding would likely end.
    In fiscal year 2013 the President's budget proposed consolidating 
Ready To Learn into a larger grant program. APTS and PBS are concerned 
that the consolidation of this program would end the ground-breaking 
educational impact that RTL has had on kids nationwide, and 
particularly those with limited access to other educational resources. 
Consolidation would deny RTL the benefits that come from the unique 
understanding of needs and relationship that local public media 
stations have with the communities they serve. At the same time, 
consolidation undermines PBS's ability to create television and online 
content on an economy of scale that results from producing once for 
national distribution through member stations who can tailor outreach 
to the demands of their communities. This model allows PBS and local 
stations to annually reach 80 percent of America's children ages 2 to 8 
through television and another 13 million per month online and on 
mobile apps. The local-national partnership has made RTL tremendously 
efficient and effective and consolidation or elimination of the program 
would severely affect the ability of local stations to respond to their 
communities' educational needs, eliminating the critical resources 
provided by this program for children, parents and teachers.
    Ready To Learn symbolizes the mission of public media and is a 
shining example of a public-private partnership as Federal funds are 
leveraged to create the most appealing and impactful children's 
educational content that is supplemented by online and on-the-ground 
resources. Without the Ready To Learn program, millions of families 
would lose access to this incredible high-quality education content, 
especially the low-income and underserved households that are a 
particular focus of this program.
    One hundred seventy million Americans regularly rely on public 
broadcasting--on television, on the radio, online, and in the 
classroom--because we provide them something they need that no one else 
in the media world provides: A place to think. A place to learn. A 
place to grow. A tool for the citizen. None of this would be possible 
without the Federal investment in public broadcasting.
    We request that Congress continue its commitment to this highly 
successful public-private partnership by continuing to provide level 
funding for the two-year advance of the Corporation for Public 
Broadcasting and the stand alone Ready To Learn Program.
                                 ______
                                 
     Prepared Statement of the Association of Rehabilitation Nurses

                              INTRODUCTION

    On behalf of the Association of Rehabilitation Nurses (ARN), I 
appreciate having the opportunity to submit written testimony to the 
Senate LHHS Appropriations Subcommittee regarding funding for nursing 
and rehabilitation related programs in fiscal year 2014. ARN represents 
nearly 12,000 rehabilitation nurses that work to enhance the quality of 
life for those affected by physical disability and/or chronic illness. 
ARN understands that Congress has many concerns and limited resources, 
but believes that chronic illnesses and physical disabilities are heavy 
burdens on our society that must be addressed.

            REHABILITATION NURSES AND REHABILITATION NURSING

    Rehabilitation nurses help individuals affected by chronic illness 
and/or physical disability adapt to their condition, achieve their 
greatest potential, and work toward productive, independent lives. We 
take a holistic approach to meeting patients' nursing and medical, 
vocational, educational, environmental, and spiritual needs. 
Rehabilitation nurses begin to work with individuals and their families 
soon after the onset of a disabling injury or chronic illness. They 
continue to provide support and care, including patient and family 
education, which empowers these individuals when they return home, or 
to work, or school. The rehabilitation nurse often teaches patients and 
their caregivers how to access systems and resources.
    Rehabilitation nursing is a philosophy of care, not a work setting 
or a phase of treatment. We base our practice on rehabilitative and 
restorative principles by: (1) managing complex medical issues; (2) 
inter professional collaboration with other specialists; (3) providing 
ongoing patient/caregiver education; (4) setting goals for maximum 
independence; and (5) establishing plans of care to maintain optimal 
wellness. Rehabilitation nurses practice in all settings, including 
freestanding rehabilitation facilities, hospitals, long-term subacute 
care facilities/skilled nursing facilities, long-term acute care 
facilities, comprehensive outpatient rehabilitation facilities, home 
health, and private practices, just to name a few.
    As we celebrate the third anniversary of the Affordable Care Act 
(ACA)--which focused on creating a system that will increase access to 
quality care, emphasizes prevention, and decreases costs--it is 
critical that a substantial investment be made in the nursing workforce 
programs and in the scientific research that provides the basis for 
nursing practice. To ensure that patients receive the best quality care 
possible, ARN supports Federal programs and research institutions that 
address the national nursing shortage and conduct research focused on 
nursing and medical rehabilitation, e.g., traumatic brain injury. 
Therefore, ARN respectfully requests that the subcommittee provide 
increased funding for the following programs:
nursing workforce and development programs at the health resources and 

                     SERVICES ADMINISTRATION (HRSA)

    ARN supports efforts to resolve the national nursing shortage, 
including appropriate funding to address the shortage of qualified 
nursing faculty. Rehabilitation nursing requires a high-level of 
education and technical expertise, and ARN is committed to assuring and 
protecting access to professional nursing care delivered by highly-
educated, well-trained, and experienced registered nurses for 
individuals affected by chronic illness and/or physical disability.
    According to the Bureau of Labor Statistics' Employment Projections 
for 2010-2020, the expected number of practicing nurses will grow from 
2.74 million in 2010 to 3.45 million in 2020, an increase of 712,000 or 
26 percent. The projections further explain the need for 495,500 
replacements in the nursing workforce, bringing the total number of job 
openings for nurses due to growth and replacements to 1.2 million by 
2020. The demand for nurses will continue to grow as the baby-boomer 
population ages, nurses retire, and the need for healthcare 
intensifies. Implementation of the new health reform law will also 
increase the need for a well-trained and highly skilled nursing 
workforce. The Institute of Medicine has released recommendations on 
how to help the nursing workforce meet these new demands, but we are 
destined to fall short of these lofty goals if there are not enough 
nurses to facilitate change.
    For nearly 50 years, the Nursing Workforce Development programs, 
authorized under Title VIII of the Public Health Service Act, have 
helped build the supply and distribution of qualified nurses to meet 
our Nation's healthcare needs. The Title VIII programs bolster nursing 
education at all levels, from entry-level preparation through graduate 
study, and provide support for institutions that educate nurses for 
practice in rural and medically underserved communities. Today, the 
Title VIII programs are essential to ensure the demand for nursing care 
is met. Between fiscal year 2005 and 2010 alone, the Title VIII 
programs supported over 400,000 nurses and nursing students as well as 
numerous academic nursing institutions, and healthcare facilities. 
Educating new nurses to fill these vacancies is a great way to put 
Americans back to work and simultaneously enhance an ailing health care 
system.
    ARN strongly supports the national nursing community's request of 
$251 million in fiscal year 2014 funding for Federal Nursing Workforce 
Development programs at HRSA.

  NATIONAL INSTITUTE ON DISABILITY AND REHABILITATION RESEARCH (NIDRR)

    The National Institute on Disability and Rehabilitation Research 
(NIDRR) provides leadership and support for a comprehensive program of 
research related to the rehabilitation of individuals with 
disabilities. As one of the components of the Office of Special 
Education and Rehabilitative Services at the U.S. Department of 
Education, NIDRR operates along with the Rehabilitation Services 
Administration and the Office of Special Education Programs.
    The mission of NIDRR is to generate new knowledge and promote its 
effective use to improve the abilities of people with disabilities to 
perform activities of their choice in the community, and also to expand 
society's capacity to provide full opportunities and accommodations for 
its citizens with disabilities. NIDRR conducts comprehensive and 
coordinated programs of research and related activities to maximize the 
full inclusion, social integration, employment and independent living 
of individuals of all ages with disabilities. NIDRR's focus includes 
research in areas such as: employment, health and function, technology 
for access and function, independent living and community integration, 
and other associated disability research areas.
    ARN strongly supports the work of NIDRR and encourages Congress to 
provide the maximum possible fiscal year 2014 funding level.

             NATIONAL INSTITUTE OF NURSING RESEARCH (NINR)

    ARN understands that research is essential for the advancement of 
nursing science, and believes new concepts must be developed and tested 
to sustain the continued growth and maturation of the rehabilitation 
nursing specialty. The National Institute of Nursing Research (NINR) 
works to create cost-effective and high-quality health care by testing 
new nursing science concepts and investigating how to best integrate 
them into daily practice. Through grants, research training, and inter 
professional collaborations, NINR addresses care management of patients 
during illness and recovery, reduction of risks for disease and 
disability, promotion of healthy lifestyles, enhancement of quality of 
life for those with chronic illness, and care for individuals at the 
end of life. NINR's broad mandate includes seeking to prevent and delay 
disease and to ease the symptoms associated with both chronic and acute 
illnesses. NINR's recent areas of research focus include the following:
  --End of life and palliative care in rural areas;
  --Research in multi-cultural societies;
  --Bio-behavioral methods to improve outcomes research; and
  --Increasing health promotion through comprehensive studies.
    ARN respectfully requests $150 million in fiscal year 2014 funding 
for NINR to continue its efforts to address issues related to chronic 
and acute illnesses.

                      TRAUMATIC BRIAN INJURY (TBI)

    According to the Brain Injury Association of America, 1.7 million 
people sustain a traumatic brain injury (TBI) each year.\1\ This figure 
does not include the 150,000 cases of TBI suffered by soldiers 
returning from wars in Afghanistan and conflicts around the world.
    The annual national cost of providing treatment and services for 
these patients is estimated to be nearly $60 million in direct care and 
lost workplace productivity. Continued fiscal support of the Traumatic 
Brain Injury Act will provide critical funding needed to further 
develop research and improve the lives of individuals who suffer from 
traumatic brain injury.
    Continued funding of the TBI Act will promote sound public health 
policy in brain injury prevention, research, education, treatment, and 
community-based services, while informing the public of needed support 
for individuals living with TBI and their families.
    ARN strongly supports the current work being done by the Centers 
for Disease Control and Prevention (CDC) and HRSA on TBI programs. 
These programs contribute to the overall body of knowledge in 
rehabilitation medicine.
    ARN urges Congress to support the following fiscal year 2014 
funding requests for programs within the TBI Act: $10 million for CDC's 
TBI registries and surveillance, prevention and national public 
education and awareness efforts; $8 million for the HRSA Federal TBI 
State Grant Program; and $4 million for the HRSA Federal TBI Protection 
and Advocacy Systems Grant Program.

                               CONCLUSION

    ARN appreciates the opportunity to share our priorities for fiscal 
year 2014 funding levels for nursing and rehabilitation programs. ARN 
maintains a strong commitment to working with Members of Congress, 
other nursing and rehabilitation organizations, and other stakeholders 
to ensure that the rehabilitation nurses of today continue to practice 
tomorrow. By providing the fiscal year 2014 funding levels detailed 
above, we believe the subcommittee will be taking the steps necessary 
to ensure that our Nation has a sufficient nursing workforce to care 
for patients requiring rehabilitation from chronic illness and/or 
physical disability.
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    \1\ http://www.biausa.org/living-with-brain-injury.htm.
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                                 ______
                                 
    Prepared Statement of the Association of University Programs in 
                Occupational Health and Safety (AUPOHS)

    I am testifying on behalf of the Association of University Programs 
in Occupational Health and Safety (AUPOHS), an organization 
representing the 18 multidisciplinary, university-based Education and 
Research Centers (ERCs) and the nine Agricultural Centers for Disease 
and Injury Research, Education, and Prevention funded by the National 
Institute for Occupational Safety and Health (NIOSH), the Federal 
agency responsible for supporting education, training, and research for 
the prevention of work-related injuries and illnesses in the United 
States.
    We respectfully request that the fiscal year 2014 Labor, Health and 
Human Services Appropriations bill include level funding of $24.268 
million for the Education and Research Centers and $22 million for the 
Agriculture, Forestry and Fishing Program within the NIOSH budget.
    The ERCs are regional resources for parties involved with 
occupational health and safety--industry, labor, Government, academia, 
and the public. Collectively, the ERCs provide training and research 
resources to every Public Health Region in the United States. ERCs 
contribute to national efforts to reduce losses associated with work-
related illnesses and injuries by offering:
    Prevention Research.--Developing the basic knowledge and associated 
technologies to prevent work-related illnesses and injuries.
    Professional Training.--ERC's support 86 graduate degree programs 
in Occupational Medicine, Occupational Health Nursing, Safety 
Engineering, Industrial Hygiene, and other related fields to provide 
qualified professionals in essential disciplines.
    Research Training.--Preparing doctoral-trained scientists who will 
respond to future research challenges and who will prepare the next 
generation of occupational health and safety professionals.
    Continuing Education.--Short courses designed to enhance 
professional skills and maintain professional certification for those 
who are currently practicing in occupational health and safety 
disciplines. These courses are delivered throughout the regions of the 
18 ERCs as well as through distance learning technologies.
    Regional Outreach.--Responding to specific requests from local 
employers and workers on issues related to occupational health and 
safety.
    Occupational injury and illness represent a striking burden on 
America's health and well-being. Despite significant improvements in 
workplace safety and health over the last several decades, each year 
nearly 1.2 million workers are injured seriously enough to require time 
off work and, daily, an average of 11,000 U.S. workers sustain 
disabling injuries on the job, 13 workers die from an injury suffered 
at work, and 146 workers die from work-related diseases. This burden 
costs industry and citizens an estimated $4 billion per week--$250 
billion dollars per year. This is an especially tragic situation 
because work-related fatalities, injuries and illnesses are preventable 
with effective, professionally directed, health and safety programs.
    The rapidly changing workplace continues to present new health 
risks to American workers that need to be addressed through 
occupational safety and health research. For example, between 2000 and 
2015, the number of workers 55 years and older will increase 72 percent 
to over 31 million. Work related injury and fatality rates increase at 
age 45, with rates for workers 65 years and older nearly three times 
greater than younger workers. In addition to changing demographics, the 
rapid development of new technologies (e.g., nanotechnology) poses many 
unanswered questions with regard to workplace health and safety that 
require urgent attention.
    The heightened awareness of terrorist threats, and the increased 
responsibilities of first responders and other homeland security 
professionals, illustrates the need for strengthened workplace health 
and safety in the ongoing war on terror. The NIOSH ERCs play a crucial 
role in preparing occupational safety and health professionals to 
identify and mitigate vulnerabilities to terrorist attacks and to 
increase readiness to respond to biological, chemical, or radiological 
attacks. In addition, occupational health and safety professionals have 
worked for several years with emergency response teams to minimize 
disaster losses. For example, NIOSH took a lead role in protecting the 
safety of 9/11 emergency responders in New York City and Virginia, with 
ERC-trained professionals applying their technical expertise to meet 
immediate protective needs and to implement evidence-based programs to 
safeguard the health of clean-up workers. Additionally, NIOSH is now 
administering grants to provide health screening of World Trade Center 
responders. We need manpower to address these challenges and it is the 
NIOSH ERCs that train the professionals who fill key positions in 
health and safety programs, regionally and around the Nation. And 
because ERCs provide multi-disciplinary training, ERC graduates protect 
workers in virtually every walk of life. Despite the success of the 
ERCs in training such qualified professionals, the country continues to 
have ongoing manpower shortages.
    The Agricultural Safety and Health Centers program was established 
by Congress in 1990 (Public Law 101-517) in response to evidence that 
agricultural workers were suffering substantially higher rates of 
occupational injury and illness than other U.S. workers.
    Today the NIOSH Agriculture, Forestry, and Fishing (AFF) Initiative 
includes nine regional Centers for Agricultural Disease and Injury 
Research, Education, and Prevention and one national center to address 
children's farm safety and health. The AFF program is the only 
substantive Federal effort to meet the obligation to ensure safe 
working conditions for workers in this most vital production sector. 
While agriculture, forestry, and fishing constitute one of the largest 
industry sectors in the U.S. (DOL 2011), most AFF operations are 
themselves small: nearly 78 percent employ fewer than 10 workers, and 
most rely on family members and/or immigrant, part-time, contract and 
seasonal labor. Thus, many AFF workers are excluded from labor 
protections, including many of those enforced by OSHA.
    In 2010 the AFF sector had a work-related fatality rate of 28 per 
100,000 workers, the highest of any sector in the Nation. More than 1 
in 100 AFF workers incur nonfatal injuries resulting in lost work days 
each year. These reported figures do not even include men, women, and 
youths on farms with fewer than 11 full-time employees. In addition to 
the harm to individual men, women, and families, these deaths and 
injuries inflict serious economic losses including medical costs and 
lost capital, productivity, and earnings. The life-saving, cost-
effective work of the NIOSH AFF program is not replicated by any other 
agency:
  --State and Federal OSHA personnel rely on NIOSH research in the 
        development of evidence-based standards for protecting 
        agricultural workers and would not be able to fulfill their 
        mission without the NIOSH AFF program.
  --While committed to the well-being of farmers, the USDA has little 
        expertise in the medical or public health sciences. USDA no 
        longer funds, as it did historically, land grant university-
        based farm safety specialists.
  --Staff members of USDA's National Institute of Food and Agriculture 
        interact with NIOSH occupational safety and health research 
        experts to keep abreast of cutting-edge research and new 
        directions in this area.

NIOSH Agricultural Center activities include:
  --AFF research has shown that the use of rollover protective 
        structures (ROPS or rollbars) and seatbelts on tractors can 
        prevent 99 percent of overturn-related deaths. A New York 
        program has increased the installation of ROPS by 10-fold and 
        recorded over 100 close calls with no injuries among farmers 
        who had installed ROPS. 99 percent of program participants said 
        they would recommend the program to other farmers.
  --Working in partnership with producers and farm owners, the NIOSH 
        AFF Centers have developed evidence-based solutions for 
        reducing exposure to pesticides and other farm chemicals among 
        farmers, farm workers and their children.
  --Commercial Fishing had a reported annual fatality rate 58 times 
        higher than the rate for all U.S. workers in 2009. Research has 
        shown that knowledge of maritime navigation rules and emergency 
        preparedness means survival. A NIOSH AFF-funded team produced 
        an interactive navigation training CD in three languages, 
        demonstrated the effectiveness of refresher survival drill 
        instruction, and assisted the U.S. Coast Guard's revision of 
        regulations requiring commercial fishing vessel captains 
        completed navigation training.
  --The Centers have partnered with producers, employers, the Federal 
        migrant health program, physicians, nurses, and Internet 
        Technology specialists to educate farmers, employers, and 
        health care providers about the best way to treat and prevent 
        agricultural injury and illness.
  --In 2010, the logging industry had a reported fatality rate of 91.9 
        deaths per 100,000 workers (preliminary data), a rate more than 
        25 times higher than that of all U.S. workers. NIOSH AFF 
        Centers including the Southeast and the Northwest are uniquely 
        positioned to ensure the safety of our Nation's 86,000 workers 
        in forestry & logging.
    Thank you for the opportunity to present testimony on behalf of the 
many individuals committed to working to improve the safety and well 
being of others in our communities.
                                 ______
                                 
      Prepared Statement of the Association of Zoos and Aquariums

    Chairman Harkin and Ranking Member Moran: My name is Jim Maddy, and 
I am the President and CEO. Thank you for allowing me to testify on 
behalf of the Nation's 211 U.S. accredited zoos and aquariums. 
Specifically, I want to express my support for the inclusion of $38.6 
million for the Institute of Museum and Library Services' (IMLS) Office 
of Museum Services in the fiscal year 2014 Labor, Health and Human 
Services, Education, and Related Agencies appropriations bill.
    Founded in 1924, the Association of Zoos and Aquariums (AZA) is a 
nonprofit 501c(3) organization dedicated to the advancement of zoos and 
aquariums in the areas of conservation, education, science, and 
recreation. Accredited zoos and aquariums annually see more than 182 
million visitors, collectively generate more than $16 billion in annual 
economic activity, and support more than 142,000 jobs across the 
country. Over the last 5 years, AZA-accredited institutions supported 
more than 4,000 field conservation and research projects with 
$160,000,000 annually in more than 100 countries. In the last 10 years, 
accredited zoos and aquariums formally trained more than 400,000 
teachers, supporting science curricula with effective teaching 
materials and hands-on opportunities. School field trips annually 
connect more than 12,000,000 students with the natural world.
    Aquariums and zoological parks are defined by the ``Museum and 
Library Services Act of 2003'' (Public Law 108-81) as museums. The 
Office of Museum Services awards grants to museums to support them as 
institutions of learning and exploration, and keepers of cultural, 
historical, and scientific heritages. Grants are awarded in several 
areas including educational programming, professional development, and 
collections management, among others.
    The Nation's accredited zoos and aquariums, even while facing 
budget limitations, are thriving during these uncertain economic times. 
As valued members of local communities, zoos and aquariums offer a 
variety of programs ranging from unique educational opportunities for 
schoolchildren to conservation initiatives that benefit both local and 
global species. The competitive grants offered by the IMLS Office of 
Museum Services ensure that many of these programs, which otherwise may 
not exist because of insufficient funds, positively impact local 
communities and many varieties of species.
    For example, through its 2012 Museums for American grant, the 
Birmingham Zoo will support its Africa Zoo School program, which will 
serve 1,200 students over 2 years. Partnering with Birmingham City 
School, seventh-grade students from low-performing schools attend a 
week-long ``Zoo School'' session, where they learn about the crisis of 
the elephant species' survival in Africa, the cultures of people in 
Africa, and the scientific and engineering research involved in 
sustaining these populations. A 2011 Museums for America grant enabled 
The National Aquarium in Baltimore to create a more robust volunteer 
program by developing and testing new techniques to attract, train, 
engage, and retain a new generation of more diverse volunteers. 
Finally, the Beardsley Zoo used its 2011 Museums for America grant to 
continue its ``Conservation Discovery Corps'' teen program, a year-
round informal science education program designed to provide diverse 
and economically challenged but environmentally aware students with 
applied wildlife conservation training in the zoo and through field 
research. Students were trained in conservation and education concepts 
that were applied through field expeditions and collaborations with 
scientists in research and habitat restoration activities to prepare 
them as zoo exhibit interpreters and teen Conservation Discovery Corps 
ambassadors.
    Unfortunately, current funding has allowed IMLS to fund only a 
small fraction of all highly-rated grant applications. Despite this 
funding shortfall, zoo and aquarium attendance has increased and the 
educational services zoos and aquariums provide to schools and 
communities are in greater demand than ever. Zoos and aquariums are 
essential partners at the Federal, State, and local levels in providing 
education and cultural opportunities that adults and children may 
otherwise never enjoy.
    As museums, zoos and aquariums share the same mission of preserving 
the world's great treasures, educating the public about them, and 
contributing to the Nation's economic and cultural vitality. Therefore, 
I strongly encourage you to include $38.6 million for the Institute of 
Museum and Library Services' Office of Museum Services in the fiscal 
year 2014 Labor, Health and Human Services, Education, and Related 
Agencies appropriations bill.
    Thank you.
                                 ______
                                 
     Prepared Statement of the Brain Injury Association of America

    Chairman Harkin and Ranking Member Moran, thank you for the 
opportunity to submit this written testimony with regard to the fiscal 
year 2014 Labor-HHS-Education appropriations bill. This testimony is on 
behalf of the Brain Injury Association of America (BIAA), our national 
network of State affiliates, and hundreds of local chapters and support 
groups from across the country.
    In the civilian population alone every year, more than 1.7 million 
people sustain brain injuries from falls, car crashes, assaults and 
contact sports. Males are more likely than females to sustain brain 
injuries. Children, teens and seniors are at greatest risk.
    Recently, we are seeing an increasing number of service members 
returning from the conflicts in Iraq and Afghanistan with TBI, which 
has been termed one of the signature injuries of the War. Many of these 
returning service members are undiagnosed or misdiagnosed and 
subsequently they and their families will look to community and local 
resources for information to better understand TBI and to obtain vital 
support services to facilitate successful reintegration into the 
community.
    For the past 14 years Congress has provided minimal funding through 
the HRSA Federal TBI Program to assist States in developing services 
and systems to help individuals with a range of service and family 
support needs following their loved one's brain injury. Similarly, the 
grants to State Protection and Advocacy Systems to assist individuals 
with traumatic brain injuries in accessing services through education, 
legal and advocacy remedies are woefully underfunded. Rehabilitation, 
community support and long-term care systems are still developing in 
many States, while stretched to capacity in others. Additional numbers 
of individuals with TBI as the result of war-related injuries only adds 
more stress to these inadequately funded systems.
    BIAA respectfully urges you to provide States with the resources 
they need to address both the civilian and military populations who 
look to them for much needed support in order to live and work in their 
communities.
    With broader regard to all of the programs authorized through the 
TBI Act, BIAA specifically requests:
  --$10 million (+ $4 million) for the Centers for Disease Control and 
        Prevention TBI Registries and Surveillance, Brain Injury Acute 
        Care Guidelines, Prevention and National Public Education/
        Awareness
  --$8 million (+ $1 million) for the Health Resources and Services 
        Administration (HRSA) Federal TBI State Grant Program
  --$4 million (+ $1 million) for the HRSA Federal TBI Protection & 
        Advocacy (P&A) Systems Grant Program
    CDC--National Injury Center.--The Centers for Disease Control and 
Prevention's National Injury Center is responsible for assessing the 
incidence and prevalence of TBI in the United States. The CDC estimates 
that 1.7 million TBIs occur each year and 3.4 million Americans live 
with a life-long disability as a result of TBI. In addition, the TBI 
Act as amended in 2008 requires the CDC to coordinate with the 
Departments of Defense and Veterans Affairs to include the number of 
TBIs occurring in the military. This coordination will likely increase 
CDC's estimate of the number of Americans sustaining TBI and living 
with the consequences.
    CDC also funds States for TBI registries, creates and disseminates 
public and professional educational materials, for families, caregivers 
and medical personnel, and has recently collaborated with the National 
Football League and National Hockey League to improve awareness of the 
incidence of concussion in sports. CDC plays a leading role in helping 
standardize evidence based guidelines for the management of TBI and $1 
million of this request would go to fund CDC's work in this area.
    HRSA TBI State Grant Program.--The TBI Act authorizes the HHS, 
Health Resources and Service Administration (HRSA) to award grants to 
(1) States, American Indian Consortia and territories to improve access 
to service delivery and to (2) State Protection and Advocacy (P&A) 
Systems to expand advocacy services to include individuals with 
traumatic brain injury. For the past thirteen years the HRSA Federal 
TBI State Grant Program has supported State efforts to address the 
needs of persons with brain injury and their families and to expand and 
improve services to underserved and unserved populations including 
children and youth; veterans and returning troops; and individuals with 
co-occurring conditions
    In fiscal year 2009, HRSA reduced the number of State grant awards 
to 15, in order to increase each monetary award from $118,000 to 
$250,000. This means that many States that had participated in the 
program in past years have now been forced to close down their 
operations, leaving many unable to access brain injury care.
    Increasing the program to $8 million will provide funding necessary 
to sustain the grants for the 21 States currently receiving funding 
along with the three additional States added this year and to ensure 
funding for four additional States. Steady increases over 5 years for 
this program will provide for each State including the District of 
Columbia and the American Indian Consortium and territories to sustain 
and expand State service delivery; and to expand the use of the grant 
funds to pay for such services as Information & Referral (I&R), systems 
coordination and other necessary services and supports identified by 
the State.
    HRSA TBI P&A Program.--Similarly, the HRSA TBI P&A Program 
currently provides funding to all State P&A systems for purposes of 
protecting the legal and human rights of individuals with TBI. State 
P&As provide a wide range of activities including training in self-
advocacy, outreach, information & referral and legal assistance to 
people residing in nursing homes, to returning military seeking 
veterans benefits, and students who need educational services.
    Effective Protection and Advocacy services for people with 
traumatic brain injury is needed to help reduce Government expenditures 
and increase productivity, independence and community integration. 
However, advocates must possess specialized skills, and their work is 
often time-intensive. A $4 million appropriation would ensure that each 
P&A can move towards providing a significant PATBI program with 
appropriate staff time and expertise.
    NIDRR TBI Model Systems of Care.--Funding for the TBI Model Systems 
in the Department of Education is urgently needed to ensure that the 
Nation's valuable TBI research capacity is not diminished, and to 
maintain and build upon the 16 TBI Model Systems research centers 
around the country.
    The TBI Model Systems of Care program represents an already 
existing vital national network of expertise and research in the field 
of TBI, and weakening this program would have resounding effects on 
both military and civilian populations. The TBI Model Systems are the 
only source of non-proprietary longitudinal data on what happens to 
people with brain injury. They are a key source of evidence-based 
medicine, and serve as a ``proving ground'' for future researchers.
    In order to make this program more comprehensive, Congress should 
provide $11 million (+ $1.5 million) in fiscal year 2014 for NIDRR's 
TBI Model Systems of Care program, in order to add one new 
Collaborative Research Project. In addition, given the national 
importance of this research program, the TBI Model Systems of Care 
should receive ``line-item'' status within the broader NIDRR budget.
    We ask that you consider favorably these requests for the CDC, the 
HRSA Federal TBI Program, and the NIDRR TBI Model Systems Program to 
further data collection, increase public awareness, improve medical 
care, assist States in coordinating services, protect the rights of 
persons with TBI, and bolster vital research.
                                 ______
                                 
 Prepared Statement of the Centers for Disease Control and Prevention 
                            (CDC) Coalition

    The CDC Coalition is a nonpartisan coalition of more than 140 
organizations committed to strengthening our Nation's prevention 
programs. We represent millions of public health workers, clinicians, 
researchers, educators, and citizens served by CDC programs.
    The CDC Coalition believes that Congress should support CDC as an 
agency--not just the individual programs that it funds. Given the 
challenges and burdens of chronic disease and disability, constant 
public health emergencies, new and reemerging infectious diseases and 
other unmet public health needs--we urge a funding of $7.8 billion for 
CDC's programs in fiscal year 2014. Unfortunately, the President's 
fiscal year 2014 budget request for CDC represents a nearly $277 
million reduction when compared with fiscal year 2012. These proposed 
cuts come on top of the $577 million reduction to CDC in fiscal year 
2013 due to the sequester and reduction in Prevention and Public Health 
Fund resources. After these cuts, CDC's budget authority is now lower 
than 2003 levels. At the same time, State and local health departments 
are operating on tight budgets and with a smaller workforce. Cuts to 
CDC's programs are not sustainable and will reduce the ability to 
investigate and respond to public health emergencies as well as food 
borne and infectious disease
    By translating research findings into effective intervention 
efforts, CDC has been a key source of funding for many of our State and 
local programs that aim to improve the health of communities. Federal 
funding through CDC provides the foundation for State and local public 
health departments, supporting a trained workforce, laboratory capacity 
and public health education communications systems.
    CDC serves as the command center for our Nation's public health 
defense system, conducting surveillance and detection of emerging and 
reemerging infectious diseases. With the potential onset of a worldwide 
influenza pandemic, in addition to the many other natural and man-made 
threats that exist in the modern world, CDC is the Nation's expert 
resource and response center, coordinating communications and action 
and serving as the laboratory reference center for identifying, testing 
and characterizing potential agents of biological, chemical and 
radiological terrorism, emerging infectious diseases and other public 
health emergencies. CDC serves as the lead agency for bioterrorism and 
public health emergency preparedness and must receive sustained support 
for its preparedness programs to meet future challenges. We urge you to 
provide adequate funding for CDC's emergency preparedness and response 
activities.
    Heart disease remains the Nation's No. 1 killer. In 2010, over 
597,000 people in the U.S. died from heart disease, accounting for 
nearly 25 percent of all U.S. deaths. More males than females died of 
heart disease in 2010 (307,384 compared to 290,305), while more females 
than males died of stroke that year (77,109 compared to 52,367). Stroke 
is the fourth leading cause of death and is a leading cause of 
disability. In 2010, about 129,000 people died of stroke (60 percent of 
them females), accounting for about 1 of every 19 deaths. CDC's Heart 
Disease and Stroke Prevention Program, WISEWOMAN, and the Million 
Hearts program are working improve cardiovascular health.
    Cancer is the second most common cause of death in the United 
States. There are 1,660,290 new cancer cases and 580,350 deaths from 
cancer expected in 2013. According to the
    National Institutes of Health, in 2008 the overall cost for cancer 
in the U.S. was more than $201.5 billion: $77.4 billion for direct 
medical costs, $124.0 billion for indirect mortality costs (cost of 
lost productivity due to premature death). CDC's National Breast and 
Cervical Cancer Early Detection Program helps millions of low-income, 
uninsured and medically underserved women gain access to lifesaving 
breast and cervical cancer screenings and provides a gateway to 
treatment upon diagnosis. CDC also funds grants to all 50 States to 
develop Comprehensive Cancer Control plans, bringing together a broad 
partnership of public and private stakeholders to set joint priorities 
and implement specific cancer prevention and control activities 
customized to address each State's particular needs.
    Although more than 25.8 million Americans have diabetes, nearly 7 
million cases are undiagnosed. In 2010, about 1.9 million people aged 
20 years or older were newly diagnosed with diabetes. Diabetes is the 
leading cause of kidney failure, nontraumatic lower-limb amputations, 
and new cases of blindness among adults in the U.S. The total direct 
and indirect costs associated with diabetes were $245 billion in 2012. 
CDC's Division of Diabetes Translation funds critical diabetes 
prevention, surveillance and control programs.
    Arthritis is the most common cause of disability in the U.S., 
striking 50 million Americans of all ages, races and ethnicities. CDC's 
Arthritis Program plays a critical role in addressing this growing 
public health crisis and working to improve the quality of life for 
individuals affected by arthritis.
    Over the last 20 years, obesity rates have dramatically increased 
and rates remain high. More than one third of adults are obese and 17 
percent of children between the ages of 2-19 are obese. Obesity, diet 
and inactivity are cross-cutting risk factors that contribute 
significantly to heart disease, cancer, stroke and diabetes. CDC funds 
programs to encourage the consumption of fruits and vegetables, 
encourage sufficient exercise, and to develop other habits of healthy 
nutrition and activity.
    An estimated 443,000 people die prematurely every year due to 
tobacco use. CDC's tobacco control efforts seek to prevent tobacco 
addition in the first place, as well as help those who want to quit. We 
must continue to support these vital programs and reduce tobacco use in 
the United States.
    According to CDC, only one out of three high school students 
participate in daily physical education classes and one in three 
children and adolescents are overweight or obese. And every year, more 
than 400,000 teen girls give birth and nearly half of all sexually 
transmitted diseases occur in young people between the ages of 15 and 
24. CDC plays a critical role in ensuring good public health and health 
promotion in our Nation's schools.
    CDC provides national leadership in helping control the HIV 
epidemic by working with community, State, national, and international 
partners in surveillance, research, prevention and evaluation 
activities. CDC estimates that about 1.1 million Americans are living 
with HIV, 18 percent of who are undiagnosed. Also, the number of people 
living with HIV is increasing, as new drug therapies are keeping HIV-
infected persons healthy longer and dramatically reducing the death 
rate. Prevention of HIV transmission is the best defense against the 
AIDS epidemic that has already killed more than 636,000 in the U.S. and 
is devastating populations around the globe.
    The U.S. has the highest rates of sexually transmitted diseases in 
the industrialized world. More than 19 million new infections occur 
each year. CDC estimates that STDs, including HIV, cost the U.S. 
healthcare system as much as $17 billion annually. An adequate 
investment in CDC's STD prevention programs could save millions in 
annual health care costs in the future.
    The National Center for Health Statistics collects data on chronic 
disease prevalence, health disparities, emergency room use, teen 
pregnancy, infant mortality and causes of death. The health data 
collected through the Behavioral Risk Factor Surveillance System, Youth 
Risk Behavior Survey, Youth Tobacco Survey, National Vital Statistics 
System, and National Health and Nutrition Examination Survey are an 
essential part of the Nation's statistical and public health 
infrastructure and must be adequately funded.
    CDC oversees immunization programs for children, adolescents and 
adults, and is a global partner in the ongoing effort to eradicate 
polio worldwide. Influenza vaccination levels remain low for adults. 
Levels are substantially lower for pneumococcal vaccination among 
adults as well, with significant racial and ethnic disparities in 
vaccination levels persisting among the elderly. Childhood 
immunizations provide one of the best returns on investment of any 
public health program. For every dollar spent on childhood vaccines to 
prevent thirteen diseases, $10.20 is saved in direct and indirect 
costs. An estimated 20 million cases of disease and 42,000 deaths are 
prevented each year through timely immunization. Despite the incredible 
success of the program, it faces serious financial challenges.
    Injuries are the leading causes of death for persons aged 1-44 
years. Unintentional injuries and violence such as older adult falls, 
unintentional drug poisonings, child maltreatment and sexual violence 
accounts for over 35 percent of emergency department visits annually. 
Annually, injury and violence cost the U.S. approximately $406 billion 
in direct and indirect medical costs including lost productivity. CDC's 
Injury Center works to prevent injuries and to minimize their 
consequences when they occur by researching the problem, identifying 
the risk and protective factors, developing and testing interventions 
and ensuring widespread adoption of proven prevention strategies.
    One in every 33 babies born each year in the U.S. is born with one 
or more birth defects. Birth defects are the leading cause of infant 
mortality. Children with birth defects who survive often experience 
lifelong physical and mental disabilities. More than 50 million people 
in the U.S currently live with a disability, and 17 percent of children 
under the age of 18 have a developmental disability. The National 
Center on Birth Defects and Developmental Disabilities conducts 
programs to protect and improve health by preventing birth defects and 
developmental disabilities.
    CDC's National Center for Environmental Health is essential to 
protecting and ensuring the health and well being of the American 
public by helping to control asthma, protecting from threats associated 
with natural disasters and climate change and reducing exposure to lead 
and other environmental hazards. To ensure it can carry out these vital 
programs, we ask you to support and restore adequate funding for NCEH 
which has been cut by nearly 25 percent since 2010.
    In order to meet the ongoing public health challenges outlined 
above, we urge you to adopt our fiscal year 2014 request of $7.8 
billion for CDC's programs.
                                 ______
                                 
 Prepared Statement of the Charles R. Drew University of Medicine And 
                                Science

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

    1)  Provide funding for the Health Resources and Services 
Administration Title VII Health Professisons Training Programs, 
including:
     -- $24.602 million for the Minority Centers of Excellence.
     -- $22.133 million for the Health Careers Opportunity Program.
    2)  $32 billion for the National Institutes of Health (NIH), 
specifically:
     -- Proportional increase for the National Institute on Minority 
        Health and Health Disparities (NIMHD).
     -- Proportional increase for the Research Centers at Minority 
        Institutions Program.
    3)  $65 Million for the Department of Health and Human Services' 
Office of Minority Health.
    4)  $65 million for the Department of Education's Strengthening 
Historically Black Graduate Institutions Program.
_______________________________________________________________________

    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to present you with testimony. The Charles Drew University 
is distinctive in being the only dually designated Historically Black 
Graduate Institution and Hispanic Serving Institution in the Nation. We 
would like to thank you, Mr. Chairman, for the support that this 
subcommittee has given to our University to produce minority health 
professionals to eliminate health disparities as well as do 
groundbreaking research to save lives.
    The Charles Drew University is located in the Watts-Willowbrook 
area of South Los Angeles. Its mission is to prepare predominantly 
minority doctors and other health professionals to care for underserved 
communities with compassion and excellence through education, clinical 
care, outreach, pipeline programs and advanced research that makes a 
rapid difference in clinical practice. The Charles Drew University has 
established a national reputation for translational research that 
addresses the health disparities and social issues that strike hardest 
and deepest among urban and minority populations.

              HEALTH RESOURCES AND SERVICES ADMINISTRATION

    Title VII Health Professions Training Programs.--The health 
professions training programs administered by the Health Resources and 
Services Administration (HRSA) are the only Federal initiatives 
designed to address the longstanding under representation of minorities 
in health careers. HRSA's own report, ``The Rationale for Diversity in 
the Health Professions: A Review of the Evidence,'' found that minority 
health professionals disproportionately serve minority and other 
medically underserved populations, minority populations tend to receive 
better care from practitioners of their own race or ethnicity, and non-
English speaking patients experience better care, greater comprehension 
and greater likelihood of keeping follow-up appointments when they see 
a practitioner who speaks their language. Studies have also 
demonstrated that when minorities are trained in minority health 
professions institutions, they are significantly more likely to: 1) 
serve in medically underserved areas, 2) provide care for minorities 
and 3) treat low-income patients.
    Minority Centers of Excellence.--The purpose of the COE program is 
to assist schools, like Charles Drew University, that train minority 
health professionals, by supporting programs of excellence. The COE 
program focuses on improving student recruitment and performance; 
improving curricula and cultural competence of graduates; facilitating 
faculty and student research on minority health issues; and training 
students to provide health services to minority individuals by 
providing clinical teaching at community-based health facilities. For 
fiscal year 2014, the funding level for COE should be $24.602 million.
    Health Careers Opportunity Program.--Grants made to health 
professions schools and educational entities under HCOP enhance the 
ability of individuals from disadvantaged backgrounds to improve their 
competitiveness to enter and graduate from health professions schools. 
HCOP funds activities that are designed to develop a more competitive 
applicant pool through partnerships with institutions of higher 
education, school districts, and other community based entities. HCOP 
also provides for mentoring, counseling, primary care exposure 
activities, and information regarding careers in a primary care 
discipline. Sources of financial aid are provided to students as well 
as assistance in entering into health professions schools. For fiscal 
year 2014, the HCOP funding level of $22.133 million is recommended.

                     NATIONAL INSTITUTES OF HEALTH

    National Institute on Minority Health and Health Disparities.--The 
NIMHD is charged with addressing the longstanding health status gap 
between under-represented minority and non minority populations. The 
NIMHD helps health professional institutions to narrow the health 
status gap by improving research capabilities through the continued 
development of faculty, labs, telemedicine technology and other 
learning resources. The NIMHD also supports biomedical research focused 
on eliminating health disparities and developed a comprehensive plan 
for research on minority health at NIH. Furthermore, the NIMHD provides 
financial support to health professions institutions that have a 
history and mission of serving minority and medically underserved 
communities through the COE program and HCOP. For fiscal year 2014, an 
increase proportional to NIH's increase is recommended for NIMHD as 
well as additional FTEs.
    Research Centers at Minority Institutions.--RCMI, now at NIMHD, has 
a long and distinguished record of helping institutions like The 
Charles Drew University develop the research infrastructure necessary 
to be leaders in the area of translational research focused on reducing 
health disparities research. Although NIH has received some budget 
increases over the last 5 years, funding for the RCMI program has not 
increased by the same rate. Therefore, the funding for this important 
program grow at the same rate as NIH overall in fiscal year 2014.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Office of Minority Health.--Specific programs at OMH include: 
assisting medically underserved communities, supporting conferences for 
high school and undergraduate students to interest them in health 
careers, and supporting cooperative agreements with minority 
institutions for the purpose of strengthening their capacity to train 
more minorities in the health professions. For fiscal year 2014, I 
recommend a funding level of $65 million for OMH to support these 
critical activities. Additionally, I recommend that this Committee 
ensures that OMH continues with its grant-making authority, as this is 
one of the chief avenues by which it is able to impact the scourge of 
disparities in our communities.

                        DEPARTMENT OF EDUCATION

    Strengthening Historically Black Graduate Institutions.--The 
Department of Education's Strengthening Historically Black Graduate 
Institutions program (Title III, Part B, Section 326) is extremely 
important to CDU and other minority serving health professions 
institutions. The funding from this program is used to enhance 
educational capabilities, establish and strengthen program development 
offices, initiate endowment campaigns, and support numerous other 
institutional development activities. In fiscal year 2014, an 
appropriation of $65 million is suggested to continue the vital support 
that this program provides to historically black graduate institutions.

                               CONCLUSION

    Despite all the knowledge that exists about racial/ethnic, socio-
cultural and gender-based disparities in health outcomes, the gap 
continues to widen. Not only are minority and underserved communities 
burdened by higher disease rates, they are less likely to have access 
to quality care upon diagnosis. As you are aware, in many minority and 
underserved communities preventative care and research are inaccessible 
either due to distance or lack of facilities and expertise. As noted 
earlier, in just one underserved area, South Los Angeles, the number 
and distribution of beds, doctors, nurses and other health 
professionals are as parlous as they were at the time of the Watts 
Rebellion, after which the McCone Commission attributed the so-named 
'Los Angeles Riots' to poor services--particularly access to 
affordable, quality healthcare. The Charles Drew University has proven 
that it can produce excellent health professionals who 'get' the 
mission--years after graduation they remain committed to serving people 
in the most need. But, the university needs investment and committed 
increased support from Federal, State and local governments and is 
actively seeking foundation, philanthropic and corporate support.
    Even though institutions like The Charles Drew University are 
ideally situated (by location, population, community linkages and 
mission) to study conditions in which health disparities have been well 
documented, research is limited by the paucity of appropriate research 
facilities. With your help, the Life Sciences Research Facility will 
translate insight gained through research into greater understanding of 
disparities and improved clinical outcomes. Additionally, programs like 
Title VII Health Professions Training programs will help strengthen and 
staff facilities like our Life Sciences Research Facility.
    We look forward to working with you to lessen the huge negative 
impact of health disparities on our Nation's increasingly diverse 
populations, the economy and the whole American community.
    Mr. Chairman, thank you again for the opportunity to present 
testimony on behalf of the Charles Drew University. It is indeed an 
honor.
                                 ______
                                 
   Prepared Statement of the Children's Environmental Health Network

    We thank Chairman Reed and Ranking Member Murkowski for this 
opportunity and for your ongoing concern about environmental health 
risks to children. Our statement focuses on key programs and activities 
that safeguard the health and the future of all of our children. Today 
we are addressing activities of two agencies that are critical to 
children's environmental health and are within the subcommittee's 
jurisdiction:
  --Centers for Disease Control and Prevention, especially the National 
        Center for Environmental Health/Agency for Toxic Substances and 
        Disease Registry and related programs:
      --Healthy Homes and Lead Poisoning Prevention Program
      --National Asthma Control Program
      --National Environmental Public Health Tracking Program
      --Environmental Health Laboratory
      --Healthy Community Design Initiative (HCDI)
      --Pediatric Environmental Health Specialty Units (PEHSUs)
  --National Institute of Environmental Health Sciences (NIEHS), an 
        Institute of the National Institutes of Health (NIH) that has 
        as its mission discovering how the environment affects people 
        in order to promote healthier lives. CEHN is especially 
        interested in NIEHS' Children's Environmental Health Research 
        Centers of Excellence.
    The Children's Environmental Health Network (CEHN) is a national 
organization created to protect the developing child from environmental 
health hazards and promote a healthy environment.
    Investments in programs that protect and promote children's health 
will be repaid by healthier children with brighter futures. For 
example, removing lead in gasoline has saved the U.S. an estimated $200 
billion each year since 1980 in the form of higher IQs for that year's 
newborns. Protecting our children--those born as well as those yet to 
be born--from environmental hazards is truly a national security issue.
    Our Nation's future will depend upon its future leaders. When we 
protect children from harmful chemicals in their environment, we help 
to assure that they will reach their full potential. We have a 
responsibility to our Nation's children, and to the Nation that they 
will someday lead, to provide them with a healthy environment. 
Additionally, American competiveness depends on having healthy educated 
children who grow up to be healthy productive adults. Yet, growing 
numbers of our children are diagnosed with chronic and developmental 
illnesses and disabilities such as obesity, asthma, learning 
disabilities, and autism. A child's environment plays a role in these 
chronic conditions and contributes to the distressing possibility that 
today's children may be the first generation to see a shorter life 
expectancy than their parents due to poor health. Thus it is vital that 
the Federal programs and activities that protect children from 
environmental hazards receive adequate resources.
    We strongly urge the Committee to take a balanced approach to 
deficit reduction that does not include further cuts to children's 
environmental health programs. Key programs in your jurisdiction, which 
CEHN urges you to support, include:
    Centers for Disease Control and Prevention (CDC).--As the Nation's 
leader in public health promotion and disease prevention, the CDC 
should receive top priority in Federal funding. CDC continues to be 
faced with unprecedented challenges and responsibilities. CEHN applauds 
your support for CDC in past years and urges you to support a funding 
level of $7.8 billion for CDC's core programs in fiscal year 2014.
    The National Center for Environmental Health (NCEH) is particularly 
important to protecting the environmental health of young children. 
NCEH's programs are key national assets. Yet, since fiscal year 2009, 
NCEH funding has been cut approximately 25 percent while, as mentioned 
above, environment plays a role in the cause, prevention, or mitigation 
of today's pediatric epidemics of obesity, asthma, learning 
disabilities, and autism.
    Agency for Toxic Substances and Disease Registry (ATSDR).--CEHN 
urges the subcommittee to provide funding at or above the requested 
levels for ATSDR activities. ATSDR uses the best science in taking 
public health actions, such as site assessments and toxicological 
profiles, to prevent harmful exposures and diseases of communities and 
individuals related to toxic substances.
    ATSDR understands that in communities faced with contamination of 
their water, soil, air, or food, infants and children can be more 
sensitive to environmental exposure than adults and that assessment, 
prevention, and efforts to find remedies for exposures must focus on 
children because of their vulnerability and importance to the Nation's 
future. We support the full funding of ATSDR and the continuation of 
their varied responsibilities.
    We continue to be concerned about the elimination of Healthy Homes 
and Lead Poisoning Prevention Program funding for State and local 
programs in fiscal year 2012. The loss of vigilant surveillance, 
primary prevention activities, and case management has jeopardized the 
health of children living in homes where exposure to lead, asthma and 
other illnesses related to rodent and insect infestation, chemical 
exposures, and other risk factors is likely. We must sustain reducing 
lead poisoning by supporting effective local and State efforts.
    NCEH's National Asthma Control Program funds 36 States and 
territories to conduct asthma surveillance, educate asthma patients, 
families, and health care providers, and help health departments 
eliminate potential asthma triggers. Now is the time to maintain our 
commitment to asthma control, not cut funding.
    The CDC's National Environmental Public Health Tracking Program 
helps to track environmental hazards and the diseases they may cause 
and to coordinate and integrate local, State and Federal health 
agencies' collection of critical health and environmental data. Public 
health officials need integrated health and environmental data so that 
they can protect the public's health. This network currently operates 
in 23 States and New York City to help public health officials and key 
policymakers make better policy decisions to improve population health. 
Participation in the tracking network development will decline further 
under any further cuts and erase the progress we have made across the 
country to better link data with public health action.
    Pediatric Environmental Health Specialty Units.--Funded jointly by 
the Agency for Toxic Substances and Disease Registry (ATSDR) and the 
EPA, the Pediatric Environmental Health Specialty Units (PEHSUs) form a 
valuable resource network, with a center in each of the U.S. Federal 
regions. PEHSU professionals provide medical consultation to health 
care professionals on a wide range of environmental health issues, from 
individual cases of exposure to advice regarding large-scale community 
issues. PEHSUs also provide information and resources to school, child 
care, health and medical, and community groups to help increase the 
public's understanding of children's environmental health, and help 
inform policymakers by providing data and background on local or 
regional environmental health issues and implications for specific 
populations or areas. We urge the subcommittee to fully fund this 
program in fiscal year 2014.
    CEHN also strongly supports CDC's Environmental Health Laboratory 
and the Healthy Community Design Initiative (HCDI). The HCDI provides 
essential expert assistance and consultation across HHS and national 
leadership on the impacts of the built environment on health including 
physical activity levels.
    National Institute of Environmental Health Science (NIEHS).--NIEHS 
is the leading institute conducting research to understand how the 
environment influences the development and progression of human 
disease. NIEHS plays a vital role in our efforts to understand how to 
protect children, whether it is identifying and understanding the 
impact of substances that are endocrine disruptors or understanding 
childhood exposures that may not affect health until decades later. 
CEHN recommends that $717.7 million be provided for NIEHS' fiscal year 
2014 budget.
    Children's Environmental Health Research Centers of Excellence.--
The Children's Environmental Health Research Centers, jointly funded by 
the NIEHS and the U.S. Environmental Protection Agency (EPA), play a 
key role in providing the scientific basis for protecting children from 
environmental hazards. With their modest budgets, which have been 
unchanged for more than 10 years, these centers generate valuable 
research. The scientific output of these centers has been outstanding. 
Several Centers have established longitudinal cohorts, which have 
resulted in valuable research results. The Network is concerned that as 
a Center's multi-year grant ends and the Center is shuttered, these 
cohorts and the invaluable information they can provide are being lost. 
The Network urges the subcommittee to assure that NIEHS has the funding 
and the direction to support Centers in continuing these cohorts. The 
work of these Centers has also shown us that, in addition to research 
regarding a specific pollutant or health outcome, research is 
desperately needed in understanding the totality of the child's 
environment--for example, all of the exposures the child experiences in 
the home, school, and child care environment--and how to evaluate those 
multiple factors. CEHN urges you to support these Centers to assure 
they receive full funding and are extended and expanded as described 
above.
    In conclusion, healthier children with brighter futures will repay 
investments in programs that protect and promote children's health, an 
outcome we can all support.
    Thank you for the opportunity to submit this testimony.
                                 ______
                                 
       Prepared Statement of the Coalition of EPSCoR/IDeA States

    Mr. Chairman and members of the subcommittee; thank you for the 
opportunity to submit this statement regarding fiscal year 2014 funding 
for the National Institutes of Health's Institutional Development Award 
or ``IDeA'' Program. The IDeA program is supported by NIH's National 
Institute of General Medical Sciences (NIGMS), and was authorized by 
the 1993 NIH Revitalization Act (Public Law 103-43). I submit this 
testimony on behalf of the Coalition of EPSCoR/IDeA States \1\ and LSU, 
and respectfully request that this committee recommend that the IDeA 
program be funded in fiscal year 2014 at $310 million.
    The National Institutes of Health's (NIH) Institutional Development 
Award Program (IDeA) was established in 1993 to broaden the geographic 
distribution of NIH funding for biomedical and behavioral research. The 
IDeA program funds only merit-based, peer-reviewed research that meets 
NIH research objectives. The program fosters health-related research 
and enhances the competitiveness of investigators at institutions in 23 
States and Puerto Rico. The program also serves unique populations, 
such as rural and medically underserved communities, in these States. 
The IDeA program has two key components: Centers of Biomedical Research 
Excellence (COBRE) and IDeA Networks of Biomedical Research Excellence 
(INBRE). COBRE programs build multi-disciplinary research centers with 
a thematic scientific focus. Junior investigators graduate from the 
program after they obtain NIH competitive funding on their own. INBRE 
programs enhance biomedical research capacity in primarily 
undergraduate institutions in alliance with LSU, as a major research 
institution in Louisiana. These two programs play complementary roles 
in developing research capability and human capital in biomedical 
fields in Louisiana and the rest of the IDeA States.

Impact of the IDeA Program on Louisiana
    Louisiana leads all the EPSCoR/IDeA States in successfully 
competing for COBRE and INBRE grants. Ten different COBRE grants and 
one INBRE Center grant have been funded in the last 10 years totaling 
more than $200 million dollars. The Louisiana INBRE is led by the LSU 
in Baton Rouge as the flagship institution, which coordinates the 
training of scientists from a number of primarily undergraduate 
institutions in Louisiana such as the University of Louisiana in 
Monroe, LSU-Shreveport, Southern University in Baton Rouge, Xavier 
University in New Orleans, and Louisiana-Tech University in Ruston. All 
other Louisiana universities participate in the INBRE program through 
the summer research program. These students and faculty are trained at 
major research facilities around the State including: LSU, Pennington 
Biomedical Research Center, Tulane Medical Center in New Orleans, and 
the LSU Health Sciences Centers in New Orleans and Shreveport. The 
INBRE program provides opportunities via collaboration with all 
Louisiana-based COBRE programs, therefore creating a highly regarded 
network of life scientists throughout Louisiana.
    The Louisiana success in COBRE funding has been focused on highly 
important areas of research of particular significance to the health of 
the citizens of Louisiana. These research areas include: (1) obesity 
and cardiovascular health (COBREs at Pennington Biomedical Research 
Center in Baton Rouge, LSU Health Sciences Center in New Orleans, and 
Tulane University in New Orleans); (2) cancer research (COBREs at 
Tulane University and LSU Health Sciences Center in Shreveport; (3) 
neurosciences (COBRE at LSU Health Sciences in New Orleans); (4) 
infectious disease research (COBRE at the LSU School of Veterinary 
Medicine and Tulane National Primate Research Center); (5) obesity and 
diabetes (COBRE at Pennington Biomedical Research Center in Baton 
Rouge); (6) aging research (COBRE at Tulane University); and (7) oral 
health (COBRE at the LSU School of Dentistry in New Orleans). Recently, 
special COBRE funding was awarded to Louisiana for the establishment of 
the Louisiana Clinical & Translational Science Center (LACaTS) 
involving all biomedical research and medical training programs in 
Louisiana working together to translate research findings to improve 
clinical care. Specifically, this collaborative network of scientists 
and clinicians focuses on the prevention, care and research of chronic 
diseases in the underserved population of Louisiana and the Nation. 
This COBRE Clinical and Translational Research award (COBRE-CTR) is led 
by the Pennington Biomedical Research Center in Baton Rouge.
    The COBRE and INBRE Project grants require the presence of senior 
mentors for junior investigators including students, postdoctoral 
fellows and junior faculty. The COBRE and INBRE funding has been a key 
factor in the retention of well-funded investigators serving as 
principal investigators or mentors in each program.
    Total economic impact for Louisiana stemming from the IDeA program 
is approximately $300 million, when taking into account the presence of 
senior researchers that have been retained in Louisiana. This amounts 
to a total economic impact of $600 million based on an economic impact 
multiplier of 2. Importantly, the IDeA funding has enabled the 
formation of a Louisiana-wide network of life scientists, opening up 
new collaborations and unsurpassed training opportunities for all 
students and faculty. The Louisiana Optical Network Initiative (LONI), 
funded by State funds, has enabled direct connectivity and 
communication among all COBRE and INBRE recipients through the INBRE-
led access grid network; allowing remote training, sharing of seminar 
speakers and other training functions across Louisiana. IDeA funding 
has impacted the teaching and training of more than 1000 researchers 
and students in Louisiana.
    While IDeA was authorized by the 1993 NIH Revitalization Act 
(Public Law 103-43), sizable increases in funding only began in fiscal 
year 2000. The program then grew rapidly, due in large part to the 
thoughtful actions of this subcommittee. This funding permitted the 
initiation of the COBRE and INBRE, which have been crucial to the 
success of the program. On behalf of the Coalition and LSU, I want to 
express gratitude to this subcommittee for the efforts it has made over 
the years to provide increased funding for IDeA, in particular this 
committee's work to ensure the successful inclusion of a $50 million 
increase for the program in fiscal year 2012. I hope that you will 
continue to invest in this program, which is so important to almost 
half of the States in the Union.
    We request that this committee recommend the IDeA program be funded 
in fiscal year 2014 at $310 million. As you know, the EPSCoR/IDeA 
Coalition has maintained that IDeA program should constitute at least 1 
percent of the total NIH budget. This level of funding would restore 
and continue funding for COBRE and INBRE, provide funding for the COBRE 
Clinical and Translational Research (CTR) program, and provide for co-
funding opportunities which allow researchers and institutions to merge 
with the overall national biomedical research community.
    Over 22 percent of the Nation's population live in the EPSCoR/IDeA 
States, yet in fiscal year 1999, the year before COBRE grants were 
initiated, the 23 IDeA States and Puerto Rico received a total of $596 
million from NIH. And that is why the IDeA program is so important. It 
is helping to ensure that all regions of the country participate in 
biomedical research and education. Citizens from all States should have 
the opportunity to benefit from the latest innovations in health care, 
which are most readily available in centers of biomedical research 
excellence.
    To put the value of the IDeA investment into perspective, the 
overall fiscal year 2012 IDeA budget, $276.48 million, is only 42 
percent of the $645.3 million in NIH funding that Johns Hopkins 
University alone, in a non-IDeA State, received in fiscal year 2011. In 
fiscal year 2011, the top seven States with NIH funding received over a 
$1 billion each, and California alone received over $3.5 billion. Given 
this, $310 million for 23 States and Puerto Rico seems more than 
reasonable.
    On behalf of the EPSCoR/IDeA Coalition, LSU and our partner 
institutions across Louisiana, I thank the subcommittee for the 
opportunity to submit this testimony.
---------------------------------------------------------------------------
    \1\ Alabama, Alaska, Arkansas, Delaware, Hawaii, Idaho, Iowa, 
Kansas, Kentucky, Louisiana, Maine, Mississippi, Montana, Nebraska, 
Nevada, New Hampshire, New Mexico, North Dakota, Oklahoma, Puerto Rico, 
Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, 
West Virginia, and Wyoming.
    States in italic letters are eligible for the IDeA program. All of 
the States listed above are also eligible for the EPSCoR program.
---------------------------------------------------------------------------
                                 ______
                                 
    Prepared Statement of the Coalition for Usher Syndrome Research

   PARENT OF 12 YEAR OLD TWINS WITH USHER SYNDROME, PARENT ADVOCATE 
REPRESENTING THE COALITION FOR USHER SYNDROME RESEARCH AND INDIVIDUALS 
                          WITH USHER SYNDROME

    My name is Susie Trotochaud from the State of Georgia. I submit 
testimony on behalf of the Coalition for Usher Syndrome Research to 
respectfully request this committee encourage NIH funding of $20 
million in fiscal year 2014 to promote more research into Usher 
Syndrome.
    Usher Syndrome is the number one cause of deaf-blindness. Deaf-
Blindness. Imagine being unable to hear my words and unable to see me. 
Silence and darkness. In the United States, it is estimated that about 
45,000 people have this rare genetic disorder. Two of them are my 
children, Cory and Joanie Dorfman.
    Cory and Joanie were born 8 weeks early. Although they spent 
several weeks in ICU fighting to learn basic survival skills, like 
breathing and eating, these would not be their greatest challenges. 
Before they were released from the hospital, they were given a newborn 
hearing screening. It was determined that they were both profoundly 
deaf. As we struggled to understand what this meant and how this could 
have happened, I realized that they would never be able to hear me say 
``I love you'' and I would never hear those sweet words from their 
lips. The sounds of our life, children laughing, singing, school plays, 
graduations, celebrations, were suddenly silenced.
    Our heartache changed to hope when we found out about the cochlear 
implant. By 12 months, Cory and Joanie were implanted and began hearing 
their first sounds. By 1-1/2 years, they had said their first words, 
and by 3 years, we realized that they could be mainstreamed, go on 
through high school and even college, just like their peers. Although 
they would always have to work a little harder, the sounds of 
opportunity returned to our lives. And I remember my husband saying to 
me at that time, ``At least they're not blind.''
    But about a year ago, that all changed. After my daughter entered a 
darkened hallway in a restaurant and asked me where the bathroom was, 
when the door was literally four feet in front of her, we became 
concerned. When she gingerly stepped down a pathway at night, seemingly 
feeling her way with her feet, we knew we had a problem. Many months of 
extensive testing and waiting confirmed what we, by then, already knew. 
Joanie had Type I Usher Syndrome. Reading the description of Type I 
Usher was like reading her biography: Born profoundly deaf, delayed 
development especially walking, balance issues, and loss of night 
vision beginning at around 10 years of age. What would follow would be 
loss of peripheral vision leading to tunnel vision, and eventually 
blindness. With no intervention, my 12 year old daughter will be blind 
by 20. And although my son currently has less vision issues, testing 
confirms he also has Usher. He may retain some of his vision into his 
30s.
    That's the thing with Usher. It strikes in varying timeframes. Type 
I, like with my children, is characterized by profound deafness at 
birth followed by blindness in early adolescence; Type II individuals 
may have moderate to severe hearing loss followed by blindness; and 
Type III experience loss of hearing and sight throughout their lives. 
How quickly and how completely each person losses their vision also 
varies, but the way it happens is consistent. Night blindness, then 
peripheral vision is lost as darkness closes in on their sight. Usher 
is a rollercoaster ride of loss, grief, adjustment, and loss again that 
never ends as one more setback always lies around the corner.
    People with Usher Syndrome, like Cory and Joanie, have worked hard 
to overcome some of their hearing challenges by using cochlear 
implants, hearing aids, sign language and more. But how do you overcome 
the loss of sight? Think of yourself, sitting here communicating by 
sign, knowing that you are losing your vision, knowing you are about to 
lose your way of communicating with the world around you. Frightening, 
isn't it?
    Like you, my hopes and dreams for my children have always been that 
they grow up happy, do well in school, attend good colleges, get 
meaningful jobs and give back to their community. But the reality we 
are facing is that 8 out of 10 deaf-blind people are unemployed, not to 
mention the physical and emotional hardships, the stereotypes of being 
deaf-blind, the loss of productivity and ability to do a job, ultimate 
depression, and perhaps even suicide.
    Add to that the reality that our country spends an estimated $27 
billion annually in care and support services for people with major 
visual disorders. That doesn't even include the costs associated with 
hearing impairment.
    Those are statistics; people with Usher aren't. Since joining the 
Coalition for Usher Syndrome Research, I have spoken with or met dozens 
of people who are determined, focused, and working every day to help 
themselves, their loved one, or in some cases complete strangers, 
figure out how to treat this syndrome. Usher genes are complex, long 
protein cells which require significant investment in research if we 
are ever to find a cure or treatment. We can't do it alone.
    Through the Coalition, we have brought the Usher community and 
researchers together by:
  --Establishing a registry of individuals with Usher Syndrome which is 
        available for research or clinical trials at no cost. Our 
        registry currently has families from each of the 50 States and 
        23 countries.
  --Sponsoring annual family conferences, webinars and monthly 
        conferences that provide information and support to all of 
        those living with Usher.
  --Paving the way for an International Symposium on Usher Syndrome 
        Research in 2014 to develop a roadmap for future research 
        projects to bring us closer to viable clinical trials.
    With this in place, we have begun bringing brilliant researchers 
together who are working on developing treatments every day. 
Researchers like those in Oregon and Pennsylvania who are working on 
gene therapy treatments, one of which began clinical trials this year. 
Researchers in Louisiana, who have been able to rescue the hearing in 
mice with Usher Syndrome using a drug therapy that holds promise for 
rescuing vision, as well. Researchers in Iowa, California, Nebraska, 
Massachusetts, Florida, Texas, and many other States, who are 
collaborating with each other and with families through the Coalition 
to advance all kinds of Usher syndrome research.
    But still this is not enough. My daughter, Joanie, will be blind 
within 10 years; my son, Cory, in 20. Jessica, a 17-year old with 
Usher, remains hopeful that something will help her retain her vision 
before she loses it at 30. Megan, a promising architect, has already 
altered her career goals as her vision has begun to slowly fade and 
every day she prays for something to help. Moira has lived well into 
her adult life working harder than everyone else to compete in a 
hearing and seeing world, but complete blindness is now taking away her 
ability to lip read and communicate with her friends and family.
    We cannot help any of these people or the tens of thousands who 
have Usher or countless others that will be born in the future with 
this devastating genetic disorder without Federal support. There are 
dozens of different mutations that cause Usher Syndrome and the pace of 
research is slowed dramatically by the lack of researchers and funding. 
The infrastructure is there to find treatments, but the significant 
financial support is not. We believe that $20 million in support this 
year and an increase of that amount over the next several years would 
lead to viable treatments for those with Usher Syndrome within a 
decade. We are asking you to supply this last critical resource to help 
us find a cure.
    When you review the report on categorical spending by the NIH, 
Usher Syndrome is not even listed. Rare diseases with similar incident 
rates average around $50 million annually. These investments have 
resulted in significant discoveries for these diseases, and there is 
reason to believe that we can see these same results or better for 
Usher Syndrome. The researchers are there, waiting to discover what we 
only dare dream of: An opportunity to allow deaf children and adults 
who are going blind, a chance to see.
    I will leave you with the words of Helen Keller. ``It is a terrible 
thing to see, but have no vision.'' I hope that this committee will 
have the vision to see the opportunities before them. Together, we can 
find a way to end deaf-blindness. I thank you on behalf of all those 
with Usher Syndrome, their families, and most importantly to me, my 
children, Cory and Joanie.
                                 ______
                                 
     Prepared Statement of the Coalition of Northeastern Governors

    As the subcommittee begins to develop the fiscal year 2014 Labor, 
Health and Human Services, Education, and Related Agencies 
appropriations bill, the Coalition of Northeastern Governors (CONEG) 
urges you to fund the Low Income Home Energy Assistance Program 
(LIHEAP) at the authorized level of $5.1 billion but no less than $4.7 
billion in the core block grant program. The Governors appreciate the 
subcommittee's continued support for LIHEAP, and recognize the 
difficult fiscal challenges facing Congress this year. However, the 
economic challenges facing the Nation's low-income households have made 
this program more essential than ever. Adequate, predictable and timely 
Federal funding is vital for LIHEAP to assist the vulnerable, low-
income households who struggle to pay increased home energy bills. 
Therefore, we urge the subcommittee to provide the fiscal year 2014 
funds in a manner consistent with the LIHEAP statutory objective: ``to 
assist low-income households, particularly those with the lowest 
incomes that pay a high proportion of household income for home energy, 
primarily in meeting their immediate home energy needs.
    LIHEAP is a vital safety net for the most vulnerable citizens in 
every region of the Nation: the elderly, disabled, and families with 
young children struggling to pay for the basic necessity of home 
energy. According to the National Energy Assistance Directors' 
Association (NEADA), 8.9 million households received heating and 
cooling assistance in fiscal year 2012. Nationwide, the majority of 
LIHEAP households have at least one member defined as ``vulnerable,'' 
and many of these households are not likely to benefit from the modest 
improvements in national economic and employment patterns. Moreover, 
approximately 20 percent of LIHEAP households contain at least one 
member who served this country in the military. LIHEAP is a resource 
that States across the country are able to use to assist vulnerable 
households in paying a portion of their heating bills in the cold 
winter months and a portion of their electricity bills for cooling in 
the hot months.
    Households in the Northeast face some of the Nation's highest home 
heating bills due to the extended winter heating season and heating 
fuel prices that typically exceed national averages regardless of the 
fuel used. Recent trends in residential heating fuel prices suggest 
that low-income households in the Northeast will continue to experience 
a heavy energy burden. According to the recent Energy Information 
Administration (EIA) Winter Fuels Outlook, Northeast households are 
more likely to face higher natural gas prices than other regions of the 
Nation. While delivered fuels, such as heating oil and propane, are 
used nationwide, Northeast households--more than any other region of 
the country--are dependent upon these expensive delivered fuels, 
particularly in the many areas where there is limited or no access to 
natural gas service. In the Northeast, 30 percent of households rely 
upon delivered fuels, and they account for approximately 80 percent of 
the homes nationwide that use home heating oil. When prices rise, these 
households are particularly vulnerable. Low-income households that use 
delivered fuels are less likely to have the option of payment plans, 
access to utility assistance programs, and the protection of utility 
service shut-off moratoria during the heating season. If LIHEAP funds 
are not available to these households, the fuel delivery truck simply 
does not come.
    According to EIA's current data, residential heating oil prices 
have been stable over the past two heating seasons, but at the 
historically high average price of approximately $4.00 per gallon--a 
price that is almost 30 percent higher than the five year average 
price. At this price, and with the more typical winter temperatures 
experienced by the region, EIA anticipates that expenditures for 
heating oil this heating season could increase by 32 percent from last 
winter. In the past 2 years, the average price of residential heating 
oil in the Northeast has increased 43 percent--from an average of $2.89 
per gallon in February 2010 to an average of $4.15 per gallon in 
February 2013. During the same period, the annual LIHEAP funding level 
has declined by 30 percent--from $5.1 billion in fiscal year 2010 to 
approximately $3.3 billion in fiscal year 2013.
    LIHEAP is the foundation of efforts to provide immediate, 
meaningful assistance to low-income households, many living on modest, 
fixed incomes. Most LIHEAP assistance is targeted to households whose 
income is close to or below 150 percent of the Federal poverty level, 
which for a two-person household is $23,265 in 2013. These households 
spend a disproportionate amount of their income on home energy, often 
over three times more than non-low-income households. LIHEAP not only 
helps households better manage and pay home energy bills, it protects 
the health and safety of the elderly, young children and the disabled. 
Without adequate resources to pay home heating bills, these vulnerable 
households may resort to unsafe and dangerous heating sources such as 
ovens and space heaters. In the summer, these populations are 
particularly susceptible to heat-related illness and even death.
    While LIHEAP funding has been reduced by more than 30 percent since 
fiscal year 2010, the need for the program continues to grow 
nationwide. States have faced significant challenges in trying to 
stretch scarce LIHEAP dollars as far as possible while still providing 
a meaningful benefit to those households most in need of assistance. 
States have worked with utilities to develop payment plans to reduce 
arrearages and lessen the prospect of utility shut-offs after the 
heating season ends. They have negotiated with fuel dealers to receive 
discounts on deliverable fuels, and have entered into agreements to 
purchase fuel in the summer when prices are lowest. Some Northeast 
States have also stretched their own limited budgets to provide 
supplemental LIHEAP funds or to leverage Federal dollars. Even after 
taking significant cost-cutting steps, States have had to take actions 
such as tightening program eligibility, closing the program early, and 
reducing benefit levels. The most recent funding reductions, coming as 
the heating season winds down and utility shut-off moratoriums expire, 
have created additional challenges. The potential result is a loss of 
funding for benefits to pay down arrearages, as well as inadequate 
staff to assist those households facing utility shut-offs to find 
alternative arrangements.
    In summary, the CONEG governors appreciate the subcommittee's 
continued support for LIHEAP, and urge you to fund the program at the 
authorized level of $5.1 billion but no less than $4.7 billion in the 
core block grant program for fiscal year 2014.
                                 ______
                                 
  Prepared Statement of the College of Veterinary Medicine, Nursing & 
                             Allied Health

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

    1)  Title VII Health Professions Training Programs:
     -- $24.602 million for thE Minority Centers of Excellence.
     -- $22.133 million for the Health Careers Opportunity Program.
    2)  Increased support for the National Institutes of Health's 
National Institute on Minority Health and Health Disparities.
    3)  $32 billion for the National Institutes of Health.
     -- Proportional funding increase for the Natioanl Institute on 
        Minority Health and Health Disparities.
     -- Proportional funding for Research Centers for Minority 
        Institutions.
    4)  $65 million for the Department of Health and Human Services' 
Office of Minority Health.
    5)  $65 million for the Department of Education's Strengthening 
Historically Black Graduate Institutions Program.
_______________________________________________________________________

    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to present my views before you today. I am Dr. Tsegaye 
Habtemariam, dean of the College of Veterinary Medicine, Nursing, and 
Allied Health at Tuskegee University. The mission (purpose) of Research 
and Advanced Studies at the College of Veterinary Medicine, Nursing & 
Allied Health (CVMNAH) is to transform trainees into ambassadors of the 
Tuskegee tradition to benefit Man and animals. Such a tradition is 
honed in the ``one medicine-one health'' concept that for decades has 
guided our academic mission, to expand biosciences and create bridges 
between veterinary medicine, agricultural and food sciences on one side 
and human health and welfare on the other.
    Mr. Chairman, I speak for our institutions, when I say that the 
minority health professions institutions and the Title VII Health 
Professionals Training programs address a critical national need. 
Persistent and severe staffing shortages exist in a number of the 
health professions, and chronic shortages exist for all of the health 
professions in our Nation's most medically underserved communities. 
Furthermore, even after the landmark passage of health reform, it is 
important to note that our Nation's health professions workforce does 
not accurately reflect the racial composition of our population. For 
example while blacks represent approximately 15 percent of the U.S. 
population, only 2-3 percent of the Nation's health professions 
workforce is black. Mr. Chairman, I would like to share with you how 
your committee can help Tuskegee continue our efforts to help provide 
quality health professionals and close our Nation's health disparity 
gap.
    There is a well established link between health disparities and a 
lack of access to competent healthcare in medically underserved areas. 
As a result, it is imperative that the Federal Government continue its 
commitment to minority health profession institutions and minority 
health professional training programs to continue to produce healthcare 
professionals committed to addressing this unmet need--even in austere 
financial times.
    An October 2006 study by the Health Resources and Services 
Administration (HRSA)--during the Bush Administration--entitled ``The 
Rationale for Diversity in the Health Professions: A Review of the 
Evidence'' found that minority health professionals serve minority and 
other medically underserved populations at higher rates than non-
minority professionals. The report also showed that; minority 
populations tend to receive better care from practitioners who 
represent their own race or ethnicity, and non-English speaking 
patients experience better care, greater comprehension, and greater 
likelihood of keeping follow-up appointments when they see a 
practitioner who speaks their language. Studies have also demonstrated 
that when minorities are trained in minority health profession 
institutions, they are significantly more likely to: 1) serve in rural 
and urban medically underserved areas, 2) provide care for minorities 
and 3) treat low-income patients.
    As you are aware, Title VII Health Professions Training programs 
are focused on improving the quality, geographic distribution and 
diversity of the healthcare workforce in order to continue eliminating 
disparities in our Nation's healthcare system. These programs provide 
training for students to practice in underserved areas, cultivate 
interactions with faculty role models who serve in underserved areas, 
and provide placement and recruitment services to encourage students to 
work in these areas. Health professionals who spend part of their 
training providing care for the underserved are up to 10 times more 
likely to practice in underserved areas after graduation or program 
completion.
    In fiscal year 2014, funding for the Title VII Health Professions 
Training programs must be robust, especially the funding for the 
Minority Centers of Excellence (COEs) and Health Careers Opportunity 
Program (HCOPs). In addition, the funding for the National Institutes 
of Health (NIH)'s National Institute on Minority Health and Health 
Disparities (NIMHD), as well as the Department of Health and Human 
Services (HHS)'s Office of Minority Health (OMH), should be preserved.
    Minority Centers of Excellence.--COEs focus on improving student 
recruitment and performance, improving curricula in cultural 
competence, facilitating research on minority health issues and 
training students to provide health services to minority individuals. 
COEs were first established in recognition of the contribution made by 
four historically black health professions institutions to the training 
of minorities in the health professions. Congress later went on to 
authorize the establishment of ``Hispanic'', ``Native American'' and 
``Other'' Historically black COEs. For fiscal year 2014, I recommend a 
funding level of $24.602 million for COEs. Additionally, I encourage 
the Committee direct HRSA to re-evaluate the funding mechanism for the 
original four COEs, as it does not always lead to funding based on the 
merit of an institution's proposal.
    Health Careers Opportunity Program (HCOP).--HCOPs provide grants 
for minority and non-minority health profession institutions to support 
pipeline, preparatory and recruiting activities that encourage minority 
and economically disadvantaged students to pursue careers in the health 
professions. Many HCOPs partner with colleges, high schools, and even 
elementary schools in order to identify and nurture promising students 
who demonstrate that they have the talent and potential to become a 
health professional. For fiscal year 2014, I recommend a funding level 
of $22.133 million for HCOPs.

                     NATIONAL INSTITUTES OF HEALTH

    National Institute on Minority Health and Health Disparities.--The 
National Institute on Minority Health and Health Disparities (NIMHD) is 
charged with addressing the longstanding health status gap between 
minority and nonminority populations. The NIMHD helps health 
professions institutions to narrow the health status gap by improving 
research capabilities through the continued development of faculty, 
labs, and other learning resources. The NIMHD also supports biomedical 
research focused on eliminating health disparities and develops a 
comprehensive plan for research on minority health at the NIH. 
Furthermore, the NIMHD provides financial support to health professions 
institutions that have a history and mission of serving minority and 
medically underserved communities through its Centers of Excellence 
program. For fiscal year 2014, I recommend funded increases 
proportional with the funding of the overall NIH, with increased FTEs.
    Research Centers at Minority Institutions.--The Research Centers at 
Minority Institutions program (RCMI), newly moved to the National 
Institute on Minority Health and Health Disparities has a long and 
distinguished record of helping our institutions develop the research 
infrastructure necessary to be leaders in the area of health 
disparities research. Although NIH has received unprecedented budget 
increases in recent years, funding for the RCMI program has not 
increased by the same rate. Therefore, the funding for this important 
program grow at the same rate as NIH overall in fiscal year 2014.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Office of Minority Health.--Specific programs at OMH include: 
assisting medically underserved communities with the greatest need in 
solving health disparities and attracting and retaining health 
professionals; assisting minority institutions in acquiring real 
property to expand their campuses and increase their capacity to train 
minorities for medical careers; supporting conferences for high school 
and undergraduate students to interest them in health careers, and 
supporting cooperative agreements with minority institutions for the 
purpose of strengthening their capacity to train more minorities in the 
health professions.
    The OMH has the potential to play a critical role in addressing 
health disparities, but that role is only possible if this agency 
continues to keep its grant-making authority. For fiscal year 2014, I 
recommend a funding level of $65 million for the OMH.

                        DEPARTMENT OF EDUCATION

    Strengthening Historically Black Graduate Institutions.--The 
Department of Education's Strengthening Historically Black Graduate 
Institutions (HBGI) program (Title III, Part B, Section 326) is 
extremely important to AMHPS. The funding from this program is used to 
enhance educational capabilities, establish and strengthen program 
development offices, initiate endowment campaigns, and support numerous 
other institutional development activities. In fiscal year 2014, an 
appropriation of $65 million is suggested to continue the vital support 
that this program provides to historically black graduate institutions.
    Mr. Chairman, please allow me to express my appreciation to you and 
the members of this subcommittee. With your continued help and support, 
Tuskegee University's College of Veterinary Medicine, Nursing, and 
Allied Health , Title VII Health Professions Training programs and the 
historically black health professions schools can help this country to 
overcome health disparities. Congress must be careful not to eliminate, 
paralyze or stifle the institutions and programs that have been proven 
to work. CVMNAH seeks to close the ever widening health disparity gap. 
If this subcommittee will give us the tools, we will continue to work 
towards the goal of eliminating that disparity everyday.
    Thank you, Mr. Chairman.
                                 ______
                                 
    Prepared Statement of the College on Problems of Drug Dependence

    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to submit testimony to the subcommittee in support of the 
National Institute on Drug Abuse. The College on Problems of Drug 
Dependence (CPDD), a membership organization with over 800 members, has 
been in existence since 1929. It is the longest standing group in the 
United States addressing problems of drug dependence and abuse. The 
organization serves as an interface among governmental, industrial and 
academic communities maintaining liaisons with regulatory and research 
agencies as well as educational, treatment, and prevention facilities 
in the drug abuse field. CPDD also often works in collaboration with 
the World Health Organization.
    Recognizing that so many health research issues are inter-related, 
CPDD requests that the subcommittee provide at least $32 billion for 
the National Institutes of Health (NIH). Because of the critical 
importance of drug abuse research for the health and economy of our 
Nation, we also request that you provide a proportionate increase for 
the National Institute on Drug Abuse in your Fiscal 2014 Labor, Health 
and Human Services, Education and Related Agencies Appropriations bill.
    Drug abuse is costly to Americans; it ruins lives, while tearing at 
the fabric of our society and taking a huge financial toll on our 
resources. Beyond the unacceptably high rates of morbidity and 
mortality, drug abuse is often implicated in family disintegration, 
loss of employment, failure in school, domestic violence, child abuse, 
and other crimes. Placing dollar figures on the problem; smoking, 
alcohol and illegal drug use results in an exorbitant economic cost on 
our Nation, estimated at over $600 billion annually. We know that many 
of these problems can be prevented entirely, and that the longer we can 
delay initiation of any use, the more successfully we mitigate future 
morbidity, mortality and economic burdens.
    Over the past three decades, NIDA-supported research has 
revolutionized our understanding of addiction as a chronic, often-
relapsing brain disease--this new knowledge has helped to correctly 
situate drug addiction as a serious public health issue that demands 
strategic solutions. By supporting research that reveals how drugs 
affect the brain and behavior and how multiple factors influence drug 
abuse and its consequences, scholars supported by NIDA continue to 
advance effective strategies to prevent people from ever using drugs 
and to treat them when they cannot stop.
    NIDA supports a comprehensive research portfolio that spans the 
continuum of basic neuroscience, behavior and genetics research through 
medications development and applied health services research and 
epidemiology. While supporting research on the positive effects of 
evidence-based prevention and treatment approaches, NIDA also 
recognizes the need to keep pace with emerging problems. We have seen 
encouraging trends--significant declines in a wide array of youth drug 
use--over the past several years that we think are due, at least in 
part, to NIDA's public education and awareness efforts. However, areas 
of significant concern, such as prescription drug abuse, remain and we 
support NIDA in its efforts to find successful approaches to these 
difficult problems.
    The Nation's previous investment in scientific research to further 
understand the effects of abused drugs on the body has increased our 
ability to prevent and treat addiction. As with other diseases, much 
more needs be done to improve prevention and treatment of these 
dangerous and costly diseases. Our knowledge of how drugs work in the 
brain, their health consequences, how to treat people already addicted, 
and what constitutes effective prevention strategies has increased 
dramatically due to support of this research. However, since the number 
of individuals continuing to be affected is still rising, we need to 
continue the work until this disease is both prevented and eliminated 
from society.
    We understand that the fiscal year 2014 budget cycle will involve 
setting priorities and accepting compromise, however, in the current 
climate we believe a focus on substance abuse and addiction, which 
according to the World Health Organization account for nearly 20 
percent of disabilities among 15-44 year olds, deserves to be 
prioritized accordingly. We look forward to working with you to make 
this a reality. Thank you for your support for the National Institute 
on Drug Abuse.
                                 ______
                                 
  Prepared Statement of the Consortium of Social Science Associations

    Mr. Chairman and members of the subcommittee: The Consortium of 
Social Science Associations (COSSA) welcomes the opportunity to comment 
on the fiscal year 2014 Appropriations for the National Institutes of 
Health (NIH), Centers for Disease Control and Prevention (CDC), and the 
Agency for Healthcare Research and Quality (AHRQ).
    COSSA is an advocacy group for the social and behavioral sciences 
supported by 115 professional associations, scientific societies, 
universities and research centers. COSSA serves as a bridge between the 
academic research and Washington policy-making community. Our 
organizations are appreciative of the subcommittee's and the Congress' 
continued support of the NIH, CDC, and AHRQ. Strong, sustained funding 
is essential to the national priorities of better health and economic 
revitalization.
    COSSA joins the Ad Hoc Group for Medical Research in requesting a 
minimum appropriation of $32 billion for NIH for fiscal year 2014. As a 
member of the CDC Coalition, COSSA requests $7.8 billion in funding for 
CDC in fiscal year 2014. Lastly, we join the Friends of AHRQ in 
recommending a funding level of $181.5 million for AHRQ in fiscal year 
2014.

Social and Behavioral Science Research at the National Institutes of 
        Health
    As this Committee knows, the mission of the NIH is to support 
scientifically rigorous, peer/merit-reviewed, investigator-initiated 
research, including basic and applied behavioral and social science 
research. The fundamental understanding of how disease works, including 
the impact of social environment on these disease processes, underpins 
our ability to conquer devastating illnesses. And while Americans have 
achieved very high levels of health over the past century and are 
healthier than people in many other nations, according to the recently 
released National Academies' report, U.S. Health in International 
Perspective: Shorter Lives, Poorer Health, ``a growing body of research 
suggests that the health of the U.S. population is not keeping pace 
with the health of people in other economically advanced, high-income 
countries.''
    The behavioral and social sciences make important contributions to 
the well-being of this Nation. Due in large part to the behavioral and 
social science research sponsored by the NIH, we are now aware of the 
enormous role behavior plays in our health. Though we have made 
enormous progress toward achieving genetic control over disease, 
knowledge of the behavioral influences on health will always be a 
crucial component in our battles against the leading causes of 
morbidity and mortality: obesity, heart disease, cancer, AIDS, 
diabetes, age-related illnesses, accidents, substance abuse, and mental 
illness.
    As a result of the strong Congressional commitment to the NIH in 
years past, our knowledge of the social and behavioral factors 
surrounding chronic disease health outcomes is steadily increasing. The 
NIH's behavioral and social science portfolio has emphasized the 
development of effective and sustainable interventions and prevention 
programs targeting those very illnesses that are the greatest threats 
to our health, but the work is just beginning. This includes NIH's 
support of economic research, specifically, research on the linkages 
between socioeconomic status and health outcomes in the elderly and 
achievement and health outcomes in children. This research has been an 
integral part of the interdisciplinary science NIH has historically 
supported. Accordingly, the agency's investment has yielded key data, 
methodologies and substantive insights on some of the most important 
and pressing issues facing the U.S. For example, NIH-funded surveys 
such as the Health and Retirement Survey, the Panel Study of Income 
Dynamics (PSID), parts of the National Longitudinal Survey of Labor 
Market Experiences, and surveys on international aging and retirement 
provide data necessary to monitor and detect changes in important 
socioeconomic trends in health. This in turn allows NIH to support 
research that will provide the greatest return on its investment when 
it comes to the health of our citizens.
    Social and behavioral scientists have made significant strides in 
shedding light on the basic social and cultural structures and 
processes that influence health. Social and cultural factors influence 
health by affecting exposure and vulnerability to disease, risk-taking 
behaviors, the effectiveness of health promotion efforts, and access 
to, availability of, and quality of health care. Social and cultural 
factors also play a role in shaping perceptions of and responses to 
health problems and the impact of poor health on individuals' lives and 
well-being. In addition, such factors contribute to understanding 
societal and population processes such as current and changing rates of 
morbidity, survival, and mortality.
    Despite the dramatic contributions that behavioral and social 
science research has made to date, much more remains to be understood 
in the role behavioral and social factors play in disease and how to 
use that knowledge to improve the Nation's health. Breakthroughs in the 
behavioral and social sciences over the next 20 years will be critical 
to addressing our most pressing public health challenges and 
transforming health care.
    The application of the results of basic research to the detection, 
diagnosis, treatment and prevention of disease is the ultimate goal of 
medical research. Ensuring a steady pipeline of basic research 
discoveries while also supporting the translational efforts necessary 
to bring the promise of this knowledge to fruition requires a sustained 
investment in NIH.

Social and Behavioral Science Research at the Centers for Disease 
        Control and Prevention
    As the country's leading health protection and surveillance agency, 
the CDC works with State, local, and international partners to protect 
Americans from infectious diseases; prevent the leading causes of 
disease, disability, and death; protect Americans from natural and 
bioterrorism threats; monitor health and ensure laboratory excellence; 
keep Americans safe from environmental and work-related hazard; and 
ensure global disease protection. To cite just one example of the 
enormous strides the CDC is making in keeping America and the world 
safe from disease, with adequate investment, the CDC expects to stop 
all wild poliovirus transmissions by the end of 2014, as part of the 
Global Polio Eradication Initiative.
    Social and behavioral science plays a crucial role in helping the 
CDC carry out its mission. Scientists from fields ranging from 
psychology, sociology, anthropology, and geography to health 
communications, social work, and demography work in every CDC Center to 
design, analyze, and evaluate behavioral surveillance systems, public 
health interventions, and health promotion and communication programs 
using a variety of both quantitative and qualitative methods.
    These scientists play a key role in the CDC's surveillance and 
monitoring efforts, which collect and analyze data to better target 
public health prevention efforts. For example, the Behavioral Risk 
Factor Surveillance System, which collects data about Americans' 
health-related risk behaviors and events, chronic health conditions, 
and use of preventive services, is used to establish and track State 
and local health objectives, plan health programs, implement disease 
prevention and health promotion activities, and monitor trends.
    Another vital contribution of the social and behavioral sciences to 
CDC activities is in identifying and understanding health disparities. 
Although the overall health of Americans has improved over the last 
decades, differences in health based on race, ethnicity, gender, 
income, geographical location, education level, disability status, and 
sexual orientation persist. Rigorous, cross-disciplinary efforts are 
needed to develop effective interventions to reduce these entrenched 
disparities and inequities.
    The social and behavioral sciences play an important role in the 
evaluation of CDC programs. When programs conduct strong, practical 
evaluations on a routine basis, the findings are better positioned to 
inform their management and improve program effectiveness. Evaluating 
public health programs tells us what is and isn't working and can help 
policymakers make informed, evidence-based decisions on how to 
prioritize in a resource-scarce environment.
    The CDC is the home of the Nation's principal health statistics 
agency, the National Center for Health Statistics (NCHS). NCHS collects 
data on chronic disease prevalence, health care disparities, emergency 
room use, teen pregnancy, infant mortality, causes of death and rates 
of insurance, to name a few. It provides critical data on all aspects 
of our health care system through data cooperatives and surveys that 
serve as the gold standard for data collection around the world. Data 
from NCHS surveys like the National Health Interview Survey (NHIS), the 
National Health and Nutrition Examination Survey (NHANES) and the 
National Vital Statistics System (NVSS) are used by agencies across the 
Federal Government, State and local governments, public health 
officials, Federal policymakers, and demographers, epidemiologists, 
health services researchers, and other scientists.

Health Services Research at the Agency for Healthcare Research and 
        Quality
    AHRQ's sole purpose is to improve health care in America. Just as 
biomedical research helps us find cures for disease, the health 
services research AHRQ supports helps find ways to cure our health care 
system--improving its quality, safety, and efficiency for the benefit 
of patients. AHRQ's research identifies what works and what doesn't in 
health care to improve patient care and provide policymakers and other 
health care leaders with the information needed to make critical health 
care decisions.
    AHRQ helps providers help patients. Americans want to take personal 
responsibility for their health, and they rely on their doctors, 
nurses, pharmacists and other health care providers for guidance in 
making difficult choices. AHRQ's research generates valuable evidence 
to help providers help patients make the right health care decisions 
for themselves and their loved ones. For example, the American College 
of Physicians used AHRQ-funded research to inform their recommendations 
for treatment of type 2 diabetes. These evidence-informed 
recommendations give physicians a foundation for describing what the 
best care looks like, so patients can determine what the right care 
might be for them.
    AHRQ is keeping patients safe. The science funded by AHRQ ensures 
patients receive high quality, appropriate care every time they walk 
through the hospital, clinic, and medical office doors. AHRQ's research 
provides the basis for protocols that prevent medical errors and reduce 
hospital-acquired infections (HAI), and improve patient experiences and 
outcomes. In just one example, AHRQ's evidence-based Comprehensive 
Unit-based Safety Program to Prevent Healthcare-Associated Infections 
(CUSP)--first applied on a large scale in 2003 across more than 100 
ICUs across Michigan--saved more than 1,500 lives and nearly $200 
million in the program's first 18 months. The protocols have since been 
expanded to hospitals in all 50 States, the District of Columbia, and 
Puerto Rico to continue the national implementation of this approach 
for reducing HAIs.
    AHRQ helps health care providers--from private practice physicians 
to large hospital systems--understand how to deliver the best care most 
efficiently. For example, AHRQ maintains the National Quality 
Measurement Clearinghouse (NQMC) to provide health care providers, 
health plans, delivery systems, and others with an accessible resource 
for quality measures and a one-stop-shop for benchmarks on providing 
more safe, effective and timely care. The breadth of evidence available 
from AHRQ empowers health care providers to understand not just how 
they compare to their peers, but also how to improve their performance 
to be more competitive.
    COSSA recognizes the tremendous challenges facing our Nation's 
economy and acknowledges the difficult decisions that must be made to 
restore our country's fiscal health. Nevertheless, we believe that 
strong support for public health research is an essential part of the 
solution to the Nation's economic restoration. Strengthening our 
commitment to public health, through robust funding of the NIH, CDC, 
and AHRQ is a critical element of ensuring the health and well-being of 
the American people and our economy.
                                 ______
                                 
Prepared Statement of the Corporate Friends of the Centers for Disease 
                      Control and Prevention (CDC)

    My name is David Ratcliffe, and I am the Co-Chairman of the 
Corporate Friends of the Centers for Disease Control and Prevention 
(CDC), alongside Co-Chairman, John Rice of General Electric. I am 
testifying in support of CDC's budget for fiscal year 2014 and 
requesting that the Chairman and his colleagues on the Senate Labor, 
Health and Human Services, Education and Related Agencies Subcommittee 
Committee consider restoring CDC's budget authority to the fiscal year 
2010 level of $6.39 billion. I am also asking the Committee to consider 
allowing more flexibility for the Director of the CDC with his annual 
budget.
    Chairman Harkin, Ranking Member Moran, and distinguished members of 
the subcommittee, it is my honor to submit a statement on behalf of the 
Corporate Friends of CDC. My message to Congress is that, while cuts to 
the Federal budget may be inevitable and indeed necessary, CDC should 
not be targeted for disproportionately large cuts. CDC is our Nation's 
designated health protection agency and an operating division of the 
Department of Health and Human Services. We must protect CDC's core 
mission of securing Americans from health threats, saving American 
lives, and saving money by keeping Americans healthy.
    As a Federal agency, CDC cannot and does not advocate or lobby on 
its behalf. The Corporate Friends is a registered 501(c) 4 corporation 
structured to provide advocacy and education efforts about CDC's 
significance to our Nation's health and safety. As a former President 
and CEO of Southern Company, I fully support CDC's operation as vitally 
important to our Nation's security. Much like our Department of Defense 
protects American's from military threats; CDC is committed to its job 
of protecting Americans from health, safety and security threats both 
foreign and domestic. Whether diseases start at home or abroad, are 
chronic or acute, curable or preventable, human error or deliberate 
attack, CDC and its collaboration with State and local health 
departments are our first line of defense. CDC applies groundbreaking 
health and medical research and real-time emergency response to keep 
America healthy, safe, and secure.
    Since 2011, I have had the privilege of working closely with one of 
Atlanta's most treasured resources, the CDC. The CDC is unique in that 
it is one of the only Federal agencies headquartered outside of the 
Washington, D.C. beltway. This makes the connection to corporations and 
what CDC does even more evident. Atlanta is my hometown, along with 5 
million other people, and CDC is a substantial contributor to 
employment, investment and tax base in Georgia, with almost $940 
million in payroll annually to Georgia, and over 8,000 employees, 
making it one of the State's top 15 employers.
    I see firsthand that CDC's research science and outreach keeps 
employees and their families safe and healthy, while ensuring that our 
businesses can compete around the world in a safe, healthy environment. 
CDC is vital to a healthy national workforce and economy. CDC 
contributions expand well beyond Georgia, as more than 70 percent of 
CDC's funding goes to State and local agencies across the U.S. By doing 
so, CDC further sets the standard for action-oriented public health 
initiatives and research. CDC provides emergency preparedness and 
response 24/7 to any health threat. Through its efforts CDC has 
prevented 5-10 million cases of influenza, 30,000 hospitalizations, and 
about 1,500 deaths in the U.S. In the past few years, CDC has conducted 
more than 750 field investigations on health threats in the U.S. and in 
more than 35 countries. Whether through its global health initiatives 
or local foodborne illness investigations, the work of the CDC could 
not be more important. CDC's world-class work and importance to our 
Nation's economic health and security is not lost on the voting public 
who national polls, now, for many years have voted CDC as the most 
trusted agency of the Federal Government.
    Therefore, I must express my concern for CDC's budget outlook for 
fiscal years 2013 and 2014. For Fiscal 2013, as a result of the 
sequestration and the President's recently announced plan to allocate 
funding within the Prevention and Public Health Fund, CDC's program 
authority will total $6.291 billion, which represents a $575 million or 
8.4 percent reduction from Fiscal 2012 levels. For Fiscal 2014, the 
President's budget would reduce CDC's Budget Authority $432 million 
below its fiscal year 2012 levels and $228 million less than the Fiscal 
2013 post-sequestration level. By comparison, the President's Fiscal 
2014 Budget Authority level for CDC is more than $1 billion less than 
CDC's Fiscal 2010 Budget Authority level.
    Mr. Chairman, I respectfully request that you restore CDC's Budget 
Authority in your Fiscal 2014 Labor, Health and Human Services 
Appropriations bill to CDC's Fiscal 2010 level, as a commitment to our 
Nation's safety against current and unknown health threats. It is 
important for the Members of the Committee to understand that CDC's 
budget has been cut almost five percent, yet our Nation's health 
threats continue to grow.
    The current and future budgetary challenges and economic landscape 
make the need for a strong CDC greater than ever. Recession-driven cuts 
in Federal, State, and local spending have reduced public health 
workers by about a fifth. The latest round of budget cuts and the fact 
that CDC's 2013 budget is locked into Fiscal 2012 budgetary priorities, 
as a result of Congress' inability to pass a Fiscal 2013 Labor, Health 
and Human Services Appropriations bill, provide even less flexibility 
for the CDC Director to improve the effectiveness of his budget and to 
respond to unanticipated and emerging public health threats. Americans 
and the American corporations, for whom I speak, want to know that they 
will be protected from a possible meningitis outbreak, E. coli threat, 
a whooping cough outbreak, chemical and biological terrorist threats, a 
new virus or other unknown epidemic. The snowballing impact of proposed 
cuts, from annual budgeting or sequestration, reduces the ability of 
the CDC to swiftly respond to problems.
    Unless we can change proposed allocations and give the CDC director 
more flexibility to better use more limited resources, long standing 
core programs like Immunization Services across the country and 
Infectious Disease detection and response at CDC will be compromised. 
Prevention and public health are best buys, and in many cases can help 
reduce long-term health costs and save taxpayer dollars. The world, our 
country and our national and global workforces are facing more drug 
resistance and emerging diseases, and protection against this is being 
compromised. Disease knows no borders and affects people anywhere and 
everywhere. We need CDC to protect the health of the world, and also 
the health of the economy. The CDC is the Nation's defense department 
for health, working 24/7 to protect Americans from health safety and 
security threats that could negatively impact our bottom lines.
    On behalf of the Corporate Friends of CDC, I am happy to be a 
resource to you all as you anticipate the 2014 budgeting process, so 
please do not hesitate to contact me.
                                 ______
                                 
       Prepared Statement of the Council on Social Work Education

    On behalf of the Council on Social Work Education (CSWE), I am 
pleased to offer this written testimony to the Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies for inclusion in the official Committee record. I will 
focus my testimony on the importance of fostering a skilled, 
sustainable, and diverse social work workforce to meet the health care 
needs of the Nation through professional education, training, and 
financial support programs for social workers at the Department of 
Health and Human Services (HHS).
    CSWE is a nonprofit national association representing more than 
2,500 individual members and more than 700 master's and baccalaureate 
programs of professional social work education. Founded in 1952, this 
partnership of educational and professional institutions, social 
welfare agencies, and private citizens is the sole accrediting body for 
social work education in the United States. Social work education 
prepares students for leadership and professional interdisciplinary 
practice with individuals, families, groups, and communities in a wide 
array of service sectors, including health, mental health, adult and 
juvenile justice, PK-12 education, child welfare, aging, and others. 
Social work practice is facilitated by a collaborative relationship 
that empowers people to be healthy, productive, contributing members of 
their communities.
    Recruitment and retention in social work continues to be a serious 
challenge that threatens the workforce's ability to meet societal 
needs. The U.S. Bureau of Labor Statistics estimates that employment 
for social workers is expected to grow faster than the average for all 
occupations through 2018, particularly for social workers specializing 
in the aging population and working in rural areas. In addition, the 
need for social workers specializing in mental health and substance use 
is expected to grow by almost 20 percent over the 2008-2018 decade.\1\
    CSWE understands the difficult funding decisions Congress is faced 
with this year given the challenging budget climate. In these 
challenging times, it is my hope that the Committee will prioritize 
funding for health professions training in fiscal year 2014 to help to 
ensure that the Nation continues to foster a sustainable, skilled, and 
culturally competent workforce that will be able to keep up with the 
increasing demand for social work services and meet the unique health 
care needs of diverse communities.

          HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA)
          TITLE VII AND TITLE VIII HEALTH PROFESSIONS PROGRAMS

    CSWE urges the Committee to provide $520 million in fiscal year 
2014 for the health professions education programs authorized under 
Titles VII and VIII of the Public Health Service Act and administered 
through HRSA, which is equal to the fiscal year 2012 enacted level. 
HRSA's Title VII and Title VIII health professions programs represent 
the only Federal programs designed to train health care providers in an 
interdisciplinary way to meet the health care needs of all Americans, 
including the underserved and those with special needs. These programs 
also serve to increase minority representation in the health care 
workforce through targeted programs that improve the quality, 
diversity, and geographic distribution of the health professions 
workforce. The Title VII and Title VIII programs provide loans, loan 
guarantees and scholarships to students, and grants to institutions of 
higher education and non-profit organizations to help build and 
maintain a robust health care workforce. Social workers and social work 
students are eligible for funding from the suite of Title VII health 
professions programs.
    The Title VII and Title VIII programs were reauthorized in 2010, 
which helped to improve the efficiency of the programs as well as 
enhance efforts to recruit and retain health professionals in 
underserved communities. Recognizing the severe shortages of mental and 
behavioral health providers within the health care workforce, a new 
Title VII program was authorized in the Patient Protection and 
Affordable Care Act (Public Law 111-148). The Mental and Behavioral 
Health Education and Training Grants program provides grants to 
institutions of higher education (schools of social work and other 
mental health professions) for faculty and student recruitment and 
professional education and training. The program received first-time 
funding of $10 million in the final fiscal year 2012 appropriations 
bill. The President's fiscal year 2014 budget request would expand the 
program through a partnership with the Substance Abuse and Mental 
Health Services Administration (SAMHSA) to expand the mental health 
workforce by almost 3,500 professionals focused on transition-age youth 
(16-25). CSWE urges the Committee to maintain funding for this 
critically important program at the highest level possible in fiscal 
year 2014. CSWE supports the proposed expansion of the program but 
encourages the committee to be inclusive of non-youth populations 
needing mental and behavioral health services and not to reduce the 
scope of the original intent of the program through the expansion. This 
is the only program in the Federal Government that is explicitly 
focused on recruitment and retention of social workers and other mental 
and behavioral health professionals.

   SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)
                      MINORITY FELLOWSHIP PROGRAM

    CSWE urges the Committee to appropriate the highest level possible 
for the Minority Fellowship Program (MFP) in fiscal year 2014. The goal 
of the SAMHSA Minority Fellowship Program (MFP) is to achieve greater 
numbers of minority doctoral students preparing for leadership roles in 
the mental health and substance use fields. According to SAMHSA, 
minorities make up approximately one-fourth of the population, but only 
10 percent of mental health providers come from ethnic minority 
communities. CSWE is one of six grantees of this critical program and 
administers funds to exceptional minority doctoral social work 
students. Other grantees include national organizations representing 
nursing, psychology, psychiatry, marriage and family therapy, and 
professional counselors. SAMHSA makes grants to these six 
organizations, who in turn recruit minority doctoral students into the 
program from the six distinct professions. CSWE administers the funds 
to qualified doctoral students and helps facilitate mentoring and 
networking throughout the duration of the fellowship as well as 
facilitates an alumni group to help continue to engage former fellows 
long after their formal fellowship has ended.
    Since its inception in 1974, the MFP has helped support doctoral-
level professional education for over 1,000 ethnic minority social 
workers, psychiatrists, psychologists, psychiatric nurses, and family 
and marriage therapists. Still, the program continues to struggle to 
keep up with the demands that are plaguing these health professions. 
Severe shortages of mental health professionals often arise in 
underserved areas due to the difficulty of recruitment and retention in 
the public sector. Nowhere are these shortages more prevalent than 
within Tribal communities, where mental illness and substance use go 
largely untreated and incidences of suicide continue to increase. 
Studies have shown that ethnic minority mental health professionals 
practice in underserved areas at a higher rate than non-minorities. 
Furthermore, a direct positive relationship exists between the numbers 
of ethnic minority mental health professionals and the utilization of 
needed services by ethnic minorities.\2\ The President's fiscal year 
2014 budget request includes $9.4 million for MFP core activities; CSWE 
urges the committee to support this request.
    Thank you for the opportunity to express these views. Please do not 
hesitate to call on the Council on Social Work Education should you 
have any questions or require additional information.
---------------------------------------------------------------------------
    \1\ U.S. Bureau of Labor Statistics. 2009. Occupational Outlook 
Handbook, 2010-11 Edition: Social Workers, http://data.bls.gov/cgi-bin/
print.pl/oco/ocos060.htm. Retrieved March 28, 2012.
    \2\ U.S. Department of Health and Human Services, Substance Abuse 
and Mental Health Services Administration, Center for Mental Health 
Services. (2001). Mental Health: Culture, Race, and Ethnicity--A 
Supplement to Mental Health: A Report of the Surgeon General. Retrieved 
from http://www.surgeongeneral.gov/library/mentalhealth/cre/sma-01-
3613.pdf.
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                                 ______
                                 
  Prepared Statement of the Crohn's and Colitis Foundation of America

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

    1)  $32 billion for the National Institutes of Health (NIH) at an 
increase of $1 billion over fiscal year 2013. Increase funding for the 
National Cancer Institute (NCI), The National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK) and the National Institute of 
Allergy and Infectious Diseases (NIAID) by 12 percent.
    2)  Continued focus on Digestive Disease Research and Education at 
NIH, including Inflammatory Bowel Disease (IBD) and Colorectal Cancer.
    3)  $6,860,000 for the Centers for Disease Control and Prevention's 
(CD C) IBD Epidemiology Activities.
    4)  $50 million for the Center for Disease Control and Prevention's 
(CDC) Colorectal Cancerscreening and Prevention Program.
_______________________________________________________________________

    Thank you for the opportunity to again submit testimony to the 
subcommittee. CCFA has remained committed to its mission of finding a 
cure for Crohn's disease and ulcerative colitis and improving the 
quality of life of children and adults affected by these diseases for 
over 46 years. Impacting an estimated 1.4 million Americans, 30 percent 
of whom are diagnosed in their childhood years, Inflammatory Bowel 
Diseases (IBD) are chronic disorders of the gastrointestinal tract 
which cause abdominal pain, fever, and intestinal bleeding. IBD 
represents a major cause of morbidity from digestive illness and has a 
devastating impact on both patients and their families.
    The social and economic impact of digestive disease is enormous and 
difficult to grasp. Digestive disorders afflict approximately 65 
million Americans. This results in 50 million visits to physicians, 
over 10 million hospitalizations, collectively 230 million days of 
restricted activity. The total cost associated with digestive diseases 
has been conservatively estimated at $60 billion a year.
    The CCFA would like to thank the subcommittee for its past support 
of digestive disease research and prevention programs at the National 
Institutes of Health (NIH) and the Centers for Disease Control and 
Prevention (CDC).
    Specifically the CCFA recommends:
  --$32 billion for the NIH.
  --$2.16 billion for the National Institute of Diabetes and Digestive 
        and Kidney Disease (NIDDK).
    We at the CCFA respectfully request that any increase for NIH does 
not come at the expense of
    other Public Health Service agencies. With the competing and the 
challenging budgetary constraints the subcommittee currently operates 
under, the CCFA would like to highlight the research being accomplished 
by NIDDK which warrants the increase for NIH.

                       INFLAMMATORY BOWEL DISEASE

    In the United States today about one million people suffer from 
Crohn's disease and ulcerative colitis, collectively known as IBD. 
These are serious diseases that affect the gastrointestinal tract 
causing bleeding, diarrhea, abdominal pain, and fever. Complications 
arising from IBD can include anemia, ulcers of the skin, eye disease, 
colon cancer, liver disease, arthritis, and osteoporosis. The cause of 
IBD is still unknown, but research has led to great breakthroughs in 
therapy.
    In recent years researchers have made significant progress in the 
fight against IBD. The CCFA encourages the subcommittee to continue its 
support of IBD research at NIDDK and NIAID at a level commensurate with 
the overall increase for each institute. The DDNC would like to applaud 
the NIDDK for its strong commitment to IBD research through the 
Inflammatory Bowel Disease Genetics Research Consortium. The CCFA urges 
the Consortium to continue its work in IBD research.

      CENTERS FOR DISEASE CONTROL AND PREVENTION IBD EPIDEMIOLOGY

    CDC, in collaboration with a nationwide, geographically diverse 
network of large managed health care delivery systems, has led an 
epidemiological study of IBD to understand IBD incidence, prevalence, 
demographics, and healthcare utilization. The group, comprised of 
investigators at the Massachusetts General Hospital in Boston, Rhode 
Island Hospital, the Crohn's and Colitis Foundation of America, and 
CDC, has piloted the Ocean State Crohn's and Colitis Registry (OSCAR), 
which includes both pediatric and adult patients. Since 2008, the OSCAR 
investigators have recruited 22 private-practice groups and hospital 
based physicians in Rhode Island and are that enrolling newly diagnosed 
patients into the registry. This study found an average annual 
incidence rate of 8.4 per 100,000 people for Crohn's disease and 12.4 
per 100,000 for Ulcerative Colitis; published in Inflammatory Bowel 
Disease Journal, April 2007.
  --Over the course of the initial 3-year epidemiologic collaboration, 
        CDC laboratory scientists and epidemiologists worked to improve 
        detection tools and epidemiologic methods to study the role of 
        infections (infectious disease epidemiology) in pediatric IBD, 
        collaborating with extramural researchers who were funded by a 
        National Institutes of Health (NIH) research award.
  --Since 2006, CDC epidemiologists have been working in conjunction 
        with the Crohn's and Colitis Foundation of American and a large 
        health maintenance organization to better understand the 
        natural history of IBD and factors that predict the course of 
        disease.
    The Crohn's and Colitis Foundation of America encourages the CDC to 
continue to support a nationwide IBD surveillance and epidemiological 
program in fiscal year 2014.

                      COLORECTAL CANCER PREVENTION

    Colorectal cancer is the third most commonly diagnosed cancer for 
both men and woman in the United States and the second leading cause of 
cancer-related deaths. Colorectal cancer affects men and women equally.
    The CCFA recommends a funding level of $50 million for the CDC's 
Colorectal Cancer Screening and Prevention Program. This important 
program supports enhanced colorectal screening and public awareness 
activities throughout the United States. The DDNC also supports the 
continued development of the CDC-supported National Colorectal Cancer 
Roundtable, which provides a forum among organizations concerned with 
colorectal cancer to develop and implement consistent prevention, 
screening, and awareness strategies.

                               CONCLUSION

    The CCFA understands the challenging budgetary constraints and 
times we live in that this subcommittee is operating under, yet we hope 
you will carefully consider the tremendous benefits to be gained by 
supporting a strong research and education program at NIH and CDC. 
Millions of Americans are pinning their hopes for a better life, or 
even life itself, on digestive disease research conducted through the 
National Institutes of Health. Mr. Chairman, on behalf of our patients, 
we appreciate your consideration of our view. We look forward to 
working with you and your staff.
                                 ______
                                 
                   Prepared Statement of the CURE CMD

    On behalf of the thousands of Americans with Congenital Muscular 
Dystrophy (CMD), we urge the subcommittee to support the National 
Institutes of Health (NIH) at $32 billion in fiscal year 2014.
    Cure CMD is a nonprofit organization dedicated to finding 
treatments and, eventually, a cure for the devastating ravages of the 
congenital muscular diseases. CMD is a group of diseases causing muscle 
weakness at birth or within the first 2 years of childhood. Several 
defined genetic mutations cause muscles to break down faster than they 
can repair or grow. A child with CMD may have various neurological or 
physical impairments and may never gain the ability to walk. Cure CMD 
represents the network of family, friends, caretakers and affected 
individuals tirelessly battling this devastating disease every day. 
Aubrey, Katie, and Maia are just a few of the affected population, but 
their stories are common among the CMD community. An introduction to 
their stories is below:
    Aubrey has never been able to stand, sit up unaided, or even roll 
over. Despite her challenges, she remains an energetic, intelligent and 
enthusiastic 6\1/2\-year-old. The most challenging part of her overall 
weakness is her inability to cough--leaving her susceptible to frequent 
respiratory illness. A simple runny nose can very quickly turn into 
pneumonia. In her short life, she, like many children with CMD, has 
been hospitalized with pneumonia multiple times. With each admission, 
parents often wonder whether their child will be strong enough to fight 
through it again. It is a long and difficult battle.
    Katie, an honors student in college, lost her ability to walk in 
sixth grade. Weighing just 55 pounds, Katie needs help showering, 
getting dressed, brushing her hair, preparing a meal, getting books 
from her backpack and breathing with a machine at night. On a college 
study abroad trip to France earlier this year, Katie suffered acute 
respiratory failure. She required specialized care and fully recovered 
because Cure CMD guided the entire care process from the U.S. with 
physicians in France.
    Maia, 15-year-old with CMD, is a profoundly disabled teen who 
overcame tremendous odds through her sheer determination and resolve of 
her family, therapists and school aides. She has the great misfortune 
of receiving multiple disadvantages: static cognitive impairment and 
progressive muscle weakness. Her speech is limited to 5 words.
    CMD is a progressive disease without treatment. The future is 
bleak. It is a life that ends after years of non-stop caregiving, 
dependency, hospitalizations and loss . . . loss of ambulation, loss of 
integration within society, loss of ability to sign and communicate, 
loss of an ability to breathe on one's own and loss of life.
    Cure CMD is deeply appreciative of the critical support NIH has 
provided to congenital muscular dystrophy research and the 
organization's steadfast pathway toward clinical trials. With help from 
the NIH, in just 5 years Cure CMD has brought scientists together from 
around the world to work toward common therapeutic targets, launched an 
International Patient Registry, created a CMD family conference to 
share learnings, developed a bio bank for investigators and created new 
care guidelines for families and physicians--the first step in 
``treatment'' to improve and save the lives of people with CMD.
    The research NIH supports is making significant advances in better 
understanding and treating CMD. Without this vital research, the CMD 
community will be setback years in making progress and improving the 
quality of life of those suffering with this devastating disorder.
    We respectfully ask the subcommittee to encourage NIH to continue 
to support grants and other funding mechanisms to advance key 
congenital muscle disease initiatives for clinical trial readiness. 
Furthermore, we would like the subcommittee to request an update from 
NIH in future fiscal year congressional budget justifications on total 
dollars spent on congenital muscular dystrophy and congenital myopathy 
research.
    We applaud the subcommittee's past support of NIH and urge you to 
fund NIH at $32 billion in fiscal year 2014. We understand the need for 
fiscal responsibility, but this cannot come at the expense of research 
that could significantly impact the daily lives of those living with 
CMD.
                                 ______
                                 
          Prepared Statement of the Cystic Fibrosis Foundation

    On behalf of the Cystic Fibrosis Foundation and the 30,000 people 
with cystic fibrosis (CF) in the United States, we submit the following 
testimony to the Senate Appropriations Committee's Subcommittee on 
Labor, Health and Human Services, Education, and Related Agencies on 
our funding requests for fiscal year 2014.
    The Cystic Fibrosis Foundation remains significantly concerned 
about the impact of the recently-enacted sequester and other funding 
reductions on biomedical research and the health of the CF population. 
The Foundation requests the highest possible funding level for the 
National Institutes of Health, its National Center for Advancing 
Translational Sciences, and programs that provide access to health care 
in fiscal year 2014, in order to support continued scientific 
discoveries and promote the well-being of those living with this 
serious illness.

Developing Cystic Fibrosis Treatments and a Cure through NIH Funding
    As the Committee considers its funding priorities for the coming 
fiscal year, we urge consideration of the critical role that NIH plays 
in the development of treatments for cystic fibrosis and other diseases 
and respectfully request increased funding for this vital agency.
    NIH-funded advances like the mapping of the human genome and the 
development of high throughput screening were essential to the creation 
of KalydecoTM, a cystic fibrosis treatment approved in 
January 2012 and called ``the most important drug of 2012'' by Forbes 
Magazine. This breakthrough drug, developed by Vertex Pharmaceuticals 
in cooperation with the Cystic Fibrosis Foundation, is the first to 
treat the underlying cause of cystic fibrosis in those with a 
particular genetic mutation of CF that impacts about 4 percent of the 
CF population. More exciting advancements are in the pipeline, as phase 
3 clinical trials are underway to study a combination of Kalydeco and a 
new compound, VX-809. This combination would treat those with the most 
common CF mutation, comprising about 50 percent of those with CF in the 
United States.
    Other NIH-funded research could be the key to future cystic 
fibrosis treatments, such as research conducted through NIH's pediatric 
liver disease consortium at the National Institute of Diabetes, 
Digestive, and Kidney Diseases (NIDDK), which helps researchers 
discover treatments for CF-related liver disease and other diseases 
that affect thousands of children each year.
    NIH also issued two Requests for Applications (RFAs) last year that 
specifically target cystic fibrosis, one to study early lung disease 
and the other to study cystic fibrosis-related diabetes, both of which 
could lead to new scientific discoveries. The agency also invests in 
research at the University of Iowa that studies the effects of CF in 
both pig and ferret models. The ferret model in particular is expected 
to be uniquely informative of early events in CF-related diabetes and 
will compliment the ongoing work done through the NIDDK's RFA efforts.
    CF-related genetic research also benefits from Federal funding. 
Research into cystic fibrosis transmembrane conductance regulator 
(CFTR) folding and trafficking and CFTR protein structure is critical 
to the creation of new drugs that treat the underlying cause of the 
disease. The data that emerged from Kalydeco Phase 2 and 3 clinical 
trials provided proof that CFTR protein function modulation, the 
mechanism by which this drug targets the physiological defect in those 
with a particular CF mutation, is a viable therapeutic approach. More 
NIH-funded research is needed to understand the more than 1,000 other 
genetic mutations of CF.
    Lastly, it is important to note that NIH funding benefits the 
economy, supporting more than 402,000 jobs and $57 billion in economic 
output in 2012 according to a report by United for Medical Research. 
Funding for NIH also attracts the next generation of promising 
researchers through programs like the National Research Service Awards 
(NRSAs). Robust funding for NIH promotes much-needed economic growth 
and supports the scientific progress that makes the United States the 
worldwide leader in biomedical research.

Advancing Innovation Through Translational Science
    The Cystic Fibrosis Foundation strongly supports efforts to 
strengthen the field of translational science and urges the Committee 
to increase funding for the NIH's National Center for Advancing 
Translational Sciences (NCATS). NCATS' use of innovative methods and 
technologies to improve the development, testing and implementation of 
diagnostics and therapeutics improves the efficiency of the translation 
of basic scientific discoveries into new therapies and advances the 
search for cures.
    Certain NCATS programs are integral to the center's success and 
merit special consideration. These include the Clinical and 
Translational Science Awards (CTSA), the Cures Acceleration Network 
(CAN) and the Therapeutics for Rare and Neglected Diseases (TRND) 
program, all designed to support clinical and translational research 
and transform the way in which it is conducted and funded. TRND in 
particular, inspired by the Cystic Fibrosis Foundation's Therapeutics 
Development Network of clinical research centers, is essential to the 
advancement of treatments for rare illnesses.
    NCATS also emphasizes collaboration across sectors, promoting more 
efficient and innovative drug discovery and development. For example, 
the center is working with the Defense Advanced Research Projects 
Agency (DARPA) and the Food and Drug Administration (FDA) to design a 
tissue chip for drug screening. This chip, composed of diverse human 
cells and tissues, mimics how drugs interact with the human body. If 
successful, this chip could make drug safety and efficacy assessments 
possible at an earlier stage in drug development, enabling 
investigators to concentrate on the most promising new drugs.
    Other significant collaborative projects include the Regulatory 
Science Initiative and the FDA-NIH Joint Leadership Council. As 
treatments like Kalydeco are developed to target specific genetic 
mutations and smaller populations, collaborative efforts between NIH, 
FDA and others in Government, industry and academia will promote the 
swift advancement of therapies from the laboratory to the patients who 
need them most.

Promoting Access to Quality, Specialized Health Care
    The Cystic Fibrosis Foundation encourages robust funding for 
provisions of the Affordable Care Act (ACA) that ensure affordable 
access to quality, specialized health care for those with cystic 
fibrosis.
    In order to receive the highest quality care, people with CF 
require treatment by a multidisciplinary team of providers who 
specialize in CF and practice at an accredited CF care center. Cystic 
fibrosis patients also need a variety of drugs and therapies to keep 
them healthy, many requiring 2-3 hours of treatment per day.
    Cystic fibrosis is also an expensive disease. People with cystic 
fibrosis typically have medical costs 15 times greater than an average 
person. Unfortunately, the high cost of CF care is increasingly passed 
on to patients, placing a financial burden on those already struggling 
with a serious, chronic illness. Twenty 5 percent of CF patients in a 
recent survey reported that they have delayed or skipped medical care 
due to cost, and 31 percent said they skipped doses of medication or 
took less than prescribed due to cost concerns.
    Affordable insurance that provides coverage for comprehensive, 
specialized care and medications allows those with CF to access the 
best treatment available for this difficult disease. High co-payments, 
excessive co-insurance rates and unnecessary prior authorization 
requirements are burdensome barriers for those who need treatment to 
stay healthy.
    We urge the Committee to provide sufficient funding for the ACA 
provisions that will help those with cystic fibrosis afford the care 
they need, including the expansion of the Medicaid program, the 
development of Health Insurance Marketplaces to ensure adequate and 
affordable coverage for high-quality, specialized cystic fibrosis care 
and the creation of Essential Health Benefits that include access to 
specialized CF care centers and medications and prevent overly 
burdensome barriers to needed treatments.
About Cystic Fibrosis and the Cystic Fibrosis Foundation
    Cystic fibrosis is a rare genetic disease that causes the body to 
produce abnormally thick mucus that clogs the lungs and results in 
life-threatening infections. This mucus also obstructs the pancreas and 
stops natural enzymes from helping the body break down and absorb food.
    The Cystic Fibrosis Foundation's mission is to find a cure for CF 
and improve the quality of life for those living with the disease. 
Through the Foundation's efforts, the life expectancy of a child with 
CF has doubled in the last 30 years and research to find a cure is more 
promising than ever. The Foundation's research efforts have helped 
create a robust pipeline of potential therapies that target the disease 
from every angle. Nearly every CF drug available today was made 
possible because of the Foundation's support and our ongoing work to 
find a cure.
    Once again, we urge the Committee to increase funding for 
biomedical research at the National Institutes of Health and for 
programs that provide access to specialized health care in fiscal year 
2014. We stand ready to work with the Committee and Congressional 
leaders on the challenges ahead. Thank you for your consideration.
                                 ______
                                 
       Prepared Statement of the Deans' Nursing Policy Coalition

    Dear Chairman Harkin and Ranking Member Moran: As the subcommittee 
begins its deliberations on the fiscal year 2014 Labor, HHS, and 
Education appropriations bill, we write as members of the Deans' 
Nursing Policy Coalition (the Coalition) to urge you to protect and 
sustain funding for nursing science, research, practice, and education 
programs, which are critical to our efforts to provide high-quality, 
affordable care for a growing and increasingly diverse patient 
population.
    The Coalition comprises seven top research-based schools of nursing 
that generate evidence for effective health care practice and translate 
that knowledge to the education and policy environments. As leaders in 
graduate-level nursing, our schools also focus on educating advanced 
practice nurses to direct patient care in clinical settings, expert 
faculty practitioners to train the next generation of nurses, and 
Ph.D.-level nurse researchers to conduct cutting-edge research that 
promotes health and helps manage chronic conditions such as diabetes, 
obesity and cardiovascular disease.
    The Coalition's funding priorities play a foundational role in 
supporting the nursing profession. We urge you to support the following 
agencies and programs:
  --National Institutes of Health (NIH), including $150 million for the 
        National Institute for Nursing Research (NINR), which funds 
        research that establishes the scientific basis for disease 
        prevention, cancer care, health promotion, and high quality 
        nursing care;
  --At least $231 million for the Nursing Workforce Development 
        Programs at the Health Resources and Services Administration 
        (HRSA) to build a more highly educated nursing workforce, as 
        recommended by the Institute of Medicine's report, The Future 
        of Nursing: Leading Change, Advancing Health; and
  --As much funding as possible for Nurse-Managed Health Clinics 
        (NMHCs), funded through Title III of the Public Health Services 
        Act, which will enable nurses to help expand and improve 
        delivery of care.

National Institutes of Health; National Institute of Nursing Research
    As our top priority, we urge you to support a funding request of at 
least $32 billion for NIH in fiscal year 2014. Of particular importance 
to the Coalition is NINR, the smallest institute at NIH and an 
important source of Federal funding for nursing science and research. 
We respectfully request $150 million for NINR in fiscal year 2014.
    Nursing science is the care of people. Through NINR awards, nurse 
researchers investigate strategies to prevent chronic health 
conditions, such as diabetes, heart disease and HIV/AIDS; provide 
symptom management for cancer patients; promote health and healthier 
treatment outcomes; eliminate health disparities by identifying 
culturally appropriate interventions and care strategies; and improve 
processes and strategies for palliative care, easing suffering at the 
end of life. NINR supports research that is highly translational, 
focused on the effectiveness and cost-effectiveness of health care 
interventions.
    In fact, much of the care patients receive in hospital settings 
today is based on NINR research and is widely adopted as best practices 
by physicians, hospitals and insurers. For example, chronic diseases 
cause seven out of every 10 deaths in the United States and are among 
the most costly and preventable health problems. NIH support to Emory 
University is helping nurse researchers address this growing epidemic 
by launching an inter-professional education and mentoring program to 
prepare nurse scientists for the challenges of translating scientific 
research for chronically ill patients.

Nursing Workforce Development Programs
    We also urge you to provide at least $231 million for HRSA's 
Nursing Workforce Development programs (Title VIII of the Public Health 
Service Act), the largest source of dedicated funding for nurse 
education. Of specific interest to the Coalition, Title VIII programs 
support future nurse faculty, such as the Advanced Education Nurse 
Program and the Nurse Faculty Loan Program. According to the American 
Association of Colleges of Nursing's most recent survey, the nursing 
shortage is caused and perpetuated by insufficient numbers of nurse 
faculty and clinical preceptors, not a lack of interested and 
academically qualified students.
    The Coalition appreciates the budgetary challenges associated with 
the current fiscal environment, but we believe that these programs are 
critical to promote academic progression, as highlighted in the IOM 
report, and to enable nursing schools to open admissions, expand 
student capacity, and ensure a supply of qualified nurse professionals.

Nurse-Managed Health Clinics
    Finally, we urge you to designate as much as possible for Nurse-
Managed Health Clinics (Title III of the Public Health Service Act, 
administered by HRSA) in fiscal year 2014 and to reject the 
Administration's actions to merge NHMCs with federally Qualified Health 
Clinics (FQHCs).
    NMHCs, closely linked to schools of nursing, were created under the 
Affordable Care Act as part of a comprehensive primary care workforce 
development strategy; the program was authorized at $50 million. 
Although a small amount of funding from other sources was made 
available for NMHCs in fiscal years 2010 through 2012, this important 
and cost-effective program has been hindered by inconsistent funding 
and administration. We remain concerned that the President has folded 
NMHCs into the Community Health Center program; the Administration's 
approach contains an explicit expectation for current and new NMHCs to 
become FQHCs, sacrificing the unique qualities of NMHCs in the process. 
FQHCs operate under a number of very rigid requirements related to 
governance and administration which are not likely to be modified. 
Coming into compliance with those requirements will cause NMHCs to lose 
many of the attributes that make them excellent sites for nurse 
education and for development of improved care models.
    Of particular importance to the Coalition, each NMHC is required 
under the ACA to be affiliated with a school, college, university or 
department of nursing, or independent nonprofit health or social 
services agency, and plays an important role in nurse education, 
serving as clinical education and practice sites for students and 
faculty. FQHCs are not required to partner with schools of nursing and 
as the NMHC program is merged with FQHCs and required to meet new 
governance requirements, schools of nursing will lose an important 
teaching site for their student nurses and for other health 
professionals on interdisciplinary teams.
    We understand that the subcommittee and the Congress will need to 
make difficult decisions regarding fiscal year 2014 and the larger 
budget environment, but we urge you to consider the impact of recent 
funding reductions--and the threat of additional cuts--to programs 
designed to educate and train our health care workforce to meet the 
needs of the American public. We greatly appreciate your leadership on 
nursing issues and consideration of these requests.
            Sincerely,
                    Bobbie Berkowitz, PhD, RN, FAAN, Dean and 
                            Professor, Columbia School of Nursing, 
                            Senior Vice President, Columbia University 
                            Medical Center; Colleen Conway-Welch, PhD, 
                            CNM, FAAN, FACNM, Nancy & Hilliard Travis 
                            Professor of Nursing, Dean, Vanderbilt 
                            University School of Nursing; Catherine L. 
                            Gilliss, PhD, RN, FAAN, Dean and Helene 
                            Fuld Health Trust Professor of Nursing, 
                            Duke University School of Nursing, Vice 
                            Chancellor for Nursing Affairs, Duke 
                            University; Margaret Grey, DrPH, RN, FAAN, 
                            Dean and Annie Goodrich Professor, Yale 
                            University School of Nursing; Linda A. 
                            McCauley, RN, PhD, FAAN, Dean and 
                            Professor, Nell Hodgson Woodruff School of 
                            Nursing, Emory University; Afaf I. Meleis, 
                            PhD, DrPS(hon), FAAN, Margaret Bond Simon 
                            Dean of Nursing, University of Pennsylvania 
                            School of Nursing; Kathy Rideout, EdD, PNP-
                            BC, FNAP, Dean, University of Rochester 
                            School of Nursing.
                                 ______
                                 
Prepared Statement of the Diabetes Advocacy AllianceTM (DAA)

    Dear Chairman Harkin and members of the subcommittee: The Diabetes 
Advocacy AllianceTM (DAA), a coalition of 19 members 
representing patient advocacy organizations, professional societies, 
trade associations, other nonprofit organizations, and corporations 
committed to changing the way diabetes is viewed and treated in 
America, is pleased to provide this written testimony in support of 
funding for the National Diabetes Prevention Program (National DPP). As 
you craft the fiscal year 2014 Labor, Health & Human Services, 
Education and Related Agencies (LHHS) appropriations bill, the DAA 
urges you to include $20 million in funding for the National DPP.
    Since the National DPP was first established in the Affordable Care 
Act (ACA) with the goal to ``eliminate the preventable burden of 
diabetes,'' the DAA has advocated strongly for Federal funding to bring 
the program to scale nationally. A unique public-private partnership 
that seeks to roll out across the country clinically-proven, community-
based diabetes prevention programs targeted to people with prediabetes, 
the National DPP received $10 million in Federal funding in 2012 and 
the Senate appropriated $20 million in fiscal year 2013 that was never 
enacted. The National DPP has received no Congressional funding since 
2012--despite the continuing growth in diabetes prevalence across the 
Nation.

The Diabetes Epidemic and its Toll Continues Unabated
    Currently 26 million Americans have diabetes, and another 79 
million have prediabetes and are at high risk for developing type 2 
diabetes within seven to 10 years.\1\ In fact, 70 percent of those with 
prediabetes could progress to type 2 diabetes without intervention.\2\ 
Over the past 30 years, the percentage of Americans diagnosed with 
diabetes has more than doubled.\3\ According to the Centers for Disease 
Control and Prevention (CDC), as many as 1 in 3 adults could have 
diabetes by the year 2050.\4\ Even among the youth of our nation--who 
historically have not developed type 2 diabetes--rates of the disease 
are on the rise. In fact, a CDC study projects that the number of 
children with type 2 diabetes will increase by nearly 50 percent by 
2050 if current trends continue. If type 2 diabetes incidence increases 
even slightly, mirroring other countries, the rate of type 2 diabetes 
among children in the U.S. could grow fourfold by 2050.\5\
    Diabetes is a gateway disease, often leading to life-altering 
complications. The longer people live with diabetes, the more likely it 
is that they will develop complications that include heart attack, 
stroke, blindness, kidney failure and limb amputations.\6\ Each day, 
because of diabetes, 230 people have limbs amputated, 120 people 
develop kidney failure, and 55 people go blind.\7\ Diabetes and its 
complications shorten the life expectancy of those living with the 
disease by seven to 8 years.\8\
    Diabetes affects our Nation's fiscal health as well. In 2012, the 
Nation spent $245 billion on diagnosed diabetes, an increase of 41 
percent from 2007.\9\

Type 2 Diabetes: A Chronic Disease we Know How to Prevent
    Despite these grim statistics, there is hope for bending the impact 
curve of diabetes and altering both the human and economic toll of the 
disease--and that hope is the National DPP. The National DPP is based 
on a clinically-proven program, the National Institutes of Health-
funded Diabetes Prevention Program, which showed that adults with 
prediabetes could reduce their risk for developing type 2 diabetes by 
up to 58 percent through moderate weight loss and regular physical 
activity. Older adults, those age 60 and over, who made these same 
lifestyle changes reduced their risk of developing type 2 diabetes by 
71 percent.\10\ Follow-up research confirmed that these positive 
outcomes persist for at least a decade after participating in the 
lifestyle intervention and that the program can be offered effectively 
and cost-effectively within group settings at YMCAs and other 
community-based locations.\11\
    More recent research, published just this month, examined the 10-
year effectiveness of the DPP among participants who were adherent to 
the lifestyle intervention--those who lost at least 5 percent of their 
body weight--and showed that the lifestyle intervention, which is 
essentially the National DPP, ``represents a good value for money.'' 
And it improved the quality of life for participants.\12\

The Promise of the National DPP: A Public-Private Partnership that is 
        Getting Results
    The National DPP, administered through the CDC, can help improve 
our Nation's health by halting or stopping the progression to type 2 
diabetes; and improve our fiscal health as well by decreasing what we 
spend on treating diabetes and its life-altering complications. If 
fully scaled, the NDPP holds the promise of delivering cost-effective 
diabetes prevention programs in communities across the Nation to the 79 
million Americans at high risk for diabetes.
    The National DPP authorized in the Affordable Care Act, got its 
start as a public-private partnership in 2010 when the YMCA of the USA 
(Y-USA) partnered with the CDC's National Diabetes Prevention Program 
and the Diabetes Prevention and Control Alliance to offer diabetes 
prevention programs cost effectively at local Ys. About 80 percent of 
U.S. households live within five miles of a Y. Through the partnership, 
four UnitedHealthcare plans were the first private plans to offer the 
program as a covered benefit and reimburse Ys on a pay-for-performance 
basis, including meeting weight loss goals. Since then, 18 additional 
plans from UnitedHealthcare, as well as Medica, MVP and Florida Blue 
have joined DPCA's network of payers. Today, Y-USA, the Diabetes 
Prevention and Control Alliance and many others are working with CDC in 
this successful public-private partnership to continue to roll out this 
program nationwide.
    In fact, through the National DPP, the YMCA's Diabetes Prevention 
Program is now available at about 500 sites across 32 States. 
Approximately 9,000 individuals have enrolled and attended classes 
since 2010, and more than half of the participants have completed the 
full year-long program.
    The Center for Medicare & Medicaid Innovation (CMMI) awarded a $12 
million Health Care Innovation Award to Y-USA, recognizing the YMCA'S 
Diabetes Prevention Program's success and cost-effectiveness. Under the 
grant, Y-USA will deliver its Diabetes Prevention Program to 10,000 
adults age 65+ with prediabetes in 17 communities across the Nation, 
with an estimated cost savings to Medicare of $4.2 million over 3 years 
and $53 million over 6 years.
What $20 Million in Federal Funding Will Provide
    Providing $20 million in Federal funding for the National DPP in 
fiscal year 2014 is a good investment for the Nation. It will:
  --Put the program on track to reach 250,000 people with prediabetes;
  --Establish five business outreach coalitions to engage and educate 
        employers and insurers on the return on investment for offering 
        proven lifestyle interventions for type 2 diabetes to high risk 
        individuals.
  --Support the provision of training nationally for individuals who 
        will deliver the lifestyle intervention in community and 
        clinical settings and worksites, and to develop a web-based 
        learning center.
  --Maintain the CDC's Recognition Program for the NDPP, which provides 
        an imprimatur ensuring the quality, consistency, and integrity 
        of the lifestyle intervention.
  --Support a national awareness campaign to expand the adoption and 
        impact of the National DPP.
    According to the Urban Institute, rolling out evidence-based 
diabetes prevention programs nationally through the National DPP could 
save the Nation $191 billion over the next decade--with 75 percent of 
savings going to Medicare and Medicaid.\13\
    The National DPP is without question a good investment for the 79 
million Americans with prediabetes and for our country. In closing, the 
DAA urges you to include $20 million in funding for the National DPP in 
the fiscal year 2014 Labor, Health & Human Services, Education and 
Related Agencies (LHHS) appropriations bill to bring this program to 
scale nationally for the 79 million Americans with prediabetes in the 
U.S. who are on a relentless march toward diabetes without 
intervention.
---------------------------------------------------------------------------
    \1\ CDC National Diabetes Factsheet 2011. Available at CDC website: 
http://www.cdc.gov/
diabetes/pubs/factsheet11.htm. Accessed April 15, 2013.
    \2\ Geiss LS, James C, Gregg EW et al. Diabetes Risk Reduction 
Behaviors among US Adults with Prediabetes. American Journal of 
Preventive Medicine. 2010. 38(4):403-409.
    \3\ CDC National Diabetes Factsheet 2011. Available at CDC website: 
http://www.cdc.gov/
diabetes/pubs/factsheet11.htm. Accessed April 15, 2013.
    \4\ Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. 
Projection of the Year 2050 Burden of Diabetes in the US Adult 
Population: Dynamic Modeling of Incidence, Mortality and Prediabetes 
Prevalence. Population Health Metrics. 8(29), October 2010.
    \5\ Imperatore G et al. Projections of Type 1 and Type 2 Diabetes 
in the US Population Aged < 20 Years Through 2050. Diabetes Care. 
35(12), December 2012.
    \6\ CDC National Diabetes Factsheet 2011. Available at CDC website: 
http://www.cdc.gov/
diabetes/pubs/factsheet11.htm. Accessed April 15, 2013.
    \7\ American Diabetes Association. Diabetes: A National Epidemic, 
January 2008. Available at: http://house.gov/degette/diabetes/docs/
Diabetes%20A%20National%20Epidemic.fs.08.pdf. Accessed April 15, 2013.
    \8\ Franco OH, Steyerberg EW, Hu FB et al. Associations of Diabetes 
Mellitus with Total Life Expectancy and Life Expectancy with and 
without Cardiovascular Disease. Archives of Internal Medicine. 
2007;167:1145-51.
    \9\ American Diabetes Association. Economic Costs of Diabetes in 
the US in 2012. Published online before print. Diabetes Care. March 6, 
2013.
    \10\ Diabetes Prevention Program Research Group. Reduction in the 
Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. 
New England Journal of Medicine. 346(6): 393-403, 2002.
    \11\ Diabetes Prevention Program Research Group. 10-Year Follow Up 
of Diabetes Incidence and Weight Loss in the DPPOS. Lancet. 
2009;374(9702): 1677-1686 and Ackermann RT, Finch EA, Brizendine e, 
Zhou H, Marrero DG. Translating the DPP into the Community: The DEPLOY 
Pilot Study. American Journal of Preventive Medicine. 2008;35(4): 357-
63.
    \12\ Herman WH et al. Effectiveness and Cost Effectiveness of 
Diabetes Prevention among Adherent Participants. American Journal of 
Managed Care. 2013;19(3):194-202.
    \13\ Berenson RA et al. Urban Institute. How Can We Pay for Health 
Care Reform? July 2009.
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                                 ______
                                 
     Prepared Statement of the Digestive Disease National Coalition

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

    1)  $32 billion for the National Institutes of Health (NIH) at an 
increase of $1 billion over fiscal year 2012. Increase funding for the 
National Cancer Institute (NCI), the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK) and the National Institute of 
Allergy and Infectious Diseases (NIAID) by 12 percent.
    2)  Continue focus on Digestive Disease Research and Education at 
NIH, including Inflammatory Bowel Disease (IBD), Hepatitis and Other 
Liver Diseases, Irritable Bowel Syndrome (IBS), Colorectal Cancer, 
Endoscopic Research, Pancreatic Cancer, and Celiac Disease.
    3)  $50 million for the Centers for Disease Control and 
Prevention's (CDC) Hepatitis Prevention and Control Activities.
    4)  $50 million for the Center for Disease Control and Prevention's 
(CDC) Colorectal Cancerscreening and Prevention Program.
_______________________________________________________________________

    Chairman Harkin, thank you for the opportunity to again submit 
testimony to the subcommittee. Founded in 1978, the Digestive Disease 
National Coalition (DDNC) is a voluntary health organization comprised 
of 33 professional societies and patient organizations concerned with 
the many diseases of the digestive tract. The DDNC promotes a strong 
Federal investment in digestive disease research, patient care, disease 
prevention, and public awareness. The DDNC is a broad coalition of 
groups representing disorders such as Inflammatory Bowel Disease (IBD), 
Hepatitis and other liver diseases, Irritable Bowel Syndrome (IBS), 
Pancreatic Cancer, Ulcers, Pediatric and Adult Gastroesophageal Reflux 
Disease, Colorectal Cancer, and Celiac Disease.
    The social and economic impact of digestive disease is enormous and 
difficult to grasp. Digestive disorders afflict approximately 65 
million Americans. This results in 50 million visits to physicians, 
over 10 million hospitalizations, collectively 230 million days of 
restricted activity. The total cost associated with digestive diseases 
has been conservatively estimated at $60 billion a year.
    The DDNC would like to thank the subcommittee for its past support 
of digestive disease research and prevention programs at the National 
Institutes of Health (NIH) and the Centers for Disease Control and 
Prevention (CDC).
    Specifically the DDNC recommends:
  --32 billion for the NIH.
  --$2.16 billion for the National Institute of Diabetes and Digestive 
        and Kidney Disease (NIDDK).
    We at the DDNC respectfully request that any increase for NIH does 
not come at the expense of other Public Health Service agencies. With 
the competing and the challenging budgetary constraints the 
subcommittee currently operates under, the DDNC would like to highlight 
the research being accomplished by NIDDK which warrants the increase 
for NIH.

                       INFLAMMATORY BOWEL DISEASE

    In the United States today about one million people suffer from 
Crohn's disease and ulcerative colitis, collectively known as 
Inflammatory Bowel Disease (IBD). These are serious diseases that 
affect the gastrointestinal tract causing bleeding, diarrhea, abdominal 
pain, and fever. Complications arising from IBD can include anemia, 
ulcers of the skin, eye disease, colon cancer, liver disease, 
arthritis, and osteoporosis. The cause of IBD is still unknown, but 
research has led to great breakthroughs in therapy.
    In recent years researchers have made significant progress in the 
fight against IBD. The DDNC encourages the subcommittee to continue its 
support of IBD research at NIDDK and NIAID at a level commensurate with 
the overall increase for each institute. The DDNC would like to applaud 
the NIDDK for its strong commitment to IBD research through the 
Inflammatory Bowel Disease Genetics Research Consortium. The DDNC urges 
the Consortium to continue its work in IBD research. Therefore the DDNC 
and its member organization the Crohn's and Colitis Foundation of 
America encourage the CDC to continue to support a nationwide IBD 
surveillance and epidemiological program in fiscal year 2014.

              VIRAL HEPATITIS: A LOOMING THREAT TO HEALTH

    The DDNC applauds all the work NIH and CDC have accomplished over 
the past year in the areas of hepatitis and liver disease. The DDNC 
urges that funding be focused on expanding the capability of State 
health departments, particularly to enhance resources available to the 
hepatitis State coordinators. The DDNC also urges that CDC increase the 
number of cooperative agreements with coalition partners to develop and 
distribute health education, communication, and training materials 
about prevention, diagnosis and medical management for viral hepatitis.
    The DDNC supports $50 million for the CDC's Hepatitis Prevention 
and Control activities. The hepatitis division at CDC supports the 
hepatitis C prevention strategy and other cooperative nationwide 
activities aimed at prevention and awareness of hepatitis A, B, and C. 
The DDNC also urges the CDC's leadership and support for the National 
Viral Hepatitis Roundtable to establish a comprehensive approach among 
all stakeholders for viral hepatitis prevention, education, strategic 
coordination, and advocacy.

                      COLORECTAL CANCER PREVENTION

    Colorectal cancer is the third most commonly diagnosed cancer for 
both men and woman in the United States and the second leading cause of 
cancer-related deaths. Colorectal cancer affects men and women equally.
    The DDNC recommends a funding level of $50 million for the CDC's 
Colorectal Cancer Screening and Prevention Program. This important 
program supports enhanced colorectal screening and public awareness 
activities throughout the United States. The DDNC also supports the 
continued development of the CDC-supported National Colorectal Cancer 
Roundtable, which provides a forum among organizations concerned with 
colorectal cancer to develop and implement consistent prevention, 
screening, and awareness strategies.

                           PANCREATIC CANCER

    In 2013, an estimated 33,730 people in the United States will be 
found to have pancreatic cancer and approximately 32,300 died from the 
disease. Pancreatic cancer is the fifth leading cause of cancer death 
in men and women. Only lout of 4 patients will live 1 year after the 
cancer is found and only l out of 25 will survive five or more years.
    The National Cancer Institute (NCI) has established a Pancreatic 
Cancer Progress Review Group charged with developing a detailed 
research agenda for the disease. The DDNC encourages the subcommittee 
to provide an increase for pancreatic cancer research at a level 
commensurate with the overall percentage increase for NCI and NIDDK.

                     IRRITABLE BOWEL SYNDROME (IBS)

    IBS is a disorder that affects an estimated 35 million Americans. 
The medical community has been slow in recognizing IBS as a legitimate 
disease and the burden of illness associated with it. Patients often 
see several doctors before they are given an accurate diagnosis. Once a 
diagnosis of IBS is made, medical treatment is limited because the 
medical community still does not understand the pathophysiology of the 
underlying conditions.
    Living with IBS is a challenge, patients face a life of learning to 
manage a chronic illness that is accompanied by pain and unrelenting 
gastrointestinal symptoms. Trying to learn how to manage the symptoms 
is not easy. There is a loss of spontaneity when symptoms may intrude 
at any time. IBS is an unpredictable disease. A patient can wake up in 
the morning feeling fine and within a short time encounter abdominal 
cramping to the point of being doubled over in pain and unable to 
function.
    Mr. Chairman, much more can still be done to address the needs of 
the nearly 35 million Americans suffering from irritable bowel syndrome 
and other functional gastrointestinal disorders. The DDNC recommends 
that NIDDK increase its research portfolio on Functional 
Gastrointestinal Disorders and Motility Disorders.

                      DIGESTIVE DISEASE COMMISSION

    In 1976, Congress enacted Public Law 94-562, which created a 
National Commission on Digestive Diseases. The Commission was charged 
with assessing the state of digestive diseases in the U.S., identifying 
areas in which improvement in the management of digestive diseases can 
be accomplished and to create a long-range plan to recommend resources 
to effectively deal with such diseases.
    The DDNC recognizes the creation of the National Commission on 
Digestive Diseases, and looks forward to working with the National 
Commission to address the numerous digestive disorders that remain in 
today's diverse population.

                               CONCLUSION

    The DDNC understands the challenging budgetary constraints and 
times we live in that this subcommittee is operating under, yet we hope 
you will carefully consider the tremendous benefits to be gained by 
supporting a strong research and education program at NIH and CDC. 
Millions of Americans are pinning their hopes for a better life, or 
even life itself, on digestive disease research conducted through the 
National Institutes of Health. Mr. Chairman, on behalf of the millions 
of digestive disease sufferers, we appreciate your consideration of the 
views of the Digestive Disease National Coalition. We look forward to 
working with you and your staff.
                                 ______
                                 
     Prepared Statement of the Dystonia Medical Research Foundation

            SUMMARY OF RECOMMENDATIONS FOR FISCAL YEAR 2014
_______________________________________________________________________

    1)  $32 billion for the National Institutes of Health (NIH) and 
proportional increases across its institutes and centers.
    2)  Continue to support the Dystonia Coalition Within the Rare 
Disease Clinical Research Network (RDCRN) coordinated by the Office of 
Rare Diseases Research (ORDR) in the National Center for Advancing 
Translational Sciences (NCATS).
    3)  Expand dystonia research supported by NIH through the National 
Institute on Neurological Disorders and Stroke (NINDS), the National 
Institute on Deafness and Other Communication Disorders (NIDCD) and the 
National Eye Institute (NEI).
_______________________________________________________________________

    Dystonia is a neurological movement disorder characterized by 
involuntary muscle spasms that cause the body to twist, repetitively 
jerk, and sustain postural deformities. Focal dystonia affects specific 
parts of the body, while generalized dystonia affects multiple parts of 
the body at the same time. Some forms of dystonia are genetic but 
dystonia can also be caused by injury or illness. Although dystonia is 
a chronic and progressive disease, it does not impact cognition, 
intelligence, or shorten a person's life span. Conservative estimates 
indicate that between 300,000 and 500,000 individuals suffer from some 
form of dystonia in North America alone. Dystonia does not 
discriminate, affecting all demographic groups. There is no known cure 
for dystonia and treatment options remain limited.
    Although little is known regarding the causes and onset of 
dystonia, two therapies have been developed that have demonstrated a 
great benefit to patients and have been particularly useful to 
controlling patient symptoms. Botulinum toxin (e.g., Botox, Xeomin, 
Disport and Myobloc) injections and deep brain stimulation have shown 
varying degrees of success alleviating dystonia symptoms. Until a cure 
is discovered, the development of management therapies such as these 
remains vital, and more research is needed to fully understand the 
onset and progression of the disease in order to better treat patients.
      dystonia research at the national institutes of health (nih)
    Currently, dystonia research supported by NIH is conducted through 
the National Institute of Neurological Disorders and Stroke (NINDS), 
the National Institute on Deafness and Other Communication Disorders 
(NIDCD), the National Eye Institute (NEI), and the Office of Rare 
Diseases Research (ORDR) within the National Center for Advancing 
Translational Sciences (NCATS).
    ORDR coordinates the Rare Disease Clinical Research Network (RDCRN) 
which provides support for studies on the natural history, 
epidemiology, diagnosis, and treatment of rare diseases. RDCRN includes 
the Dystonia Coalition, a partnership between researchers, patients, 
and patient advocacy groups to advance the pace of clinical research on 
cervical dystonia, blepharospasm, spasmodic dysphonia, craniofacial 
dystonia, and limb dystonia. The Dystonia Coalition has made tremendous 
progress in preparing the patient community for clinical trials as well 
as funding promising studies that hold great hope for advancing our 
understanding and capacity to treat primary focal dystonias. DAN urges 
the subcommittee to continue its support for the Dystonia Coalition, 
part of the Rare Disease Clinical Research Network coordinated by ORDR 
within NCATS.
    The majority of dystonia research at NIH is conducted through 
NINDS. NINDS has utilized a number of funding mechanisms in recent 
years to study the causes and mechanisms of dystonia. These grants 
cover a wide range of research including the genetics and genomics of 
dystonia, the development of animal models of primary and secondary 
dystonia, molecular and cellular studies in inherited forms of 
dystonia, epidemiology studies, and brain imaging. DAN urges the 
subcommittee to support NINDS in conducting and expanding critical 
research on dystonia.
    NIDCD and NEI also support research on dystonia. NIDCD has funded 
many studies on brainstem systems and their role in spasmodic 
dysphonia, or laryngeal dystonia. Spasmodic dysphonia is a form of 
focal dystonia which involves involuntary spasms of the vocal cords 
causing interruptions of speech and affecting voice quality. NEI 
focuses some of its resources on the study of blepharospasm. 
Blepharospasm is an abnormal, involuntary blinking of the eyelids which 
can render a patient legally blind due to a patient's inability to open 
their eyelids. DAN encourages partnerships between NINDS, NIDCD and NEI 
to further dystonia research.
    In summary, DAN recommends the following for fiscal year 2014:
  --$32 billion for NIH and a proportional increase for its Institutes 
        and Centers.
  --Support for the Dystonia Coalition within the Rare Diseases 
        Clinical Research Network coordinated by ORDR within NCATS.
  --Expansion of the dystonia research portfolio at NIH through NINDS, 
        NIDCD, NEI, and ORDR.

                     THE DYSTONIA ADVOCACY NETWORK

    The Dystonia Medical Research Foundation (DMRF) submits these 
comments on behalf of the Dystonia Advocacy Network (DAN), a 
collaborative network of five patient organizations: the Benign 
Essential Blepharospasm Research Foundation, the Dystonia Medical 
Research Foundation, the National Spasmodic Dysphonia Association, the 
National Spasmodic Torticollis Association, and ST/Dystonia, Inc. DAN 
advocates for all persons affected by dystonia and supports a 
legislative agenda that meets the needs of the dystonia community.
    DMRF was founded over 33 years ago. Since its inception, the goals 
of DMRF have remained to advance research for more effective treatments 
of dystonia and ultimately find a cure; to promote awareness and 
education; and support the needs and well being of affected individuals 
and their families.
    Thank you for the opportunity to present the views of the dystonia 
community, we look forward to providing any additional information.
                                 ______
                                 
         Prepared Statement of the Eldercare Workforce Alliance

    Mr. Chairman, Ranking Member Moran, and members of the 
subcommittee: We are writing on behalf of the Eldercare Workforce 
Alliance (EWA), which is comprised of 28 national organizations united 
to address the immediate and future workforce crisis in caring for an 
aging America. As the subcommittee begins consideration of funding for 
programs in fiscal year 2014, the Alliance \1\ urges you to provide 
adequate funding for programs designed to increase the number of health 
care professionals prepared to care for America's growing senior 
population and to support family caregivers in the essential role they 
play in this regard.
    Today's health care workforce is inadequate to meet the special 
needs of older Americans, many of whom have multiple chronic physical 
and mental health conditions and cognitive impairments. It is estimated 
that an additional 3.5 million trained health care workers will be 
needed by 2030 just to maintain the current level of access and 
quality. Without a national commitment to expand training and 
educational opportunities, the workforce will be even more constrained 
in its ability to care for the growth in the elderly population as the 
baby boom generation ages. Reflecting this urgency, the Health 
Resources and Services Administration (HRSA) has identified ``enhancing 
geriatric/elder care training and expertise'' as one of its top five 
priorities.
    Of equal importance is supporting the legions of family caregivers 
who annually provide billions of hours of uncompensated care that 
allows older adults to remain in their homes and communities. The 
estimated economic value of family caregivers' unpaid care was 
approximately $450 billion in 2009.
    The number of Americans over age 65 is expected to reach 70 million 
by 2030, representing a 71 percent increase from today's 41 million 
older adults. That is why Title VII and Title VIII geriatrics programs 
and Administration on Aging (AoA) programs that support family 
caregivers are so critical to ensure that there is a skilled eldercare 
workforce and knowledgeable, well-supported family caregivers available 
to meet the complex and unique needs of older adults.
    We hope you will support a total of $47.4 million in funding for 
geriatrics programs in Title VII and Title VIII of the Public Health 
Service Act and $173 million in funding for programs administered by 
the Administration on Aging that support the vital role of family 
caregivers in providing care for older adults. Specifically, we 
recommend the following levels:
  --$42.4 million for Title VII Geriatrics Health Professions Programs;
  --$5 million for Title VIII Comprehensive Geriatric Education 
        Programs; and
  --$173 million for Family Caregiver Support Programs.
    Geriatrics health profession training programs are integral to 
ensuring that America's healthcare workforce is prepared to care for 
the Nation's rapidly expanding population of older adults. In light of 
current fiscal constraints, EWA specifically requests $47.4 million in 
funding for the following programs administered through the Health 
Resources and Services Administration (HRSA) under Title VII and VIII 
of the Public Health Service Act.

Title VII: Geriatrics Health Professions
Appropriations Request: $42.4 Million

    Title VII Geriatrics Health Professions programs are the only 
Federal programs that seek to increase the number of faculty with 
geriatrics expertise in a variety of disciplines. These programs offer 
critically important training for the healthcare workforce overall to 
improve the quality of care for America's elders.
  --Geriatric Academic Career Awards (GACA).--The goal of this program 
        is to promote the development of academic clinician educators 
        in geriatrics. Program Accomplishments: In the Academic Year 
        2011-2012, the GACA program funded 66 full-time junior faculty. 
        These awardees delivered over 1,000 interprofessional 
        continuing education courses specific to geriatric-related 
        topics to over 44,000 students and providers. Collectively, 
        awardees of the program provided a total of 32,000 hours of 
        instruction through continuing education courses. Additionally, 
        they provided 4,700 clinical trainings to providers of many 
        professions and disciplines throughout the academic year. HRSA, 
        through the Affordable Care Act (ACA), expanded the awards to 
        be available to more disciplines. EWA strongly supports this 
        expansion and requests adequate funding to make it possible. 
        Currently, new awardees are selected only every 5 years. To 
        meet the need for clinician educators in all disciplines, EWA 
        believes that awards should be made available to clinical 
        educators annually in order to develop adequate numbers of 
        faculty to provide geriatric instruction and training. EWA's 
        fiscal year 2014 request of $5.5 million will support current 
        GAC Awardees in their development as clinician educators.
  --Geriatric Education Centers (GEC).--The goal of Geriatric Education 
        Centers is to provide high quality interprofessional geriatric 
        education and training to current members of the health 
        professions workforce, including geriatrics specialists and 
        non-specialists. Program Accomplishments: In Academic Year 
        2011-2012, the 45 GEC grantees developed and provided over 
        4,100 continuing education and clinical training offerings to 
        nearly 80,000 health professionals, students, faculty, and 
        practitioners, significantly exceeding the program's 
        performance target. Three quarters of the continuing education 
        offerings were interprofessional in focus. Of the sites that 
        offered clinical training sessions, almost 75 percent of these 
        sites were in a medically underserved community and/or Health 
        Professional Shortage Area. The GECs provide much needed 
        education and training. As part of the ACA, Congress authorized 
        a supplemental grant award program that will train additional 
        faculty through a mini-fellowship program. The program provides 
        training to family caregivers and direct care workers. Our 
        funding request of $22.7 million includes support for the core 
        work of 45 GECs and $2.7 million for awards to 24 GECs that 
        would be funded to undertake the development of mini-
        fellowships under the supplemental grants program included in 
        ACA.
  --Alzheimer's Disease Prevention, Education, and Outreach Program 
        (GECs).--These funds, included in the President's fiscal year 
        2014 budget request, will allow HRSA to expand efforts to 
        provide training to healthcare providers on Alzheimer's disease 
        and related dementias, utilizing the already existing Geriatric 
        Education Centers (GECs). EWA Requests $5.3 million.
  --Geriatric Training Program for Physicians, Dentists, (GTPD) and 
        Behavioral and Mental Health Professions.--The goal of the GTPD 
        program is to increase the number and quality of clinical 
        faculty with geriatrics and cultural competence, including 
        retraining mid-career faculty in geriatrics. Program 
        Accomplishments: In Academic Year 2011-2012, a total of 63 
        physicians--including psychiatrists-, dentists, and 
        psychologists, were supported through this fellowship program. 
        During that year alone, fellows provided geriatric care to 
        older adults on 23,358 occasions. This program supports 
        training additional faculty in medicine, dentistry, and 
        behavioral and mental health so that they have the expertise, 
        skills, and knowledge to teach geriatrics and gerontology to 
        the next generation of health professionals in their 
        disciplines. EWA's funding request of $8.9 million will support 
        12 institutions to continue this important faculty development 
        program.

Title VIII Geriatrics Nursing Workforce Development Programs
Appropriations Request: $5 million

    Title VIII programs, administered by the HRSA, are the primary 
source of Federal funding for advanced education nursing, workforce 
diversity, nursing faculty loan programs, nurse education, practice and 
retention, comprehensive geriatric education, loan repayment, and 
scholarship.
  --Comprehensive Geriatric Education Program.--The goal of this 
        program is to provide quality geriatric education and training 
        to individuals caring for the elderly. Program Accomplishments: 
        In Academic Year 2011-2012, a total of 18 Comprehensive 
        Geriatric Education Program (CGEP) grantees provided a variety 
        of services, including over 1,700 hours of instruction to over 
        8,200 trainees. Topics included geriatric training for direct 
        care providers, palliative and end-of-life care, and health 
        care and older adults. This program supports additional 
        training for nurses who care for the elderly; development and 
        dissemination of curricula relating to geriatric care; training 
        of faculty in geriatrics; and continuing education for nurses 
        practicing in geriatrics.
  --Traineeships for Advanced Practice Nurses.--Through the ACA, the 
        Comprehensive Geriatric Education Program is being expanded to 
        include advanced practice nurses who are pursuing long-term 
        care, geropsychiatric nursing, or other nursing areas that 
        specialize in care of older adults. EWA's funding request of $5 
        million will support the education and training of individuals 
        who provide geriatric care.

Administration on Aging: Family Caregiver Support
Appropriations Request: $172.9 million

    These programs support caregivers, elders, and people with 
disabilities by providing critical respite care and other support 
services for family caregivers, training and recruitment of care 
workers and volunteers, information and outreach, counseling, and other 
supplemental services.
    Family Caregiver Support Services.--This program provides a range 
of support services to approximately 700,000 family and informal 
caregivers annually in States, including counseling, respite care, 
training, and assistance with locating services that assist family and 
informal caregivers in caring for their loved ones at home for as long 
as possible. EWA requests $154.5 million.
    Native American Caregiver Support.--This program provides a range 
of services to Native American caregivers, including information and 
outreach, access assistance, individual counseling, support groups and 
training, respite care and other supplemental services. EWA requests 
$6.4 million.
    Alzheimer's Disease Support Services.--One critical focus of this 
program is to support the family caregivers who provide countless hours 
of unpaid care, thereby enabling their family members with dementia to 
continue living in the community. Funds will go towards evidence-based 
interventions and expand the dementia-capable home and community-based 
services, enabling additional older adults to live in their residence 
of choice. EWA requests $9.5 million.
    Lifespan Respite Care.--This program funds grants to improve the 
quality of and access to respite care for family caregivers of children 
or adults of any age with special needs. EWA requests $2.5 million.
    On behalf of the members of the Eldercare Workforce Alliance, we 
commend you on your past support for geriatric workforce programs and 
ask that you join us in supporting the geriatrics workforce at this 
critical time--for all older Americans deserve quality care, now and in 
the future. Thank you for your consideration.
---------------------------------------------------------------------------
    \1\ The positions of the Eldercare Workforce Alliance reflect a 
consensus of 75 percent or more of its members. This testimony reflects 
the consensus of the Alliance and does not necessarily represent the 
position of individual Alliance member organizations.
---------------------------------------------------------------------------
                                 ______
                                 
              Prepared Statement of the Endocrine Society

    The Endocrine Society is pleased to submit the following testimony 
regarding fiscal year 2014 Federal appropriations for biomedical 
research, with an emphasis on appropriations for the National 
Institutes of Health (NIH). The Endocrine Society is the world's 
largest and most active professional organization of endocrinologists 
representing more than 16,000 members worldwide. Our organization is 
dedicated to promoting excellence in research, education, and clinical 
practice in the field of endocrinology. The Society's membership 
includes thousands of researchers who depend on Federal support for 
their careers and their scientific advances. The Endocrine Society 
recommends that NIH receive at least $32 billion in fiscal year 2014. 
This funding recommendation represents the minimum investment necessary 
to avoid further erosion of national research priorities and global 
preeminence, while allowing the NIH's budget to keep pace with 
biomedical inflation.
    A half century of sustained investment by the United States Federal 
Government in biomedical research has dramatically advanced the health 
and improved the lives of the American people. The NIH specifically has 
had a significant impact on the United States' global preeminence in 
research and fostered the development of a biomedical research 
enterprise that remains unrivaled throughout the world. However, the 
preeminence of the U.S. research enterprise is being tested due to 
consistently flat funding for Federal research agencies coupled with 
the increasing cost of conducting basic biomedical research. Meanwhile, 
emerging economies such as China and India continue to recognize the 
importance of investing in scientific research. China's R&D spending is 
expected to increase by 11.6 percent in the coming year while India's 
spending for R&D is expected to rise by nearly 12 percent, keeping pace 
with the past several years.\1\
    The societal benefits of biomedical research, from improvements in 
diabetes care to personalized genomics, include treatments, 
technologies, and cures that extend lifespan and improve quality of 
life. The foundation for these benefits is the NIH research grants that 
support the basic research done by scientists. Since 2004, the number 
of NIH research grants to scientists in the United States has been 
declining. Consequently, the likelihood of a scientist successfully 
being awarded a grant has dropped from 31.5 percent in 2000 to 17.6 
percent in 2012; this means that experienced scientists are 
increasingly spending time writing fruitless grant applications instead 
of applying their expertise to productive research. Meanwhile younger, 
highly skilled Ph.D. holders struggle to find a job in the United 
States that makes use of the unique skills generated during graduate 
education. The Chinese Government, in contrast, has created incentives 
to draw biomedical researchers to institutions in China.\2\ The 
potential loss of technical skills and knowledge generated by the 
investment of resources in training could reduce the long-term 
international competitiveness of the United States and result in 
innovative new biomedical therapeutics being developed in other 
countries.
    The United States cannot afford to fall further behind while the 
rising burden of chronic disease (now at 75 percent of total healthcare 
expenditure) places a tremendous strain on the national economy. Nearly 
half of all Americans have a chronic medical condition, and these 
diseases now cause more than half of all deaths worldwide. Deaths 
attributed to chronic conditions could reach 36 million by 2015 if the 
trend continues unabated. In order to prevent and treat these diseases, 
and save the country billions in healthcare costs, significant 
investment in biomedical research will be needed. The national cost of 
diabetes in 2012 is estimated at $245 billion,\3\ while the cost of 
obesity has been estimated at $147 billion; \4\ many Endocrine Society 
members study these diseases and stand ready to conduct valuable 
research to improve care and reduce the financial burden of disease. To 
do so, however, they require funding from the NIH.
    Besides improving healthcare delivery and reducing costs, basic 
biomedical research represents a source of new wealth for the Nation 
and jobs for its citizens. The translation of new knowledge into 
innovative products can be shown by the frequency in which patents are 
granted to University researchers. Data compiled by the Association of 
University Technology Managers (AUTM) shows that academic research 
institutions were issued 4,700 patents in 2011. These patents can then 
be used to form the intellectual property foundation for a startup, or 
licensed to a large company to generate future revenue streams from the 
patented technology. In 2011, AUTM reported 4899 university 
technologies were licensed to companies, demonstrating the potential 
economic value of the products of federally-funded basic research to 
private companies. Basic research at academic universities and research 
institutions, funded in part by NIH, generated 617 startup companies 
and 591 new commercial products in 2011 alone. AUTM also reported $36 
billion in net product sales generated from university-initiated 
companies, while recent startups reported supporting nearly 25,000 
jobs. From 1996 to 2007, a ``moderately conservative estimate'' yields 
a total contribution to GDP for this period of more than $82 billion 
\5\ from university technologies.
    Because the financial risks associated with basic biomedical 
research projects are high, and the economic realization of an 
investment in biomedical research could take years to decades, private 
sector businesses are unlikely to make the financial commitments 
necessary to support basic biomedical research. The private sector, in 
fact, ``cannot appropriate the benefits such research generates, 
particularly at the early, basic stages of the research process''.\6\ 
Consequently, the private sector investment in basic science represents 
only 20 percent of the total national investment. While the private 
sector investment in applied research and development is much greater, 
basic research represents the crucial first step in the process of 
developing an innovative biomedical product. Indeed, Congress has 
acknowledged the critical and unique role of the Government in funding 
basic research to realize the unique and powerful economic benefits to 
society.\7\
    The past year alone has seen astonishing medical breakthroughs from 
NIH funded research, such as advances in HIV prevention and genomic 
characterization of cancer cells. Endocrinologists have made 
discoveries on the link between birth order and diabetes risk, the 
generational effects of BPA exposure, and the relationship between a 
mother's vitamin D levels and infant health. A member of The Endocrine 
Society, Robert Lefkowitz, was one of two recipients of the 2012 Nobel 
Prize in Chemistry for his work on hormone receptors. The NIH has 
exciting programs for the future, including a collaboration to develop 
``3-D human tissue chips containing bio-engineered tissue models that 
mimic human physiology . . .  to use these chips to better predict the 
safety and effectiveness of candidate drugs.'' \8\ Members of The 
Endocrine Society will continue to conduct important work, including 
research on the public health impact of chronic disease and endocrine-
disrupting chemicals. These projects, however, may not come to fruition 
if the current NIH budget, and the cut from sequestration, remain in 
place.
    The direct effects of the cut to the NIH and NSF budgets from 
sequestration are now just beginning to manifest after 2 months. 
Stories are emerging about how sequestration will delay, or stop 
entirely, research projects critical to our understanding of disease 
and prevention. Endocrine Society member Rebecca Riggins, Ph.D., has 
been forced to delay indefinitely an analysis of tumor samples to 
investigate why certain types of breast cancer respond differently to 
treatment with Tamoxifen.\9\ Sequestration is also forcing universities 
such as Vanderbilt University and the University of Florida, who stand 
to lose millions in Federal research dollars, to reduce the number of 
graduate students accepted into Ph.D. programs for the upcoming 
academic year.\10\ \11\ Stories such as these will become more common 
unless the Federal Government acts to prioritize the national 
investment in basic research in fiscal year 2014.
    The Endocrine Society remains deeply concerned about the future of 
biomedical research in the United States without sustained support from 
the Federal Government. Flat funding in recent years, combined with the 
impact of sequestration, threaten the Nation's scientific enterprise 
and make the fiscal year 2014 appropriations for agencies that fund 
science increasingly important. The Society strongly supports increased 
Federal funding for biomedical research in order to provide the 
additional resources needed to enable American scientists to address 
scientific opportunities and maintain the country's status of the 
preeminent research enterprise. The Endocrine Society therefore 
recommends that NIH receive at least $32 billion in fiscal year 2014.
---------------------------------------------------------------------------
    \1\ ``Global R&D Funding Forecast 2013.'' Battelle.
    \2\ ``Building a World-Class Innovative Therapeutic Biologics 
Industry in China''--China Association of Enterprises with Foreign 
Investment R&D-based Pharmaceutical Association Committee, in 
coordination with The Biotechnology Industry Organization and the 
support of The Boston Consulting Group.
    \3\ ``Economic Costs of Diabetes in the U.S. in 2012''--American 
Diabetes Association.
    \4\ Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz, W. ``Annual 
medical spending attributable to obesity: Payer- and service-specific 
estimates.'' Health Affairs 2009; 28(5): w822-w831.
    \5\ ``The Economic Impact of Licensed Commercialized Inventions 
Originating in University Research, 1996-2007.'' Biotechnology Industry 
Organization, September 2009.
    \6\ ``An Economic Engine: NIH Research, Employment and the Future 
of the Medical Innovation Sector.'' United for Medical Research, May 
2011.
    \7\ ``The Pivotal Role of Government Investment in Basic Research--
Report by the U.S. Congress Joint Economic Committee.'' May 2010.
    \8\ http://www.ncats.nih.gov/research/reengineering/tissue-chip/
funding/funding.html (accessed March 12, 2013).
    \9\ Marder, J., ``Sequester Cuts to Science Slow Biomedical 
Research.'' PBS Newshour, Science Wednesday. April 3, 2013. http://
www.pbs.org/newshour/rundown/2013/04/sequester-cuts-to-science-puts-
medical-resarch-on-hold.html (Accessed April 25, 2013).
    \10\ Smith-Barrow, D., ``What Graduate Students Should Know About 
the Sequester.'' U.S. News, April 1, 2013. http://www.usnews.com/
education/best-graduate-schools/articles/2013/04/01/what-graduate-
students-should-know-about-the-sequester (Accessed April 24, 2013).
    \11\ Schweers, J., ``UF's flow of research dollars may slow to 
trickle.'' The Gainsville Sun, March 30, 2013. http://
www.gainesville.com/article/20130330/ARTICLES/130339981?p=1&tc=pg 
(Accessed April 25, 2013).
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                                 ______
                                 
        Prepared Statement of the Epilepsy Foundation of America

    Thank you, Chairman Harkin and Ranking Member Moran, for allowing 
me to testify on behalf of the more than 2.2 million Americans living 
with epilepsy and their families, including my own. Specifically, I 
want to express my support for continued funding for critical epilepsy 
public health programs at the Centers for Disease Control and 
Prevention (CDC) and the Health Resources and Services Administration 
(HRSA), as well as funding for epilepsy research at the National 
Institutes of Health.
    Epilepsy is the Nation's fourth most common neurological disorder, 
after migraine, stroke, and Alzheimer's disease; making it an important 
public health condition. Epilepsy is a complex spectrum of disorders--
sometimes called the epilepsies--that affects millions of people in a 
variety of ways and is characterized by unpredictable seizures that 
differ in type, cause, and severity. Yet living with epilepsy is about 
much more than just seizures. For people with epilepsy, the disorder is 
often defined in practical terms, such as challenges in school, 
uncertainties about social situations and employment, limitations on 
driving, and questions about independent living. Approximately 1 in 26 
people will develop epilepsy at some point in their lives, and the 
onset of epilepsy is highest in children and older adults.
    In October, 2012, the Epilepsy Foundation began a merger with the 
Epilepsy Therapy Project to create a unified organization driving 
education, awareness, support, and new therapies for people and 
families living with epilepsy. This merger became effective on January 
1st and brings together the mission and assets of both organizations, 
including www.epilepsy.com, the leading portal for people, caregivers, 
and professionals dealing with epilepsy; 47 affiliated Epilepsy 
Foundations around the country dedicated to providing free programs and 
services to people living with epilepsy and their loved ones; 
scientific, professional, and business advisory boards comprised of 
leading epilepsy physicians, health care professionals and researchers, 
industry professionals, and investors with experience in clinical care, 
as well as in the evaluation and commercialization of new therapies; a 
track record of identifying and supporting important new science, 
translational research programs, and the most promising new therapies; 
and the Epilepsy Pipeline Conference, a leading global forum organized 
in partnership with the Epilepsy Study Consortium that showcases the 
most exciting new drugs, devices, and therapies.
    The Epilepsy Foundation has long realized that epilepsy should be a 
priority for the Federal public health system, and that public health 
programs can help build safer communities, end stigma and 
discrimination associated with epilepsy, educate community leaders, and 
build awareness that benefits everyone with epilepsy and other chronic 
health conditions. Stigma surrounding epilepsy continues to fuel 
discrimination and isolates people with epilepsy from the mainstream of 
life. Among older children and adults, epilepsy remains a formidable 
barrier to educational opportunities, employment, and personal 
fulfillment. There is a continuing need to better understand the public 
health impact of the condition, promote initiatives that encourage 
self-management, and improve mental health. Meeting these needs will 
help create an environment in which people will feel free to disclose 
their epilepsy or seizures without fear of discrimination or reprisal.
    The Epilepsy Foundation was pleased to participate in the 2012 
Institute of Medicine report: Epilepsy Across the Spectrum: Promoting 
Health and Understanding. We believe that many of the 13 
recommendations from the report reinforce the need for public health 
programs that help people with epilepsy access the best care and the 
importance of a health care workforce that is educated about seizures 
and epilepsy.
    The CDC is the lead Federal agency for protecting the people's 
health and safety. It is responsible for providing credible information 
to enhance health decisions and for promoting health through strong 
partnerships. The 2012 Institute of Medicine report calls upon the CDC 
to continue and expand collaborative surveillance and data collection, 
and we strongly support this recommendation to improve epilepsy 
surveillance within the CDC. The report also calls on the CDC to work 
with the Epilepsy Foundation and its affiliates to enhance educational 
and community services for people with epilepsy.
    The CDC epilepsy program focuses on better understanding the 
epidemiology and impacts of epilepsy, developing and bringing 
interventions to the public that improve quality of life for people 
with epilepsy, and working with partners to change systems and 
environments to better support those living with this neurological 
condition. CDC collaborates with partners to improve public awareness 
and promote education and communication at local and national levels. 
Programs focus on law enforcement and emergency medical responders, 
school-based students and staff, seniors, unemployed and underemployed 
adults, and underserved minorities living with epilepsy.
    The Epilepsy Foundation strongly believes that not only should the 
CDC program maintain its current funding to continue the quality 
programs that help address care and eliminate stigma, but also that is 
should receive additional funding to fulfill the recommendations and 
the investment of the IOM report and take advantage of the research and 
guidance that the report provides.
    HRSA directs national health programs that improve the Nation's 
health by assuring equitable access to comprehensive quality health 
care for all. HRSA promotes a community-based system of services 
mandated for all children with special health care needs; supports 
programs that are designed to break down barriers to community living 
for people with disabilities; and provides primary health care to 
medically underserved people. The 2012 Institute of Medicine report 
also calls upon stakeholders like the Foundation and HRSA to identify 
needs and improve community services for underserved populations. We 
believe that Project Access is an important part of meeting that goal 
and fully support the work of HRSA to empower families in health 
decisionmaking, promote medical home models, support access to health 
care, increase early health care screenings, and facilitate transition 
for youth to improved healthy and independent lives.
    Project Access is a national effort which involves State agencies, 
physicians and other health care providers, families, schools, and 
community resources to implement demonstration projects in medically 
underserved areas to improve health care outcomes and access for 
children with epilepsy. Demonstration projects have been conducted in 
California, Washington, D.C., Wisconsin, New Jersey, Mississippi, 
Illinois, West Virginia, Alaska, Nevada, Wyoming, Washington, New 
Hampshire, Maine, Florida, New York and Oregon. These projects not only 
serve needs of an important public health condition like epilepsy, but 
can serve as a model for other chronic health conditions and 
disabilities.
    The Epilepsy Foundation understands the financial constraints 
facing our Nation today. We encourage Congress to continue funding for 
critical epilepsy public health programs at the Centers for Disease 
Control and Prevention and the Health Resources and Services 
Administration. We also urge Congress to not abandon research 
initiatives that have been partially funded at the National Institutes 
of Health, and to support funding for a cure and better treatments for 
epilepsy.
    Thank you for your consideration of this critical issue.
                                 ______
                                 
    Prepared Statement of the Federation of American Societies for 
                          Experimental Biology

    The Federation of American Societies for Experimental Biology 
(FASEB) respectfully requests a fiscal year 2014 appropriation of no 
less than $32 billion for the National Institutes of Health (NIH) to 
prevent further erosion of the Nation's capacity for biomedical 
research and provide funding for additional grantees.
    As a federation of 26 scientific societies, FASEB represents more 
than 100,000 life scientists and engineers, making it the largest 
coalition of biomedical research associations in the United States. 
FASEB's mission is to advance health and welfare by promoting progress 
and education in biological and biomedical sciences, including the 
research funded by NIH, through service to its member societies and 
collaborative advocacy. FASEB enhances the ability of scientists and 
engineers to improve--through their research--the health, well-being, 
and productivity of all people.
    Research funded by the National Institutes of Health (NIH) has 
produced an outstanding legacy, and American leadership in biomedical 
research has made us the envy of the world. Eighty-five percent of NIH 
funds are distributed through competitive grants to more than 300,000 
scientists who work at universities, medical schools, and other 
research institutions in nearly every congressional district in the 
United States. NIH researchers developed the first screening test that 
reduced mortality from lung cancer, sponsored clinical trials to 
significantly reduce transmission of Human Immunodeficiency Virus from 
mother to child, uncovered the precise cause of more than 4,500 rare 
diseases, and completed a ten-year diet and exercise study showing how 
we can reduce the incidence of type 2 diabetes among high-risk people 
by more than 30 percent. Many of these advances arose from 
investigations designed to explain basic molecular, cellular, and 
biological mechanisms.
    More recently, NIH has supported research that led to breakthroughs 
in:
  --Preventing Colon Cancer Deaths.--A study funded primarily by the 
        National Cancer Institute found that removing polyps (abnormal 
        growths) during colonoscopy can not only prevent colorectal 
        cancer, but also reduce the chance of death from the disease by 
        53 percent. Colorectal cancer is one of the most common cancers 
        in both men and women nationwide and colonoscopies can detect 
        early-stage cancer before symptoms develop, allowing doctors to 
        remove any polyps. Early detection is important because 
        treatments are more likely to succeed if the disease is caught 
        before it takes hold. This study provides strong evidence of 
        the long-term benefit of removing polyps and supports continued 
        screening for colorectal cancer in individuals over age 50.
  --Offering New Hope For Children With An Immunodeficiency Disorder.--
        Researchers supported by the National Human Genome Research 
        Institute and the National Heart, Lung and Blood Institute 
        discovered that gene therapy can safely restore immune function 
        in children with severe combined immunodeficiency (SCID), a 
        disorder that leaves patients susceptible to a wide range of 
        infections because they cannot produce healthy white blood 
        cells. Most children with SCID die by the age of two if left 
        untreated. Previously available treatments relied on expensive 
        enzyme replacement injections that had to be continued 
        throughout the child's life. A clinical trial found that gene 
        therapy using the patient's own stem cells and low-dose 
        chemotherapy was effective in eliminating the need for enzyme 
        replacement therapy and leading to long-term improved health. A 
        second phase of the trial is now underway.
  --Repurposing Older Drugs to Treat Alzheimer's.--Bexarotene, a drug 
        that has been available for 10 years to treat skin cancer, 
        rapidly reduced beta-amyloid levels in the brains of mice of 
        all ages and shrank amyloid deposits known as plaques in most 
        age groups. Abnormally high levels of beta-amyloid have been 
        found in the brains of individuals with the most common, late-
        onset form of Alzheimer's disease. This NIH-funded study also 
        found that Bexarotene restored cognition and memory in mice and 
        improved the animals' ability to sense and respond to odors. 
        Loss of smell is often a first symptom of Alzheimer's in 
        humans.

Sustained Funding is Critical in Order to Capitalize on New Scientific 
        Opportunities
    The broad program of research supported by NIH is essential for 
advancing our understanding of basic biological functions, reducing 
human suffering, and protecting the country against new and re-emerging 
disease threats. Biomedical research is also a primary source of new 
innovations in health care and other areas.
    Exciting new NIH initiatives are poised to accelerate our progress 
in the search for cures. It would be tragic if we could not capitalize 
on the many opportunities before us. The development of a universal 
vaccine to protect adults and children against both seasonal and 
pandemic flu and development of gene chips and DNA sequencing 
technologies that can predict risk for high blood pressure, kidney 
disease, diabetes, and obesity are just a few of the research 
breakthroughs that will be delayed if we fail to sustain the investment 
in NIH.
    As a result of our prior investment, we are the world leader in 
biomedical research. We should not abdicate our competitive edge. 
Without adequate funding, NIH will have to sacrifice valuable lines of 
research. The termination of ongoing studies and the diminished 
availability of grant support will result in the closure of 
laboratories and the loss of highly skilled jobs. At a time when we are 
trying to encourage more students to pursue science and engineering 
studies, talented young scientists are being driven from science by the 
disruption of their training and lack of career opportunities.
    Rising costs of research, the increasing complexity of the 
scientific enterprise, and a loss of purchasing power at NIH due to 
flat budgets have made it increasingly competitive for individual 
investigators to obtain funding. In addition, the $1.6 billion in cuts 
to NIH due to the sequestration mandated by the Budget Control act will 
exacerbate the current challenges facing the research community. Today, 
only one in six grant applications will be supported, the lowest rate 
in NIH history. Increasing the NIH budget to $32.0 billion would 
provide the agency with an additional $1.360 billion which could 
restore funding for R01 grants (multi-year awards to investigators for 
specified projects) back to the level achieved in 2003 and support an 
additional 1,700 researchers while still providing much needed 
financial support for other critical areas of the NIH portfolio.

Federal Investment in Research is Essential to Drive Innovation in the 
        Private Sector
    The Federal Government has a unique role in supporting research. 
Scientists and engineers in every State are hard at work creating the 
knowledge that will improve health, energy independence, agricultural 
productivity, and provide the foundation for new industries.\1\ No 
other public, corporate or charitable entity is willing or able to 
provide broad and sustained funding for cutting edge science and 
engineering that will yield new innovations and technologies of the 
future. This is particularly critical for basic research, which is the 
source of profound and paradigm-shifting discoveries. While we are 
certain such discoveries will be made, there are no sign-posts for 
where and when the next major breakthrough will occur. The breadth of 
investment required has become too daunting for most of the commercial 
companies that develop new products from findings from investments in 
fundamental research, to say nothing of those enterprises yet to be 
created.
    To prevent further erosion of the Nation's capacity for biomedical 
research, FASEB recommends an appropriation of no less than $32.0 
billion for NIH in fiscal year 2014 to ensure the stability of the 
research enterprise and provide funding for additional grantees.
---------------------------------------------------------------------------
    \1\ www.faseb.org/NIHfactsheets
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                                 ______
                                 
 Prepared Statement of the Friends of the National Institute of Child 
                      Health and Human Development

    My name is Kathryn Schubert. I currently serve as Chair of the 
Friends of the National Institute of Child Health and Human Development 
(NICHD). On behalf of the Friends, I urge the Labor, Health and Human 
Services, Education Appropriations Subcommittee to support at least $32 
billion for the NIH, including $1.37 billion for NICHD for fiscal year 
2014. Our coalition includes over 100 organizations representing 
scientists, physicians, health care providers, patients and parents 
concerned with the health and welfare of women, children, families, and 
people with disabilities. We are pleased to support the extraordinary 
work of the Eunice Kennedy Shriver National Institute of Child Health 
and Human Development (NICHD).
    Since its establishment in 1963, NICHD has achieved great success 
in meeting the objectives of its broad biomedical and behavioral 
research mission, which includes research on child development before 
and after birth; maternal, child, and family health; learning and 
language development; reproductive biology and population issues; and 
medical rehabilitation. With sufficient resources, NICHD could build 
upon the promising initiatives described in this testimony and produce 
new insights into human development and solutions to health and 
developmental problems throughout the world, including families in your 
districts. Scientific breakthroughs supported by NICHD serve to prevent 
and treat many of the Nation's most devastating health problems 
including infant mortality and low birthweight, birth defects, 
intellectual and developmental disabilities, and the reproductive and 
gynecologic health of women throughout their lifespan, among others. 
Some of these are described below.
    Preterm Birth.--NICHD supports a comprehensive research program to 
study the causes of preterm birth and prevention strategies and 
treatment regimens. Pre-term birth costs our Nation $26 billion 
annually and is a leading cause of infant mortality and intellectual 
and physical disabilities. Continued prioritization of extramural 
preterm birth prevention research, the Maternal-Fetal Medicine Units 
Network, the Neonatal Research Network and intramural research program 
related to prematurity are necessary to further this work. Resources 
also should be available to support transdisiplinary science as 
recommended in NICHD's Scientific Vision to study and identify the 
complex causes of preterm birth.
    Newborn Screening.--Millions of babies in the U.S. are routinely 
screened for conditions that can affect a child's long-term health or 
survival each year. Early detection, diagnosis, and intervention can 
prevent death or disability. NICHD's newborn screening program aims to 
identify additional conditions to screen for, develop and test better 
ways to screen for conditions, study treatments and ways to improve 
outcomes, and sponsor research and training programs related to newborn 
screening. These initiatives are accelerating research in diseases 
related to newborn screening and greatly improving the process by which 
public health decisions are made.
    National Children's Study (NCS).--The NCS is the largest and most 
comprehensive study of children's health and development ever planned 
in the United States. We thank the Committee for funding the NCS 
through the NIH Office of the Director and urge funding at the current 
level, which will allow for a science-based study design and 
recruitment strategy for roll-out of the main study. When fully 
implemented, the NCS will follow a representative sample of 100,000 
children from across the U.S. from before birth until age 21, and data 
generated will inform the work of scientists in universities and 
research organizations, helping them identify precursors to disease and 
to develop new strategies for prevention and treatment.
    Brain Development.--Research on learning disabilities--neurological 
disorders that can make it difficult to acquire certain academic and 
social skills--shows that they can be prevented through effective 
evidence-based programs in school and that when children improve their 
reading and math skills, brain function normalizes.
    Behavioral Research.--We support and commend the advances NICHD has 
made in examining normative child development and the critical impact 
of stress in altering a child's developmental trajectories. Recent 
discoveries show that chronic stress from a number of factors including 
poverty, exposure to violence, child maltreatment and neglect and 
ethnic minority status may all hamper a child's potential to optimize 
their social and emotional development and academic achievement. 
Sufficient resources could go toward longitudinal research that is 
needed to understand the long-term impact of stress on mental health 
outcomes, cognitive, emotional and social development, including self-
control, inhibitory response, executive functioning, attention, memory 
and learning skills and how those variables impact later adolescent 
health behaviors, childhood obesity and academic achievement.
    Contraceptive Research and Development.--NICHD's leadership in 
ensuring acceptability and effective use of existing products in 
various settings and populations and in addressing behavioral issues 
related to fertility and contraceptive use will lead to opportunities 
and priorities in the future, including evaluation of the safety and 
effectiveness of hormonal contraceptive options for women who are 
overweight or obese. NICHD contraceptive development is critical for 
producing new contraceptive modalities that offer couples options with 
fewer side-effects and address women's concerns about contraceptive 
use. Opportunities in contraceptive development include the need for 
non-hormonal contraception, peri-coital contraception and multipurpose 
prevention technologies that would prevent both pregnancy and sexually 
transmitted infections.
    Reproductive Sciences.--NICHD's research in developing innovative 
medical therapies and technologies have improved existing treatment 
options for gynecological conditions affecting overall health and 
fertility. Future work could focus on serious conditions that have been 
overlooked and underfunded although they impact many women, such as 
infertility research into the need for treatments for disorders such as 
endometriosis, polycystic ovarian syndrome (PCOS) and uterine fibroids 
which can prevent couples from achieving desired pregnancies.
    Pelvic Floor Disorders Network (PFDN).--Female pelvic floor 
disorders (PFD) represent an under-appreciated but major public health 
burden with high prevalence, impaired quality of life and substantial 
economic costs affecting approximately 25 percent of American women. 
The PFDN is conducting research to improve treatment of these extremely 
painful gynecological conditions. Current research is aimed at 
improving female urinary incontinence outcome measures and ensuring 
high quality patient-centered outcomes.
    Development of the Research Workforce.--NICHD's Women's 
Reproductive Health Research (WRHR) Program and Reproductive Scientist 
Development Program (RSDP), both aimed at obstetrician-gynecologists to 
further their education and experience in basic, translational, and 
clinical research or for those studying cellular and/molecular biology 
and genetics and related fundamental sciences provide training grants 
to hundreds of researchers and providing new insight into a host of 
diseases, such as ovarian cancer. Continued investment in medical 
research is critical to making major scientific advances. Studies show 
that overall levels of research funding influence career choice, making 
these investments even more important.
    Sudden Unexpected Infant Death (SUID) and Stillbirth.--SUID and 
stillbirth result in the loss of more than 30,000 babies annually. 
Unsafe infant sleep environments are the major cause of SUID/SIDS 
deaths for babies between 1 month and 1 year of age and are largely 
preventable through educational outreach. We support prioritization of 
the Institute's newly expanded ``Safe to Sleep'' Campaign and continued 
research to discern the physiological basis of vulnerability to SIDS. 
Opportunities for research into late term unexplained losses and 
prioritization of prevention related to stillbirth risk factors and 
indicators such as maternal obesity and fetal growth restriction could 
be taken by convening an Interagency Consensus Group on Stillbirth to 
discuss the State of Science.
    Eosinophil-Associated Disorders.--These disorders can cause 
painful, debilitating conditions in children, many of whom are unable 
to eat normal food due to severe reactions. The NIH Task Force on the 
Research Needs of Eosinophil-Associated Diseases issued a report 
earlier this year highlighting the need for studies to improve the 
diagnosis and treatment of these incurable diseases, in which NICHD can 
play a leading role.
    Children's Cardiomyopathy.--Cardiomyopathy is a chronic disease of 
the heart muscle, which can be hard to detect or misdiagnosed with 
tragic outcomes in children. In some cases, sudden cardiac arrest is 
the first symptom of the disease. NICHD has an opportunity to 
understand the genetic and environmental causes and to explore drugs 
specific to children, and to generate public awareness materials.
    Best Pharmaceuticals for Children Act (BPCA).--NICHD funds 
meaningful research into pediatric pharmacology and we urge its 
continued funding for this along with training the next generation of 
pediatric clinical investigators. With NICHD's leadership, NIH should 
improve data collection and reporting related to the numbers of 
children who participate in NIH-funded trials. Age reporting is 
currently insufficient to determine if children are appropriately 
represented in trials pertaining to child health.
    Population Research.--The NICHD Population Dynamics branch supports 
a diverse portfolio of scientific research and research training 
programs, exploring the social, economic and health-related impacts of 
population change on families, children, and communities. The branch is 
well respected for investing wisely in the development of longitudinal, 
representative surveys, providing scientists with reliable data that 
can be used to examine the influence of early life course events on 
long-term health and achievement outcomes in particular. As an example, 
in 2012, NICHD-supported demographers using data from the Panel Study 
of Income Dynamics survey found that growing up in poor neighborhoods 
throughout the entire childhood life course can have a devastating 
effect on educational attainment. In another study, using data from the 
National Study of Adolescent Health, researchers found that women who 
are overweight or obese years during the transition from adolescence to 
adulthood are more likely to later deliver babies with a higher birth 
weight, putting the next generation at a higher risk of obesity-related 
health outcomes.
    These research efforts have made significant contributions to the 
well-being of all Americans, but there is still much to discover. We 
support the NICHD's recently released Scientific Vision and urge you to 
support NICHD at funding levels that meet current needs for addressing 
health issues across the lifespan. Thank you for your consideration and 
we look forward to working with you on these critical issues.
                                 ______
                                 
Prepared Statement of the Friends of the Health Resources and Services 
                             Administration

    The Friends of HRSA is a non-profit and non-partisan coalition of 
more than 175 national organizations dedicated to ensuring that our 
Nation's medically underserved populations have access to high-quality 
primary and preventive care. The coalition represents millions of 
public health and health care professionals, academicians and consumers 
invested in HRSA's mission to improve health and achieve health equity. 
We recommend funding of at least $7.0 billion for discretionary HRSA 
programs in fiscal year 2014.
    The recommended funding level takes into account the need to reduce 
the Nation's deficit while prioritizing the immediate and long-term 
health needs of Americans. We are deeply concerned with the failure to 
avert the sequester that will cut over $311 million from HRSA's fiscal 
year 2013 discretionary funding. These cuts come on top of the 17 
percent or more than $1.2 billion reduction to HRSA's budget authority 
since fiscal year 2010. HRSA's ability to prevent sickness, keep people 
healthy and treat illness or injury for millions of Americans will be 
severely compromised, by across-the-board cuts if the sequester is not 
reversed and the cuts restored. It is estimated that 7,400 fewer 
patients will have access to HRSA's AIDS Drug Assistance Program that 
provides life-saving HIV medications and about 25,000 fewer breast and 
cervical cancer screenings will be offered for poor, high-risk women, 
an important tool to reduce death rates, improve treatment options and 
greatly increase survival. Our recommended funding level is necessary 
to ensure HRSA is able to implement essential public health programs 
including training for public health and health care professionals, 
providing primary care services through health centers, improving 
access to care for rural communities, supporting maternal and child 
health care programs and providing health care to people living with 
HIV/AIDS.
    HRSA is a national leader in providing health services for 
individuals and families. HRSA's programs are carried out by about 
3,100 grantees in every State and U.S. territory, working to improve 
the health of people who are primarily low-income, medically vulnerable 
and geographically isolated through access to quality services and a 
skilled health care workforce. The agency operates about 80 different 
programs, working to serve roughly 55 million Americans who are 
uninsured and more than 60 million Americans who live in communities 
where primary health care services are scarce. In addition to 
delivering much needed services, the programs provide an important 
source of local employment and economic growth in many low-income 
communities.
    Our request is based on the need to continue improving the health 
of Americans by supporting critical HRSA programs including:
  --Health professions programs support the education and training of 
        primary care physicians, nurses, dentists, optometrists, 
        physician assistants, nurse practitioners, clinical nurse 
        specialists, public health personnel, mental and behavioral 
        health professionals, pharmacists and other allied health 
        providers. With a focus on primary care and training in 
        interdisciplinary, community-based settings, these are the only 
        Federal programs focused on filling the gaps in the supply of 
        health professionals, as well as improving the distribution and 
        diversity of the workforce so health professionals are well-
        equipped to care for the Nation's growing, aging and 
        increasingly diverse population. For example, HRSA offers loan 
        repayment and scholarships to nurses who work in areas 
        experiencing critical shortages of nurses. This investment has 
        increased the number of nurses working in communities with the 
        greatest need by three fold--from about 1,000 to 3,000--since 
        2008.
  --Primary care programs support nearly 8,900 community health centers 
        and clinics in every State and territory, improving access to 
        preventive and primary care to more than 20 million patients in 
        geographically isolated and economically distressed 
        communities. Close to half of the health centers serve rural 
        populations. The health centers coordinate a full spectrum of 
        health services including medical, dental, behavioral and 
        social services--often delivering the range of services in one 
        location. In addition, health centers target populations with 
        special needs, including migrant and seasonal farm workers, 
        homeless individuals and families and those living in public 
        housing.
  --Maternal and child health programs, including the Title V Maternal 
        and Child Health Block Grant, Healthy Start and others, support 
        a myriad of initiatives designed to promote optimal health, 
        reduce disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality health care for more 
        than 40 million women and children. Maternal and Child Health 
        Block Grants provide services to 6 out of every 10 women who 
        give birth and their infants. Since Title V was established in 
        1935, the infant mortality rate has declined nearly 90 percent 
        and contributed to a 51 percent decline in the U.S. child 
        fatality rate from unintentional injuries since 1987. Today, 
        MCH programs help assure that nearly 100 percent of babies born 
        in the U.S. are screened for a range of serious genetic or 
        metabolic diseases and that a community-based system of family 
        centered services is available for coordinated long-term follow 
        up for babies with a positive screen and for all children with 
        special health care needs.
  --HIV/AIDS programs provide the largest source of Federal 
        discretionary funding assistance to States and communities most 
        severely affected by HIV/AIDS. The Ryan White HIV/AIDS Program 
        delivers comprehensive care, prescription drug assistance and 
        support services for more than half a million low-income people 
        impacted by HIV/AIDS, which accounts for roughly half of the 
        total population living with the disease in the U.S. 
        Additionally, the programs provide education and training for 
        health professionals treating people with HIV/AIDS and work 
        toward addressing the disproportionate impact of HIV/AIDS on 
        racial and ethnic minorities.
  --Family planning Title X services ensure access to a broad range of 
        reproductive, sexual and related preventive health care for 
        over 5 million poor and low-income women, men and adolescents 
        at nearly 4,400 health centers nationwide. Health care services 
        include patient education and counseling, cervical and breast 
        cancer screening, sexually transmitted disease prevention 
        education, testing and referral, as well as pregnancy diagnosis 
        and counseling. This program helps improve maternal and child 
        health outcomes and promotes healthy families. Often, Title X 
        service sites provide the only continuing source of health care 
        and education for many individuals.
  --Rural health programs improve access to care for people living in 
        rural areas where there are a shortage of health care services. 
        The Office of Rural Health Policy serves as the Department of 
        Health and Human Services' primary voice for programs and 
        research on rural health issues. Rural Health Outreach and 
        Network Development Grants, Rural Health Research Centers, 
        Rural and Community Access to Emergency Devices Program and 
        other programs are designed to support community-based disease 
        prevention and health promotion projects, help rural hospitals 
        and clinics implement new technologies and strategies and build 
        health system capacity in rural and frontier areas.
  --Special programs include the Organ Procurement and Transplantation 
        Network, the National Marrow Donor Program, the C.W. Bill Young 
        Cell Transplantation Program and National Cord Blood Inventory. 
        These programs maintain and facilitate organ marrow and cord 
        blood donation, transplantation and research, along with 
        efforts to promote awareness and increase organ donation rates. 
        Over the past 20 years, 25,000 individuals have been given a 
        second chance at life from receiving blood cells, including 
        bone marrow, blood and cord blood, given by living donors 
        unrelated to their recipients.
    We urge you to consider HRSA's role in strengthening the Nation's 
health safety net programs and ensuring that vulnerable populations 
receive quality health services. By supporting, planning for and 
adapting to change within our health care system, we can build on the 
successes of the past and address new gaps that may emerge in the 
future. We advise that you to adopt our fiscal year 2014 request of 
$7.0 billion for discretionary HRSA programs to meet the public health 
needs and we thank you for the opportunity to submit our recommendation 
to the subcommittee.
                                 ______
                                 
 Prepared Statement of the Friends of the National Institute on Aging 
                                 (NIA)

    Senator Mikulski, Senator Cochran and members of the subcommittee, 
this testimony is being submitted on behalf of the Friends of the 
National Institute on Aging (FoNIA), a coalition of over 50 academic, 
patient-centered and not-for-profit organizations that conduct, fund or 
advocate for scientific endeavors to improve the health and quality of 
life for people as they age. We appreciate the opportunity to provide 
testimony in support of the National Institute on Aging (NIA) and to 
comment on the need for sustained, long-term growth in aging research. 
Considering the resources the Federal Government spends on the health 
care costs associated with age-related diseases, we feel it makes sound 
economic sense to increase Federal resources for aging research. 
Specifically, given the unique funding challenges facing the NIA, and 
the range of promising scientific opportunities in the field of aging 
research, the FoNIA recommends $1.4 billion in fiscal year 2014 for 
NIA. In addition, to ensure that progress in the Nation's biomedical, 
social, and behavioral research continues, the Coalition also endorses 
the Ad Hoc Group for Medical Research in supporting $32 billion for NIH 
in fiscal year 2014.
    The NIA leads the national scientific effort to understand the 
nature of aging in order to promote the health and well-being of older 
adults whose numbers are projected to increase dramatically in the 
coming years due to increased life expectancy and the aging of the baby 
boom generation. According to the U.S. Census Bureau, the number of 
people age 65 and older will more than double between 2010 and 2050 to 
88.5 million or 20 percent of the population; and those 85 and older 
will increase threefold, to 19 million. As the 65+ population 
increases, so will the prevalence of diseases disproportionately 
affecting older people--most notably, Alzheimer's disease (AD). NIA is 
the primary Federal agency responsible for (AD) research and receives 
nearly 70 percent of the NIH Alzheimer's disease research funding. Yet, 
we know that as many as 5 million Americans aged 65 years and older may 
have AD with a predicted increase to 13.2 million by 2050 (Hebert, 
Weuve, Scherr, et al, 2013). Last year, NIA led the AD Research Summit, 
which brought together officials representing Federal agencies, 
scientific researchers, providers, caregivers, patients and their 
families to develop final recommendations to the National Alzheimer's 
Project Act Advisory Council. NIA also supported research that 
identified relevant AD biomarkers through the groundbreaking 
Alzheimer's Disease Neuroimaging Initiative, along with a deeper 
understanding of the disease's pathology and clinical course. This led 
to the first revision of the clinical diagnostic criteria in AD in 27 
years. In a recent, highly promising pilot trial, a nasal-spray form of 
insulin delayed memory loss and preserved cognition in people with a 
range of cognitive deficits. A larger-scale study to confirm and extend 
these results is under development. NIA is making great strides, but 
the resources are inadequate given the explosion of people with AD that 
is predicted.
    NIA's current budget does not reflect the tremendous responsibility 
it has to meet the health research needs of a growing U.S. aging 
population. While the current dollars appropriated to NIA seem to have 
risen significantly since fiscal year 2003, when adjusted for 
inflation, they have decreased almost 18 percent in the last 9 years. 
According to the NIH Almanac, out of each dollar appropriated to NIH, 
only 3.6 cents goes toward supporting the work of the NIA-compared to 
16.5 cents to the National Cancer Institute, 14.6 cents to the National 
Institute of Allergy and Infectious Diseases, 10 cents to the National 
Heart, Lung and Blood Institute, and 6.3 cents to the National 
Institute of Diabetes and Digestive and Kidney Diseases. With an 
infusion of much needed support in fiscal year 2014, NIA can achieve 
greater parity with its NIH counterparts and expand promising, recent 
research activities, such as:
  --implementing new prevention and treatment clinical trials, research 
        training initiatives, care interventions, and genetic research 
        studies developed as part of the National Alzheimer's Action 
        Plan;
  --launching trans-NIH research initiatives developed by the NIH 
        Geroscience Interest Group to reduce the burden of age-related 
        disease;
  --understanding the impact of economic concerns on older adults by 
        examining work and retirement behavior, health and functional 
        ability, and policies that influence individual wellbeing;
  --supporting family caregivers by enhancing physician-family 
        communication during end-of-life and critical care; and,
  --increasing healthy lifespan in humans by testing and applying 
        evidence derived from animal models.
    NIA is poised to accelerate the scientific discoveries that we as a 
nation are counting on. With millions of Americans facing the loss of 
their functional abilities, their independence, and their lives to 
chronic diseases of aging, there is a pressing need for robust and 
sustained investment in the work of the NIA. In every community in 
America, healthcare providers depend upon NIA-funded discoveries to 
help their patients and caregivers lead healthier and more independent 
lives. In these same communities, parents are hoping NIA-funded 
discoveries will ensure that their children have a brighter future, 
free from the diseases and conditions of aging that plague our Nation 
today. Chronic diseases associated with aging afflict 80 percent of the 
age 65+ population and account for more than 75 percent of Medicare and 
other Federal health expenditures. Unprecedented increases in age-
related diseases as the population ages are one reason the 
Congressional Budget Office projects that total spending on healthcare 
will rise to 25 percent of the U.S. GDP by 2025--it is 17 percent of 
GDP today.
    Recent significant findings from NIA's Division of Biology Aging 
that could help advance understanding of a range of chronic diseases, 
include the discovery of the drug rapamycin, which has been shown to 
extend median lifespan in a mouse model. Grantees supported by this 
program have also identified genetic pathways that regulate the 
maintenance of the stem cell microenvironment in aging tissues.
    A signature project of the Behavioral and Social Science Research 
Division is the Health and Retirement Study (HRS), the Nation's leading 
source of combined data on health and financial circumstances of 
Americans over age 50. HRS data provide evidence about the effects of 
early-life exposures on later-life health, factors associated with 
cognitive and functional decline, and trends in retirement, savings, 
and other economic behaviors. The study is being replicated in 30 other 
countries. Last year, genetic data from approximately 13,000 
individuals were posted to NIH's online database, including 
approximately 2.5 million genetic markers from each person. These data 
are available for analysis by qualified researchers and will enhance 
the ability to track the onset and progression of diseases and 
conditions affecting the elderly.
    Research that can be translated quickly into effective prevention 
and efficient health care will reduce the burden of a ``Silver 
Tsunami'' of age-associated chronic diseases. Breakthroughs from NIA 
research can lead to treatments and public health interventions that 
could delay the onset of costly conditions such as arthritis, heart 
disease, stroke, diabetes, bone fractures, age-related blindness, 
Alzheimer's, ALS, and Parkinson's diseases. Such advances could save 
trillions of dollars by the middle of the current century.
    We do not yet have the knowledge needed to predict, preempt, and 
prevent the broad spectrum of diseases and conditions associated with 
aging. We do not yet have sufficient knowledge about disease processes 
to fully understand how best to prevent, diagnose, and treat diseases 
and conditions of aging, nor do we have the knowledge needed about the 
complex relationships among biology, genetics, and behavioral and 
social factors related to aging. We do not yet have a sufficient pool 
of new investigators entering the field of aging research. Bold, 
visionary, and sustainable investments in the NIA will make it possible 
to achieve substantial and measurable gains in these areas sooner 
rather than later, and perhaps too late.
    We recognize the tremendous fiscal challenges facing our Nation and 
that there are many worthy, pressing priorities to support. However, we 
believe a commitment to the Nation's aging population by making bold, 
wise investments in programs will benefit them and future generations. 
Investing in NIA is one of the smartest investments Congress can make.

                               REFERENCE

    Alzheimer disease in the U.S. (2010-2050) estimated using the 1990 
Census, Liesi E. Hebert, Jennifer Weuve, Paul A. Scherr, et al., 
Neurology; Published online before print February 6, 2013; 
WNL.0b013e31828726f5.

               FRIENDS OF THE NATIONAL INSTITUTE ON AGING

Alliance for Aging Research
Alzheimer's Association
Alzheimer's Foundation of America
American Academy of Dermatology
American Association for Geriatric Psychiatry
American Chronic Pain Association
American Federation for Aging Research
American Geriatrics Society
American Heart Association
American Pain Foundation
American Psychological Association
American Public Health Association
American Society for Bone and Mineral Research
American Society for Nutritional Sciences
American Society of Consultant Pharmacists
American Society of Hematology
American Society on Aging
Arthritis Foundation
Association of Jewish Aging Services
Association for Psychological Science
Association of Population Centers
B'nai B'rith International
BrightFocus Foundation
Brown Medical School
Consortium of Social Science Associations
Council on Social Work Education
Hospice Foundation of America
IEEE-USA
Institute for the Advancement of Social Work Research
National Association of Social Workers
National Council on the Aging
National Hispanic Council on Aging
International Cancer Advocacy Network (ICAN)
International Foundation for Anti-Cancer Drug Discovery
International Longevity Center--USA
Merck Institute of Aging and Health
National Alliance for Caregiving
National Association of Social Workers
National Council on the Aging
National Hispanic Council on Aging
National Hospice and Palliative Care Organization
National Vision Rehabilitation Association
Oral Health America
Parkinson's Action Network
Population Association of America
Society for Neuroscience
Society for Women's Health Research
Special Care Dentistry
The Ellison Medical Foundation
The Endocrine Society
The George Washington University Medical Center
The Gerontological Society of America
The North American Menopause Society
The Paget Foundation
The Simon Foundation for Continence
University of Pennsylvania Institute on Aging
University of Virginia
USAgainstAlzheimer's
      
                                 ______
                                 
  Prepared Statement of the Friends of the National Institute on Drug 
                                 Abuse

    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to submit testimony to the subcommittee in support of the 
National Institute on Drug Abuse. The Friends of the National Institute 
on Drug Abuse is a coalition of over 150 scientific and professional 
societies, patient groups, and other organizations committed to, 
preventing and treating substance use disorders as well as 
understanding their causes through the research agenda of the National 
Institute on Drug Abuse (NIDA). We are pleased to provide testimony in 
support of the work carried out by scholars around the country whose 
work is supported by NIDA.
    Recognizing that so many health research issues are inter-related, 
Friends of the National Institute on Drug Abuse (NIDA) requests that 
the subcommittee provide at least $32 billion for the National 
Institutes of Health (NIH). Because of the critical importance of drug 
abuse research for the health and economy of our Nation, we also 
request that you provide a proportionate increase for the National 
Institute on Drug Abuse in your Fiscal 2014 Labor, Health and Human 
Services, Education and Related Agencies Appropriations bill.
    Drug abuse is costly to Americans; it ruins lives, while tearing at 
the fabric of our society and taking a huge financial toll on our 
resources. Beyond the unacceptably high rates of morbidity and 
mortality, drug abuse is often implicated in family disintegration, 
loss of employment, failure in school, domestic violence, child abuse, 
and other crimes. Placing dollar figures on the problem; smoking, 
alcohol and illegal drug use results in an exorbitant economic cost on 
our Nation, estimated at over $600 billion annually. We know that many 
of these problems can be prevented entirely, and that the longer we can 
delay initiation of any use, the more successfully we mitigate future 
morbidity, mortality and economic burdens.
    Over the past three decades, NIDA-supported research has 
revolutionized our understanding of addiction as a chronic, often-
relapsing brain disease--this new knowledge has helped to correctly 
situate drug addiction as a serious public health issue that demands 
strategic solutions. By supporting research that reveals how drugs 
affect the brain and behavior and how multiple factors influence drug 
abuse and its consequences, scholars supported by NIDA continue to 
advance effective strategies to prevent people from ever using drugs 
and to treat them when they cannot stop.
    NIDA supports a comprehensive research portfolio that spans the 
continuum of basic neuroscience, behavior and genetics research through 
medications development and applied health services research and 
epidemiology. While supporting research on the positive effects of 
evidence-based prevention and treatment approaches, NIDA also 
recognizes the need to keep pace with emerging problems. We have seen 
encouraging trends--significant declines in a wide array of youth drug 
use--over the past several years that we think are due, at least in 
part, to NIDA's public education and awareness efforts. However, areas 
of significant concern, such as prescription drug abuse, remain and we 
support NIDA in its efforts to find successful approaches to these 
difficult problems.
    The Nation's previous investment in scientific research to further 
understand the effects of abused drugs on the body has increased our 
ability to prevent and treat addiction. As with other diseases, much 
more needs be done to improve prevention and treatment of these 
dangerous and costly diseases. Our knowledge of how drugs work in the 
brain, their health consequences, how to treat people already addicted, 
and what constitutes effective prevention strategies has increased 
dramatically due to support of this research. However, since the number 
of individuals continuing to be affected is still rising, we need to 
continue the work until this disease is both prevented and eliminated 
from society.
    We understand that the fiscal year 2014 budget cycle will involve 
setting priorities and accepting compromise, however, in the current 
climate we believe a focus on substance abuse and addiction, which 
according to the World Health Organization account for nearly 20 
percent of disabilities among 15-44 year olds, deserves to be 
prioritized accordingly. We look forward to working with you to make 
this a reality. Thank you for your support for the National Institute 
on Drug Abuse.
                                 ______
                                 
              Prepared Statement of the FSH Society, Inc.

    Honorable Chairwoman Mikulski and Ranking Member Harkin, thank you 
for the opportunity to submit this testimony. I am Daniel Paul Perez, 
of Bedford, Massachusetts, President and CEO of the FSH Society, Inc. 
and an individual who has lived with facioscapulohumeral muscular 
dystrophy (FSHD) for 51 years. For hundreds of thousands of men, women, 
and children worldwide the major consequence of inheriting this form of 
muscular dystrophy is a lifelong progressive loss of all skeletal 
muscles. FSHD is a crippling and life shortening disease. No one is 
immune. It is both genetically and spontaneously transmitted to 
children. It can affect multiple generations and entire family 
constellations.
    The National Institutes of Health (NIH) is the principal source of 
funding of research on Facioscapulohumeral Muscular Dystrophy (FSHD) 
currently at the $6 million level. Over many years, this Committee has 
supported the incremental growth in funding for FSHD research. I am 
pleased to report that this modest investment has produced huge 
scientific returns.

     1. CONGRESS HAS MADE A MAJOR DIFFERENCE IN MUSCULAR DYSTROPHY

    I have testified many times before Congress. When I first 
testified, we did not know the mechanism of this disease. Now we do. 
When I first testified, we assumed that FSHD was a rare form of 
muscular dystrophy. Now we understand it to be one of the most 
prevalent forms of muscular dystrophy. Congress is responsible for this 
success, through its sustaining support of the National Institutes of 
Health (NIH), and the enactment of the Muscular Dystrophy CARE Act. I 
am testifying in order to document this success and call on Congress to 
continue the momentum of discovery you have set in motion.
    Congress enacted The Muscular Dystrophy Community Assistance, 
Research and Education Amendments of 2001 (the MD-CARE Act, Public Law 
107-84) on December 18, 2001. It was reauthorized in 2008 and new 
efforts are underway to reauthorize the MD-CARE Act as it will expire 
in 2013. We are hopeful that this reauthorization bill will receive the 
same overwhelming bi-partisan support enjoyed in earlier enactments.

 2. QUANTUM LEAPS IN OUR UNDERSTANDING OF FSHD HAVE OCCURRED IN PAST 3 
                                 YEARS

    The past 3 years have seen remarkable contributions made by 
researchers funded by NIH.
  --On August 19, 2010, American and Dutch researchers published a 
        paper which dramatically expanded our understanding of the 
        mechanism of FSHD.\1\ A front page story in the New York Times 
        quoted the NIH Director Dr. Francis Collins saying, ``If we 
        were thinking of a collection of the genome's greatest hits, 
        this would go on the list.'' \2\
  --Two months later, another paper was published that made a second 
        critical advance in determining the cause of FSHD.\3\ The 
        research shows that FSHD is caused by the inefficient 
        suppression of a gene that may be normally expressed only in 
        early development.
  --On January 17, 2012, an international team of researchers based out 
        of Seattle discovered a gene called DUX4 required to develop 
        chromosome 4-linked FSHD.\4\
  --Six months later, another high profile paper produced by the NIH 
        funded University of Massachusetts Senator Paul D. Wellstone 
        Cooperative Research Center for FSHD, used sufficiently 
        ``powered'' large collections of genetically matched FSHD cell 
        lines generated by the NIH center that are both unique in scope 
        and shared with all researchers worldwide, to improve on the 
        Seattle group's finding by postulating that DUX4-fl expression 
        is necessary but not sufficient by itself for FSHD muscle 
        pathology.\5\ This work was also supported by a NIH cooperative 
        research center grant mandated by MD CARE Act.
  --On July 13, 2012, a team of international researchers from the, 
        United States, Netherlands and France identified mutations in a 
        gene causing 80 percent of another form of FSHD. This paper 
        furthers our understanding of the molecular pathophysiology of 
        FSHD. This work too was supported in part by a program project 
        grant from NIH.\6\
  --On April 4, 2013, an international team published a mouse model 
        that appears more promising than previous models of FSHD. The 
        result of a decade's worth of work, during which scientific 
        understanding of FSHD exploded. ``We hope that in the near 
        future these mouse models will serve an important purpose in 
        drug development programs for FSHD,'' remarked senior author 
        Silvere van der Maarel of Leiden University in the Netherlands. 
        The herculean project was initiated in 2003, by the FSH 
        Society's Marjorie Bronfman Fellowship grant. The patient-
        driven charity was seeking a definitive mouse model based on a 
        genetic unit called D4Z4. Normally, people have ten or more of 
        these units, repeated one after the other near the tip of 
        chromosome 4. The majority of FSHD patients, in contrast, have 
        fewer than ten D4Z4 units. The newly published mouse model 
        contains 2.5 copies of the D4Z4 unit, a truncated number 
        comparable to that seen in human FSHD patients. The D4Z4 unit 
        contains the gene called DUX4, which is toxic to muscle 
        cells.\7\ This work was also supported by NIH grants.
    I am proud to say that many of these researchers have started their 
efforts in FSHD with seed funding from the FSH Society and have 
received continued support from the FSH Society, the National 
Institutes of Health, and the Muscular Dystrophy Association and other 
partners. This shows the power of the collaboration among funders, 
patient groups and researchers to advance the search for cures and 
treatments.

  3. REMARKABLE PROGRESS IN FSHD RESEARCH AND THE NEED TO KEEP MOVING 
                                FORWARD

    Given the recent developments, there is a need to ramp up the 
preclinical enterprise and build/organize infrastructure needed to 
conduct clinical trials. Our immediate priorities should be to confirm 
the new hypotheses and targets. We need to be prepared for this new era 
in the science of FSHD, by accelerating efforts in the following five 
areas: \8\
    1. Genetics/epigenetics.--There is general acceptance that 
transcriptional deregulation of D4Z4 is central to FSHD1 and FSHD2. The 
FSHD2 gene SMCHD1 explains approximately 80 percent of FSHD2. There is 
a need for better understanding of the factors that modulate DUX4 
activity and disease penetrance.
    2. FSHD molecular networks.--D4Z4 chromatin relaxation on FSHD-
permissive chromosome-4 haplotypes leads to activation of downstream 
molecular networks. In addition to considering DUX4 as the ``target'' 
and downstream targets, the upstream processes and targets--triggering 
of activation--are equally important. Hence, understanding what DUX4lf 
does as a target and targets up- and down-stream of it are priorities. 
Detailed studies on these processes are crucial for insight in the 
molecular mechanisms of FSHD pathogenesis and may contribute to 
explaining the large intra- and interfamily clinical variability. 
Importantly such work may lead to intervention (possibly also 
prevention) targets. Additional FSHD genes and modifiers are still 
likely to exist. Apart from chromatin modifiers, these include, but are 
not limited to, CAPN3 and the FAT1 gene that was recently suggested to 
be involved in FSHD.
    3. Clinical trial readiness.--It is now broadly accepted that 
deregulation of the expression of D4Z4/DUX4 is at the heart of FSHD1 
and FSHD2. This finding opens perspectives for intervention along 
different avenues. Intervention trials are envisaged within the next 
several years. The FSHD field needs to be prepared for this crucial 
step. There is an increasing need to improve the translational process. 
This includes, but is not limited to, the need for consensus on data 
capture and storage, overcoming national and international barriers, 
definition of natural history, identification of (meaningful) and 
sensitive outcome measures, biomarkers, and meaningful functional 
measures. There is a need to work more closely with FDA to help define 
acceptable measures for trials.
    4. Model systems.--There was already a good set of cellular and 
models, based on different pathogenic (candidate gene) hypotheses. This 
was further expanded during the last year. The phenotypes are very 
diverse and often difficult to compare with the human FSHD phenotype. 
Many basic questions remain unanswered and dearly need to be answered 
for further translational studies: when and where is DUX4 expressed in 
skeletal muscle and what regulates DUX4 activity. It was recognized 
that there still exists a gap in our knowledge linking the basic 
genetic and molecular findings with the observed muscle pathology. The 
University of Massachusetts NIH Sen. Wellstone center and the 
University of Rochester continue to generate human cellular resources. 
These resources continuously deserve attention and need to be 
replenished. Recent progress in ES-cell technology, including iPS 
lines, allows for inter-group distribution and dedicated molecular 
(epi)genetic studies.
    5. Sharing.--Timely sharing of information and resources remains a 
critical contributor to the progress in the field. Sharing of resources 
other information remains a priority (e.g. protocols, guide to FSHD 
muscle pathology, etc.).
    We would be pleased to provide the Committee with detailed 
information on each of these areas. The pace of discovery and numbers 
of experts in the field of biological science and clinical medicine 
working on FSHD are rapidly expanding. Many leading experts are now 
turning to work on FSHD not only because it is one of the most 
complicated and challenging problems seen in science, but because it 
represents the potential for great discoveries, insights into stem 
cells and transcriptional processes and new ways of treating human 
disease.

                 4. NIH FUNDING FOR MUSCULAR DYSTROPHY

    Mr. Chairman, these major advances in scientific understanding and 
epidemiological surveillance are not free. They come at a cost. Since 
Congress passed the MD CARE Act, research funding at NIH for muscular 
dystrophy has increased 4-fold. While FSHD research funding has 
increased 12-fold during this period, the level of funding is still 
exceedingly modest.

                                  FSHD RESEARCH DOLLARS & FSHD AS A PERCENTAGE OF TOTAL NIH MUSCULAR DYSTROPHY FUNDING
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                   Fiscal Year--
                                                          ----------------------------------------------------------------------------------------------
                                                            2000    2001    2002    2003    2004    2005    2006    2007   2008  2009  2010  2011  2012e
--------------------------------------------------------------------------------------------------------------------------------------------------------
All MD ($ millions)......................................    12.6    21      27.6    39.1    38.7    39.5    39.9    47.2    56    83    86    75     75
FSHD ($ millions)........................................     0.4     0.5     1.3     1.5     2.2     2.0     1.7     3       3     5     6     6      6
FSHD (percent total MD)..................................     3       2       5       4       6       5       4       5       5     6     7     8      8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sources: NIH/OD Budget Office & NIH OCPL & NIH RCDC RePORT
(e = estimate; as fiscal year 2012 actuals not available on-line as of March 12, 2013)

    Despite the great success of the past two and a half years in the 
science of FSHD brought about by Congress we are concerned that the 
budget cuts required by the sequester are coming at a time when many of 
the FSHD research projects are ending. It is likely that new research 
projects will not be funded or existing programs will not be renewed. 
This is a perfect storm that could have devastating effects on FSHD 
research efforts. I served on the Federal advisory committee MDCC for 9 
years until 2011. We have conveyed to the Executive Secretary of the 
MDCC our grave concern that the current portfolio of research on FSHD 
has a disproportionate number of FSHD grants near the end or in the 
last year of their grant cycles. While most are competitively renewable 
this occurrence could not have happened at a worst time with 
sequestration making meat axe cuts across all Federal agencies.
    We request for fiscal year 2014, a doubling of the 
facioscapulohumeral muscular dystrophy (FSHD) research budget to $12 
million dollars. This will allow an expansion of the U.S. DHHS NIH 
Senator Paul D. Wellstone Muscular Dystrophy Cooperative Research 
Centers, an increase in research awards, expansion of post-doctoral and 
clinical training fellowships, and a dedicated center to design and 
conduct clinical trials on FSHD.
    We are aware of the great pressures on the Federal budget, but 
cutting the NIH budget and research funding for FSHD at this time would 
be the wrong decision. We have come so far with such modest funding. 
This is not the time to lessen our endeavor. This is the time to fully 
and expeditiously exploit the advances for which the American taxpayer 
has paid.
    Thank you for this opportunity to testify before your committee.
---------------------------------------------------------------------------
    \1\ Lemmers, RJ, et al, A Unifying Genetic Model for 
Facioscapulohumeral Muscular Dystrophy Science 24 September 2010: Vol. 
329 no. 5999 pp. 1650-1653.
    \2\ Kolata, G., Reanimated `Junk' DNA Is Found to Cause Disease. 
New York Times, Science. Published online: August 19, 2010 http://
www.nytimes.com/2010/08/20/science/20gene.html.
    \3\ Snider, L., Geng, L.N., Lemmers, R.J., Kyba, M., Ware, C.B., 
Nelson, A.M., Tawil, R., Filippova, G.N., van der Maarel, S.M., 
Tapscott, S.J., and Miller, D.G. (2010). Facioscapulohumeral dystrophy: 
incomplete suppression of a retrotransposed gene. PLoS Genet. 6, 
e1001181.
    \4\ Geng et al., DUX4 Activates Germline Genes, Retroelements, and 
Immune Mediators: Implications for Facioscapulohumeral Dystrophy, 
Developmental Cell (2012), doi:10.1016/j.devcel.2011.11.013.
    \5\ Jones TI, et al, Facioscapulohumeral muscular dystrophy family 
studies of DUX4 expression: evidence for disease modifiers and a 
quantitative model of pathogenesis. Hum Mol Genet. 2012 Oct 
15;21(20):4419-30. Epub 2012 Jul 13.
    \6\ Lemmers, RJ, et al, Digenic inheritance of an SMCHD1 mutation 
and an FSHD-permissive D4Z4 allele causes facioscapulohumeral muscular 
dystrophy type 2. Nat Genet. 2012 Dec;44(12):1370-4. doi: 10.1038/
ng.2454. Epub 2012 Nov 11.
    \7\ Krom YD, Thijssen PE, Young JM, den Hamer B, Balog J, et al. 
(2013) Intrinsic Epigenetic Regulation of the D4Z4 Macrosatellite 
Repeat in a Transgenic Mouse Model for FSHD. PLoS Genet 9(4): e1003415. 
doi:10.1371/journal.pgen.1003415.
    \8\ 2012 FSH Society FSHD International Research Consortium, held 
November 6, 2012 co-sponsored by DHHS NIH NICHD Boston Biomedical 
Research Institute Senator Paul D. Wellstone MD CRC for FSHD. To read 
the expanded summary and recommendations of the group see: http://
www.fshsociety.org/pages/sciConsortium.html.
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                                 ______
                                 
            Prepared Statement of the Girl Scouts of the USA

    As the preeminent leadership development organization for girls, 
Girl Scouts of the USA (Girl Scouts) serves over two million girls each 
year, ages 5 to 17, from every corner of the United States and its 
territories, with value placed on diversity and inclusiveness. We also 
serve nearly 17,000 American girls living outside of the United States 
in over 90 countries. Through our 112 councils, USA Girl Scouts 
Overseas, and more than 800,000 dedicated volunteers, we continue to 
deliver the Girl Scout Leadership Experience (GSLE)--the world's best 
and most comprehensive program for girls' leadership development.

                       BUILDING GIRLS' LEADERSHIP

    Girl Scout experiences through GSLE are, as much as possible, girl-
led and encourage hands-on and cooperative learning. The GSLE framework 
specifies 15 outcomes--behaviors, attitudes, skills, and values--that 
develop girls of courage, confidence, and character. We provide 
significant financial assistance to girls who cannot afford to join the 
Girl Scouts. In many communities, Girl Scouts is the single most 
visible and viable positive choice for these girls.
    Research shows that girl-only settings not only provide a sense of 
belonging, but are also more effective environments for personal 
development, learning new skills, and building self-confidence. In 
emotionally and physically safe environments like those provided by 
Girl Scouts, girls partner with positive role models in a range of 
activities not limited by gender stereotypes. Girl Scout programs also 
emphasize partnerships, public education campaigns, mentorship 
programs, career exploration, traditional badges, and innovative 
programming. By combining our girl-only learning environment, our 
unique national program, our unparalleled delivery infrastructure, and 
our proven expertise working with partners, we offer powerful learning 
experiences for girls across all sectors, including girls in 
traditionally underserved and underrepresented communities. And in so 
doing, we are preparing a generation of girls to take leadership roles 
in business, society, and our collective future.
    Women today are well educated but still underrepresented in high-
paying and leadership positions. They face many societal barriers to 
leading and achieving success in fields ranging from technology and 
science to business and industry. With this in mind, we need a bold 
policy shift so that girls are able to start building the skills they 
need so that they are better positioned to achieve their full 
leadership potential as women. Girl Scouts is eager to work with 
policymakers to create opportunities and environments that foster 
girls' leadership development.

                             PENSION RELIEF

    Under Department of Labor, General Provisions, Girl Scouts 
respectfully requests the insertion of the following language as our 
highest priority request:
          Sec. __. ELECTION NOT TO BE TREATED AS AN ELIGIBLE CHARITY 
        PLAN. A plan sponsor of an eligible charity plan (as defined in 
        subsection (d) of section 104 of the Pension Protection Act of 
        2006) may elect, effective for the first plan year beginning 
        after December 31, 2013, to have section 104 of such Act not 
        apply to such plan. In the case of such an election, solely for 
        plan years beginning after December 31, 2013, section 430(c) of 
        the Internal Revenue Code of 1986 and section 303(c) of the 
        Employee Retirement Income Security Act of 1974 shall apply as 
        if such sections had applied to the first two plan years 
        beginning after December 31, 2009, and as if the plan sponsor 
        had elected to apply section 430(c)(2)(D)(iii) of such Code and 
        section 303(c)(2)(D)(iii) of such Act with respect to those two 
        plan years.
    The proposed language, which would only affect eligible charities 
and thus should not have an associated cost, would modify the rule 
established by section 202(b) of the Preservation of Access to Care for 
Medicare Beneficiaries and Pension Relief Act of 2010, Public Law 111-
192. The effect of the proposed language is similar in effect to 
section 2 of H.R. 4915, as passed by the Senate in December of 2010, 
which also allowed a plan sponsor of an eligible charity plan not to 
have section 104 of the Pension Protection Act of 2006 apply.
    Girl Scouts of the USA, on behalf of the millions of girls we 
serve, respectfully requests this technical fix. The language simply 
says that, as of 2014, we, and all similarly structured charities, be 
permitted to elect in to the Pension Protection Act funding rules, 
which are the Federal pension rules applicable to corporate America.
    In addition to our request pertaining to pension relief, the 
following are the key policy priority areas where we can offer research 
and programmatic success stories:

                             STEM EDUCATION

    As the preeminent organization for girls and a leader on informal 
STEM education, Girl Scouts is committed to ensuring that every girl 
has the opportunity to explore and build an interest in science, 
technology, engineering, and mathematics. The strength of our Nation 
depends on increasing girls' involvement in STEM so that they can 
develop critical thinking, problem solving, and collaboration skills 
that will serve be important throughout their lives.
    In 2012, the Girl Scout Research Institute (GSRI) released 
Generation STEM: What Girls Say about Science, Technology, Engineering, 
and Math, which found that girls are interested in STEM subjects and 
aspire to STEM careers, but need further exposure and education about 
what STEM careers can offer and how STEM can help girls make a 
difference in the world.
    Among some of Generation STEM's other findings:
  --74 percent of teen girls are interested in STEM fields and STEM 
        subjects. Girls like the process of learning, asking questions, 
        and problem solving.
  --Girls who are interested in STEM are significantly better students 
        and have higher confidence in their abilities and higher 
        academic goals.
  --But while 81 percent say they are interested in pursuing a STEM 
        career, only 13 percent say it's their first choice. About half 
        of all girls feel that STEM isn't a typical career path for 
        girls. Fifty-seven percent of girls say that if they went into 
        a STEM career, they'd have to work harder than a man just to be 
        taken seriously.
  --African American and Hispanic girls have high interest in STEM, 
        high confidence, and a strong work ethic, but they also say 
        they have fewer supports and less STEM exposure than Caucasian 
        girls.
    As Congress considers consolidations and a redesign of existing 
Federal STEM programs, we urge you to focus more on engaging and 
motivating girls in STEM, in particular younger girls and girls in 
underrepresented communities. Strategies include introducing girls to 
diverse role models and mentors; promoting proven techniques for 
engaging girls in STEM, such as single-gender learning; and hands-on 
and experiential learning opportunities in after-school or out-of-
school environments.

                           FINANCIAL LITERACY

    The world's current economic challenges have made financial 
literacy matter now more than ever. Girl Scouts offers a financial 
literacy program at every grade level, K-12. Through our Girl Scout 
financial education programming, girls learn to handle money and the 
basics of budgeting, banking, saving, using credit, planning for 
retirement, and even practicing philanthropy.
    Additionally, the Girl Scout Cookie Program is often girls' first 
foray into business planning and entrepreneurship. The $790-million 
program is the largest girl-led business in the world.
    While lack of financial literacy is a growing concern, relatively 
little research has been conducted on how girls think about and 
experience money and finances. To address this gap, the Girl Scout 
Research Institute recently conducted a study, Having It All: Girls and 
Financial Literacy, with girls and their parents. It found that girls 
need and want financial literacy skills to help them achieve their 
dreams, with 90 percent saying it is important for them to learn how to 
manage money. However, just 12 percent of girls surveyed feel ``very 
confident'' about making financial decisions.
    To be successful and sustainable, financial education must begin 
early, be relevant, and continue throughout elementary and secondary 
education. And although 93 percent of the public believes all high 
school students should be required to take a class in financial 
education, only four States have made a semester-long course in 
financial literacy a graduation requirement.\1\ In addition to 
providing teachers with training and materials, we believe policy 
makers should increase support for critical after-school and community-
based programs so that girls have the opportunity to learn money-
management skills and have real-world financial literacy experiences 
that will serve them throughout their lives.

           HEALTHY LIVING--BULLYING AND RELATIONAL AGGRESSION

    As exemplified through our program experience and research, Girl 
Scouts understands the complex issue of healthy living and what 
motivates youth--especially girls--to adopt healthy lifestyles. 
Improving youths' physical health and emotional well-being are not 
mutually exclusive. Youth, especially girls, experience them in an 
interrelated fashion. Girls place the same or even greater emphasis on 
social and emotional health as physical health.
    The Girl Scout Research Institute's original research report, 
Feeling Safe: What Girls Say, found that nearly half (46 percent) of 
girls define safety as not having their feelings hurt, and 
approximately one-third of all girls worry about being teased, bullied, 
threatened, or having their feelings hurt when spending time with 
peers, participating in groups, and trying new things. Another GSRI 
report, The New Normal? What Girls Say About Healthy Living, tells us 
that a girl's relationships with her peers are critical components of 
her health and safety.
    Our BFF (Be a Friend First) curriculum is focused on middle-school 
girls and designed to easily integrate into existing health or 
character education classes. It can even serve as an after-school 
program in the community.
    The Department of Education has proposed a safe schools initiative 
that includes a positive school climate focus, and Girl Scouts supports 
this kind of effort, which embraces a holistic definition of health 
that addresses both the physical health and emotional wellness of 
youth. National youth-serving organizations such as Girl Scouts should 
be seen as vital partners for schools in developing relevant solutions, 
such as policies and programs that address relational aggression and 
building healthy relationships.

                                CLOSING

    We look forward to being a partner with Congress as you make 
difficult funding decisions in the areas of supporting healthy living, 
improving the financial education of our youth, and building a pipeline 
of girls and underrepresented minorities in STEM careers. Thank you, 
and please consider us a resource in these areas.
---------------------------------------------------------------------------
    \1\ Back to School Survey Shows Americans Want Personal Finance 
Taught in the Classroom, Visa, July 20, 2010.
---------------------------------------------------------------------------
                                 ______
                                 
     Prepared Statement of the Global Health Technologies Coalition

    Chairman Harkin, Ranking Member Moran, and Members of the 
Committee, thank you for the opportunity to provide testimony on the 
fiscal year 2014 appropriations funding for the National Institutes of 
Health (NIH) and the Centers for Disease Control and Prevention (CDC). 
We appreciate your leadership in promoting the importance of 
international development, in particular global health. We hope that 
your support will continue. I am submitting this testimony on behalf of 
the Global Health Technologies Coalition (GHTC), a group of over 25 
nonprofit organizations working together to promote the advancement of 
research and development (R&D) of new global health innovations--
including new vaccines, drugs, diagnostics, microbicides, and other 
tools--to combat global health diseases. The GHTC's members strongly 
believe that to meet the global health needs of tomorrow, it is 
critical to invest in research today so that the most effective health 
solutions are available when we need them. My testimony reflects the 
needs expressed by our member organizations which work with a wide 
variety of partners to develop new and more effective life-saving 
technologies for the world's most pressing health issues. We strongly 
urge the Committee to continue its established support for global 
health R&D by (1) sustaining and supporting the U.S. investment in 
global health research and product development by providing $32 billion 
for NIH, and providing robust funding for CDC, with $362.9 million for 
the CDC Center for Global Health, (2) requiring leaders at the National 
Institutes for Health, the Centers for Disease Control and Prevention, 
the Food and Drug Administration and the Secretariat of the U.S. 
Department of Health and Human Services to join leaders of other U.S. 
agencies to develop a five-year cross-Government strategy for global 
health research and product development, and to ensure that global 
health R&D is robust, efficient, coordinated, and streamlined, 3) 
instructing the NIH and CDC, in collaboration with other agencies 
involved in global health, to continue their commitment to global 
health in their R&D programs, and to document coordination efforts 
between agencies for the use of Congress and the public, and (3) to 
request that the newly-formed National Center for Advancing 
Translational Sciences (NCATS) expand its clinical trials mandate to 
include all stages of research.

Critical need for new global health tools
    Our Nation's investments have made historic strides in promoting 
better health around the world: nearly six million people living with 
HIV/AIDS now have access to life-saving medicines; new, cost-effective 
tools help us diagnose diseases quicker and more efficiently than ever 
before; and innovative new vaccines are making significant dents in 
childhood mortality. While we must increase access to these and other 
proven, existing health tools to tackle global health problems, it is 
just as critical that we continue to invest in developing the next 
generation of tools to stamp out disease and address current and 
emerging threats. For instance, newer, more robust, and easier to use 
antiretroviral drugs (ARV), particularly for infants and young 
children, are needed to treat and prevent HIV, and even an AIDS vaccine 
that is 50 percent effective has the potential to prevent one million 
HIV infections every year. Drug-resistant tuberculosis (TB) is on the 
rise globally, including in the United States, however the only vaccine 
on the market is insufficient at 90 years old, and most therapies are 
more than 50 years old, extremely toxic, and too expensive. New tools 
are also urgently needed to address fatal neglected tropical diseases 
(NTDs) such as sleeping sickness, for which diagnostic tools are 
inadequate and the few drugs available are toxic or difficult to use. 
There are many very promising technology candidates in the R&D pipeline 
to address these and other health issues; however, these tools will 
never be available if the support needed to continue R&D is not 
supported and sustained.

Research and U.S. global health efforts
    The United States is at the forefront of innovation in global 
health technologies. For example, in November 2010, the NIH announced 
the results of the iPrEx clinical trial, a large, multi-country 
research study examining pre-exposure prophylaxis (PrEP). The study 
found that a daily dose of two anti-retroviral drugs could provide an 
average of 44 percent additional protection to high-risk populations 
who also received a comprehensive package of HIV prevention services. 
Additional studies supported by the CDC and the University of 
Washington confirmed that a daily oral dose of ARV drugs used to treat 
HIV infection can reduce the risk of HIV acquisition among uninfected 
individuals by between 63 and 73 percent.
    The NIH is the largest funder of global health research in the U.S. 
Government, and the agency continues to demonstrate growing interest in 
global health issues, particularly in the area of translational 
research. NIH Director Francis Collins has made global health one of 
his top five priorities for the future of the NIH, and our coalition 
members have been pleased to see this implemented via the launch of a 
new Center for Global Health Studies at the Fogarty International 
Center, new initiatives on global health at the National Cancer 
Institute, ongoing exceptional work of the National Institute for 
Allergy and Infectious Diseases (NIAID), and the creation of the new 
National Center for Advancing Translational Sciences (NCATS). 
Additionally, the Model Non-Profit License Agreement for NTDs, HIV, TB, 
and Malaria Technologies was created for nonprofit institutions and 
PDPs with a demonstrated commitment to neglected diseases to apply for 
the use of patented inventions and non-patented biological materials 
from the NIH and the FDA intramural laboratories. Finally, NCATS 
recently began a pilot partnership between NCATS and private industry 
aimed at finding new cures and treatments using a library of compounds 
that already exist. Each of these efforts built on the historic work 
carried out by the agency which contributes to improved health around 
the world.
    With operations in more than 54 countries, the CDC is engaged in 
many global health research efforts. The work of CDC scientists has led 
to major advances against devastating diseases. Although the CDC is 
known for its expertise and participation in HIV, TB, and malaria 
programs, it also operates several activities for neglected diseases in 
its National Center for Zoonotic, Vector-Borne, and Enteric Diseases. 
The CDC's Center for Global Health employs 1,100 staff members, and has 
people on the ground in 55 countries.

Leveraging the private sector for innovation
    The NIH, CDC, and other U.S. agencies involved in global health R&D 
regularly collaborate with the private sector in developing, 
manufacturing, and introducing important technologies such as those 
described above through public-private partnerships, including product 
development partnerships. These partnerships leverage public-sector 
expertise in developing new tools, partnering with academia, large 
pharmaceutical companies, the biotechnology industry, and governments 
in developing countries to drive greater development of products for 
neglected diseases in which private industries have not historically 
invested. This unique model has generated sixteen new global health 
products and has enormous potential for continued success if robustly 
supported. NIH Director Francis Collins has stated that such 
partnership is key to the development of therapies and health tools 
based on NIH-funded research.

Innovation as a smart economic choice
    Global health R&D brings life-saving tools to those who need them 
most, however the benefits of these efforts bring are much broader than 
preventing and treating disease. Global health R&D is also a smart 
economic investment in the United States, where it drives job creation, 
spurs business activity, and benefits academic institutions. Biomedical 
research, including global health, is a $100 billion enterprise in the 
United States. Sixty-four cents out of every U.S. dollar invested in 
global health R&D goes directly to U.S.-based researchers. In a time of 
global financial uncertainty, it is important that the United States 
support industries, such as global health R&D, which build the economy 
at home and abroad.
    An investment made today can help save significant money in the 
future. The recently released meningitis A vaccine MenAfriVac is on 
course to save nearly $600 million in health care costs over the next 
decade. In addition, new therapies to treat drug-resistant tuberculosis 
have the potential to reduce the price of tuberculosis treatment by 90 
percent and cut health system costs significantly. The United States 
has made smart investments in research in the past that have resulted 
in lifesaving breakthroughs for global health diseases, as well as 
important advances in diseases endemic to the United States. We must 
now build on those investments to turn those discoveries into new 
vaccines, drugs, tests, and other tools.

Recommendations
    In this time of fiscal constraint, support for global health 
research that improves the lives of people around the world--while at 
the same time creating jobs and spurring economic growth at home--
should unquestionably be one of the Nation's highest priorities. In 
keeping with this value, the GHTC respectfully requests that the 
Committee do the following:
  --Sustain and support U.S. investment in global health research and 
        product development by fully funding NIH, CDC, and FDA to carry 
        out their work.
  --Require leaders at the National Institutes for Health, the Centers 
        for Disease Control and Prevention, the Food and Drug 
        Administration and the Secretariat of the U.S. Department of 
        Health and Human Services to join leaders of other U.S. 
        agencies to develop a five-year cross-Government strategy for 
        global health research and product development, and to ensure 
        that global health R&D is robust, efficient, coordinated, and 
        streamlined.
  --Instruct the NIH and CDC, in collaboration with other agencies 
        involved in global health, to continue their commitment to 
        global health within their R&D programs, and to request that 
        the newly-formed National Center for Advancing Translational 
        Sciences (NCATS) expand its clinical trials mandate to include 
        all stages of research.
  --Instruct the FDA to continue to elevate global health in its 
        mandate by creating an office of neglected diseases, building 
        stronger partnerships with global regulatory stakeholders, 
        ensuring that it can review health products for all neglected 
        diseases, taking steps to increase transparency by reporting to 
        Congress on its neglected disease activities, and strengthening 
        its internal capacity on global health.
    As a leader in science and technology, the United States has the 
ability to capitalize upon our strengths to help reduce illness and 
death and ultimately eliminate disabling and fatal diseases for people 
worldwide, contributing to a healthier world and a more stable global 
economy. Sustained investments in global health research to develop new 
drugs, vaccines, tests, and other health tools--combined with better 
access to existing methods to prevent and treat disease--present the 
United States with an opportunity to dramatically alter the course of 
global health while building political and economic security across the 
globe.
    On behalf of the members of the GHTC, I would like to extend my 
gratitude to the Committee for the opportunity to submit written 
testimony for the record.
                                 ______
                                 
    Prepared Statement of the Guillain-Barre Syndrome (GBS)/Chronic 
     Inflammatory Demyelinating Polyneuropathy (CIDP) Foundation, 
                             International

Fiscal Year 2014 Appropriations Recommendations:
  --For the National Institutes of Health, provide $32 billion in 
        fiscal year 2014, with proportional increases to the National 
        Institute of Neurological Disorders and Stroke, the National 
        Center for Advancing Translational Sciences, the National 
        Institutes of Allergy and Infectious Disease and the Office of 
        Rare Disease Research.
  --The Committee recommendation for the Centers for Disease Control 
        and Prevention to improve health outcomes for GBS and CIDP 
        patients by promoting enhanced awareness and recognition 
        activities in partnership with stakeholders.
  --The Committee's commendation of National Institute of Neurological 
        Disorders and Stroke research portfolio focused on disorders of 
        the nervous system and encouragement to pursue expanded 
        research focused on inflammatory disorders impacting the 
        peripheral nervous system such as Guillain--Barre Syndrome, 
        Chronic Inflammatory Demyelinating Polyneuropathy, and related 
        conditions.
  --The Committee's recommendation that the Office of Rare Diseases 
        Research initiate research activities in peripheral nervous 
        system disorders and express support for the National Center 
        for Advancing Translational Sciences to pursue a GBS indication 
        for current, off-label treatment options.
    Chairman Harkin, Ranking Member Moran and members of the 
subcommittee, thank you for providing me with the opportunity to submit 
written testimony to the Labor, Health and Human Services, Education 
and Related Agencies Appropriations Subcommittee on behalf of the 
Guillain-Barre Syndrome (GBS)/Chronic Inflammatory Demyelinating 
Polyneuropathy (CIDP) Foundation, International.
    As a non-profit, 501(c)(3) organization, the GBS/CIDP Foundation, 
International advocates for research into prevention, access to 
affordable treatments and high quality patient care. Inspired by his 
experience with GBS, Bob and Estelle Benson founded the GBS/CIDP 
Foundation, International. Starting as a small support group for 
patients with GBS in 1980, the first support group meeting consisted of 
eight people in the Benson's dining room.
    Over the past thirty years, the Foundation has expanded to over 
30,000 members in 33 countries, offering support and assistance to 
ensure that patients with GBS, CIDP and associated disease variants are 
provided with proper diagnosis, treatment and support. In line with the 
founding principles of the Bensons, the mission of the Foundation 
remains to improve the quality of life for individuals and families 
worldwide affected by GBS, CIDP and variants by:
  --Providing a network for all patients, their caregivers and families 
        so that GBS or CIDP patients can depend on the Foundation for 
        support, and reliable up-to-date information.
  --Providing public and professional educational programs worldwide 
        designed to heighten awareness and improve the understanding 
        and treatment of GBS, CIDP and variants.
  --Expanding the Foundation's role in sponsoring research and engaging 
        in patient advocacy.

Guillain-Barre Syndrome and Chronic Inflammatory Demyelinating 
        Polyneuropathy:
    GBS and CIDP are inflammatory, autoimmune disorders which affect 
the Peripheral Nervous System and the myelin insulation surrounding the 
sensory, motor or autonomic nerves. Patients with Guillain-Barre 
Syndrome experience a sudden onset of muscle weakness or paralysis over 
a few days, which presents through decreased reflexes in the arms and 
legs, low blood pressure and in severe cases, trouble breathing or 
swallowing. While the cause is unknown, nearly half of cases occur 
after the patient experiences a viral or bacterial infection. Given the 
sudden and unexpected onset of GBS, patients require swift and costly 
treatments with hospitalization. Patients undergo plasma exchange (PE) 
and physician administered intravenous immune globulins (IVIg), which 
lessen the severity of the acute phase and accelerate patient recovery. 
An estimated three thousand to six thousand Americans develop GBS each 
year.
    Chronic Inflammatory Demyelinating Polyneuropathy is the chronic 
form of GBS and patients with this disease experience a gradual onset 
which causes weakness and often a loss of reflexes. The associated 
disease variants describe the development of the disease which include 
``progressive,'' developing a several year development, ``recurrent,'' 
consisting of multiple active episodes or ``monophasic'', occurring in 
a single episode. The management of the disease requires systematic 
treatments with IVIg to ensure the best patient prognosis. Without 
proper diagnosis and treatment, the disease can progress and leave 
patients disabled. CIDP is extremely rare and occurs in one out of 
every 1.5 to 3 million Americans.
    For both GBS and CIDP, costly biologic treatments are necessary and 
the only medical option for the management and treatment of these 
chronic and life threatening conditions. Some private health insurance 
companies which offer prescription drug coverage, have created a 
``specialty'' or fourth tiered payment plan for high cost treatments 
like IVIg. Unlike other out of pocket requirements for traditional drug 
co-pays, which require patients to pay $10-$50, patients receiving 
drugs on this ``specialty'' tier are required to pay co-insurance for 
the treatment, sometimes up to 25-33 percent. For IVIg, this could over 
$2,500 for a single treatment.
    The high costs of these ``specialty'' tiers place a large financial 
burden on GBS and CIDP patients and their families, restrict patient 
access to medically necessary treatments and at times force patients to 
go without vital, prescription drugs. The promise of federally 
supported medical advancements at the National Institutes of Health, 
into more effective treatments and lower cost treatments and hopefully 
one day a cure, are important to the thousands of patients impacted by 
these diseases each year.

Federal Investment at NIH and CDC:
    The medical community has provided countless examples of the impact 
biomedical research has had on devastating and once terminal illnesses. 
Simple and small NIH grants from unknown, unestablished medical 
researchers have led to groundbreaking discoveries providing effective 
preventions and interventions, life-saving treatments and for some 
diseases, a cure. We cannot guarantee nor expect that if left to the 
private medical research and drug development sectors, these 
revolutionary developments would be made. Some disease like GBS, CIDP 
and the associated disease variants do not lend themselves to quick 
profit or a patient base large enough to bring about private 
investment. Some discoveries take the lifetime commitment of dedicated 
researchers that are not aimed at profits, but at people. Not aimed at 
fame, but of relieving human suffering.
    It's not only the reason why the National Institutes of Health was 
established, but also why the Federal investment in medical research is 
so highly respected and supported by the American public. The American 
people support the promise of what NIH discoveries can accomplish and 
the impact it could have on a mother or father with Alzheimer 's 
disease, wife or husband struck by GBS or child with cancer. And they 
are proud to the lead the world in medical innovation and the 
investment it brings about. But, as the funding our Nation provides for 
medical research fails to keep pace with opportunity, this leadership 
role could be slipping through our grasp.
    Reversing sequestration and the corresponding NIH cuts is 
imperative in our goal of maintaining the Nation's status as the leader 
of groundbreaking biomedical health discoveries. The GBS/CIDP 
Foundation supports a $32 billion request for fiscal year 2014 for the 
National Institutes of Health, with proportional increases to the 
National Institute of Neurological Disorders and Stroke (NINDS), the 
National Center for Advancing Translational Sciences (NCATS), the 
National Institutes of Allergy and Infectious Disease and the Office of 
Rare Disease Research (ORDR). This increase will allow for the 
possibility of an expanded research portfolio focused on inflammatory 
disorders of the nervous system at NINDS, ORDR to initiate research 
activities in peripheral nervous system disorders, and for NCATS to 
pursue a GBS indication for current, off-label treatment options 
through this Committee's support and encouragement.
    Additionally, given the importance of accurate patient diagnosis 
for nervous system disorders and the swift administration of the 
correct treatments which supply the best patient prognosis, we 
respectfully request the subcommittee recommendation for the Centers 
for Disease Control and Prevention to promote enhanced awareness and 
recognition activities of GBS and CIDP, in partnership with 
stakeholders.
    This subcommittee's past investment in biomedical research has 
provided hope to the millions of patients with rare diseases which are 
difficult to diagnose, treat and prevent. I respectfully urge your 
continued support of important health related research and patient care 
programs at NIH and CDC. Thank you again for providing me with the 
opportunity to submit written testimony on behalf of the thousands of 
GBS and CIDP patients and their families and the GBS/CIDP Foundation, 
International.
                                 ______
                                 
           Prepared Statement of the Harm Reduction Coalition

    We thank you for the opportunity to submit testimony regarding 
fiscal year 2014 Appropriations. Our testimony focuses on the urgency 
of scaling up Federal overdose prevention efforts.
    The Centers for Disease Control and Prevention (CDC) reports that 
``Drug overdose death rates in the United States have more than tripled 
since 1990 and have never been higher. In 2008, more than 36,000 people 
died from drug overdoses, and most of these deaths were caused by 
prescription drugs . . . there is currently a growing, deadly epidemic 
of prescription painkiller abuse . . . the misuse and abuse of 
prescription painkillers was responsible for more than 475,000 
emergency department visits in 2009, a number that doubled in just 5 
years.''
    A recent report published by the CDC demonstrates that overdose 
deaths continued to increase for the 11th consecutive year in 2010 and 
approximately 100 American lives were lost every single day. Overdose 
deaths continue to persist as a leading cause of preventable death in 
the United States.
    The Obama Administration's 2013 National Drug Control Strategy 
prioritizes overdose prevention and intervention as a key component in 
addressing this public health epidemic. In order to meet the 
Administration's goal of reducing overdose deaths by 15 percent, the 
Office of National Drug Control Policy has emphasized the role of 
emergency opioid antagonist therapy in reducing mortality in their 2013 
Strategy. ``Naloxone is an opioid antagonist that has long been used as 
an emergency intervention to reverse the potentially fatal respiratory 
depressant effects of an opioid overdose (opioids include licit drugs 
such as morphine, codeine, oxycodone, methadone and hydrocodone as well 
as Schedule 1 illicit drugs such as heroin). Naloxone can be given by 
injection into a muscle or with a nasal spray in the nose. When 
administered to an individual who has taken opioids, it is believed 
naloxone dislodges the opioids from the opioid receptors in the brain. 
This can reverse the effects of an overdose and help restore breathing 
that may have stopped or slowed during the overdose episode. As death 
typically does not occur until several hours after an opioid overdose, 
there is a window of opportunity to intervene by calling 911, giving 
rescue breathing, and by the administration of naloxone by a trained 
lay person . . . Research has shown that naloxone is an important and 
cost-effective tool to prevent overdose and ultimately reduce drug use 
and its consequences.''
    However, despite the powerful life-saving properties of naloxone 
and overdose prevention education, it is underutilized. HHS, the 
Department of Justice, and other agencies have been working to address 
prescription drug misuse, abuse, and diversion, but there is no 
coordinated Federal public health effort focused specifically on 
preventing death from overdose and no Federal funding is currently 
being allocated to these evidence-based practices.
    To that end, as advocates dedicated to preventing deaths from 
opioid overdose, we request that the subcommittee consider including 
report language in the fiscal year 2014 Appropriations bill which urges 
the Department of Health and Human Services and appropriate Federal 
agencies to adopt the following priorities:
    1. Prioritize overdose prevention and intervention to receive 
current funding mechanisms and link to treatment and recovery services:
  --Given the important role of the Substance Abuse Prevention and 
        Treatment Block Grant in providing funding to single State 
        agencies for prevention, treatment, and recovery services, the 
        Substance Abuse and Mental Health Services Administration 
        should take steps to encourage and support the use of Substance 
        Abuse Prevention and Treatment Block Grant funds for opioid 
        safety education, training, and programming, with a focus on 
        initiatives that distribute emergency opioid antagonist therapy 
        to those likely to witness--and those at risk of--an overdose.
    2. Take steps to increase awareness of--and access to--the use of 
opioid antagonist therapy:
  --All Federal agencies involved in research, policies, regulation, 
        and programs related to opioid misuse should coordinate efforts 
        and develop and disseminate information about naloxone to 
        health care professionals, individuals, and families and 
        otherwise take other steps to facilitate its use, so that lives 
        can be saved.
  --The Department of Health and Human Services should coordinate a 
        national public health campaign to increase awareness of the 
        signs and symptoms of overdose and improve understanding of the 
        steps that individuals can take to save the life of someone who 
        is experiencing an overdose. Such a national campaign should 
        include information regarding the use of naloxone, rescue 
        breathing, and calling emergency services, such as 9-1-1 and/or 
        poison control centers.
  --CDC, working in collaboration with the Substance Abuse Mental 
        Health Services Administration (SAMHSA) and the Health 
        Resources and Services Administration (HRSA), should enable 
        best practices, by providing technical assistance and toolkits 
        for community programs and health professionals who wish to 
        distribute naloxone.
    3. Increase Federal surveillance and data collection regarding 
opioid use, misuse, and deaths to ensure that policies and programs are 
designed to target the actual causes of opioid misuse and death and to 
monitor the impact of recent State legislative actions that expand 
access and utilization of naloxone.
    4. Continue Federal investment in the basic, clinical, and 
translational research supported by the National Institute of Drug 
Abuse (NIDA).
    The Harm Reduction Coalition believes that these measures are 
critical to meeting the goal of reversing the overdose epidemic in the 
United States.
    We thank you for your consideration of the important issues.
                                 ______
                                 
  Prepared Statement of the Health Professions and Nursing Education 
                               Coalition

    The members of the Health Professions and Nursing Education 
Coalition (HPNEC) are pleased to submit this statement for the record 
recommending $520 million in fiscal year 2014 for the health 
professions education programs authorized under Titles VII and VIII of 
the Public Health Service Act and administered through the Health 
Resources and Services Administration (HRSA). HPNEC is an alliance of 
national organizations (https://www.aamc.org/advocacy/hpnec/
members.htm) dedicated to ensuring the health care workforce is trained 
to meet the needs of the country's growing, aging, and diverse 
population.
    Designed to provide education and training opportunities to 
aspiring health care professionals, in 2013, the programs celebrate 50 
years of helping the workforce adapt to Americans' changing health care 
needs. With a focus on primary care, Titles VII and VII are the only 
Federal programs designed to train providers in interdisciplinary, 
community-based settings to meet the needs of the country's special and 
underserved populations, increase minority representation in the health 
care workforce, and fill the gaps in the supply of health professionals 
not met by traditional market forces. Further, the programs are able to 
advance timely priorities, such as strengthening education and training 
opportunities in geriatrics to better care for the Nation's aging 
population and closing the gap in access to mental and behavioral 
health services.
    While HPNEC recognizes the subcommittee faces difficult decisions 
in a constrained budget environment, a continued commitment to programs 
supporting health care workforce development should remain a high 
priority. The Nation faces a shortage of health professionals, and 
residents of underserved rural and urban areas alike already struggle 
to access health providers. Further, the number of Americans over age 
65 is expected to reach 70 million by 2030, and as the Nation's baby 
boomers age, they will require more care. Coupled with the millions of 
newly insured individuals entering the system, this increased demand 
for health services only will exacerbate the existing deficit of health 
professionals.
    Diversifying the health care workforce is a central focus of the 
Title VII and VIII programs, making them a key player in the fight to 
mitigate racial, ethnic, and socio-economic health disparities, which 
cost the Nation billions of dollars each year. In particular, the 
Health Careers Opportunity Program (HCOP) trained 20 percent more 
minority and disadvantaged students than expected, helping students 
successfully complete their coursework and creating a more competitive 
health professions applicant pool.
    Further, 1 in 3 Title VII and Title VIII program completers enter 
practice in a medically underserved community (MUC) or health 
professions shortage area (HPSA), helping to increase access to 
services in rural and urban underserved communities. Failure to fully 
fund the Title VII and VIII programs would jeopardize efforts to 
address these challenges and prepare the next generation of health 
professionals.
    The Title VII and Title VIII programs can be considered in seven 
general categories:
  --The Primary Care Medicine and Oral Health Training programs support 
        education and training of primary care professionals, to 
        improve access and quality of health care in underserved areas. 
        Two-thirds of Americans interact with a primary care provider 
        every year. Approximately one-half of primary care providers 
        trained through these programs work in underserved areas, 
        compared to 10 percent of those trained in other programs. The 
        General Pediatrics, General Internal Medicine, and Family 
        Medicine programs provide critical funding for primary care 
        physician training in community-based settings and support a 
        range of initiatives, including medical student and residency 
        training, faculty development, and the development of academic 
        administrative units. The primary care cluster also provides 
        grants for Physician Assistant programs to encourage and 
        prepare students for primary care practice in rural and urban 
        Health Professional Shortage Areas. The General Dentistry, 
        Pediatric Dentistry, and Public Health Dentistry programs 
        provide grants to dental schools and hospitals to create or 
        expand primary care and public health dental residency training 
        programs.
  --Because much of the Nation's health care is delivered in remote 
        areas, the Interdisciplinary, Community-Based Linkages cluster 
        supports community-based training of health professionals. 
        These programs are designed to encourage health professionals 
        to return to such settings after completing their training and 
        to encourage collaboration between two or more disciplines. The 
        Area Health Education Centers (AHECs) offer clinical training 
        opportunities to health professions and nursing students in 
        rural and other underserved communities by extending the 
        resources of academic health centers to these areas. AHECs, 
        which leverage State and local matching funds, form networks of 
        health-related institutions to provide education services to 
        students, faculty and practitioners, including continuing 
        education on a variety of topics such as cultural competence, 
        health disparities, and issues affecting veterans. In the 2011-
        2012 academic year, AHECs trained more than 28,000 medical 
        students in rural or underserved communities, half of which 
        were located in a medically underserved community (MUC) and/or 
        health professions shortage area (HPSA). Geriatric Health 
        Professions programs support geriatric faculty fellowships, the 
        Geriatric Academic Career Award, and Geriatric Education 
        Centers, all designed to bolster the number and quality of 
        health care providers caring for older generations, as well as 
        faculty with geriatrics expertise. The Graduate Psychology 
        Education program, which supports interdisciplinary training of 
        doctoral-level psychology students with other health 
        professionals, provides mental and behavioral health services 
        to underserved populations (i.e., older adults, children, 
        chronically ill, and victims of abuse and trauma, including 
        returning military personnel and their families), especially in 
        rural and urban communities. The Mental and Behavioral Health 
        Education and Training Grant Program supports the training of 
        psychologists, social workers, and child and adolescent 
        professionals. These programs together work to close the gap in 
        access to quality mental and behavioral health care services by 
        increasing the number of trained mental and behavioral health 
        providers.
  --The Minority and Disadvantaged Health Professionals Training 
        cluster helps improve health care access in underserved areas 
        and the representation of minority and disadvantaged 
        individuals in the health professions. Diversifying the health 
        care workforce is a central focus of the programs, making them 
        a key player in the fight to mitigate racial, ethnic, and 
        socio-economic health disparities. Further, the programs 
        emphasize cultural competency for all health professionals, an 
        important role as the Nation's population is growing and 
        becoming increasingly diverse. Minority Centers of Excellence 
        support increased research on minority health issues, 
        establishment of an educational pipeline, and the provision of 
        clinical opportunities in community-based health facilities. 
        The Health Careers Opportunity Program seeks to improve the 
        development of a competitive applicant pool through 
        partnerships with local educational and community 
        organizations. The Faculty Loan Repayment and Faculty 
        Fellowship programs provide incentives for schools to recruit 
        underrepresented minority faculty. The Scholarships for 
        Disadvantaged Students make funds available to eligible 
        students from disadvantaged backgrounds who are enrolled as 
        full-time health professions students.
  --The Health Professions Workforce Information and Analysis program 
        provides grants to institutions to collect and analyze data to 
        advise future decisionmaking on the health professions and 
        nursing programs. The Health Professions Research and Health 
        Professions Data programs have developed valuable, policy-
        relevant studies on the distribution and training of health 
        professionals, including the Eighth National Sample Survey of 
        Registered Nurses, the Nation's most extensive and 
        comprehensive source of statistics on registered nurses. 
        Reflecting the need for better health workforce data to inform 
        both public and private decisionmaking, the National Center for 
        Workforce Analysis serves as a source of such analyses.
  --The Public Health Workforce Development programs help increase the 
        number of individuals trained in public health, identify the 
        causes of health problems, and respond to such issues as 
        managed care, new disease strains, food supply, and 
        bioterrorism. The Public Health Traineeships and Public Health 
        Training Centers seek to alleviate the critical shortage of 
        public health professionals by providing up-to-date training 
        for current and future public health workers, particularly in 
        underserved areas. Preventive Medicine Residencies, which do 
        not receive funding through Medicare GME, provide training in 
        the only medical specialty that teaches both clinical and 
        population medicine to improve community health. This cluster 
        also includes a focus on loan repayment as an incentive for 
        health professionals to practice in disciplines and settings 
        experiencing shortages. The Pediatric Subspecialty Loan 
        Repayment Program offers loan repayment for pediatric medical 
        subspecialists, pediatric surgical specialists, and child and 
        adolescent mental and behavioral health specialists, in 
        exchange for service in underserved areas.
  --The Nursing Workforce Development programs under Title VIII provide 
        training for entry-level and advanced degree nurses to improve 
        the access to, and quality of, health care in underserved 
        areas. These programs provide the largest source of Federal 
        funding for nursing education, providing loans, scholarships, 
        traineeships, and programmatic support that, between fiscal 
        year 2005 and 2010, supported over 400,000 nurses and nursing 
        students as well as numerous academic nursing institutions and 
        health care facilities. Each year, nursing schools turn away 
        tens of thousands of qualified applications at all degree 
        levels due to an insufficient number of faculty, clinical 
        sites, classroom space, clinical preceptors, and budget 
        constraints. At the same time, the need for nursing services 
        and licensed, registered nurses is expected to increase 
        significantly over the next 20 years. The Advanced Education 
        Nursing program awards grants to train a variety of nurses with 
        advanced education, including clinical nurse specialists, nurse 
        practitioners, certified nurse-midwives, nurse anesthetists, 
        public health nurses, nurse educators, and nurse 
        administrators. Workforce Diversity grants support 
        opportunities for nursing education for students from 
        disadvantaged backgrounds through scholarships, stipends, and 
        retention activities. Nurse Education, Practice, and Retention 
        grants help schools of nursing, academic health centers, nurse-
        managed health centers, State and local governments, and other 
        health care facilities to develop programs that provide nursing 
        education, promote best practices, and enhance nurse retention. 
        The Loan Repayment and Scholarship Program repays up to 85 
        percent of nursing student loans and offers full-time and part-
        time nursing students the opportunity to apply for scholarship 
        funds in exchange for 2 years of practice in a designated 
        nursing shortage area. The Comprehensive Geriatric Education 
        grants are used to train RNs who will provide direct care to 
        older Americans, develop and disseminate geriatric curriculum, 
        train faculty members, and provide continuing education. The 
        Nurse Faculty Loan program provides a student loan fund 
        administered by schools of nursing to increase the number of 
        qualified nurse faculty.
  --The loan programs under Student Financial Assistance support 
        financially disadvantaged health professions students. The 
        Nursing Student Loan (NSL) is for undergraduate and graduate 
        nursing students with a preference for those with the greatest 
        financial need. The Primary Care Loan (PCL) program provides 
        loans in return for dedicated service in primary care. The 
        Health Professional Student Loan (HPSL) program provides loans 
        for financially needy health professions students based on 
        institutional determination. These programs are funded out of 
        each institution's revolving fund and do not receive Federal 
        appropriations. The Loans for Disadvantaged Students program 
        provides grants to institutions to make loans to health 
        professions students from disadvantaged backgrounds.
    By improving the supply, distribution, and diversity of the 
Nation's health care professionals, the Title VII and Title VIII 
programs not only prepare aspiring professionals to meet the Nation's 
workforce needs, but also help to improve access to care across all 
populations. Further, with the Bureau of Labor Statistics projecting 
that the health care industry will generate 3.2 million jobs through 
2018 (more than any other industry), these programs can help 
individuals in reaching their career goals and communities in filling 
their health needs. The multi-year nature of health professions 
education and training, coupled with provider shortages across many 
disciplines and in many communities, necessitate a strong, continued, 
and reliable commitment to the Title VII and Title VIII programs.
    While HPNEC members understand the immense fiscal pressures facing 
the subcommittee, we respectfully urge support for $520 million for the 
Title VII and VIII programs. We look forward to working with the 
subcommittee to prioritize the health professions programs in fiscal 
year 2014 and into the future.
                                 ______
                                 
           Prepared Statement of the HIV Medicine Association

    The HIV Medicine Association (HIVMA) of the Infectious Diseases 
Society of America (IDSA) represents more than 5,000 physicians, 
scientists and other health care professionals who practice on the 
frontline of the HIV/AIDS pandemic. Our members provide medical care 
and treatment to people with HIV/AIDS throughout the U.S., lead HIV 
prevention programs and conduct research to develop effective HIV 
prevention and treatment options. We work in communities across the 
country and around the globe as medical providers and researchers 
dedicated to the field of HIV medicine.
    We recognize the difficult fiscal environment Congress is facing. 
However, as you make tough spending decisions for fiscal year 2014, we 
strongly urge you to maintain adequate funding for critical HIV/AIDS 
treatment, prevention and research programs. Our past investment in 
HIV-related research has supported critical discoveries that now allow 
leaders worldwide to envision a world without AIDS.
    Despite our remarkable progress in HIV prevention, diagnosis and 
treatment, HIV/AIDS remains a serious and significant epidemic in the 
United States with a record 1.2 million people living with HIV and an 
estimated 50,000 new infections occurring annually. HIV disease 
disproportionately impacts racial and ethnic minority communities and 
low income people who depend on public services for their life-saving 
health care and treatment. Early and reliable access to HIV care and 
treatment help patients with HIV live healthy and productive lives and 
is cost effective. In addition, having persons living with HIV 
virologically suppressed on antiretroviral therapy decreases 
transmission of HIV and thus is critical in curbing the epidemic. The 
comprehensive, expert HIV care model that is supported by the Ryan 
White Program has been highly successful at achieving positive clinical 
outcomes with a complex patient population. In fact, Ryan White funded 
clinics have become models for ``medical homes''. Once in care, 
patients who attend at least one Ryan White medical visit do well--with 
70 percent of those on antiretroviral treatment having undetectable 
levels of the virus in their blood. This is much higher than the 
estimate from the CDC that just 25 percent of people living with HIV in 
the U.S. are virally suppressed. The annual health care costs for HIV 
patients who are not able to achieve viral suppression (often due to 
delayed diagnosis and care) are nearly 2.5 times that of healthier HIV 
patients.
    In order to dramatically change the trajectory of the HIV epidemic 
in the U.S. and around the world, we strongly urge you to support at 
minimum the President's proposed fiscal year 2014 funding levels for 
the Centers for Disease Control and Prevention (CDC)'s HIV and STD 
prevention programs and the Ryan White Program at the Health Resources 
and Services and Administration, as well as the President's fiscal year 
2014 request level for the medical research supported by the National 
Institutes of Health, including the President's proposed $47 million 
increase for HIV/AIDS research across the institutes and centers. 
Failure to maintain adequate funding for these critical priorities will 
set us back in the fight against HIV infection and harm the Nation's 
health and fiscal well-being. The funding requests in our testimony 
largely reflect the consensus of the Federal AIDS Policy Partnership 
(FAPP), a coalition of HIV organizations from across the country, and 
are estimated to be the amounts necessary to strengthen our investment 
in combatting HIV disease and meet the need in communities across the 
country.
    Health Care Reform.--We strongly support at a minimum the 
President's fiscal year 2014 request level for health care reform 
discretionary funding under the Patient Protection and Affordable Care 
Act (ACA). Of particular importance is funding to support health care 
workforce education and training programs under Titles VII and VIII of 
the Public Health Service Act (PHSA); health care quality improvement 
programs, and the Medicare and Medicaid demonstration programs.
    If we are to succeed in improving the quality and efficiency of our 
health care delivery system while addressing health care costs, it is 
essential to fully fund the Centers for Medicare and Medicaid 
Innovation (CMMI). In particular, we would hope to see CMMI evaluate 
the health outcomes and cost effectiveness of managing the care of 
people with HIV through ``patient centered medical homes.'' HIV disease 
is included among the qualifying chronic disease conditions under the 
new State Medicaid Health Home option that allows Medicaid enrollees 
with at least two chronic conditions to designate a provider as a 
health home. Since a majority of people with HIV rely on Medicaid for 
their health care coverage, it is vital that this model of care is 
pilot-tested and supported by Medicaid programs.
    HIV/AIDS Bureau of the Health Resources and Services 
Administration.--We strongly urge you to increase funding for the Ryan 
White Program by $276 million in fiscal year 2014 with at least an 
increase of $21.5 million over the fiscal year 2013 continuing 
resolution level for Part C. Ryan White Part C funds comprehensive HIV 
care and treatment--services that are directly responsible for the 
dramatic decreases in AIDS-related mortality and morbidity over the 
last decade. On average it costs $3,501 per person per year to provide 
the comprehensive outpatient care available at Part-C funded programs 
(excluding medications), including lab work, STD/TB/Hepatitis 
screening, ob/gyn care, dental care, mental health and substance abuse 
treatment, and case management. Part C funding covers a small 
percentage of the total cost of providing comprehensive care with some 
programs receiving $450 or lower per patient per year to cover care. 
The HIV medical clinics funded through Part C have been in dire need of 
increased funding for years, but efforts to bring more people with HIV 
into care through routine HIV screening along with ongoing economic 
pressures are creating a crisis in communities across the country. An 
increase in funding is critical to prevent additional staffing and 
service cuts and ensure the public health of our communities. At a bare 
minimum, we strongly urge you to support an increase of $20 million 
over fiscal year 2013 appropriated funding for Ryan White Part C.
    Center for Disease Control and Prevention's (CDC) National Center 
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).--HIVMA 
strongly urges total fiscal year 2014 funding of $1.424 billion for the 
CDC's NCHHSTP, an increase of $314 million over the fiscal year 2013 
level, including increases of: $180 million for HIV prevention and 
surveillance, $5.3 million for viral hepatitis and $102.7 million for 
Tuberculosis prevention.
    Every nine and a half minutes a new HIV infection happens in the 
U.S. with more than 60 percent of new cases occurring among African 
Americans and Hispanic/Latinos. The CDC estimates that the 50,000 new 
HIV infections each year in the U.S. may result in $56 billion in 
medical care and lost productivity costs. Despite the known benefit of 
effective treatment, nearly 20 percent of people living with HIV in the 
U.S. are still not aware of their status and as many as 36 percent of 
people newly diagnosed with HIV progress to AIDS within 1 year of 
diagnosis. A sustained commitment to HIV prevention funding is critical 
to enhance HIV/AIDS surveillance and expand HIV testing and linkage to 
care, in order to lower HIV incidence and prevalence in the U.S. 
Particularly in light of steep State budget cuts, a failure to invest 
now in HIV prevention will be costly. At a bare minimum we strongly 
urge the Committee to at least support an increase of $180 million for 
HIV prevention and an increase of $5.3 million for viral hepatitis at 
the CDC. We also support a funding level of at least $363 million for 
CDC's global health programs, which includes resources for the agency's 
essential role in implementing PEPFAR programs in developing nations.
    Agency for Health Care Quality and Research (AHRQ).--HIVMA urges 
the Committee to provide $2 million for the HIV Research Network 
(HIVRN). The HIVRN is a consortium of 19 HIV primary care sites co-
funded by AHRQ and HRSA to evaluate health care utilization and 
clinical outcomes in HIV infected children, adolescents and adults in 
the U.S. The Network analyzes and disseminates information on the 
delivery and outcomes of health care services to people with HIV 
infection. These data help to improve delivery and outcomes of HIV care 
in the U.S. and to identify and address disparities in HIV care that 
exist by race, gender, and HIV risk factor. The HIVRN is a valuable and 
highly utilized source of information on the cost and cost-
effectiveness of HIV care in the U.S. at a time when such data is 
particularly needed to inform health systems reform and the development 
and implementation of a National HIV/AIDS Strategy.
    National Institutes of Health (NIH)--Office of AIDS Research 
(OAR).--HIVMA strongly supports an fiscal year 2014 funding level of 
$36 billion for the NIH, including $3.6 billion for the NIH Office of 
AIDS Research. This level of funding is vital to sustain the pace of 
research that will improve the health and quality of life for millions 
of men, women and children in the U.S. and in the developing world. Our 
past investment in a comprehensive portfolio was responsible for the 
dramatic gains that we made in our HIV knowledge base, gains that 
resulted in reductions in mortality from AIDS of nearly 80 percent in 
the U.S. and in other countries where treatment is available. Gains 
that also helped us to reduce the mother to child HIV transmission rate 
from 25 percent to less than 1 percent in the U.S. and to very low 
levels in other countries where treatment is available.
    Strong, sustained NIH funding is a critical national priority that 
will foster better health, economic revitalization and an effective 
National HIV/AIDS Strategy. In every State across the country, the NIH 
supports research at hospitals, universities and medical schools, and 
community based service organizations. This includes the creation of 
jobs that will be essential to future discovery. Sustained increases in 
funding are also essential to train the next generation of scientists 
and prepare them to make tomorrow's HIV discoveries.
    The benefits of HIV research are far reaching. Researchers have 
applied HIV research methods and findings to studying and treating 
other serious conditions, such as cancer, and hepatitis B and C virus. 
Congress should ensure the Nation does not delay vital HIV/AIDS 
research progress. We must increase HIV/AIDS research funding to 
sustain medical research capacity and maintain our worldwide leadership 
in HIV/AIDS research leadership and innovation.
    Policy Riders--Remove the Harmful Ban on Federal Funding for 
Syringe Exchange Programs.--HIVMA strongly urges adoption of language 
included in the President's fiscal year 2014 budget that would re-
instate language previously enacted into law in fiscal year 2010 and 
fiscal year 2011 allowing Federal funding to be used for syringe 
exchange programs. Such action will support local control by letting 
local communities make their own decisions about how best to prevent 
new HIV and viral hepatitis infections. It is well proven that syringe 
exchange programs are a cost-effective means to lower rates of HIV/AIDS 
and viral hepatitis, reduce the use of illegal drugs and help connect 
people to medical treatment, including substance abuse treatment. We 
cannot afford to dismiss any of the scientifically proven tools in the 
HIV prevention tool box if we are going to end AIDS in the U.S. and 
around the globe.

                               CONCLUSION

    Historically, our Nation has made significant strides in responding 
to the HIV pandemic here at home and around the world, but we have lost 
ground in recent years, as funding priorities have shifted away from 
public health and research programs. We appreciate the many difficult 
decisions that Congress faces this year, but urge you to recognize the 
importance of investing in HIV prevention, treatment and research now 
to avoid the much higher cost that individuals, communities and broader 
society will incur if we fail to support these programs. We must seize 
the opportunity to limit the toll of this deadly infectious disease on 
our planet, to save the lives of millions who are infected or at risk 
of infection here in the U.S. and around the globe, and to realize the 
vision of an AIDS-free generation.
                                 ______
                                 
   Prepared Statement of the Humane Society of the United States and 
                    Humane Society Legislative Fund

    On behalf of The Humane Society of the United States (HSUS) and the 
Humane Society Legislative Fund (HSLF), we appreciate the opportunity 
to provide testimony on our top NIH funding priorities for the House 
Labor, Health and Human Services, Education and Related Agencies 
Appropriations Subcommittee in fiscal year 2014.

          SUPPORT OF FEDERALLY OWNED CHIMPANZEES IN SANCTUARY

    The HSUS and HSLF request that Congress address budget issues 
currently restricting chimpanzee sanctuary expenditures so that the 
National Institutes of Health can make cost-effective and humane 
decisions regarding the care of these animals.
    In 2000, Congress passed the Chimpanzee Health Improvement 
Maintenance and Protection Act (CHIMP Act) that established the 
national chimpanzee sanctuary system for chimpanzees no longer used in 
research and included a $30 million cap on related Federal 
expenditures. No such cap exists for spending on maintaining 
chimpanzees in laboratories--a more expensive and less humane form of 
housing. Unfortunately, the sanctuary expenditure cap is about to be 
reached, at just the moment when NIH is poised to declare that nearly 
all federally-owned chimpanzees should be retired to sanctuary. This 
crisis can be averted by enacting a sentence (see Language Requested 
below) in the final fiscal year 2014 budget.
    Further basis of our request can be found below.

Background Cost Information
    Currently, NIH owns approximately 580 chimpanzees and is 
responsible for their lifetime care and support. Of those chimpanzees, 
roughly 360 continue to be housed in laboratories. According to an 
independent economic analysis conducted for The HSUS in 2012, the 
average per diem cost to taxpayers of maintaining a chimpanzee in a 
laboratory is $60. The per diem cost to taxpayers of caring for a 
chimpanzee in the national sanctuary system during the same time was 
$44. As a result of economies of scale, the per diem for sanctuary care 
is projected to decrease to $32 per chimpanzee with the addition of 100 
chimpanzees.\1\
    Given that chimpanzees can live up to 60 years in captivity, the 
difference in per diem costs can add up quickly. The Government would 
save a substantial amount of money over time by moving the Government 
owned chimpanzees to the national sanctuary.

Chimpanzees are not necessary for most research
    In December of 2011, the Institute of Medicine (IOM) and National 
Research Council released a report which found that chimpanzees are 
``largely unnecessary'' for research and, further, could not identify 
any current area of research for which chimpanzees are essential. The 
report also called for a sharp reduction in the use of chimpanzees in 
research and noted that the ``current trajectory indicates a decreasing 
scientific need for chimpanzee studies due to the emergence of non-
chimpanzee models and technologies.'' \2\
    Following that report, the National Institutes of Health 
immediately accepted the IOM findings and created an independent 
Council of Councils Working Group of experts to advise the agency on 
implementation of the findings. After nearly a year of deliberations, 
the Working Group presented their recommendations in January 2013. 
Among other things, the recommendations included the retirement of the 
majority of the more than 350 Government-owned chimpanzees currently in 
laboratories to sanctuary, a substantial decrease in the number of 
Government funded grants involving chimpanzees in laboratories and no 
revitalization of chimpanzee breeding for research purposes.\3\
    The NIH is expected to make a final decision on the recommendations 
in the very near future. But, given the consistent results of the IOM 
and NIH Working Group reports, it's safe to anticipate that a large 
number of chimpanzees will be retired in the near future. By including 
the language suggested here, Congress can ensure cost-effective 
sanctuary space is available so NIH is not forced to maintain retired 
chimpanzees in more expensive laboratories.

Ethologically appropriate chimpanzee housing only available in 
        sanctuary
    In addition to their other findings, the IOM committee stated that 
chimpanzees used in research should be kept in ``ethologically 
appropriate physical and social environments.'' However, the concept 
was not clearly defined in the IOM report. Therefore, the NIH Council 
of Councils Working Group produced several recommendations to more 
clearly define ``ethologically appropriate'' environments for 
chimpanzees.\2\ Those recommendations included providing large, complex 
social groups, year round outdoor access and more than 1,000 square 
feet of living space per chimpanzee, among other things. Importantly, 
no laboratory meets the Working Group's definition of ``ethologically 
appropriate'' and the report described the national sanctuary system as 
the ``most species-appropriate environment currently available.'' \3\
    Upgrading laboratories to meet the needs of chimpanzees would be 
extremely expensive and, given the lack of necessity for chimpanzees in 
research, a waste of taxpayer dollars. It makes fiscal sense to send 
retired chimpanzees to sanctuary where they will receive optimal care 
at a lower cost than in laboratories.

Ethical and public concerns
    Americans are clearly concerned about the use of chimpanzees in 
research and believe that chimpanzees deserve sanctuary. A national 
poll found that 74 percent support permanent retirement to sanctuaries 
for chimpanzees no longer used in experiments; 71 percent believe that 
chimpanzees who have been in the laboratory for over 10 years should be 
sent to sanctuary for retirement \4\; and 54 percent believe that it is 
unacceptable for chimpanzees to ``undergo research which causes them to 
suffer for human benefit.'' \5\
    We respectfully request the following bill language: ``Funds 
provided to the National Institutes of Health in this and subsequent 
acts may be used to support the Sanctuary System for Surplus 
Chimpanzees authorized by section 404K of the Public Health Service 
Act, including for the construction, renovation, and funding of current 
or additional facilities of the sanctuary system as authorized by 
section 404K, notwithstanding the limitations in subsection (g) of such 
section.''
    We appreciate the opportunity to share our views for the Labor, 
Health and Human Services, Education and Related Agencies 
Appropriations Act for fiscal year 2014. We hope the Committee will be 
able to accommodate this modest request that will save the Government a 
substantial sum of money, benefit chimpanzees, and allay some concerns 
of the public at large. Thank you for your consideration.
recommendations of the council of councils working group on the use of 

                 CHIMPANZEES IN NIH-SUPPORTED RESEARCH

    As was discussed above, in their December 2011 report entitled 
Chimpanzees in Biomedical and Behavioral Research: Assessing the 
Necessity, the Institute of Medicine found that chimpanzees are 
``largely unnecessary'' for current research. Following the IOM report, 
the National Institutes of Health commissioned an independent Working 
Group of experts to advise them on how to implement the findings of the 
IOM report. The Working Group released their recommendations in January 
2013.
    These recommendations include retiring the majority of federally 
owned chimpanzees to sanctuary, a clear set of criteria for housing and 
maintaining chimpanzees in a manner appropriate to the needs of the 
species, a decrease in grants for chimpanzee research, a rigorous 
review process for protocols to ensure that any future research 
conducted on chimpanzees is necessary, a cessation of breeding for 
research and an increased investment in alternatives to chimpanzee use. 
The Working Group has also recommended that a small number of 
chimpanzees be available for research in the unlikely event of a new or 
reemerging threat that requires it. However, the Working Group advised 
that these chimpanzees be kept in ethologically appropriate conditions 
and that the need for this group should be reassessed frequently.
    By adopting these recommendations, NIH will not only free up funds 
that would otherwise be spent on unnecessary chimpanzee research to be 
spent on research that is more relevant to human health, it will save 
taxpayer dollars by retiring the chimpanzees into the less-costly 
sanctuary system, providing them with optimal care.
    We respectfully request the following committee report language: 
``The Committee thanks the National Institutes of Health for their 
thorough review of the use of chimpanzees in research and supports the 
acceptance and implementation of the recommendations proposed by the 
NIH Council of Councils Working Group on the Use of Chimpanzees in NIH-
supported Research. In particular, we urge implementation of those 
recommendations related to the retirement to sanctuary of hundreds of 
government-owned chimpanzees, phasing out of current biomedical 
research on chimpanzees, meeting standards for ethologically 
appropriate physical and social environments for chimpanzees, 
prohibiting NIH financial support for chimpanzee breeding, creation of 
an independent Oversight Committee to ensure a proper and transparent 
review of any future uses of chimpanzees in government-funded research 
and increased funding for alternative research methods. These 
recommendations are in the best interests of human health and 
chimpanzee welfare. They will also result in significant taxpayer 
savings because care in ethologically appropriate sanctuaries is less 
expensive than care in laboratories and, further, the federal 
government will no longer be footing the bill for unnecessary and 
costly research protocols and breeding programs.''

 HIGH THROUGHPUT SCREENING, TOXICITY PATHWAY PROFILING, AND BIOLOGICAL 
                       INTERPRETATION OF FINDINGS
         NATIONAL INSTITUTES OF HEALTH--OFFICE OF THE DIRECTOR

    In 2008, NIH, NIEHS and EPA signed a memorandum of understanding 
(MOU) to collaborate with each other to identify and/or develop high 
throughput screening assays that investigate ``toxicity pathways'' that 
contribute to a variety of adverse health outcomes (e.g., from acute 
oral toxicity to long-term effects like cancer). In addition, the MOU 
recognized the necessity for these Federal research organizations to 
work with ``acknowledged experts in different disciplines in the 
international scientific community.'' Much progress has been made, 
including FDA joining the MOU, but there is still a significant amount 
of research, development and translational science needed to bring this 
vision forward to where it can be used with confidence for safety 
determinations by regulatory programs in the Government and product 
stewardship programs in the private sector. In particular, there is a 
growing need to support research to develop the key science-based 
interpretation tools which will accelerate using 21st century 
approaches for predictive risk analysis. We believe the Office of the 
Director at NIH can play a leadership role for the entire U.S. 
Government by funding both extramural and intramural research.
    In April, 2013, the Obama Administration announced an initiative to 
map the human brain, Brain Research through Advancing Innovative 
Neurotechnologies (BRAIN), which the White House describes as ``a bold 
new research effort to revolutionize our understanding of the human 
mind.'' According to the White House, the Brain Initiative will `` . . 
. accelerate the development and application of new technologies that 
will enable researchers to produce dynamic pictures of the brain that 
show how individual brain cells and complex neural circuits interact at 
the speed of thought.'' \6\ The goals of this initiative are to shed 
light on normal brain function as well as understanding the development 
of neurological diseases such as Alzheimer's and Parkinson's, childhood 
developmental issues such as autism, and acute events such as stroke--
and hopefully find new ways of treating them.
    We respectfully request the following committee report language, 
which is supported by The HSUS, HSLF and the American Chemistry 
Council:
    NIH Director
          ``The Committee supports NIH's leadership role in the 
        creation of a new paradigm for chemical risk assessment based 
        on the incorporation of advanced molecular biological and 
        computational methods in lieu of animal toxicity tests. NIH has 
        indicated that development of this science is critical to 
        several of its priorities, from personalized medicine to 
        tackling specific diseases such as cancer and diabetes and 
        including critical initiatives such as BRAIN. The Committee 
        encourages NIH to continue to expand both its intramural and 
        extramural support for the use of human biology-based 
        experimental and computational approaches in health research to 
        further define human biology, disease pathways and toxicity and 
        to develop tools for their integration into evaluation 
        strategies. Extramural and intramural funding should be made 
        available for the evaluation of the relevance and reliability 
        of human biology-based and Tox21-related methods and prediction 
        tools to assure readiness and utility for regulatory purposes, 
        including pilot studies of pathway-based risk assessments. The 
        Committee requests NIH provide a report on associated funding 
        in FY 2014 for such activity and a progress report of related 
        activities in the congressional justification request, 
        featuring a 5-year plan for projected budgets for the 
        development of human biology-based and Tox21-related methods, 
        including prediction models, and activities specifically 
        focused on establishing scientific confidence in them for 
        regulatory use. The Committee also requests NIH prioritize an 
        additional (1-3%) of its research budget within existing funds 
        for such activity.''
---------------------------------------------------------------------------
    \1\ Phillips, Carl for The Humane Society of the United States 
(2012) Federal Government budget savings from defunding invasive 
research on chimpanzees and retiring Government-owned laboratory 
chimpanzees to sanctuary [white paper].
    \2\ Institute of Medicine and National Research Council. (2011). 
Chimpanzees in Biomedical and Behavioral Research: Assessing the 
Necessity. National Academies Press: Washington, D.C.
    \3\ 2013 Report of the National Institutes of Health Council of 
Councils Working Group on the Use of Chimpanzees in NIH-Supported 
Research.
    \4\ 2006 poll conducted by the Humane Research Council for Project 
Release & Restitution for Chimpanzees in laboratories.
    \5\ 2001 poll conducted by Zogby International for the Chimpanzee 
Collaboratory.
    \6\ Boseley, S. 2013. Obama unveils brain mapping initiative and 
calls for further research. The Guardian, Tuesday 2 April 2013. http://
www.guardian.co.uk/science/2013/apr/02/obama-brain-
initiative-fight-disease.
---------------------------------------------------------------------------
                                 ______
                                 
    Prepared Statement of the Infectious Diseases Society of America

    The Infectious Diseases Society of America (IDSA) represents more 
than 10,000 infectious diseases (ID) physicians and scientists devoted 
to patient care, prevention, public health, education, and research. 
Investment in ID research and public health efforts can reduce health 
care costs, save lives, and create jobs. IDSA urges you to provide 
strong funding for the Department of Health and Human Services' (HHS) 
National Institutes of Health, Centers for Disease Control and 
Prevention, Office of the Assistant Secretary for Preparedness and 
Response, and Biomedical Advanced Research and Development Authority as 
well as adopt appropriate report language for the Centers for Medicare 
and Medicaid Services.

                  NATIONAL INSTITUTES OF HEALTH (NIH)
     NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES (NIAID)

    IDSA recommends that the subcommittee continue to invest strongly 
in medical research funding at the NIH, and at NIAID, in particular, so 
that patients may continue to benefit from the live-saving benefits 
that medical research affords. In April, IDSA released an updated 
report on the dire status of the antibiotic pipeline, which found only 
seven (7) antibiotics to treat Gram-negative bacteria, which represent 
the most urgent needs, in Phase II development or later. Given the 
growing crisis related to antibiotic-resistant infections and the lack 
of new antibiotics in development (read more at 
www.AntibioticsNow.org), we believe it is particularly imperative that 
NIAID invest more vigorously in antibacterial resistance research, 
including related diagnostics research, so that our Nation can better 
respond to these dangerous and expensive pathogens, which threaten 
patient care, public health and national security. Our funding goal for 
NIAID's antibacterial resistance and related diagnostics efforts is at 
least $500 million annually by the end of fiscal year 2014. As part of 
this effort, we believe NIAID should invest at least $100 million/year 
in the antibiotic-resistance focused clinical trials network that the 
institute now is establishing and which should be up and running in 
2014. NIAID should be applauded for establishing this new network, but 
unfortunately, the planned investment of $10 million/year over the next 
7 years will not be sufficient to undertake the critical studies needed 
to address what are quickly becoming untreatable infections.
    The subcommittee also should adopt report language urging NIAID to 
invest in research on new antiviral drugs and related diagnostics that 
are effective against emerging drug-resistant influenza variants. The 
dearth of novel antiviral influenza drugs is of concern, especially as 
resistance grows.
    IDSA also urges the subcommittee to restore the salary cap for NIH 
grantees to Executive Level I. The salary cap reduction enacted in 
fiscal year 2012 disproportionately affects physician-investigators and 
serves as a deterrent to their recruitment into research careers.

            CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)
 NATIONAL CENTER FOR EMERGING AND ZOONOTIC INFECTIOUS DISEASES (NCEZID)

    IDSA supports strong funding for NCEZID, which houses CDC's 
antimicrobial resistance activities. We must be able to track 
resistance, understand its driving factors and measure the impact of 
efforts to limit resistance. State and local public health laboratories 
are key, but they depend largely upon CDC for funding, and currently 
only about half of them can provide some level of antimicrobial 
susceptibility testing. NCEZID also needs strong funding to enhance 
data collection on antimicrobial use and to promote the uptake of 
antimicrobial stewardship programs to help protect the effectiveness of 
these precious drugs. In particular, IDSA urges the subcommittee to 
fully fund two requests in the President's budget proposal: (1) the 
Advanced Molecular Detection (AMD) initiative and (2) the National 
Healthcare Safety Network (NHSN). AMD is a necessary and overdue effort 
that will allow CDC to more quickly determine the origin of emerging 
diseases, whether microbes are resistant to antibiotics, and how 
microbes are moving through a population. The AMD initiative will 
strengthen CDC's epidemiologic and laboratory expertise to effectively 
guide public health action. Additional funding for NHSN will allow CDC 
to further invest in the EpiCenters--five academic centers which 
conduct research projects on health care-associated infections and 
antibiotic-resistant infections. The EpiCenters have survived on a $2 
million budget over the past 15 years with no increase. Critical areas 
where the EpiCenters could expand their work include: evaluating 
interventions to prevent or limit the development of antimicrobial 
resistance, facilitating public health research on the prevention and 
control of resistant organisms, and assessing the appropriateness of 
surveillance and prevention programs in health care and institutional 
settings. IDSA also urges strong funding for the Emerging Infections 
Program (EIP) to assess the epidemiology of emerging resistant 
pathogens in infectious diseases of public health importance.
    IDSA also encourages the subcommittee to adopt antimicrobial 
resistance report language to encourage the following activities to the 
extent possible given the current budgetary constraints:
  --Urging CDC to implement prevention collaboratives with State health 
        departments to prevent the transmission of significant 
        resistant pathogens across health care settings.
  --Encouraging CDC to expand academic public health partnerships 
        through the EpiCenters.
  --Recommending CDC pilot and test quality measures to help measure 
        antimicrobial use.

   NATIONAL CENTER FOR IMMUNIZATION AND RESPIRATORY DISEASES (NCIRD)

    IDSA recommends strong funding for NCIRD, including the Section 317 
Immunization Program. The Society remains concerned that the 
Administration once again has proposed decreasing immunizations 
funding. Even with implementation of expanded immunizations coverage 
under the Affordable Care Act, immunization funding through CDC is 
needed to help providers obtain and store vaccines; establish and 
maintain vaccine registries; provide education about vaccines; and 
promote vaccination of health care workers. IDSA recommends report 
language urging CDC to work with State and local governments to ensure 
immunization recommendations, defined by the Advisory Committee on 
Immunization Practices (ACIP), are implemented except when medically-
contraindicated.
    Given that recent outbreaks of pertussis (whooping cough) are among 
the largest in the U.S. during the past half century, it is 
particularly important to ensure that more individuals receive this 
vaccination.
    Also worrisome, influenza vaccination rates among health care 
workers overall remained stagnant in 2012. Funding to address this 
issue is critical to protect the health of those individuals most 
needed to respond to influenza outbreaks and pandemics and to protect 
patients at risk of infection.
    IDSA strongly supports the President's proposed funding increase 
for influenza preparedness activities. In IDSA's recently updated 
Pandemic and Seasonal Influenza Principles for United States Action, 
the Society recommends strong funding for such activities, including 
public health infrastructure and countermeasures as well as long-term 
governmental coordination and planning. Lack of sufficient funding 
could lead to an increased incidence and severity of influenza, 
hospitalization costs and mortality.
    Recent infectious outbreaks have underscored the need for a strong 
investment to maintain our capacity to detect and respond to 
emergencies as they occur, such the fungal meningitis outbreak caused 
by a contaminated steroid product that killed more than 50 people, and 
emerging H7N9 influenza in China, as well as infectious threats 
associated with disasters such as Hurricanes Katrina and Sandy. Funding 
is needed to provide coordination, guidance and technical assistance to 
State and local governments; support the Strategic National Stockpile; 
strengthen and sustain epidemiologic and public health laboratory 
capacity; and provide clear and effective communications during an 
emergency.

  THE NATIONAL CENTER FOR HIV, VIRAL HEPATITIS, STD AND TB PREVENTION 
                               (NCHHSTP)

    IDSA strongly urges total fiscal year 2014 funding of $1.424 
billion for the CDC's NCHHSTP, an increase of $314 million over the 
fiscal year 2013 level, including increases of: $180 million for HIV 
prevention and surveillance, $5.3 million for viral hepatitis and 
$102.7 million for Tuberculosis prevention.
    Every nine and a half minutes a new HIV infection happens in the 
U.S. with more than 60 percent of new cases occurring among African 
Americans and Hispanic/Latinos. The CDC estimates that the 50,000 new 
HIV infections each year in the U.S. may result in $56 billion in 
medical care and lost productivity costs. Despite the known benefit of 
effective treatment, nearly 20 percent of people living with HIV in the 
U.S. are still not aware of their status and as many as 36 percent of 
people newly diagnosed with HIV progress to AIDS within 1 year of 
diagnosis. A sustained commitment to HIV prevention funding is critical 
to enhance HIV/AIDS surveillance and expand HIV testing and linkage to 
care, in order to lower HIV incidence and prevalence in the U.S. 
Particularly in light of steep State budget cuts, a failure to invest 
now in HIV prevention will be costly. At a bare minimum we strongly 
urge the Committee to at least support an increase of $180 million for 
HIV prevention and an increase of $5.3 million for viral hepatitis at 
the CDC. We also support a funding level of at least $363 million for 
CDC's global health programs, which includes resources for the agency's 
essential role in implementing PEPFAR programs in developing nations.
    A strong investment is needed to implement CDC's new hepatitis C 
screening policy, including funding to support education, testing, 
referral, vaccination and surveillance. Hepatitis B and C affect nearly 
six million Americans, the vast majority of whom do not know they are 
infected. These infections lead to chronic liver disease, with a loss 
of 15,000 lives each year,\1\ liver cancer, and increased 
transplantations for those suffering liver failure.
    IDSA recommends strong funding to support Federal, State, and local 
health tuberculosis (TB) detection, treatment, and prevention efforts. 
Adequate funding also must be directed to the TB Trials Consortium that 
is testing new TB therapeutics--an urgent need as the threat of drug-
resistant TB grows.

        ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE (ASPR)

    In addition to strongly investing in ASPR's critical preparedness 
and response activities, IDSA urges the subcommittee to adopt report 
language to encourage the development of clear Federal guidelines for 
conducting research during a public health emergency. Specifically, 
report language should urge the ASPR to include the Office for Human 
Research Protections (OHRP) and other HHS offices and agencies involved 
in public health emergency research in the ASPR-led discussions 
concerning a public health emergency research review board. Also, ASPR 
should issue appropriate provisions and guidances to reduce ambiguity 
and improve harmonization among various agencies.

     BIOMEDICAL ADVANCED RESEARCH AND DEVELOPMENT AUTHORITY (BARDA)

    IDSA supports robust funding for BARDA to facilitate advanced 
research and development (R&D) of medical countermeasures, including 
therapeutics, diagnostics, vaccines, and other technologies, including 
new antibiotics to address both intentional attacks and naturally 
emerging infections. BARDA is a critical source of funding for public-
private collaborations for antibiotic R&D.

                 INDEPENDENT STRATEGIC INVESTMENT FIRM

    IDSA supports the establishment and funding of the Medical 
Countermeasure Strategic Investor (MCMSI), proposed by the ASPR in 
August 2010 and again included in the President's fiscal year 2014 
budget request. The MCMSI would be a non-government, non-profit entity 
that would partner with small ``innovator'' companies and private 
investors to address urgent needs, including the development of novel 
antimicrobials.

            CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)

    IDSA urges the subcommittee to adopt report language urging CMS to 
help address the growing problem of antimicrobial resistance by working 
with healthcare institutions to develop and implement physician-led 
antimicrobial stewardship programs in all healthcare facilities.
    Moreover, we ask for report language that supports the submission 
by acute care hospitals of summary data on influenza vaccination of 
health care personnel and the expansion of this requirement to all 
hospitals and nursing facilities.

          HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA)
                            HIV/AIDS BUREAU

    IDSA strongly urges the subcommittee to increase funding for the 
Ryan White Program by $276 million in fiscal year 2014 with at least an 
increase of $21.5 million over the fiscal year 2013 continuing 
resolution level for Part C. Ryan White Part C funds comprehensive HIV 
care and treatment--services that are directly responsible for the 
dramatic decreases in AIDS-related mortality and morbidity over the 
last decade. On average it costs $3,501 per person per year to provide 
the comprehensive outpatient care available at Part-C funded programs 
(excluding medications), including lab work, STD/TB/Hepatitis 
screening, ob/gyn care, dental care, mental health and substance abuse 
treatment, and case management. Part C funding covers a small 
percentage of the total cost of providing comprehensive care with some 
programs receiving $450 or lower per patient per year to cover care. 
The HIV medical clinics funded through Part C have been in dire need of 
increased funding for years, but efforts to bring more people with HIV 
into care through routine HIV screening along with ongoing economic 
pressures are creating a crisis in communities across the country. An 
increase in funding is critical to prevent additional staffing and 
service cuts and ensure the public health of our communities. At a bare 
minimum, IDSA strongly urges you to support an increase of $20 million 
over fiscal year 2013 appropriated funding for Ryan White Part C.
    Thank you again for the opportunity to submit this statement on 
behalf of the Nation's infectious diseases physicians and scientists. 
Forward any questions to [email protected].
---------------------------------------------------------------------------
    \1\ ``Combating the Silent Epidemic of Viral Hepatitis: Action Plan 
for the Prevention, Care and Treatment of Viral Hepatitis,'' U.S. 
Department of Health and Human Services (May, 2011).
---------------------------------------------------------------------------
                                 ______
                                 
   Prepared Statement of the International Foundation For Functional 
                       Gastrointestinal Disorders
_______________________________________________________________________

    1)  $32 billion for the National Institutes of Health (NIH) at an 
increase of $1 billion over fiscal year 2012. Increase funding for the 
National Cancer Institute (NCI), the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK) and the National Institute of 
Allergy and Infectious Diseases (NIAID) by 12 percent.
    2)  Continue focus on Digestive Disease Research and Education at 
NIH, including), Irritable Bowel Syndrome (IBS), Fecal Incontinence 
Gastroesophageal Reflux Disease (GERD) Gastroparesis, and Cyclic 
Vomiting Syndrome (CVS).
_______________________________________________________________________

    Thank you for the opportunity to present the views of the 
International Foundation for Functional Gastrointestinal Disorders 
(IFFGD) regarding the importance of functional gastrointestinal and 
motility disorders (FGIMD) research. Established in 1991, IFFGD is a 
patient-driven nonprofit organization dedicated to assisting 
individuals affected by FGMIDs, and providing education and support for 
patients, healthcare providers, and the public. IFFGD also works to 
advance critical research on FGIMDs in order to develop better 
treatment options and to eventually find cures. IFFGD has worked 
closely with the National Institutes of Health (NIH) on many 
priorities, and I served on the National Commission on Digestive 
Diseases (NCDD), which released a long-range plan in 2009, entitled 
Opportunities and Challenges in Digestive Diseases Research: 
Recommendations of the National Commission on Digestive Diseases.
    The need for increased research, more effective and efficient 
treatments, and the hope for discovering a cure for FGIMDs are close to 
my heart. My own experiences of suffering from FGIMDs motivated me to 
establish IFFGD, and I was shocked to discover that despite the high 
prevalence of FGIMDs among all demographic groups, such a lack of 
research existed. This translates into a dearth of diagnostic tools, 
treatments, and patient supports. Even more shocking is the lack of 
awareness among the medical community and the public, leading to 
significant delays in diagnosis, frequent misdiagnosis, and 
inappropriate treatments including unnecessary surgery. Most FGIMDs 
have no cure and limited treatment options, so patients face a lifetime 
of chronic disease management. The costs associated with these diseases 
range from $25-$30 billion annually; economic costs are also reflected 
in work absenteeism and lost productivity.

                     IRRITABLE BOWEL SYNDROME (IBS)

    IBS affects 30 to 45 million Americans, conservatively at least 1 
out of every 10 people. It is a chronic disease that causes abdominal 
pain and discomfort associated with a change in bowel pattern, such as 
diarrhea and/or constipation. As a ``functional disorder,'' IBS affects 
the way the muscles and nerves work, but the bowel does not appear to 
be damaged on medical tests. Without a diagnostic test, IBS often goes 
undiagnosed or misdiagnosed for years. Even after IBS is identified, 
treatment options are limited and vary from patient to patient. Due to 
persistent pain and bowel unpredictability, individuals may distance 
themselves from social events and work. Stigma surrounding bowel habits 
may act as barrier to treatment, as patients are not comfortable 
discussing their symptoms with doctors. Many people also dismiss their 
symptoms or attempt to self-medicate with over-the-counter medications. 
Outreach to physicians and the general public remain critical to 
overcome these barriers to treatment and assist patients.

                           FECAL INCONTINENCE

    At least 12 million Americans suffer from fecal incontinence. 
Incontinence crosses all age groups, but is more common among women and 
the elderly of both sexes. Often it is associated with neurological 
diseases, cancer treatments, spinal cord injuries, multiple sclerosis, 
diabetes, prostate cancer, colon cancer, and uterine cancer. Causes of 
fecal incontinence include: damage to the anal sphincter muscles, 
damage to the nerves of the anal sphincter muscles or the rectum, loss 
of storage capacity in the rectum, diarrhea, or pelvic floor 
dysfunction. People may feel ashamed or humiliated, and most attempt to 
hide the problem for as long as possible. Some don't want to leave the 
house in fear they might have an accident in public; they withdraw from 
friends and family, and often limit work or education efforts. 
Incontinence in the elderly is the primary reason for nursing home 
admissions, an already significant social and economic burden in our 
aging population. In 2002, IFFGD sponsored a consensus conference 
entitled, Advancing the Treatment of Fecal and Urinary Incontinence 
Through Research: Trial Design, Outcome Measures, and Research 
Priorities. IFFGD also collaborated with NIH on the NIH State-of-the-
Science Conference on the Prevention of Fecal and Urinary Incontinence 
in Adults in 2007.
    NIDDK recently launched a Bowel Control Awareness Campaign (BCAC) 
that provides resources for healthcare providers, information about 
clinical trials, and advice for individuals suffering from bowel 
control issues. The BCAC is an important step in reaching out to 
patients, and we encourage continued support for this campaign. Further 
research on fecal incontinence is critical to improve patient quality 
of life and implement the research goals of the NCDD.

                 GASTROESOPHAGEAL REFLUX DISEASE (GERD)

    GERD is a common disorder which results from the back-flow of 
stomach contents into the esophagus. GERD is often accompanied by 
chronic heartburn and acid regurgitation, but sometimes the presence of 
GERD is only revealed when dangerous complications become evident. 
There are treatment options available, but they are not always 
effective and may lead to serious side effects. Gastroesophageal reflux 
(GER) affects as many as one-third of all full term infants born in 
America each year and even more premature infants. GER results from 
immature upper gastrointestinal motor development. Up to 8 percent of 
children and adolescents will have GER or GERD due to lower esophageal 
sphincter dysfunction and may require long-term treatment.

                             GASTROPARESIS

    Gastroparesis, or delayed gastric emptying, refers to a stomach 
that empties slowly. Gastroparesis is characterized by symptoms from 
the delayed emptying of food, namely: bloating, nausea, vomiting, or 
feeling full after eating only a small amount of food. Gastroparesis 
can occur as a result of several conditions, and is present in 30 
percent to 50 percent of patients with diabetes mellitus. A person with 
diabetic gastroparesis may have episodes of high and low blood sugar 
levels due to the unpredictable emptying of food from the stomach, 
leading to diabetic complications. Other causes of gastroparesis 
include Parkinson's disease and some medications. In many patients the 
cause cannot be found and the disorder is termed idiopathic 
gastroparesis.

                     CYCLIC VOMITING SYNDROME (CVS)

    CVS is a disorder with recurrent episodes of severe nausea and 
vomiting interspersed with symptom free periods. The periods of 
intense, persistent nausea and vomiting, accompanied by abdominal pain, 
prostration, and lethargy, last hours to days. Previously thought to 
occur primarily in pediatric populations, it is increasingly understood 
that this crippling syndrome can occur in many age groups, including 
adults. CVS patients often go for years without correct diagnosis. CVS 
leads to significant time lost from school and from work, as well as 
substantial medical morbidity. The cause of CVS is not known. Research 
is needed to help identify at-risk individuals and develop more 
effective treatment strategies.

                     SUPPORT FOR CRITICAL RESEARCH

    IFFGD urges Congress to fund the NIH at level of $32 billion for 
fiscal year 2014.--Strengthening and preserving our Nation's biomedical 
research enterprise fosters economic growth and supports innovations 
that enhance the health and well-being of the Nation. Concurrent with 
overall NIH funding, IFFGD supports the growth of research activities 
on FGIMDs to strengthen the medical knowledge base and improve 
treatment, particularly through the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK). Such support would expedite the 
implementation of recommendations from the NCDD. It is also vital for 
NIDDK to work with the National Institute of Child Health and Human 
Development (NICHD) to expand its research on the impact FGIMDs have on 
pediatric populations. Following years of near level-funding, research 
has been negatively impacted across all NIH Institutes and Centers. 
Without additional funding, medical researchers run the risk of losing 
promising research opportunities that could benefit patients.
    We applaud the recent establishment of the National Center for 
Advancing Translational Sciences (NCATS) at NIH. Initiatives like the 
Cures Acceleration Network are critical to overhauling the 
translational research process and overcoming the challenges that 
plague treatment development. In addition, new efforts like taking the 
lead on drug repurposement hold the potential to speed new treatment to 
patients. We ask that you support NCATS and provide adequate resources 
for the Center in fiscal year 2014.
    Thank you for the opportunity to present these views on behalf of 
the FGIMD community.
                                 ______
                                 
      Prepared Statement of the Interstitial Cystitis Association

            SUMMARY OF RECOMMENDATIONS FOR FISCAL YEAR 2014
_______________________________________________________________________

  --$660,000 for the IC Education and Awareness Program at the Centers 
        for Disease Control and Prevention.
  --$32 billion for the National Institutes of Heatlh (NIH) and 
        Proportional Increases Across All Institutes and Centers.
  --Support for NIH Research on IC, including:
    --The Multidisciplinary Approach to the Study of Chronic Pelvic 
            Pain (MAPP) Research Network.
    --Research on IC in Children.
_______________________________________________________________________

    Thank you for the opportunity to present the views of the 
Interstitial Cystitis Association (ICA) regarding the importance of 
interstitial cystitis (IC) public awareness and research.
    ICA was founded in 1984 and remains the only nonprofit organization 
dedicated to improving the lives of those affected by IC. The 
Association provides an important avenue for advocacy, research, and 
education relating to this painful condition. Since its founding, ICA 
has acted as a voice for those living with IC, enabling support groups 
and empowering patients. ICA advocates for the expansion of the IC 
knowledge-base and the development of new treatments, including 
investigator initiated research. Finally, ICA works to educate 
patients, healthcare providers, and the public at large about IC.
    IC is a condition that consists of recurring pelvic pain, pressure, 
or discomfort in the bladder and pelvic region. It is often associated 
with urinary frequency and urgency. This condition may also be referred 
to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and 
chronic pelvic pain (CPP). It is estimated that as many as 12 million 
Americans have IC symptoms. Approximately two-thirds of these patients 
are women, though this condition does severely impact the lives of as 
many as 4 million men as well. IC has been seen in children and many 
adults with IC report having experienced urinary problems during 
childhood. However, little is known about IC in children, and 
information on statistics, diagnostic tools and treatments specific to 
children with IC are limited.
    The exact cause of IC is unknown and there are few treatment 
options available. There is no diagnostic test for IC and diagnosis is 
made only after excluding other urinary/bladder conditions. It is not 
uncommon for patients to experience one or more years delay between the 
onset of symptoms and a diagnosis of IC. This is exacerbated when 
healthcare providers are not properly educated about IC and some 
patients suffer many years before they are diagnosed and empowered to 
attempt potential therapies.
    The effects of IC are pervasive and insidious, damaging work life, 
psychological well-being, personal relationships, and general health. 
The impact of IC on quality of life is equally as severe as rheumatoid 
arthritis and end-stage renal disease. Health-related quality of life 
in women with IC is worse than in women with endometriosis, vulvodynia, 
and overactive bladder. IC patients have significantly more sleep 
dysfunction, and higher rates of depression, anxiety, and sexual 
dysfunction.
    Some studies suggest that certain conditions occur more commonly in 
people with IC than in the general population. These conditions include 
allergies, irritable bowel syndrome, endometriosis, vulvodynia, 
fibromyalgia, and migraine headaches. Chronic fatigue syndrome, pelvic 
floor dysfunction, and Sjogren's syndrome have also been reported.

                   IC PUBLIC AWARENESS AND EDUCATION

    The IC Education and Awareness Program at the Centers for Disease 
Control and Prevention (CDC) is critical to improving public and 
provider awareness of this devastating disease, reducing the time to 
diagnosis for patients, and disseminating information on pain 
management and IC treatment options.
    The IC program has utilized opportunities with charitable 
organizations to leverage funds and maximize public outreach. Such 
outreach includes public service announcements in major markets and the 
Internet, as well as a billboard campaign along major highways across 
the country. The IC program has also made information on IC available 
to patients and the public though videos, booklets, publications, 
presentations, educational kits, websites, self-management tools, 
webinars, blogs, and social media communities such as Facebook, 
YouTube, and Twitter. For healthcare providers, this program has 
included the development of a continuing medical education module, 
targeted mailings, and exhibits at national medical conferences.
    The CDC IC Education and Awareness Program also provides patient 
support that empowers patients to self-advocate for their care. Many 
physicians are hesitant to treat IC patients because of the time it 
takes to treat the condition and the lack of answers available. 
Further, IC patients may try numerous potential therapies, including 
alternative and complementary medicine, before finding an approach that 
works for them. For this reason, it is especially critical for the IC 
program to provide patients with information about what they can do to 
manage this painful condition and lead a normal life.
    ICA recommends continued support for the CDC IC Education and 
Awareness Program and a specific appropriation of $660,000 for fiscal 
year 2014. ICA also encourages continued support for the National 
Center for Chronic Disease Prevention and Health Promotion which 
administers the IC program.

           RESEARCH THROUGH THE NATIONAL INSTITUTES OF HEALTH

    The National Institutes of Health (NIH) maintains a robust research 
portfolio on IC. The National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK) is the primary Institute for IC research. Major 
studies that have yielded significant new information include the RAND 
IC Epidemiology (RICE) studies which found that nearly 2.7-6.7 percent 
of adult women and 2 to 4 million men have symptoms consistent with IC. 
The IC Genetic Twin study found environmental factors, rather than 
genetic factors, to be substantial risk factors for developing IC. The 
Events Preceding Interstitial Cystitis (EPIC) study linked non-bladder 
conditions and infectious agents to the development of IC in many 
newly-diagnosed IC patients. The findings of the EPIC study have been 
reinforced by a Northwestern University study which found that an 
unusual form of toxic bacterial molecule (LPS) impacts the development 
of IC as a result of an infectious agent. Finally, the Urologic Pelvic 
Pain Collaborative Research Network (UPPCRN) indicated promising 
results for a new therapy for IC patients.
    Research currently underway also holds great promise to improving 
our understanding of IC and developing better treatments and a cure. 
The NIDDK Multidisciplinary Approach to the Study of Chronic Pelvic 
Pain (MAPP) Research Network studies the underlying causes of chronic 
urological pain syndromes. The Specialized Centers of Research on Sex 
and Gender Factors Affecting Women's Health established by the Office 
of Research on Women's Health (ORWH) includes an IC component. Research 
on chronic pelvic pain is supported by the National Institute of 
Neurological Disorders and Stroke (NINDS) as well as the National 
Center for Complementary and Alternative Medicine (NCCAM). 
Additionally, the NIH investigator-initiated research portfolio 
continues to be an important mechanism for IC researchers to create new 
avenues for interdisciplinary research.
    ICA also supports the National Center for Advancing Translational 
Sciences (NCATS), including the Cures Acceleration Network (CAN). 
Initiatives like CAN are critical to overhauling the translational 
research process and overcoming the research ``valley of death'' that 
currently plagues treatment development. In addition, drug 
repurposement and other efforts led by NCATS hold the potential to 
speed access to new treatment for patients. ICA encourages support for 
NCATS and the provision of adequate resources for the Center in fiscal 
year 2014.
    ICA recommends a funding level of $32 billion for NIH in fiscal 
year 2014. ICA also recommends continued support the MAPP study 
administered by NIDDK, and the expansion of research focused on IC in 
children.
    Thank you for the opportunity to present the views of the 
interstitial cystitis community.
                                 ______
                                 
        Prepared Statement of the Joint Advocacy Coalition (JAC)

JAC Fiscal Year 2014 LHHS Appropriations Recommendations
  --Protect clinical and translational research and research training 
        programs from devastating funding cuts due to sequestration and 
        deficit reduction initiatives.
  --Provide $32 billion for NIH, an increase of $1.3 billion over 
        fiscal year 2012.
  --Provide $434 million for AHRQ, an increase of $29 million over 
        fiscal year 2012, and meaningful funding increases for related 
        agencies that support patient-centered and comparative 
        effectiveness research.
  --Provide $7 billion for the Health Resources and Services 
        Administration (HRSA), an increase of $789 million from fiscal 
        year 2012, and meaningful funding increase for related agencies 
        that support clinical and translational research, including 
        research into the health system and healthcare delivery.
  --Provide continued support for Federal research training and career 
        development activities such as the ``K'' and ``T'' awards 
        programs.
    Chairman Harkin, Ranking Member Moran, and distinguished members of 
the subcommittee, thank you for the opportunity to submit written 
testimony on behalf of JAC.

The JAC
    JAC is comprised of organizations representing the clinical and 
translational research and research training community, and is led by 
the Association for Clinical and Translational Science and Clinical 
Research Forum. These organizations are dedicated to improving the 
health of the public through clinical and translational research and to 
supporting this Nation's research training and career development 
pipeline. JAC speaks with one voice on behalf of this community to 
advocate for adequate funding of clinical and translational research 
and research training programs at NIH, AHRQ, and related Federal 
agencies, and the Patient-Centered Outcomes Research Institute (PCORI).

Deficit Reduction and Sequestration
    Our Nation's investment in the full spectrum of biomedical research 
from molecules to populations is an engine that drives economic growth 
while improving health outcomes for patients with chronic, costly, and 
life-threatening conditions. Research projects funded through NIH, 
AHRQ, HRSA, and related agencies are conducted at academic health 
centers, community hospitals, and other local settings across the 
country. federally-supported clinical and translational research 
activities have a major economic impact on local communities, which 
includes high-quality job creation, in addition to forming a 
cornerstone of this Nation's biotechnology industry. Translational 
research embraces and connects the two poles of biomedical research, 
from bench to bedside and from clinical trials to broad application in 
the population. Cutting funding to NIH, AHRQ, HRSA, and related 
programs would have direct and immediate negative consequences for the 
local communities that support clinical and translational research 
activities.
    Equally troubling and problematic is the message that funding cuts 
to biomedical research send to the next generation of young scientists. 
Medical research activities are not a faucet that can simply be turned 
off and on with funding. When funding begins to dry up, our best and 
brightest are faced with a strong disincentive to pursue a career in 
this field. It is difficult to justify a long and demanding period of 
training when a young investigator has slim chances of securing a 
Federal grant to support their research. Currently, NIH cannot fund 
many promising meritorious grant submissions and only funds less than 
10 percent of all grant applications. Further, the average age for a 
researcher to receive their first grant is presently 42. If funding is 
cut further, the ``pay line'' at which funding is possible will 
continue to drop and the average age for securing a grant will rise. 
Compounding this situation is a very real threat to losing top research 
talent posed by biotechnology investments being made by several other 
countries. China alone plans to dedicate $300 billion to medical 
research over the next 5 years; this amount is double the current NIH 
budget over the same period of time. Research is not beholden to 
language or culture and young investigators will gravitate towards any 
country that has the resources to support their promising research. 
Unless we provide a meaningful investment in clinical and translational 
research training programs over the coming years, our loss will be our 
competitors' gain. We will concede innovation in healthcare delivery 
and cutting-edge therapies to foreign biotech industries.
    Most importantly, cutting funding to clinical and translational 
research programs will delay and jeopardize healthcare advances that 
would benefit patients dealing with serious and life-threatening 
medical conditions and cut healthcare costs. Research leading to new 
therapies and how these new therapies can be used in evidence-based 
medical care is essential to controlling healthcare costs. Prevention 
through interventions like new vaccines has been demonstrated to save 
healthcare costs. Federal programs focused on developing personalized 
medicine and patient-focused care are only just beginning to be 
implemented. If these programs are forced to confront reduced resources 
in their infancy, they may never be able to achieve their potential or 
accomplish their missions. A loss of funding for NIH, AHRQ, HRSA, and 
related agencies would seriously undermine the ongoing effort to bring 
this country's healthcare system in to the 21st century. Setbacks in 
this area would be felt by members of every community; since neither 
industry nor hospitals support these critical components of research 
that lead to new drugs, vaccines, devices, and diagnostics.

Support for Clinical and Translational Research Activities
    With the establishment of the Clinical and Translational Science 
Awards (CTSA) program in 2006, NIH began a commitment to supporting the 
full spectrum of research to bridge the ``valley of death'' between 
basic scientific discoveries and bedside therapies, diagnostic tools, 
and practices. In 2011, the CTSA Consortium reached its planned size of 
approximately 60 medical research institutions located in 30 States 
throughout the Nation, linking them together to energize the discipline 
of clinical and translational science. The CTSAs have an explicit goal 
of improving healthcare in the United States by transforming the 
biomedical research enterprise to become more effectively 
translational.
    Although the promise of the CTSA program is recognized both 
nationally and internationally, it has suffered from a lack of adequate 
funding. In 2006, 16 initial CTSAs were funded, followed by 12 in 2007, 
14 in 2008, 4 in 2009, 9 in 2010, and 5 in 2011. Level funding at NIH 
curtailed the growth of the CTSAs, preventing institutions from fully 
implementing their awards and causing them to drastically alter their 
budgets after research had already begun. As a testament to the 
strength of the concept, the CTSA program continues to generate 
significant scientific progress with limited resources. With full 
funding, the CTSA program could be even more successful and productive. 
While the Nation could benefit from additional CTSAs in the future, the 
current sites are having an enormous impact, so any attempt to provide 
full funding should not curtail the current number of sites or limit 
the geographic diversity of the program.
    Prevention science and comparative effectiveness research (CER) are 
new approaches to evaluate the impact of different options that are 
available for preventing or treating a given medical condition for a 
particular set of patients. These can include medications, lifestyle 
therapies, and medical devices, among other interventions. Both AHRQ 
and NIH have long histories of supporting CER and prevention research, 
and the standards for research instituted by these agencies serve as 
models for best practices worldwide. Not only are these agencies 
experienced in CER, they are universally recognized as impartial and 
honest brokers of information. Moreover, their approach enables and 
does not duplicate the approach of PCORI. Continued support is critical 
to ensuring that patients benefit from the best information for them 
and their doctors to make healthcare decisions.

Support for Research Training and Career Development Programs
    The future of our Nation's biomedical research enterprise relies 
heavily on the maintenance and continued recruitment of promising young 
investigators. The ``T'' and ``K'' series awards at NIH and AHRQ 
provide much-needed support for the career development of young 
investigators. These programs are efficient because they provide 
training to small groups and not individual trainees. As clinical and 
translational medicine takes on increasing importance, there is a great 
need to grow these programs, not to reduce them. Career development 
grants are crucial to the recruitment of promising young investigators, 
as well as to the continuing education of established investigators. 
Reduced commitment to the K-12, K-23, K-24, and K-30 awards would have 
a devastating impact on our pool of highly trained clinical 
researchers. Even with the full implementation of the CTSA program, it 
is critical for institutions without CTSAs to retain their K-30 
Clinical Research Curriculum Awards, as the K-30s remain a highly cost-
effective method of ensuring quality clinical research training. The 
JAC urges you to support the ongoing commitment to research training 
through adequate funding for T and K series awards.
    Thank you for the opportunity to present the views and 
recommendations of the clinical research training community. Please 
contact JAC if you have any questions or if you would like any 
additional information.
                                 ______
                                 
             Prepared Statement of the Lung Cancer Alliance

    Lung Cancer Alliance is grateful for the opportunity to share our 
views on the pending fiscal year 2014 Appropriations and the potential 
impact on the operation of the U.S. Preventive Services Task Force 
(USPSTF) and the Agency for Healthcare Research and Quality (AHRQ) 
within the Department of Health and Human Services (HHS).
    Lung Cancer is the leading cause of cancer death in the United 
States. Nearly one third of all cancer deaths in the U.S. are lung 
cancer deaths. Each year, 160,000 lives are lost to lung cancer. Sixty 
percent of the people diagnosed with lung cancer today are former 
smokers who heeded the call to quit. Over 75 percent of lung cancers 
are diagnosed at late stage when treatment options are limited, 
expensive and sadly, often futile. This can change.
    In November 2010, the National Cancer Institute (NCI) announced it 
was terminating the largest, most expensive randomized control trial in 
its history because the trial demonstrated conclusively--sooner than 
expected--that screening those at high risk for lung cancer with CT 
scans could greatly reduce lung cancer deaths. The National Lung 
Screening Trial (NLST) compared low dose CT screening to x-rays for the 
detection of lung cancer in people over 55 with a significant smoking 
history and found that low dose CT screening provided a 20 percent 
mortality benefit. To put this into context, the overall mortality 
benefit for mammography is 15 percent. These are substantial mortality 
benefits and for a cancer as widespread and impactful as lung cancer, 
it means that tens of thousands of lives could be saved each year if 
lung cancer screening is deployed responsibly and equitably.
    Despite this conclusive scientific evidence and subsequent 
published and peer reviewed studies that show low dose CT screening is 
cost effective from a commercial payers perspective, to date, USPSTF 
has failed to make a recommendation. This failure to make a 
recommendation has literally been the difference between life and death 
for those who continue to be diagnosed for lung cancer at late stage.
    We have profound concerns about the operation of the U.S. 
Preventive Services Task Force in this era of expanded authority under 
the Affordable Care Act (ACA). Because of the ACA, USPSTF now not only 
determines what benefits will be covered by Medicare and Medicaid but 
also what services will be considered an Essential Health Benefit for 
coverage in State and Federal health care exchanges. Preventive 
Services receiving less than an A or B recommendation are not required 
to be covered by the commercial health plans offered through these 
exchanges.
    The ACA is replete with references to transparency in the operation 
of exchanges and other provisions, but silent in this regard with 
respect to USPSTF. Initially, and in anticipation of an escalation in 
the number of concerns already being expressed by some members of 
Congress, USPSTF announced in 2011 a new initiative to ``make its 
recommendations clearer and its processes more transparent.''
    With lung cancer screening under review at the time, Lung Cancer 
Alliance was asked to participate in the pilot project, which included 
the first ``Topic Groups for Stakeholders'' (TOPS), a key component of 
the new openness that USPSTF described as an effort to make its work 
``more transparent and trustworthy.'' As you can imagine, Lung Cancer 
Alliance immediately agreed to participate. Unfortunately, since that 
first and only call on November 10, 2011, there has been no additional 
actions or activities. Despite repeated requests, Lung Cancer Alliance 
has not been given any information regarding the other members of the 
lung cancer TOPS, the final research plan, the reviewers who were 
selected, how they were selected or the timeline for draft 
recommendations. We have not even been told who else was on the one 
TOPS call.
    While the lack of transparency is deeply disappointing and 
inexplicable, the lethargic pace of USPSTF in reviewing CT screening is 
having tragic consequences in lives lost. On average, 435 people a day 
die of lung cancer. If screening is implemented right and well, 200 
people a day could be saved. Thus, tens of thousands of lives a year 
are at stake. Studies by Milliman Inc. have also validated its cost 
efficiency.
    Yet, as it now stands, since lung cancer screening has not yet 
received an A or B recommendation, CT lung cancer screening for those 
at high risk will not be covered under Medicare, Medicare or included 
as an Essential Health Benefit for insurance purchased through the 
exchanges.
    For many of those at high risk, unless action is taken by Congress, 
this unfortunate convergence of bureaucratic delays and the arbitrary 
deadline in inclusion under the Affordable Care Act will be a de facto 
of denial of access to this life saving, cost efficient benefit.
    We urge the Committee to direct the Secretary of Health and Human 
Services to include CT screening of those at high risk for lung cancer 
as an Essential Health Benefit and as a covered benefit under Medicare 
and Medicaid.
                                 ______
                                 
          Prepared Statement of the March of Dimes Foundation

       MARCH OF DIMES: FISCAL YEAR 2014 FEDERAL FUNDING PRIORITIES
                         [Dollars in thousands]
------------------------------------------------------------------------
                                                             Fiscal Year
                          Program                                2014
                                                               Request
------------------------------------------------------------------------
National Institutes of Health (Total)......................   32,000,000
------------------------------------------------------------------------
National Children's Study..................................      192,000
Common Fund................................................      570,530
National Institute of Child Health and Development.........    1,370,000
National Human Genome Research Institute...................      536,967
National Institute on Minority Health and Disparities......      289,426
------------------------------------------------------------------------
Centers for Disease Control and Prevention (Total).........    7,800,000
------------------------------------------------------------------------
National Center for Birth Defects and Developmental              139,000
 Disabilities..............................................
    Birth Defects Research and Surveillance................       22,300
    Folic Acid Campaign....................................        2,800
Section 317................................................      720,000
Polio Eradication..........................................      126,400
Safe Motherhood Initiative.................................       44,000
    Preterm Birth..........................................        2,000
National Center for Health Statistics......................      162,000
------------------------------------------------------------------------
Health Resources and Services Administration (Total).......    7,000,000
------------------------------------------------------------------------
Title V, Maternal and Child Health Block Grant.............      640,000
    SPRANS--Infant Mortality and Preterm Birth.............        3,000
Heritable Disorders........................................       13,300
Universal Newborn Hearing..................................       18,660
Community Health Centers...................................    1,580,000
Healthy Start..............................................      103,532
Children's Graduate Medical Education......................      317,500
------------------------------------------------------------------------
Agency for Healthcare Research and Quality (Total).........      430,000
------------------------------------------------------------------------

    The three million volunteers and 1,200 staff members of the March 
of Dimes Foundation appreciate the opportunity to submit Federal 
funding recommendations for fiscal year 2014 (fiscal year 2014). The 
March of Dimes is a unique partnership of scientists, clinicians, 
parents, members of the business community and other volunteers 
affiliated with 51 chapters and 213 divisions in every State, the 
District of Columbia and Puerto Rico. The March of Dimes recommends the 
following funding levels for programs and initiatives that are 
essential investments in maternal and child health.

Preterm Birth
    Preterm birth is a serious health problem that costs the United 
States more than $26 billion annually. Employers, private insurers and 
individuals bear approximately half of the costs of health care for 
these infants, and another 40 percent is paid by Medicaid. One in nine 
infants in the U.S. is born preterm. Prematurity is the leading cause 
of newborn mortality and the second leading cause of infant mortality. 
Among those who survive, one in five faces health problems that persist 
for life such as cerebral palsy, intellectual disabilities, chronic 
lung disease, and deafness. In 2011, the Nation's preterm birth dropped 
for the fifth consecutive year to 11.7 percent, giving thousands more 
infants a healthy start in life and saving billions in health and 
social costs. We believe one of the factors behind the decline was 
Congress's passage of the 2006 PREEMIE Act (Public Law 109-450), which 
brought the first-ever national focus to prematurity prevention. The 
Surgeon General's Conference on the Prevention of Preterm Birth created 
by the Act generated a public-private agenda to spur innovative 
research at the National Institutes of Health (NIH) and Centers for 
Disease Control and Prevention (CDC) and advanced evidence-based 
interventions to prevent preterm birth. The March of Dimes' fiscal year 
2014 funding requests regarding preterm birth are based on the 
recommendations from 2008 conference and the PREEMIE Act.

National Children's Study (NCS)
    The March of Dimes recommends $192 million in fiscal year 2014 for 
the National Children's Study to allow for roll-out of the main study 
with a science-based design and recruitment strategy. The NCS is the 
largest and most comprehensive study of children's health and 
development ever planned in the U.S. When fully implemented, this study 
will follow 100,000 children in the U.S. from before birth until age 
21. The data has the potential to transform our understanding of child 
health and development, and to lead to new forms of prevention and 
treatment for a multitude of conditions and diseases of childhood.

Eunice Kennedy Shriver National Institute of Child Health and Human 
        Development (NICHD)
    The March of Dimes recommends at least $1,370 million for the NICHD 
in fiscal year 2014. This funding will allow NICHD to sustain its 
preterm birth-related research through extramural grants, Maternal-
Fetal Medicine Units, the Neonatal Research Network and the intramural 
research program. This funding would also allow for NICHD to invest in 
transdisciplinary research to identify the causes of preterm birth, as 
recommended in the Director's 2012 Scientific Vision for the next 
decade, the Institute of Medicine 2006 report on preterm birth, and the 
2008 Surgeon General's Conference on the Prevention of Preterm Birth. 
The March of Dimes fully supports NICHD's pursuit of transdisiplinary 
science, which will facilitate the exchange of scientific ideas and 
lead to novel approaches to understanding complex health issues and 
their prevention.

Centers for Disease Control and Prevention--Preterm Birth
    The mission of the CDC's National Center for Chronic Disease 
Prevention and Health Promotion's Safe Motherhood Initiative is to 
promote optimal reproductive and infant health. The March of Dimes 
recommends funding of $44 million for the Safe Motherhood program and 
re-instatement of the preterm birth sub-line at $2 million, as 
authorized in the PREEMIE Act, to reflect current preterm birth 
research within the CDC.

Health Resources and Services Administration (HRSA)--Preterm Birth
    The March of Dimes recommends the subcommittee specify $3 million 
within the Title V, Special Projects of Regional and National 
Significance account be used to support current preterm birth and 
infant mortality initiatives, as authorized in the PREEMIE Act, and to 
support the expansion of its initiatives nationwide. The PREEMIE Act 
authorized preterm birth-related demonstration projects, which are 
aimed at improving education, treatment and outcomes for babies born 
preterm. Currently, HRSA is pursuing the Collaborative Improvement & 
Innovation Network (COIN) to Reduce Infant Mortality, which brings 
together infant mortality experts to share best practices and lessons 
learned. Through the COIN, State agencies are focusing on a range of 
interventions proven to reduce preterm birth and improve maternal and 
child health, including reducing elective deliveries before 39 weeks 
and implementing evidence-based smoking cessation initiatives. 
Expanding the COIN initiative nationwide will reduce preterm birth 
rates and infant mortality.

Birth Defects
    According to the CDC, an estimated 120,000 infants in the U.S. are 
born with major structural birth defects each year. Birth defects are 
the leading cause of infant mortality and the causes of more than 70 
percent are unknown. Additional Federal resources are sorely needed to 
support research to discover the causes of all birth defects and for 
the development of effective interventions to prevent or at least 
reduce their prevalence.

CDC--National Center on Birth Defects and Developmental Disabilities 
        (NCBDDD)
    For fiscal year 2014, the March of Dimes requests funding of $139 
million for NCBDDD. We also encourage the subcommittee to provide at 
least $2.8 million to support folic acid education and $22.3 million to 
support birth defects research and surveillance--a $2 million increase 
from fiscal year 2012 enacted levels. Allocating an additional $2 
million to birth defects research and surveillance will support genetic 
analysis of the research samples already obtained through the NCBDDD's 
National Birth Defects Prevention Study--the largest case-controlled 
study of birth defects ever conducted. Further, allocating at least $2 
million to folic acid education will allow the CDC to sustain its 
effective education campaign aimed at reducing the incidence of spina 
bifida and anencephaly by promoting consumption of folic acid.

Newborn Screening
    Newborn screening is a vital public health activity designed to 
identify genetic, metabolic, hormonal and functional disorders in 
newborns. Screening detects conditions in newborns that, if left 
untreated, can cause disability, developmental delays, intellectual 
disabilities, serious illnesses or even death. If diagnosed early, many 
of these disorders can be managed successfully. The March of Dimes 
urges the subcommittee to provide $13.3 million for HRSA's heritable 
disorders program and the work of the Advisory Committee on Heritable 
Disorders in Newborns and Children, as authorized by the Newborn 
Screening Saves Lives Act (Public Law 110-204). In 2013, the United 
States will mark the 50th anniversary of newborn screening. The 
Heritable Disorders program plays a critical role in assisting States 
in the adoption of additional screenings, enhancing provider and 
consumer education and ensuring coordinated follow-up care.
Closing
    The Foundation's volunteers and staff in every State, the District 
of Columbia and Puerto Rico look forward to working with Members of 
this subcommittee to secure the resources needed to improve the health 
of the Nation's mothers, infants and children.
                                 ______
                                 
    Prepared Statement of the Meals On Wheels Association of America

    Thank you for the opportunity to present testimony to your 
subcommittee concerning fiscal year 2014 funding for Older Americans 
Act (OAA) Nutrition Programs administered by the Administration for 
Community Living (ACL)/Administration on Aging (AoA) within the U.S. 
Department of Health and Human Services (HHS). I am Ellie Hollander, 
President and CEO of the Meals On Wheels Association of America. As you 
may know, we are the oldest and largest national organization 
representing local, community-based Senior Nutrition Programs--both 
congregate and home-delivered (commonly referred to as Meals on 
Wheels)--in all 50 States and Territories. As a national organization 
and network, we are working together to end senior hunger in America by 
2020.
    Every day, thousands of Senior Nutrition Programs in every State 
provide nutritious meals and daily social contact to seniors 60 years 
of age or older who are at significant risk of hunger and losing their 
ability to remain independent in their own homes and communities. More 
than 70 percent of the Members of our Association provide both types of 
meals authorized under the OAA--nutritious meals served in congregate 
locations such as senior centers, as well those served directly to the 
residences of homebound seniors. Today, I speak on behalf not only of 
the national network of Senior Nutrition Programs and for the hundreds 
of thousands of seniors nationwide who rely on these programs for their 
primary source of nutritious food. But I also speak for millions of 
other seniors who need meals but are not able to receive them--not 
because we lack the infrastructure and expertise to serve them but 
because there are not adequate financial resources to do so.
    One of the great strengths of Senior Nutrition Programs for which 
we are truly proud, is that they are strong public-private 
partnerships. Not only do these programs engage volunteers from the 
community, they raise significant private funds in their communities to 
augment the limited Federal funds furnished through the annual Labor, 
Health and Human Services, Education and Related Agencies appropriation 
bills. Nationally, about 30 percent of the total spending for 
congregate and home-delivered meals is provided through Older Americans 
Act funding. The rest must be raised from State and local sources as 
well as private donations. However, in recent years, it has proven more 
and more difficult to leverage funding from these other sources. Year 
after year, Senior Nutrition Programs are serving fewer seniors and 
meals at a time when the need and demand is growing at an unprecedented 
pace.
    Currently, Senior Nutrition Programs face ongoing challenges, 
including:
  --Sequestration;
  --Year-over-year Federal, State and local budget cuts;
  --Rising costs for food, transportation and employees;
  --Fewer and smaller private donations due to the slow economy;
  --Increased demand, as Baby Boomers turn 65 at the rate of 10,000 a 
        day;
  --Increased need, with 8.3 million seniors--or 1 in 7--struggling 
        with hunger today.
    Data relating to utilization of OAA Senior Nutrition Programs 
illustrate how these compounding factors have already reduced the 
number of meals being served. For example, in 2011, OAA Nutrition 
Programs served 14 million fewer meals as compared to 2010. Despite the 
increasing need due to demographics and economic conditions, 88,000 
fewer seniors were able to be served across the United States in 2011 
as compared to the previous year.
    Yet another example of these compounding effects is outlined in the 
President's fiscal year 2014 Budget, which proposes continued funding 
for OAA Nutrition Programs for another fiscal year at the fiscal year 
2012 level. According to ACL's Congressional Budget Justification, the 
request for OAA Nutrition Programs--$816 million--is estimated to 
support the provision of 214 million meals for 2.3 million seniors. 
This represents nearly a 14 million meal reductions from 2011 and 
nearly 28 million fewer meals from 2010. In terms of the decreases in 
the number of individuals able to be served, it is about 100,000 per 
year--in 2011, 2.5 million seniors were served; and in 2010, that 
number was 2.6 million.
    Clearly, these compounding factors were already causing reductions 
in meals and the number of seniors served, even before the automatic 
cuts were ordered on March 1 of this year. While the specific impact of 
sequestration is not yet quantifiable, it will be devastating to Senior 
Nutrition Programs, and in turn devastating, perhaps even life 
threatening to frail older Americans who rely on them as their only 
source of nutritious food. As a result of sequestration and the 
aforementioned challenges, Senior Nutrition Programs have been forced 
to further reduce meals, cut delivery days, and establish waiting 
lists, leaving so many of our hidden hungry without the nutrition they 
need to remain healthy and out of more costly healthcare settings, such 
as hospitals or nursing homes.
    Given these facts, we appeal to this subcommittee to provide 
increases above the President's request for Title III C1 (Congregate 
Meals), Title III C2 (Home-Delivered Meals) and Nutrition Services 
Incentive Program (NSIP) of the OAA. We ask this knowing that the 
fiscal context in which you are working for this fiscal year 2014 
appropriation bill is extraordinarily challenging and knowing that 
providing increases to our programs likely means reducing or 
eliminating others. However, we believe that investing in OAA Nutrition 
Programs is not only morally right, but that there is a strong business 
and economic case that demonstrates that spending on these programs 
actually helps to save taxpayers' dollars.
    Specifically, research released from Brown University in December 
2012, demonstrates the positive impact of increased spending on home-
delivered meals programs for seniors. The study compared State-level 
expenditures on OAA programs with the population of ``low-care'' 
seniors in nursing homes (i.e., residents of nursing homes that might 
not need the suite of services that a nursing home provides). According 
to the analysis from a decade of spending and nursing home resident 
data, those States that invest more in home-delivered meals to seniors 
have lower rates of ``low-care'' seniors in nursing homes. Home-
delivered meals emerged as the most significant factor among OAA 
services that affected State-to-State differences in low-care nursing 
home population. The research found that for every $25 per year per 
older adult above the national average that States spend on home-
delivered meals, they could reduce their percentage of low-care nursing 
home residents by one percentage point compared to the national 
average. As you know, a 1 percent reduction in Medicare and Medicaid 
expenditures can result in significant savings.
    At a time when Federal and State budgets are looking for ways to 
reduce costs, the impact of an investment in home-delivered meal 
programs, such as Meals on Wheels, can reap tremendous benefits for 
both the seniors that receive them and the communities that often bear 
the costs of supporting our seniors. Previous studies have suggested 
that anywhere from 5 to 30 percent of nursing home residents have low-
care needs and could perhaps be better served in their homes.
    Additionally, the Center for Effective Government (formerly OMB 
Watch) released a study on April 30, 2013, that demonstrates the 
potentially devastating impact sequestration could have not only on 
Meals on Wheels programs and the seniors they serve, but on our 
Nation's budget. The report estimated that 39,000 seniors nationwide 
could, as a result of sequestration's reduction in OAA Home-Delivered 
Nutrition funding, be forced into nursing homes rather than relying on 
a combination of home care and home-delivered meals. The shift in 
living arrangements could cost taxpayers an estimated $489 million per 
year in increased Medicaid costs.
    Providing adequate funds above fiscal year 2012 levels for Senior 
Nutrition Programs can only be regarded as a strong and demonstrable 
value proposition. The more local, community-based Senior Nutrition 
Programs are able to keep seniors well-nourished and in their own homes 
where they want to be, the less the Federal Government will need to 
spend on long-term care, on doctor visits, and stays in the hospital 
funded by Medicare and Medicaid. The return on investment of each 
taxpayer dollar spent on OAA Nutrition Programs is high. In fact, a 
Senior Nutrition Program can provide meals to a senior for a whole year 
for approximately the same cost of care for just one day in the 
hospital or six days in a nursing home.
    In closing, I would like to thank this subcommittee again for its 
longstanding support and acknowledge that our Association understands 
the difficulty of your task in this challenging budget year. As you 
consider our request, we respectfully ask that you think of Senior 
Nutrition Programs not simply as one of the hundreds of programs 
supported through the Labor, Health and Human Services, Education and 
Related Agencies appropriations bill, but instead as a high-reward 
investment--morally and economically--and as a means of helping to 
reduce our Federal spending by avoiding higher Medicare and Medicaid 
expenditures.
    Again, we thank you for the opportunity to present this testimony 
to you.
                                 ______
                                 
 Prepared Statement of the Medical Library Association and Association 
                 of Academic Health Sciences Libraries

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

  --Continue the commitment to the National Library of Medicine (NLM) 
        by supporting the President's budget proposal which requests 
        $382,252,000, and an additional $8,200,000 from amounts under 
        Section 241 of the Public Health Service Act, for the National 
        Information Center on Health Services Research and Health Care 
        Technology.
  --Continue to support the medical library community's role in NLM's 
        outreach, telemedicine, disaster preparedness, health 
        information technology initiatives, and health care reform 
        implementation.
_______________________________________________________________________
                              INTRODUCTION

    The Medical Library Association (MLA) and Association of Academic 
Health Sciences Libraries (AAHSL) thank the subcommittee for the 
opportunity to submit testimony regarding fiscal year 2014 
appropriations for the National Library of Medicine (NLM), an agency of 
the National Institutes of Health (NIH). Working in partnership with 
the NIH and other Federal agencies, NLM is the key link in the chain 
that translates biomedical research into practice, making the results 
of research readily available to all who need it.

NLM Leverages NIH Investments in Biomedical Research
    In today's challenging budget environment, we recognize the 
difficult decisions Congress faces as it seeks to improve our Nation's 
fiscal stability. We thank the subcommittee for its long-standing 
commitment to strengthening NLM's budget. While extramural funding 
comprises the largest portion of funding for institutes within the NIH, 
some eighty percent of NLM's budget supports intramural services and 
programs. Intramural funding builds, sustains, and continually augments 
NLM's suite of more than 200 databases which provide information access 
to health professionals, researchers, educators, and the public. It 
also supports all aspects of library operations and programs, including 
the acquisition, organization, preservation, and dissemination of the 
world's biomedical literature, no matter the medium.
    In fiscal year 2014 and beyond, it is critical to continue 
augmenting NLM's baseline budget to support expansion of its 
information resources, services, and programs which collect, organize, 
and make readily accessible rapidly expanding biomedical knowledge 
resources and data. NLM maximizes the return on the investment in 
research conducted by the NIH and other organizations. The Library 
makes the results of biomedical information more accessible to 
researchers, clinicians, business innovators, and the public, enabling 
such data and information to be used more efficiently and effectively 
to drive innovation and improve health. NLM is a leader in Big Data and 
plays a critical role in accelerating nationwide deployment of health 
information technology, including electronic health records (EHRs) by 
leading the development, maintenance and dissemination of key standards 
for health data interchange that are now required of certified EHRs. 
NLM also contributes to Congressional priorities related to drug safety 
through its efforts to expand its clinical trial registry and results 
database in response to legislative requirements, and to the Nation's 
ability to prepare for and respond to disasters.

Growing Demand for NLM's Basic Services
    NLM delivers more than a trillion bytes of data to millions of 
users daily that helps researchers advance scientific discovery and 
accelerate its translation into new therapies; provides health 
practitioners with information that improves medical care and lowers 
its costs; and gives the public access to resources and tools that 
promote wellness and disease prevention. Every day, medical librarians 
across the Nation use NLM services to assist clinicians, students, 
researchers, and the public in accessing information they need to save 
lives and improve health. Without NLM, our Nation's medical libraries 
would be unable to provide the quality information services that our 
Nation's health professionals, educators, researchers and patients 
increasingly need.
    NLM's data repositories and online integrated services such as 
GenBank, PubMed, and PubMed Central are revolutionizing medicine and 
ushering in an era of personalized medicine in which care is based on 
an individual's unique genetic profile. GenBank is the definitive 
source of gene sequence information. PubMed, with more than 22 million 
citations to the biomedical literature, is the world's most heavily 
used source of bibliographic information. Approximately 760,000 new 
citations were added in fiscal year 2012, and it was searched more than 
2.2 billion times. PubMed Central is NLM's freely accessible digital 
repository of full-text biomedical journal articles. On a typical 
weekday more than 700,000 users download 1.4 million full-text 
articles, including those submitted in compliance with the NIH Public 
Access Policy.
    As the world's largest and most comprehensive medical library, 
NLM's traditional print and electronic collections continue to steadily 
increase each year, standing at more than 11.4 million items--books, 
journals, technical reports, manuscripts, microfilms, photographs and 
images. By selecting, organizing and ensuring permanent access to 
health sciences information in all formats, NLM ensures the 
availability of this information for future generations, making it 
accessible to all Americans, irrespective of geography or ability to 
pay, and guaranteeing that citizens can make the best, most informed 
decisions about their healthcare.

Encourage NLM Partnerships
    NLM's outreach programs are essential to MLA and AAHSL membership 
and to the profession. Through the National Network of Libraries of 
Medicine (NN/LM), with over 6,000 members in communities nationwide, 
these activities educate medical librarians, health professionals and 
the general public about NLM's services and train them in the most 
effective use of these services. The NN/LM promotes educational 
outreach for public libraries, secondary schools, senior centers and 
other consumer-based settings, and its emphasis on outreach to 
underserved populations helps reduce health disparities among large 
sections of the American public. NLM's ``Partners in Information 
Access'' program improves access by local public health officials to 
information which prevents, identifies and responds to public health 
threats and ensures every public worker has electronic health 
information services that protect the public's health.
    NLM's MedlinePlus provides consumers with trusted, reliable health 
information on more than 900 topics in English and Spanish. It has 
become a top destination for those seeking information on the Internet, 
attracting nearly 850,000 visitors daily. Other products and services 
that benefit public health and wellness include the NIH MedlinePlus 
Magazine and NIH MedlinePlus Salud, available in doctors' offices 
nationwide, and NLM's MedlinePlus Connect--a utility which enables 
clinical care organizations to implement specific links from their 
electronic health records systems to patient education materials in 
MedlinePlus.
    MLA and AAHSL applaud the success of NLM's outreach initiatives, 
and we look forward to continuing to work with NLM on these programs.

Emergency Preparedness and Response
    Through its Disaster Information Management Research Center, NLM 
collects and organizes disaster-related health information, ensures 
effective use of libraries and librarians in disaster planning and 
response, and develops information services to assist responders. NLM 
responds to specific disasters worldwide with specialized information 
resources appropriate to the need, including information on 
bioterrorism, chemical emergencies, fires and wildfires, earthquakes, 
tornadoes, and pandemic disease outbreaks. MLA and NLM continue to 
develop the Disaster Information Specialization (DIS) program to build 
the capacity of librarians and other interested professionals to 
provide disaster-related health information outreach. Working with 
libraries and U.S. publishers, NLM's Emergency Access Initiative makes 
available free full-text articles from hundreds of biomedical journals 
and reference books for use by medical teams responding to disasters. 
MLA and AAHSL ask the subcommittee to support NLM's role in this 
crucial area which ensures continuous access to health information and 
use of libraries and librarians when disasters occur.

Health Information Technology and Bioinformatics
    For more than 40 years, NLM has supported informatics research, 
training and the application of advanced computing and informatics to 
biomedical research and healthcare delivery including telemedicine 
projects. Many of today's biomedical informatics leaders are graduates 
of NLM-funded informatics research programs at universities nationwide. 
A number of the country's exemplary electronic and personal health 
record systems benefit from findings developed with NLM grant support.
    The importance of NLM's work in health information technology 
continues to grow as the Nation moves toward more interoperable health 
information technology systems. A leader in supporting the development, 
maintenance, and dissemination of standard clinical terminologies for 
free nationwide use (e.g., SNOMED), NLM works closely with the Office 
of the National Coordinator for Health Information Technology to 
promote the adoption of interoperable electronic records, and has 
developed tools to make it easier for EHR developers and users to 
implement accepted health data standards in their systems.
    MLA is a nonprofit, educational organization with 4,000 health 
sciences information individual and institutional members. Founded in 
1898, MLA provides lifelong educational opportunities, supports a 
knowledge base of health information research, and works with a network 
of partners to promote the importance of quality information for 
improved health to the health care community and the public.
    The Association of Academic Health Sciences Libraries (AAHSL) 
supports academic health sciences libraries and directors in advancing 
the patient care, research, education and community service missions of 
academic health centers through visionary executive leadership and 
expertise in health information, scholarly communication, and knowledge 
management.
    Thank you again for the opportunity to present our views. We look 
forward to continuing this dialogue and supporting the subcommittee's 
efforts to secure the highest possible funding level for NLM in fiscal 
year 2014 and the years beyond to support the Library's mission and 
growing responsibilities. Information about NLM and its programs can be 
found at http://www.nlm.nih.gov.
                                 ______
                                 
           Prepared Statement of the Meharry Medical College

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

    1)  Funding for the Title VII Health Professions Training Programs, 
including:
     -- $24.602 million for the Minority Centers of Excellence.
    2)  $32 billion for the National Institutes of Health and a 
Proportional Increase for the National Institute on Minority Health and 
Health Disparities.
     -- Proportional funding increase for Research Centers for Minority 
        Institutions.
    3)  $65 million for the Department of Health and Human Services' 
Office of Minority Health.
    4)  $65 million for the Department of Education's Strengthening 
Historically Black Graduate Institutions Program.
_______________________________________________________________________

    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to present my views before you. I am Dr. Wayne J. Riley, 
President and CEO of Meharry Medical College in Nashville, Tennessee. I 
have previously served as vice-president and vice dean for health 
affairs and governmental relations and associate professor of medicine 
at Baylor College of Medicine in Houston, Texas and as assistant chief 
of medicine and a practicing general internist at Houston's Ben Taub 
General Hospital. In all of these roles, I have seen firsthand the 
importance of minority health professions institutions and the Title 
VII Health Professions Training programs.
    Mr. Chairman, time and time again, you have encouraged your 
colleagues and the rest of us to take a look at our Nation and evaluate 
our needs over the next 10 years. First, I want to say that it is clear 
that health disparities among various populations and across economic 
status are rampant and overwhelming. Over the next 10 years, we will 
need to be able to deliver more culturally relevant and culturally 
competent healthcare services. Bringing healthcare delivery up to this 
higher standard can serve as our Nation's own preventive healthcare 
agenda keeping us well positioned for the future.
    Minority health professional institutions and the Title VII Health 
Professions Training programs address this critical national need. 
Persistent and severe staffing shortages exist in a number of the 
health professions, and chronic shortages exist for all of the health 
professions in our Nation's most medically underserved communities. Our 
Nation's health professions workforce does not accurately reflect the 
racial composition of our population. For example, African Americans 
represent approximately 15 percent of the U.S. population while only 2-
3 percent of the Nation's healthcare workforce is African American.
    There is a well established link between health disparities and a 
lack of access to competent healthcare in medically underserved areas. 
As a result, it is imperative that the Federal Government continue its 
commitment to minority health profession institutions and minority 
health professional training programs to continue to produce healthcare 
professionals committed to addressing this unmet need.
    An October 2006 study by the Health Resources and Services 
Administration (HRSA), entitled ``The Rationale for Diversity in the 
Health Professions: A Review of the Evidence'' found that minority 
health professionals serve minority and other medically underserved 
populations at higher rates than non-minority professionals. The report 
also showed that; minority populations tend to receive better care from 
practitioners who represent their own race or ethnicity, and non-
English speaking patients experience better care, greater 
comprehension, and greater likelihood of keeping follow-up appointments 
when they see a practitioner who speaks their language. Studies have 
also demonstrated that when minorities are trained in minority health 
profession institutions, they are significantly more likely to: 1) 
serve in rural and urban medically underserved areas, 2) provide care 
for minorities and 3) treat low-income patients.
    As you are aware, Title VII Health Professions Training programs 
are focused on improving the quality, geographic distribution and 
diversity of the healthcare workforce in order to continue eliminating 
disparities in our Nation's healthcare system. These programs provide 
training for students to practice in underserved areas, cultivate 
interactions with faculty role models who serve in underserved areas, 
and provide placement and recruitment services to encourage students to 
work in these areas. Health professionals who spend part of their 
training providing care for the underserved are up to 10 times more 
likely to practice in underserved areas after graduation or program 
completion.
    Institutions that cultivate minority health professionals have been 
particularly hard-hit as a result of the cuts to the Title VII Health 
Profession Training programs in fiscal year 2006 (fiscal year 2006) and 
fiscal year 2007 Funding Resolution passed earlier this Congress. Given 
their historic mission to provide academic opportunities for minority 
and financially disadvantaged students, and healthcare to minority and 
financially disadvantaged patients, minority health professions 
institutions operate on narrow margins. The cuts to the Title VII 
Health Professions Training programs amount to a loss of core funding 
at these institutions and have been financially devastating.
    Mr. Chairman, I feel like I can speak authoritatively on this issue 
because I received my medical degree from Morehouse School of Medicine, 
a historically black medical school in Atlanta. I give credit to my 
career in academia, and my being here today, to Title VII Health 
Profession Training programs' Faculty Loan Repayment Program. Without 
that program, I would not be the president of my father's alma mater, 
Meharry Medical College, another historically black medical school 
dedicated to eliminating healthcare disparities through education, 
research and culturally relevant patient care.
    Minority Centers of Excellence.--COEs focus on improving student 
recruitment and performance, improving curricula in cultural 
competence, facilitating research on minority health issues and 
training students to provide health services to minority individuals. 
COEs were first established in recognition of the contribution made by 
four historically black health professions institutions (the Medical 
and Dental Institutions at Meharry Medical College; The College of 
Pharmacy at Xavier University; and the School of Veterinary Medicine at 
Tuskegee University) to the training of minorities in the health 
professions. Congress later went on to authorize the establishment of 
``Hispanic'', ``Native American'' and ``Other'' Historically black 
COEs. For fiscal year 2014, I recommend a funding level of $24.602 
million for COEs.

                  NATIONAL INSTITUTES OF HEALTH (NIH)

    National Institute on Minority Health and Health Disparities.--The 
National Institute on Minority Health and Health Disparities (NIMHD) is 
charged with addressing the longstanding health status gap between 
minority and nonminority populations. The NIMHD helps health 
professional institutions to narrow the health status gap by improving 
research capabilities through the continued development of faculty, 
labs, and other learning resources. The NIMHD also supports biomedical 
research focused on eliminating health disparities and develops a 
comprehensive plan for research on minority health at the NIH. 
Furthermore, the NIMHD provides financial support to health professions 
institutions that have a history and mission of serving minority and 
medically underserved communities. For fiscal year 2014, I recommend 
that this Institute's funding grow proportionally with the funding of 
the NIH and add additional FTEs.
    Research Centers at Minority Institutions.--The Research Centers at 
Minority Institutions program (RCMI) is now housed at the National 
Institute on Minority Health and Health Disparities (NIMHD). RCMI has a 
long and distinguished record of helping our institutions develop the 
research infrastructure necessary to be leaders in the area of health 
disparities research. Although NIH has received unprecedented budget 
increases in recent years, funding for the RCMI program has not 
increased by the same rate. Therefore, the funding for this important 
program grow at the same rate as NIH overall in fiscal year 2014.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Office of Minority Health.--Specific programs at OMH include:
  --Assisting medically underserved communities with the greatest need 
        in solving health disparities and attracting and retaining 
        health professionals,
  --Assisting minority institutions in acquiring real property to 
        expand their campuses and increase their capacity to train 
        minorities for medical careers,
  --Supporting conferences for high school and undergraduate students 
        to interest them in health careers, and
  --Supporting cooperative agreements with minority institutions for 
        the purpose of strengthening their capacity to train more 
        minorities in the health professions.
    The OMH has the potential to play a critical role in addressing 
health disparities, but this role can only be fulfilled if this agency 
continues it grant making authority. For fiscal year 2014, I recommend 
a funding level of $65 million for the OMH.

                        DEPARTMENT OF EDUCATION

    Strengthening Historically Black Graduate Institutions Program.--
The Department of Education's Strengthening Historically Black Graduate 
Institutions program (Title III, Part B, Section 326) is extremely 
important to MMC and other minority serving health professions 
institutions. The funding from this program is used to enhance 
educational capabilities, establish and strengthen program development 
offices, initiate endowment campaigns, and support numerous other 
institutional development activities. In fiscal year 2014, an 
appropriation of $65 million is suggested to continue the vital support 
that this program provides to historically black graduate institutions.
    Mr. Chairman, please allow me to express my appreciation to you and 
the members of this subcommittee. With your continued help and support, 
Meharry Medical College along with other minority health professions 
institutions and the Title VII Health Professions Training programs can 
help this country to overcome health and healthcare disparities. 
Congress must be careful not to eliminate, paralyze or stifle the 
institutions and programs that have been proven to work. Meharry and 
other minority health professions schools seek to close the ever 
widening health disparity gap. If this subcommittee will give us the 
tools, we will continue to work towards the goal of eliminating that 
disparity as we have done for 1876.
    Thank you, Mr. Chairman, for this opportunity.
                                 ______
                                 
    Prepared Statement of the Mine Safety and Health Administration

    We are writing in opposition to the fiscal year 2014 Budget Request 
for the Mine Safety and Health Administration (MSHA), which is part of 
the U.S. Department of Labor. In particular, we urge the subcommittee 
to reject MSHA's proposed de-funding of the Assistance to States grant 
program pursuant to Section 503(a) of the Mine Safety and Health Act of 
1977. Over the past several fiscal years, MSHA's budget request for 
State grants was approximately $9 million, which approached the 
statutorily authorized level of $10 million, but still did not fully 
consider inflationary and programmatic increases being experienced by 
the States. In fiscal year 2014, based on a realignment of priorities, 
MSHA has chosen to zero out funding for State assistance grants. We 
urge the subcommittee to restore funding to the statutorily authorized 
level of $10 million for State grants so that States are able to fully 
and effectively carry out their responsibilities under Sections 502 and 
503 of the Act, including the training of our Nation's miners.\1\
    The Interstate Mining Compact Commission is a multi-State 
governmental organization that represents the natural resource, 
environmental protection and mine safety and health interests of its 25 
member States. The States are represented by their Governors who serve 
as Commissioners.
    It should be kept in mind that, whereas MSHA over the years has 
narrowly interpreted Assistance to States grants as meaning ``training 
grants'' only, Section 503 was structured to be much broader in scope 
and to stand as a separate and distinct part of the overall mine safety 
and health program. In the Conference Report that accompanied passage 
of the Federal Coal Mine Health and Safety Act of 1969, the conference 
committee noted that both the House and Senate bills provided for 
``Federal assistance to coal-producing States in developing and 
enforcing effective health and safety laws and regulations applicable 
to mines in the States and to promote Federal-State coordination and 
cooperation in improving health and safety conditions in the Nation's 
coal mines.'' (H.Conf. Report 91-761). The 1977 Amendments to the Mine 
Safety and Health Act expanded these assistance grants to both coal and 
metal/non-metal mines and increased the authorization for annual 
appropriations to $10 million. The training of miners was only one part 
of the obligation envisioned by Congress.
    IMCC's member States are concerned that without full funding of the 
State grants program, the federally required training for miners 
employed throughout the U.S. will greatly suffer. States have struggled 
to maintain efficient and effective miner training programs in spite of 
increased numbers of trainees and the incremental costs associated 
therewith. The situation will likely be further exacerbated by new 
statutory, regulatory and policy requirements that grow out of the 
various reports and recommendations attending the Upper Big Branch 
tragedy. In spite of all this, MSHA has chosen to eliminate funding 
completely for this critical component of its statutory obligations. In 
addition to State training programs, these assistance grants also 
support State mine rescue training programs, mine rescue competitions, 
EMT training, miner certifications, accident investigations and 
reporting, review and approval of company safety plans, and, for those 
States that operate more comprehensive mine safety and health programs 
(such as PA, WV, VA, OH, IL, AL, KY and OK), program administrative 
costs such as supplies, staff training, and travel. We can provide a 
breakdown of these costs at the Committee's request.
    In MSHA's budget justification document (at page 68), the agency 
states that: ``Training plays a critical role in preventing deaths, 
injuries, and illnesses on the job. By providing effective training, 
miners are able to recognize possible hazards and understand the safe 
procedures to follow. MSHA will continue its increased visibility and 
emphasis on training because it is critically important to making 
progress in reducing the number of injuries and fatalities.'' 
Furthermore, in an April 25, 2013 communication to State grant 
recipients, MSHA specifically stated that ``effective and appropriate 
training will ensure that miners recognize and understand hazards and 
how to control or eliminate them.'' In a similar letter dated March 5, 
2012, MSHA noted that ``the number of miners you reach yearly through 
the training your program provides makes your contribution to the 
success of the program all that more important.''
    We are mystified about how MSHA intends to accomplish these stated 
objectives without the training and other programs that are provided by 
the States pursuant to the grants they receive from MSHA--as has been 
the case since the enactment of the Mine Safety and Health Act in 1969. 
By way of an explanation for the drastic cut to State grants, MSHA 
indicates on page 69 of its budget justification document that the 
agency has ``shifted priorities towards strengthening its enforcement 
programs. The fiscal year 2014 request prioritizes activities MSHA 
performs and applies limited budgetary resources to those areas where 
they will have the greatest impact.'' MSHA goes on to note that it 
``considers effective enforcement a top priority and proactive strategy 
to ensure workplaces in the mining industry are safe and healthy''. And 
yet, in recent fatality and accident investigation reports, MSHA has 
noted that the majority of these occurrences were due to ineffective 
training (generally by mine operators) and could have been prevented if 
more had been done to educate miners about the dangers associated with 
mining operations and conditions. See http://www.msha.gov/fatals/
fabm2013.asp.
    MSHA's suggested fix for the de-funding of the State grant program 
is to immediately shift training responsibilities and costs entirely to 
mine operators. While this idea may have merit, we are uncertain about 
the ability of the mining industry (especially small operators) to 
accommodate these new costs and suspect that any realignment of 
training responsibilities from the States to the industry will take 
considerable time and planning. Furthermore, our experience over the 
past 35 years has demonstrated that the States are often in the best 
position to design and offer this training in a way that insures that 
the goals and objectives of Sections 502 and 503 of the Mine Safety and 
Health Act are adequately met. There is some evidence of training 
programs offered by mine operators (or contractors on their behalf) 
falling well below what would be considered a minimum standard for 
these types of programs.
    There have been no discussions with the States about the impacts 
that this proposal will have on State training programs or mine safety 
and health programs or about any sort of transition in how we are 
currently doing business. To propose such a dramatic shift without 
first consulting the States is inappropriate and a denigration of the 
role the States have played in protecting our Nation's miners. 
Furthermore, to expect such a drastic change in operations to occur 
within a single fiscal year is unrealistic and will only result in 
confusion and potential negative impacts to the availability and 
quality of miner training and the overall health and safety of miners.
    MSHA notes in its budget justification document that the de-funding 
of State training grants will result in 180,000 miners in 47 States and 
the Navajo Nation not receiving training compared to results in fiscal 
year 2012. Those figures we believe are under-reported and fail to 
reflect the full impact that the elimination of this funding will have 
on the States. Examples of the direct impacts being reported by just 
some of the IMCC member States as a result of MSHA's decision follow. 
More expanded information from each State is appended to this statement 
and we request that it be included in the record. The most recent 
accounting of the number of miners trained by the States (and whose 
training could be jeopardized by funding cuts) is as follows:
  --Kentucky: Trained or tested over 10,000 people from 10/01/12-03/30/
        13.
  --Louisiana: 1,000 miners trained.
  --Alaska: 2,600 miners trained.
  --New Mexico: 2,000+ miners trained.
  --Oklahoma: 5,000 miners trained.
  --Pennsylvania: 7,000 miners trained.
  --Ohio: 2,600 miners trained (including for mine rescue).
  --Colorado: 2,800-3,700 miners trained.
  --Arkansas: 2,000 miners trained
  --North Carolina: 6,000-8,000 miners trained.
    Interestingly, while MSHA is proposing to eliminate funding for 
State training grants, it is proposing to increase funding by $800,000 
and 6 FTEs for its Educational Field Services training specialists to 
``review training plans, monitor and assist industry instructors to 
develop and improve their skills, and assist mine operators with their 
health and safety program.'' From our perspective, this reflects an 
acknowledgement on MSHA's part that the transition to a totally 
industry-lead training initiative will likely be fraught with 
difficulties. However, heavy-handed Federal oversight is not the 
solution to an effective training program. We have seen this type of 
approach fail in the past and assert that the training programs 
operated by the States have resulted in a higher level of success, as 
indicated by the significantly reduced rates of injuries and fatalities 
over the past several years. Congress has clearly understood this 
dynamic as well, appropriating the necessary moneys needed to preserve 
and enhance State training programs. It should also be kept in mind 
that effective training programs operated by the States, especially for 
small operators, are the first and best method to reduce accidents, 
injuries and fatalities in mines. On the other hand, enforcement often 
comes too late to be effective, and by its very nature is not 
preventative. We are hopeful that Congress will once again recognize 
these operational realities in fiscal year 2014 and turn back MSHA's 
efforts to undercut these valuable programs.
    While we can appreciate MSHA's desire to realign its resources to 
focus on inspection and enforcement, one of the most effective ways to 
insure miner health and safety in the first place is through 
comprehensive and excellent training. MSHA Assistant Secretary Main 
specifically spoke to this in the letter he sent to State grant 
recipients last year wherein he stated: ``As in the past, we are 
reaching out to the grantees, recognizing the positive impact you have 
in delivering training to miners. I am asking that you incorporate, as 
appropriate, training on these types of [fatal] accidents as well as 
measures needed to prevent them. Increased training and awareness is 
necessary if we are to prevent these types of deaths.'' The States have 
been in the forefront of providing this training for over 35 years and 
are best positioned to continue that work into the future. Furthermore, 
the Federal Government's relatively modest investment of money in 
supporting the States to handle this training has paid huge dividends 
in protecting lives and preventing injuries. The States are also able 
to provide these services at a cost well below what it would cost the 
Federal Government to do so.
    As you consider our request to reject MSHA's proposed cut and 
instead to increase MSHA's budget for State assistance grants, please 
keep in mind that the States play a particularly critical role in 
providing special assistance to small mine operators (those coal mine 
operators who employ 50 or fewer miners or 20 or fewer miners in the 
metal/nonmetal area) in meeting their required training needs. This has 
been a particular focus in those States where metal/non-metal mining 
operations predominate. These are often small business operators who 
cannot afford to offer the comprehensive training that is required 
under Section 502 of the Mine Safety and Health Act. Given this 
Administration's articulated concerns about the impacts of regulatory 
decisions on small businesses, it is surprising that MSHA would propose 
significant cuts to the training that States provide to these small 
operators. Some States have also recently received requests from the 
VFW to provide ``new miner training'' for returning war veterans in 
order to prepare them for potential employment in the mining industry. 
Without the funding provided to States by MSHA, this may be difficult 
to accomplish in a timely manner, if at all.\2\
    We appreciate the opportunity to submit our views on MSHA's fiscal 
year 2014 budget request. Please contact us for additional information 
or to answer any questions you may have.

State Reports re Impacts From De-Funding of Assistance to States Grants 
        Program
    In preparation for IMCC's presentation of this statement to the 
House and Senate Appropriations Committees, IMCC asked the States three 
questions, noted below. Responses from each of the reporting States are 
indicated.

What do you anticipate the impacts to your State will be from the 
        elimination of grant funding, including the number of miners 
        who may not be trained?
  --Kentucky: These cuts will have a devastating effect on our program. 
        Kentucky trains over 20,000 miners yearly. The money we get 
        from MSHA pays our instructors' salaries.
  --Louisiana: In Louisiana, the State training is performed through 
        the Louisiana Technical Community College system. If the grant 
        is eliminated, their mine safety training program would be 
        completely eliminated, closing its doors on Sept 30, 2013, and 
        laying off both of its employees. The program trains at least 
        1,000 miners each year (886 miners from Oct 1, 2012 to 
        present).
  --Alaska: Eliminating MSHA training funding potentially impacts each 
        of the 16,400 employees and thousands of owner/operators and 
        contractors working in Alaska's mining industry as of January 
        2013. Up to 2,600 students are MSHA trained and certified each 
        year by the University of Alaska Mine and Petroleum Training 
        Service (``MAPTS''). MAPTS is the MSHA training grant recipient 
        in Alaska.
  --New Mexico: In prior years the State of New Mexico, through New 
        Mexico Institute of Mining and Technology, received $147,000 
        from MSHA that was used to train miners in NM to meet the 
        regulatory requirements of 30 CFR Parts 46 and 48 which are 
        mandated training requirements for miners. We train over 2,000 
        miners in NM yearly. Most of these miners are employed at small 
        business operations in our State that cannot afford trainers at 
        their small operations. In addition we provide Spanish language 
        training to 200-300 miners yearly and are the only service 
        available to Spanish-speaking miners in the State.
  --Oklahoma: The Oklahoma Miner Training Institute (OMTI) is funded in 
        part with the State grant. Utilizing the funding provided, OMTI 
        trains 5,000 miners annually in a variety of courses, such as 
        New Miner and Annual Refresher, in accordance with 30 CFR Parts 
        46 and 48. Without the fully funded support that the State 
        grant provides, the mining community in Oklahoma will be 
        impacted.
  --Pennsylvania: Pennsylvania trains approximately 7,000 miners and 
        contractors in the Anthracite, Bituminous and Industrial 
        Minerals mines and facilities of the Commonwealth. This 
        training is provided at no cost to the mining community by in-
        house staff, Pennsylvania State University and Schuylkill Vo-
        Tech. We also provide a mine rescue program for small coal and 
        industrial minerals mines to comply with Federal mine rescue 
        requirements and required EMT training through Indiana 
        University of PA at no cost to mine operators. Although a 
        majority of large operators provide training for their 
        employees to meet Federal requirements, small mine and facility 
        operators and contractors rely on the MSHA grant for their 
        training needs. Pennsylvania also relies on the MSHA grant to 
        fund other aspects of our mine safety program. These include 
        staff training, health and safety conferences, mine rescue 
        contests, safety equipment, mine rescue supplies, and travel 
        related to these functions.
  --Ohio: After reviewing our total surface training numbers for the 
        year 2012, it would appear that 1,369 trainees would not have 
        been trained if not for receiving funding from the States Grant 
        program.
  --Colorado: The impact of the elimination of the MSHA training grant 
        to the miners of Colorado and our training program will be 
        acute. We trained 5,742 in fiscal year 2011 and 4,316 in fiscal 
        year 2012. This includes, coal, metal, non-metal and 
        contractors who serve the industry. The reduction would be 
        2,800--3,700 miners not trained, including many that receive 
        training in Spanish. The reduction would be salaries and 
        operating costs for two trainers. (The program has 5 FTE 
        total).
  --Arkansas: While it is difficult for a service provider to estimate 
        the total impact on our State from the elimination of grant 
        funding, we can address how it will impact our ability to 
        provide the mandatory training to the miners and contractors 
        who have utilized our services for years. While the Arkansas 
        MSHA State Training Program has been proactive in trying to 
        maintain the program and continuing to provide effective 
        training to those requesting our service, it has become 
        increasingly difficult to recover the cost for salaries, State 
        match and travel for the sufficient number of staff needed to 
        meet the demand, as well as the costs for maintaining training 
        equipment and supplies. We have already eliminated one part-
        time position and raised our training fees, but feel confident 
        that if we have to raise them again to generate the revenue 
        needed to sustain the program, it will become a financial 
        hardship on the small mining operations and contractors who are 
        our primary clients. At the current rate, without raising fees, 
        it is likely we would have to eliminate another part-time 
        position, therefore decreasing our ability to provide the 
        mandatory training to our clients requesting the service. Also, 
        grant funds have been used for our staff to attend national and 
        State MSHA conferences and training events. This would have to 
        be completely eliminated. The Arkansas MSHA State Training 
        Program trains an average of 2,000 individual miners and 
        contractors each year. We have been providing new miner, annual 
        refresher, and first aid training.
  --North Carolina: If State Grant funding is eliminated, we would be 
        reducing our staff of 6 to a staff of 2 based on our State 
        appropriations and the fact we would not be awarded any 
        additional appropriations. I would estimate there would be 
        6,000 miners we would not be able to provide training for based 
        on previous number of miners and contractors trained. We 
        average training at around 8,000 miners per year. This would be 
        a devastating burden on the small operators who rely on us to 
        assist them with their safety and health programs. Not only 
        will they have to pay a significant amount of money for future 
        training but the quality of training will certainly be a 
        concern. There are many private instructors who do not provide 
        effective, quality training. The mining industry is 
        experiencing the lowest incident rates ever, lowest amount of 
        accidents, and a record low number of fatalities and we feel 
        quality, effective training plays a major role with accident 
        prevention.

To what extent will the mining in your State be able to ``develop their 
        own programs or contract these services''? How long do you 
        anticipate this would take?
  --Kentucky: The majority of our mines involve small mines and have no 
        trainers. The small mines send their employees to our Office of 
        Mine Safety and Licensing to receive quality training free of 
        charge. These miners will have to pay a private instructor and 
        in turn receive inadequate training and in some cases will 
        receive no training at all. We've seen many problems in the 
        past with some private instructors not conducting adequate 
        training and they have been reported to the Federal Mine Safety 
        and Health Review Commission for sanctions.
  --Louisiana: In the absence of our State training program, the mining 
        industry would have to return to ``fending for themselves'' to 
        train its miners, resulting in an increased cost to industry 
        and possibly lower quality of training for individual miners.
  --Alaska: The majority of mines in Alaska are small operations with 
        less than 10 employees that do not have the resources or 
        capabilities to develop and maintain their own training and 
        certification systems. It is uncertain how long it may take to 
        develop programs or contract MSHA training services. At this 
        point, there are no MSHA training providers other than MAPTS 
        consistently available for small mines in Alaska.
  --Oklahoma: The training OMTI provides serves all of the mining 
        industry, in particular the smaller mining operations. Without 
        the training courses offered, the smaller mine sites are most 
        susceptible to see increased costs and lack of fully trained 
        miners as required in 30 CFR Parts 46 and 48.
  --Pennsylvania: Without the MSHA funding, small operators will have 
        to either conduct their own training or use training 
        contractors. Penn State University and Schuylkill Vo-Tech have 
        established a reputation and trust with the operators with a no 
        fee option. If the operators wish to continue this arrangement, 
        a significant cost per student must be absorbed by the 
        operators. The quality of training provided by the PA Bureau of 
        Mine Safety, Pennsylvania State University, Schuylkill Vo-Tech 
        and Indiana University of PA is very high and loss of this 
        program will have a negative impact on miner safety. It will 
        also impact Pennsylvania's ability to maintain its world class 
        mine safety program and ability to support program functions 
        identified above. One example: Federal law requires all mine 
        rescue teams to attend at least two competitions each year, 
        with the States supporting this requirement by holding and 
        supporting these contests. With State budgets shrinking, the 
        ability to support these contests without Federal funding is in 
        jeopardy.
  --Ohio: From past experience, the larger mining companies could deal 
        with developing their own programs and could contract out these 
        services if needed. The smaller companies and contract miners 
        would be the ones who either would be left out, or would 
        struggle with maintaining their training programs. As far as 
        the time it would take for these companies and contractors to 
        assume total responsibility for complying with MSHA's training 
        law standards, it would take a considerable amount of time.
  --Colorado: The reduction in support of mine training particularly 
        affects the medium and small operators who make up 95 percent 
        of the mining operations in Colorado. This severely reduces the 
        affect we can all have on preventing accidents and injuries 
        BEFORE they become a major incident. Unfortunately, this will 
        leave many operators with few resources for safety and health 
        and result in an increase in MSHA enforcement inspection time, 
        citations, and most unfortunately, a likely increase in injury 
        and accident rates in our State.
  --Arkansas: Since the Arkansas MSHA State Training Program places 
        emphasis on assisting small mining operations and contractors, 
        we are aware that most of these companies are neither staffed 
        nor equipped to provide effective training; whereas, the State 
        Grant staff has multiple years of combined training experience. 
        Small companies are at a distinct disadvantage in the area of 
        providing their own training.
  --North Carolina: Many small operators will not have the resources to 
        develop their own programs adequately. Many of them would not 
        know how to develop lesson plans, outlines, and have the time 
        or resources to prepare a training program. They would have to 
        contract their training out to consultants. Mine safety 
        training was geared to be site-specific and company-specific 
        which is how we prepare for our classes for mining operations. 
        Consultants will use a ``canned program'' and there are quality 
        control concerns with a canned program. We know of operators 
        who also rely on on-line training and the miners do not like it 
        because there is no interaction or discussion taking place with 
        on-line training. In terms of how long it will take for an 
        operator to implement its own safety and health training 
        program--probably at least a year or longer.

What other unanticipated consequences from the elimination of State 
        grant funding might there be, particularly with respect to 
        miner safety and health?
  --Kentucky: In our opinion the miners will be the ones to suffer 
        most. They will have to pay for the classes, they will not get 
        adequate training, and the end result will be an increase in 
        mine fatalities.
  --Louisiana: It strikes us as particularly unfortunate that MSHA 
        would choose this route of cost savings given that many 
        fatalities are found to have insufficient training as a root 
        cause.
  --Alaska: Eliminating training funding is expected to lead to an 
        increase in mining accidents and creates an artificial need for 
        increased enforcement on mine sites. Reduced MSHA-supported 
        training will damage the evolution of safety culture 
        improvements in the mining industry. Focusing solely on 
        enforcement is likely to further deteriorate individual 
        attitudes toward MSHA and voluntary compliance with MSHA 
        requirements.
  --New Mexico: The Mine Act of 1977 was very specific in Sections 502 
        and 503 regarding the requirement to train miners and to fund 
        State programs to meet the requirements of the Act. We are a 
        small organization that uses our funding wisely to provide low 
        cost training services to small business and non-English 
        speaking miners in our State. We believe this to be an 
        efficient use of these funds to educate our miners, thereby 
        providing good paying jobs in a safer environment.
  --Pennsylvania: There is no question that cutting the State Grant 
        Program goes against the intent of Congress, but more important 
        it will have a negative impact on the health and safety of our 
        Nation's miners. Every MSHA accident investigation report 
        highlights the need for quality training to eliminate and 
        reduce accidents. Not funding the State Grant Program at the 
        maximum amount ($10,000,000) is misguided and wrong and will 
        impact our ability to see that all workers go home to their 
        families at the end of each work shift.
  --Ohio: For smaller mines and with the contract miners, their safety 
        training would suffer, thus causing a potential increase in 
        mining accidents and serious injuries.
  --Colorado: Like other States, we maintain a unique and trusting 
        relationship with our mine operators and contractors through 
        regular contact, assistance (such as safety audits, etc.) and 
        education and training. We can quickly access and update our 
        mining community regarding the wide range of regulatory 
        requirements, technological improvements in mine safety and 
        sharing of mine health and safety resources. The State program 
        is the gold standard for providing effective and innovative 
        mine health and safety training and training mine employees and 
        contractors to effectively train their own employees.
  --Arkansas: We believe we will see accidents trend upward. The 
        training provided by the Arkansas MSHA State Training Program 
        has proven to have an impact on reduction in accidents; the 
        statistics reveal that the companies who utilize the State 
        services for their training needs have fewer accidents than the 
        companies who have chosen to go another route to obtain their 
        training. Also, company training might not be comprehensive in 
        certain areas, such as miners' statutory rights, including the 
        right to be provided a safe working environment and the right 
        to refuse to perform unsafe tasks. The State Training program 
        provides comprehensive training that supports accident 
        prevention by focusing on eliminating unsafe practices and 
        conditions that contribute to accidents. State training 
        reinforces miner knowledge of safe work behavior and encourages 
        safe work practices, as well as increasing their knowledge in 
        identifying an unsafe work environment as detailed in the Code 
        of Federal Regulations. In addition to training, the State 
        Training staff receives constant e-mails and phone calls 
        regarding safety and health issues. Many of the companies and/
        or individuals the State Grants staff have worked with over the 
        years are not comfortable going directly to Federal MSHA with 
        questions or concerns; whereas, the State has developed a 
        cooperative relationship that has proven mutually beneficial.
  --North Carolina: Impacts would include not being available to 
        provide special emphasis projects such as mock drills, mine 
        safety and health law seminars, annual mine safety and health 
        State conferences, explosives safety courses, and not being 
        able to properly prepare training programs geared to site-
        specific needs of mining operations. Training plan assistance 
        will not be provided. Fatalities, accidents, and incident rates 
        will be on the rise because of ineffective training.
---------------------------------------------------------------------------
    \1\ We should also note that to date, the States have still not 
received official notification from MSHA about grant awards for fiscal 
year 2013. Until that occurs, States will be unable to submit grant 
applications as anticipated by Section 503 of the Act. In this regard, 
we would also note that MSHA has inappropriately, and likely illegally, 
expanded the across-the-board cuts required by sequestration from 9 
percent to 65 percent without justification or authorization.
    \2\ We are also concerned about proposed cuts for the National Mine 
Safety and Health Academy, which has traditionally provided State grant 
recipients access to training programs and lodging without charge. MSHA 
has proposed a $1.5 million cut for the Academy that could well 
eliminate this critical service to the States.
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                                 ______
                                 

  Prepared Statement of the National Academy of Public Administration

    Mr. Chairman and members of the subcommittee: My name is Dan G. 
Blair, President and CEO, and I appreciate this opportunity to offer 
the written views of the National Academy of Public Administration (the 
Academy) on issues affecting the fiscal year 2014 appropriations for 
agencies and programs within the jurisdiction of the Subcommittee on 
Labor, Health and Human Services, Education and Related Agencies. I am 
the President and CEO of the National Academy of Public Administration. 
Chartered by Congress, the Academy is an independent nonprofit 
organization dedicated to helping leaders address today's most critical 
and complex challenges. Our organization consists of nearly 800 
Fellows--including former cabinet officers, Members of Congress, 
governors, mayors, and State legislators, as well as distinguished 
scholars, business executives, and public administrators.
    Governing in the 21st century has become increasingly complex. As 
mandated by our Charter (Public Law 98-257, Sec. 3), the Academy helps 
public institutions address their most critical challenges through in-
depth studies and analyses, advisory services and technical assistance, 
Congressional testimony, forums and conferences, and online stakeholder 
engagement. Our Charter permits Congress to request that the Academy 
conduct work for Federal cabinet departments and agencies. Currently, 
we are providing such assistance in the following projects:
  --Assessing the STOCK Act's Financial Disclosure Requirement.--In 
        response to a Congressional mandate, the Academy is conducting 
        an independent review of the impact of providing financial 
        disclosures online for Executive Branch senior career and 
        political appointees and congressional staff. This review is 
        considering a range of issues, including how best to manage the 
        balance between promoting transparency and accountability while 
        protecting privacy and security. The Academy Panel is examining 
        such critical topics as the degree of risk to Federal missions 
        and employees associated with the online disclosure, as well as 
        any harm that has arisen from current online disclosure in the 
        legislative branch.
  --Evaluating the Pension Benefit Guaranty Corporation's Governance 
        Structure.--Congress has requested that the Academy conduct a 
        review of the current governance structure of the Pension 
        Benefit Guaranty Corporation (PBGC), which provides retirement 
        income protection to millions of Americans. The Academy has 
        formed a five-member Panel of Fellows to lead this study. The 
        Panel will issue recommendations on such key governance issues 
        as the ideal size and composition of the PBGC Board of 
        Directors and the policies necessary to enhance Congressional 
        oversight and Board transparency, as well as to mitigate 
        potential conflicts of interest.
    Over the past few years, the Academy has worked with agencies 
across the Federal Government to help them address critical governance 
and management challenges. Further examples of congressionally-mandated 
work include the two following reports that were released in January 
2013:
  --Government Printing Office.--At the request of Congress, the 
        Academy conducted a broad operational review of Government 
        Printing Office (GPO) to update past studies of GPO operations; 
        examine the feasibility of GPO continuing to perform executive 
        branch printing; and identify additional cost saving 
        operational alternatives. The Academy's independent Panel 
        concluded that, in the digital age, ensuring permanent public 
        access to authentic Government information remains a critical 
        Government responsibility. GPO and the rest of the Federal 
        Government must continue to ``reboot'' to perform this mission 
        successfully in the digital age. The Panel issued fifteen 
        recommendations intended to position the Federal Government for 
        the digital age, strengthen GPO's business model, and further 
        GPO's continuing transformation.
  --Department of Energy.--The Department of Energy's (DOE) national 
        laboratories have occupied a central place in the landscape of 
        American science for more than 50 years. Congress tasked the 
        Academy to review how DOE oversees its contractor-operated 
        labs, including a review of the performance metrics and systems 
        that DOE uses to evaluate the performance of the labs. While 
        conducting this review, the Academy Panel overseeing this study 
        determined that these management issues must be considered as 
        part of a broader issue about defining and ensuring the future 
        of the lab complex. The Academy's independent Panel issued 
        findings and recommendations regarding the labs as a national 
        asset, how to evaluate the labs, and how to conduct systems-
        based oversight.
    Apart from the traditional management and congressionally-mandated 
studies, the Academy endeavors to provide a forum for our Fellows to 
engage in thought leadership efforts and provide practical support to 
Federal agencies in addressing pressing issues in public 
administration. For example, we have been working with the Office of 
Management and Budget to manage the Collaborative Forum, whereby the 
Academy facilitates discussions, supports participants in the 
development of pilot ideas and offers its collective knowledge about 
the intergovernmental system. The Forum draws on State and other 
stakeholder expertise to generate, develop, and consult on innovations 
in how States administer federally funded assistance programs. These 
innovations seek to improve payment accuracy and service delivery, 
enhance administrative efficiency and reduce barriers to program 
access. More information on this project can be found on the Forum's 
website, http://home.community.collaborativeforumonline.com/. I believe 
that such collaborative efforts between Federal, State, local, and 
private sector stakeholders can improve program delivery and ultimately 
reduce costs.
    Another example of the exercise of the Academy's thought leadership 
efforts is evidenced in the election transition area. This past year, 
the Academy and the American Society for Public Administration (ASPA) 
launched a joint ``Memos to National Leaders'' project to develop memos 
to national leaders on how to address the most challenging policy and 
management challenges facing the Nation. These memos can be found at 
www.memostoleaders.org and addressed the following topics:
  --Strengthening the Federal Budget Process;
  --Rationalizing the Intergovernmental System;
  --Administrative Leadership;
  --Strengthening the Federal Workforce;
  --Reorganization of Government;
  --Information Technology and Transparency;
  --Managing Big Initiatives;
  --Next Steps in Improving Performance; and
  --Managing Large Task Public-Private Partnerships.
    The memos were developed with both a Presidential and Congressional 
focus, reflecting the joint ownership of problems and solutions for 
these major challenges.\1\
    The Academy has also established a ``Political Appointee Project'' 
to inform current discussions about improving the presidential 
appointments process. We hope to serve as an important forum for this 
discussion. Our website (http://www.politicalappointeeproject.org/) 
contains information on previous related studies, as well as ongoing 
commentaries on this issue by Academy Fellows and other experts in the 
field; serves as a repository of profiles of the key management 
positions in Government; and provides insights to new political 
executives on the challenge of managing in Government.
    In summary, the Academy has a long track record of working across 
the Federal Government to address critical governance and management 
challenges. Effectively managing scarce Federal dollars is a goal 
shared across the aisle. The Academy stands ready to assist the 
subcommittee in its oversight efforts to enhance and improve agency and 
program performance.
---------------------------------------------------------------------------
    \1\ These memos are the opinions and views of their respective 
authors, and are not the opinions of the Academy or ASPA. They can be 
accessed at http://www.memostoleaders.org/memos-national-leaders.
---------------------------------------------------------------------------
                                 ______
                                 
          Prepared Statement of the National AHEC Organization

    Chairman Harkin and distinguished members of the subcommittee, as 
you begin to craft the fiscal year 2014 (fiscal year 2014) Labor-HHS-
Education appropriation bill, the members of the National Area Health 
Education Center-AHEC Organization (NAO) are pleased to submit this 
statement for the record recommending $33.142 million in fiscal year 
2014 for the AHEC program authorized under Title VII of the Public 
Health Service Act and administered through the Health Resources and 
Services Administration (HRSA). This funding level ensures that AHECs 
can continue to lead the Nation in the recruitment, training and 
retention of a diverse health workforce for underserved, rural, and 
urban communities.
    The NAO is the professional organization representing AHECs. The 
AHEC Program has been established for over 40 years and acts as an 
effective national primary care training network built on committed 
partnerships of 120 medical schools and 60 nursing and allied health 
schools. Additionally, 235 AHEC community-based centers operate in 46 
States, 4 territories and 250 rural and urban underserved communities 
alongside tens of thousands of community practitioners affiliated with 
the AHEC's national clinical training network.
    AHEC is one of the Title VII Health Professions Training programs, 
originally authorized at the same time as the National Health Service 
Corps (NHSC) to create a complete mechanism to provide primary care 
providers for Community Health Centers (CHCs) and other direct 
providers of health care services for underserved areas and 
populations. The plan envisioned by creators of the legislation was 
that the CHCs would provide direct service. The NHSC would be the 
mechanism to fund the education of providers and supply providers for 
underserved areas through scholarship and loan repayment commitments. 
The AHEC program would be the mechanism to recruit providers into 
primary health careers, diversify the workforce, and develop a passion 
for service to the underserved in these future providers, i.e. Area 
Health Education Centers are the workforce development, training and 
education machine for the Nation's health care safety-net programs. The 
AHEC program is focused on improving the quality, geographic 
distribution and diversity of the primary care healthcare workforce and 
eliminating the disparities in our Nation's healthcare system.
    AHECs develop and support the community based training of health 
professions students, particularly in rural and underserved areas. They 
recruit a diverse and broad range of students into health careers, and 
provide continuing education, library and other learning resources that 
improve the quality of community-based healthcare for underserved 
populations and areas.
    The AHEC program is effective and provides vital services and 
national infrastructure. Nationwide, over 431,000 students have been 
introduced to health career opportunities, and over 30,000 mostly 
minority and disadvantaged high school students received more than 20 
hours each of health career exposure. 63,456 health professions 
students received training at 11,906 underserved clinical and 
community-based sites, and furthermore; 442,926 health professionals 
received continuing education in a variety of disciplines including 
mental health, allied health, and nursing. AHECs perform these 
education and training services through collaborative partnerships with 
Community Health Centers (CHCs) and the National Health Service Corps 
(NHSC), in addition to Rural Health Clinics (RHCs), Critical Access 
Hospitals, (CAHs), Tribal clinics and Public Health Departments.

Justification for Recommendations
    The AHEC network is an economic engine that fuels the recruitment, 
training, distribution, and retention of a national health workforce. 
AHEC stands for JOBS.
  --Primary Care services improve the health of the population, and 
        therefore increase productivity of the U.S. workforce, while at 
        the same time, contain costs within the U.S. healthcare system. 
        Primary care practitioners are the front-line in prevention of 
        disease, providing cost savings in the United States healthcare 
        system.
    -- AHECs are critical in the recruitment, training, and retention 
            of the primary care workforce.
  --Research has demonstrated that the community-training network is 
        the most effective recruitment tool for the health professions 
        and those who teach remain longer in underserved areas and 
        communities.
    -- AHECs are in almost every county in the United States.
  --With the aging and growing population, the demand for primary care 
        workforce is far outpacing the supply.
    -- AHECs continue to educate and train current workforce, as well 
            as recruiting and preparing future workforce.
  --AHECs foster a national pipeline for community-based health 
        professions education connecting students to careers, 
        professionals to communities, and communities to better health.
    -- AHECs introduce over 431,000 students to health career 
            opportunities with a special emphasis on recruiting under-
            represented minority and disadvantaged students who return 
            to their underserved communities due to the fact that AHEC 
            develops and supports community-based interdisciplinary 
            training in underserved areas.
    --AHECs facilitate and support health professionals, facilities, 
            and community based organizations in effectively addressing 
            critical local health issues by providing continuing 
            educational services to improve quality of community based 
            care.
      -- AHECs trained 442,926 Health Professionals in 46 States and 4 
            territories in 13,842 Health Professions Shortage Areas 
            (HPSAs)--28.4 percent of those trained were physicians, 19 
            percent were nurses, and 8.1 percent were allied health 
            professionals.
      -- AHECs provided 3.2 million contact hours of health education 
            programs to over 246,000 active community members.
    The AHEC network's outcomes are the backbone of the Nation's 
community-based health professions training, with a focus on training 
primary care workforce.
  --HRSA has encouraged functional linkage between Bureau of Primary 
        Care and Bureau of Health Professions Programs.
  --AHECs have partnerships with over 1,000 Community Health Centers 
        nationally to recruit, train, and retain health professionals 
        who have the cultural and linguistic skills to serve in HRSA 
        designated underserved areas.
  --AHECs via a cooperative agreement with HRSA are training 10,000 
        primary care providers throughout the county to address OIF/
        OEF/OND Veteran's mental health, substance abuse, traumatic 
        brain injury and post-traumatic stress disorder for those not 
        utilizing the VA system.
                                 ______
                                 
  Prepared Statement of National Alliance for Eye and Vision Research

                           EXECUTIVE SUMMARY

    NAEVR requests fiscal year 2014 NIH funding of $32 billion, which 
reflects a $1.38 billion, or 4.5 percent increase, over fiscal year 
2012, which consists of biomedical inflation of 2.8 percent plus modest 
growth. This recommendation reflects the minimum investment necessary 
to make up for the twenty percent loss in purchasing power over the 
last decade, as well as the impact of the sequester, which cut 5.1 
percent or $1.6 billion from NIH's $30.8 fiscal year 2013 billion 
budget.
    NIH, our Nation's biomedical research enterprise, is unique in 
that:
  --Its basic and clinical research has helped to understand the basis 
        of disease, thereby resulting in innovations in healthcare to 
        save and improve lives.
  --Its research serves an irreplaceable role the private sector could 
        not duplicate.
  --It has been shown through several studies to be a major force in 
        the economic health of communities across the Nation. The 
        latest United for Medical Research report estimates that NIH 
        funding supported more than 432,000 jobs in 2011, directly or 
        indirectly, and generated more than $62.1 billion in economic 
        activity.
    NAEVR requests National Eye Institute (NEI) funding at $730 
million, commensurate with the overall NIH funding increase. The 
President's budget proposes an fiscal year 2014 NEI funding reduction 
of $2.1 million to a level $699 million which is unacceptable since:
  --It cuts 35 competing grants. The $36 million cut in fiscal year 
        2013 NEI funding due to the sequester has already translated 
        into a loss of an estimated 90 grants--any one of which holds 
        the promise to save or restore vision.
  --The cut jeopardizes NEI's ability to fund new and compelling 
        scientific ideas to advance research, which were identified 
        through its Audacious Goals Initiative.
  --Funding at $699 million is little more than 1 percent of the $68 
        billion annual cost of eye disease/vision impairment in the 
        U.S. With the majority of the 78 million Baby Boomers turning 
        65 years of age this decade and facing the greatest risk of 
        aging eye disease, a cut jeopardizes NEI's ability to meet the 
        vision challenges presented by this ``Silver Tsunami.''

 CONGRESS MUST IMPROVE UPON THE PRESIDENT'S FISCAL YEAR 2014 REQUEST, 
SINCE IT CUTS NEI FUNDING BY $2.1 MILLION, OR 0.3 PERCENT BELOW FISCAL 
 YEAR 2012, REDUCING IT BY $8 MILLION BELOW ITS BASE FISCAL YEAR 2010 
                                 LEVEL

    Despite the President's request increasing NIH funding by $471 
million, or 1.5 percent, over the fiscal year 2012 level of $30.6 
billion (net of transfers), it proposes to cut NEI by $2.1 million, or 
0.3 percent, below its fiscal year 2012 level of $701.3 million (net of 
transfers). Although the cut is primarily driven by an $8.9 million 
reduction due to the conclusion of the NEI-sponsored Ocular 
Complications of AIDS (SOCA) studies which are funded by the NIH Office 
of AIDS Research, it is still a cut and drives NEI funding in the wrong 
direction. The President's proposed fiscal year 2014 NEI funding level 
of $699 million falls $8 million below the base fiscal year 2010 level 
of $707 million, the highest NEI funding level ever prior to the 
addition of American Recovery and Reinvestment Act (ARRA) funding.
    Most importantly, the President's proposed fiscal year 2014 NEI cut 
of $2.1 million comes after the fiscal year 2013 sequester cut of $36 
million. The President's fiscal year 2014 budget would cut 35 competing 
grants from NEI funding, which follows the sequester's cut of an 
estimated 90 grants in fiscal year 2013--any one of which may hold the 
promise to save or restore vision.
    NEI is already facing enormous challenges this decade: each day, 
from 2011 to 2029, 10,000 citizens will turn 65 and be at greatest risk 
for eye disease; the African American and Hispanic populations are 
experiencing a disproportionately higher incidence of eye disease; and 
the epidemic of obesity is significantly increasing the incidence of 
diabetic retinopathy and diabetic macular edema. In 2009, Congress 
spoke volumes in passing S. Res 209 and H. Res. 366, which designated 
2010-2020 as The Decade of Vision. With the fiscal year 2014 LHHS 
spending bill, Congress can act upon its past resolutions regarding 
vision and assure that NEI is adequately funded to meet these 
challenges.
    NAEVR also requests NEI funding at $730 million since our Nation's 
investment in vision health is an investment in overall health. NEI's 
breakthrough research is a cost-effective investment, since it is 
leading to treatments and therapies that can ultimately delay, save, 
and prevent health expenditures, especially those associated with the 
Medicare and Medicaid programs. It can also increase productivity, help 
individuals to maintain their independence, and generally improve the 
quality of life, especially since vision loss is associated with 
increased depression and accelerated mortality.
    The very health of the vision research community is also at stake 
with a decrease in NEI funding. Not only will funding for new 
investigators be at risk, but also that of seasoned investigators, 
which threatens the continuity of research and the retention of trained 
staff, while making institutions more reliant on bridge and 
philanthropic funding. If an institution needs to let staff go, that 
usually means a highly-trained person is lost to another area of 
research or an institution in another State, or even another country.
    The proposed reduction in NEI funding threatens the United States' 
leadership in biomedical research in general, and vision research, 
specifically.

 $730 million fiscal year 2014 funding enables nei to pursue audacious 
                        goals in vision research
    The NEI is in the middle of a novel planning initiative to identify 
long-term, ten-year goals in vision research. Under the auspices of the 
National Advisory Eye Council, this expansion of NEI program planning 
is designed to engage and energize the vision research community and 
help the NEI establish the most compelling research priorities by 
identifying one or more ``audacious goals.'' Most recently, NEI hosted 
200 representatives from every sector of the vision community, as well 
as Government scientists and regulators from various disciplines at the 
NEI's Audacious Goals Development meeting. NIH Director Francis 
Collins, M.D., Ph.D. was very enthusiastic about this initiative and 
urged the attendees to have a ``bold vision for vision'' by describing 
NEI's long tradition of leading in the biomedical research arena, 
including:
  --identifying more than 500 genes associated with vision loss, which 
        is one-quarter of all genes discovered to date; and
  --funding the successful human gene therapy trial for patients with 
        Leber Congenital Amaurosis, in which treated patients have 
        experienced vision improvement.
    The meeting's discussion topics were built around the ten winning 
submissions from a pool of nearly 500 entries selected through NEI's 
Audacious Goals in Vision Research and Blindness Rehabilitation 
Challenge, a competition for bold and novel ideas to dramatically 
advance vision science. These ideas included restoring light 
sensitivity to the blind through gene-based therapies and visual 
prosthetics, pinpoint correction of defective genes, and growing 
healthy tissue from stem cells for ocular tissue transplants. 
Translating these and other research ideas into safe and effective 
treatments to save and restore vision requires adequate funding.
    As a result of past funding, the NEI has made great strides in 
determining the genetic basis of age-related macular degeneration 
(AMD)--the leading cause of blindness and a disease for which very 
little could be done just a few short years ago. NEI's AMD Gene 
Consortium, a network of international investigators, has just 
discovered seven new regions of the human genome--called loci--that are 
associated with increased risk of AMD. They also confirmed 12 loci 
already identified in previous studies. These loci implicate a variety 
of biological functions, including regulation of the immune system, 
maintenance of cellular structure, growth and permeability of blood 
vessels, lipid metabolism, and atherosclerosis. By understanding the 
genetic basis of the disease and underlying disease mechanisms, NEI can 
develop appropriate diagnostic and therapies.
    As an example of NEI-supported research that saves vision, in 
February 2013 the Food and Drug Administration (FDA) approved an 
implanted retinal prosthesis to treat adult patients with advanced 
retinitis pigmentosa (RP), a rare genetic condition that damages the 
retina and leads to blindness. A small video camera mounted on a pair 
of glasses sends images to a video processing unit that converts them 
to electronic data that is wirelessly transmitted to an array of 
electrodes implanted onto the retina. The device is enabling those who 
are otherwise completely blind to identify doors, crosswalks, and even 
utensils on a table. Although this ``Bionic Eye'' may have been a 
fantasy just a few short years ago, the NEI has always envisioned the 
future. Funding must be adequate for it to successfully pursue its goal 
of saving and restoring vision.

   BLINDNESS AND VISION LOSS IS A GROWING PUBLIC HEALTH PROBLEM THAT 
        INDIVIDUALS FEAR AND WOULD TRADE YEARS OF LIFE TO AVOID

    The NEI estimates that more than 38 million Americans age 40 and 
older experience blindness, low vision, or an age-related eye disease 
such as AMD, glaucoma, diabetic retinopathy, or cataracts. This is 
expected to grow to more than 50 million Americans by year 2020. 
Although the NEI estimates that the current annual cost of vision 
impairment and eye disease to the U.S. is $68 billion, this number does 
not fully quantify the impact of indirect healthcare costs, lost 
productivity, reduced independence, diminished quality of life, 
increased depression, and accelerated mortality. NEI's proposed fiscal 
year 2014 funding of $699 million reflects just a little more than 1 
percent of this annual cost of eye disease. The continuum of vision 
loss presents a major public health problem, as well as a significant 
financial challenge to both the public and private sectors.
    Vision loss also presents a real fear to most citizens:
  --In public opinion polls over the past 40 years, Americans have 
        consistently identified fear of vision loss as second only to 
        fear of cancer. NEI's Survey of Public Knowledge, Attitudes, 
        and Practices Related to Eye Health and Disease reported that 
        71 percent of respondents indicated that a loss of their 
        eyesight would rate as a ``10'' on a 1 to 10 scale, meaning 
        greatest impact on their life.
  --In patients with diabetes, going blind or experiencing vision loss 
        rank among the top four concerns about the disease. These 
        patients are so concerned about vision loss diminishing their 
        quality of life that those with nearly perfect vision (20/20 to 
        20/25) would be willing to trade 15 percent of their remaining 
        life for ``perfect vision,'' while those with moderate 
        impairment (20/30 to 20/100) would be willing to trade 22 
        percent of their remaining life for perfect vision. Patients 
        who are legally blind from diabetes (20/200 to 20/400) would be 
        willing to trade 36 percent of their remaining life to regain 
        perfect vision.
 NAEVR URGES CONGRESS TO FUND NIH AT $32 BILLION, NEI AT $730 MILLION, 
   IN FISCAL YEAR 2014 TO ENSURE THE MOMENTUM OF RESEARCH, TO RETAIN 
            TRAINED PERSONNEL, AND MAINTAIN U.S. LEADERSHIP
                              ABOUT NAEVR

    NAEVR, which serves as the ``Friends of the NEI,'' is a 501(c)4 
non-profit advocacy coalition comprised of 55 professional 
(ophthalmology and optometry), patient and consumer, and industry 
organizations involved in eye and vision research. Visit NAEVR's Web 
site at www.eyeresearch.org.
                                 ______
                                 
  Prepared Statement of the National Alopecia Areata Foundation (NAAF)

NAAF Fiscal Year 2014 LHHS Appropriations Recommendations
  --Protect medical research and patient care programs from devastating 
        funding cuts through sequestration and deficit reduction 
        activities.
  --$7.8 billion for CDC, an increase of $1.7 billion over fiscal year 
        2012.
  --$32 billion for NIH, an increase of $1.3 billion over fiscal year 
        2012.
    Chairman Harkin, Ranking Member Moran, and distinguished members of 
the subcommittee, thank you for the opportunity to submit testimony on 
behalf of NAAF. It is my privilege to represent the great group of 
individuals affected by the autoimmune disease alopecia areata.

About the Foundation and Our Research
    NAAF, headquartered in San Rafael, CA, supports research to find a 
cure or acceptable treatment for alopecia areata, supports those with 
the disease, and educates the public about alopecia areata. NAAF is 
governed by a volunteer Board of Directors and a prestigious Scientific 
Advisory Council. Founded in 1981, NAAF is widely regarded as the 
largest, most influential, and most representative foundation 
associated with alopecia areata. NAAF is connected to patients through 
local support groups and also holds an important, well-attended annual 
conference that reaches many children and families.
    Recently, NAAF initiated the Alopecia Areata Treatment Development 
Program (TDP) dedicated to advancing research and identifying 
innovative treatment options. TDP builds on advances in immunological 
and genetic research and is making use of the Alopecia Areata Clinical 
Trials Registry which was established in 2000 with funding support from 
the National Institute of Arthritis and Musculoskeletal and Skin 
Diseases (NIAMS); NAAF took over responsibility financial and 
administrative responsibility for the Registry in 2012 and continues to 
add patients to it. NAAF is engaging scientists in active review of 
both basic and applied science in a variety of ways, including the 
November 2012 Alopecia Areata Research Summit featuring presentations 
from the Food and Drug Administration (FDA) and NIAMS.
    At the Research Summit Dr. Angela Christiano of Columbia 
University, discoverer of the genetic basis of alopecia areata, 
presented her progress in genetics research. A joint analysis performed 
with an independent genome-wide association study (GWAS) of 1435 cases 
and 2032 controls resulted in the validation of previous GWAS targets 
and the identification of new associated genes. Some of these 
associated genes are unique to the hair follicle in alopecia areata. 
Dr. Christiano discussed targeting the IFN signature in the treatment 
of alopecia areata. She also discussed the genetic relationship between 
alopecia areata and other autoimmune diseases including the minimal 
overlap with psoriasis or vitiligo. This work greatly expands our 
understanding of the genetic architecture of this highly prevalent 
autoimmune disease.
    Later this year the Proceedings of the Summit will be published in 
the Journal for Investigative Dermatology (JID). The participants will 
be finalizing the goals for the next 2 years to be met by the following 
Alopecia Areata Research Summit in the fall of 2014. Those goals 
include:
    Genetics:
    --Execute combined association and linkage studies using 250 
            multiplex families from the Alopecia Areata Registry
    --Utilize functional genomics with deep sequencing
    --Develop network pilot
    --Analyze shared variants with related diseases including celiac 
            disease, rheumatoid arthritis, type 1 diabetes; 5 loci 
            shared between type 1 diabetes and alopecia areata
    --Develop a biobank
    --Determine if there is a genetic basis for disease subsets, i.e. 
            alopecia areata patchy, alopecia areata totalis, alopecia 
            areata universalis
    --Increase alopecia areata samples to 10,000
    Immunology:
    --Study how to restore immune privilege
    --Analyze the potential of targeting IL-15 pathway
    --Identify the protolerance TCR signal; then target it 
            pharmacologically
    --Develop T cell receptor sequencing
    --Complete biomarker studies
    Animal Models:
    --Identify and develop mouse and humanized mouse models
    --Validate models
    --Determine which model will be the best to replicate alopecia 
            areata
    Clinical:
    --Finalize and validate Alopecia Areata Uniform Protocol
    --Publish quality of life studies
    --Publish incidence and prevalence studies
    --Initiate burden of diseases studies
    --Use pharmacogenomics to predict patient populations that will 
            respond and which will get side effects
    -- Determine the attractive pathways for targeted therapy
    --Continue collaborations with industry and Government agencies to 
            facilitate the regulatory path for alopecia areata 
            treatments

About Alopecia Areata
    Alopecia areata is a prevalent autoimmune skin disease resulting in 
the loss of hair on the scalp and elsewhere on the body. It usually 
starts with one or more small, round, smooth patches on the scalp and 
can progress to total scalp hair loss (alopecia totalis) or complete 
body hair loss (alopecia universalis).
    Alopecia areata affects approximately 2 percent of the population, 
including more than five million people in the United States alone. The 
disease disproportionately strikes children and onset often occurs at 
an early age. This common skin disease is highly unpredictable and 
cyclical. Hair can grow back in or fall out again at any time, and the 
disease course is different for each person. In recent years, 
scientific advancements have been made, but there remains no cure or 
indicated treatment options. We do not have known biomarkers at this 
time but an NIH-funded study is seeking to identify biomarkers.
    The true impact of alopecia areata is more easily understood 
anecdotally than empirically. Affected individuals often experience 
significant psychological and social challenges in addition to the 
biological impact of the disease. Depression, anxiety, and suicidal 
ideation are health issues that can accompany alopecia areata. The 
knowledge that medical interventions are extremely limited and of minor 
effectiveness in this area further exacerbates the emotional stresses 
patients typically experience.

Deficit Reduction and Sequestration
    As you work with your colleagues in Congress on deficit reduction, 
budget, and appropriations issues please support the alopecia areata 
community by actively pursuing meaningful funding increases for 
critical medical research and healthcare programs. Our Nation's 
investment in biomedical research, particularly through NIH, is an 
engine that drives economic growth while improving health outcomes for 
patients. NIH currently supports a modest, but integral research 
portfolio in alopecia areata. The research funded through this 
portfolio is conducted at academic health centers across the country, 
which has a direct impact on local economic activity. Further, while 
more work needs to be done, the commitment to NIH's alopecia areata 
research portfolio over the years has greatly increased our scientific 
understanding of the condition.
    If Federal funding for alopecia areata research is substantially 
reduced, the current effort to capitalize on recent advancements and 
develop treatment options will face a serious setback. Ongoing research 
projects will stall and critical new research projects will not be 
initiated. In addition, reducing support for Federal biomedical 
research efforts sends a powerful message to the next generation about 
our country's lack of commitment to this field. Many talented young 
people interested in biomedical research will seek other career paths. 
The damage done now to the research training and career development 
pipeline could last for decades and undermine this country's entire 
biomedical research industry. It should also be noted that the next 
generation of researchers will face increased competition for their 
talents from foreign competitors who are investing in their biomedical 
research infrastructure.
    The alopecia areata community is very concerned that if healthcare 
programs endure significant funding cuts, patients will see few 
improvements in health and healthcare over the coming years.

Centers for Disease Control and Prevention
    NAAF joins with other voluntary health organizations in requesting 
that you support CDC by providing an allocation of $7.8 billion in 
fiscal year 2014. This appropriation should include proportional 
funding increases for the various centers and programs at CDC, most 
notably the National Center for Chronic Disease Prevention and Health 
Promotion (NCCDPHP).
    The alopecia areata community could benefit greatly from an 
analysis of prevalence, incidence, and associated demographic 
information by CDC. Further, awareness programs could reach children 
who have not been diagnosed with the condition and who are struggling 
to understand what is going on with their bodies. Finally, healthcare 
professionals could benefit from education and awareness activities 
that would promote proper diagnosis of alopecia areata and appropriate 
intervention. To initiate new programs that have the potential to 
improve health outcomes for alopecia areata patients or patients 
dealing with other condition, CDC would require a meaningful infusion 
of additional resources. Without additional resources, CDC will be 
unable to support current programs and activities and forced to forego 
many emerging opportunities.

National Institutes of Health
    NAAF joins with the broader public health community in requesting 
that you support NIH by providing an allocation of $32 billion in 
fiscal year 2014. This appropriation should include proportional 
funding increases for the various NIH Institutes and Centers, 
particularly NIAMS, the National Institute of Allergy and Infectious 
Diseases (NIAID), the National Center for Advancing Translational 
Research (NCATS), and the Office of the Director.
    NIAMS supports the bulk of alopecia areata research currently 
conducted through NIH. In order to capitalize on this research and 
further improve our scientific understanding of the condition, NIH 
requires additional resources to expand and advance the alopecia areata 
research portfolio. NIH is presently foregoing meritorious research 
opportunities and additional funding would allow more of these grants 
applications to be funded.
    NIAID.--Innovative new research activities initiated through NIAID 
into alopecia areata would add-value to NIAID's current research 
projects by leading to breakthroughs that could impact additional 
autoimmune conditions.
    NCATS.--Clinical and translational research are of tremendous 
importance to the alopecia areata community. Expanding the Federal 
commitment to NCATS would allow the Center to work more effectively 
with FDA to facilitate the development of treatment options for 
conditions that currently lack treatments with an FDA indication.
    OD.--Due to the autoimmune and genetic components of alopecia 
areata, research in this area has a significant cross-cutting value. 
Innovative research activities initiated and coordinated by OD could 
improve our understanding of both autoimmune conditions and conditions 
with genetic components.
    Thank you for your time and your consideration of these requests. 
Please contact me if you have any questions or if you would like any 
additional information.
                                 ______
                                 
  Prepared Statement of the National Association of Community Health 
                                Centers

Introduction
    Chairman Harkin, Ranking Member Moran, and Distinguished members of 
the subcommittee: My name is Dan Hawkins, and I am the Senior Vice 
President for Public Policy and Research at the National Association of 
Community Health Centers. On behalf of the American health center 
community, including the more than 22 million patients served 
nationwide by health centers, the 153,000 full-time health center 
staff, and countless volunteer board members who serve our centers as 
well as the National Association of Community Health Centers, we thank 
you for this subcommittee's strong bipartisan support of health 
centers. I also wish to thank you for the opportunity to submit 
testimony for the committee to review as you craft the fiscal year 2014 
Labor-Health and Human Services-Education and Related Agencies 
Appropriations bill.

Health Centers--General Background
    Health Centers are community-owned non-profit entities providing 
primary medical, dental, and behavioral health care as well as pharmacy 
and a variety of enabling and support services. Today, there are over 
1,200 health centers operating at more than 9,000 urban and rural 
locations nationwide serving as medical homes for more than 22 million 
patients in all 50 States, including all of the States represented by 
the members of this subcommittee.
    By statute and mission, health centers are located in medically 
underserved areas or serve a medically underserved population. This has 
enabled health centers to become health care homes to the medically 
underserved and our Nation's most vulnerable populations.
    Health centers are also directed by patient -a majority board, 
which helps to ensure they are responsive to each individual community 
they serve, providing comprehensive primary care to all residents of 
the community who seek their care, regardless of ability to pay or 
insurance status and offer services on a sliding fee scale. This unique 
model ensures that health center operations are locally-controlled and 
responsive to each individual community's needs and, at the same time, 
reduce barriers to accessing health care.
    Approximately 39 percent of Health Center patients are covered by 
Medicaid and another 36 percent are uninsured. In return, health 
centers bring significant value to the Medicaid program, serving 15 
percent of Medicaid patients for only 1 percent of total Medicaid 
spending. Our unique model of care has enabled us to save the entire 
health system, including the Government and taxpayers, approximately 
$24 billion annually. Health Centers also reduce preventable 
hospitalizations and Emergency Department (ED) use, as well as the need 
for more expensive specialty care. The services provided at health 
centers save $1,200 per patient per year compared to expenditures for 
non-health center users. A Journal of Rural Health article entitled: 
Presence of Community Health Center and Uninsured Emergency Department 
Visit Rates in Rural Counties, written by Dr. George Rust et al, found 
that counties with a community health center site had 25 percent fewer 
uninsured ED visits. Without access to primary care, many people delay 
seeking health care until they are seriously ill and require inpatient 
hospitalization or care at an emergency room at a much higher cost. 
Health centers can help reduce those unnecessary costs by serving as 
health care homes for the underserved.\1\
    In addition to reducing health care costs, health centers can also 
serve as small businesses and economic drivers in their communities. In 
2012, health centers employed 153,000 individuals and in 2009 generated 
$20 billion in total economic benefits in poor urban and rural 
communities.

Fiscal Year 2013 Funding Background
    In fiscal year 2013, health centers are slated to receive a total 
of $3.1 billion in total Federal funding. This includes $1.58 billion 
in discretionary funding provided by the Health Resources and Services 
Administration (HRSA) and $1.5 billion in mandatory funding for health 
centers through the Affordable Care Act. This was a total increase of 
$300 million from fiscal year 2012. A portion of this increase in 
funding will go toward applications currently at HRSA. In January, HRSA 
released the fiscal year 2013 Affordable Care Act New Access Point 
(NAP) funding opportunity announcement. The NAP guidance solicited 
applications to award $19 million to support 25 NAP awards. The 
application process closed in April with approximately 400 applications 
for the anticipated 25 awards, again demonstrating a significant need 
and demand for access in many communities. We expect that the number of 
applications would have been even higher if HRSA had announced a larger 
anticipated amount of awards.
    As you know, the President's fiscal year 2013 Health Resources and 
Services Administration (HRSA) fiscal year 2013 budget proposal also 
requested total funding of $3.1 billion. However, the Administration 
proposed holding back $280 million of the total increase of $300 
million. The Senate, recognizing the pressing need for primary care, 
included language in the Consolidated and Further Continuing 
Appropriations Act of 2013 ensuring the full $300 million be spent by 
the end of fiscal year 2013. We want to thank the subcommittee for 
their efforts and support for increased funding in fiscal year 2013 
which will allow us to continue to work towards our shared goal of 
expanding access to quality and affordable health care to all 
Americans. We are grateful to our Senate supporters who worked to 
include this critical provision.
    To date, only the discretionary funding health center fiscal year 
2013 spend plan has been released by HRSA. This plan reflects the 
discretionary sequester reduction to the Health Center Program of $79 
million and an additional transfer of $15 million from the program. We 
await the second half of HRSA's fiscal year 2013 spend plan and hope it 
will recognize the current and looming demand for increased access to 
primary care.

Increasing and Overwhelming Demand for Access to Primary Care
    Today, 60 million Americans lack regular access to primary care, 
even as the Nation is preparing to provide health coverage for as many 
as 30 million newly-insured Americans. Health centers stand ready to do 
their part to meet these enormous challenges of providing a health care 
home for these individuals. Even with the investment made in the Health 
Center Program, barriers to care make it difficult for individuals to 
access primary care and the demand for primary care far exceeds the 
supply across the Nation, but health centers can play a role in solving 
this crisis.
    NACHC recently released a report entitled: Health Wanted, the State 
of Unmet Need for Primary Health Care in America (``Health Wanted'') 
which States that barriers to accessible care including affordability, 
accessibility, and availability can diminish access to primary care. 
Health Wanted demonstrated that when health centers are located in 
medically underserved areas, using the unique health center model they 
are able to overcome these barriers to care and are able to improve 
health care outcomes as well as reduce health care costs. But the 
demand for health centers continues to outpace growth. Health Wanted 
also highlights the fact that at least 25 percent of U.S. counties in 
greatest need do not have a health center.\2\
    Health centers can meet these primary care demands with proper 
resources. This means fully leveraging the funds available to health 
centers to expand the number of health centers throughout the country. 
We look forward to working with this subcommittee to ensure the promise 
of access to primary care becomes a reality in all underserved 
communities that currently lack it.

Fiscal Year 2014 Funding Request
    The President's proposed fiscal year 2014 Health Resources and 
Services Administration (HRSA) budget provides $1.58 billion in 
discretionary funding for the Health Centers program. Together with the 
$2.2 billion in fiscal year 2014 mandatory funding available for health 
centers, health centers could receive a net increase of $700 million in 
total programmatic funding for fiscal year 2014 equaling total funding 
of $3.8 billion.
    We strongly support the President's proposed funding level of $3.8 
billion for health centers as it provides the opportunity for continued 
growth of the Health Center program in the face of overwhelming need. 
The $700 million increase could enable health centers to expand access 
to care to more than 5 million new patients. Health Centers are looking 
ahead as the demand for primary care is expected to soar as millions 
receive health coverage for the first time, many of them living in the 
very communities we serve. Health centers will become the health care 
home for many of these new patients. We must create the capacity to 
serve these patients. If primary care is not accessible in the 
communities in which these people live, they will seek it out in 
emergency departments and hospitals, often when they are sicker. This 
will mean poorer health for these patients and much higher costs to the 
system.
    Health Centers are respectfully requesting a total of no less than 
$3.8 billion in funding for the Health Center program and that the full 
$700 million increase be spent in fiscal year 2014 to increase access 
to primary care. We propose that the entire increase be used 
immediately to provide for the expansion of care to 5 million new 
patients and we look forward to working with you to ensure that this 
subcommittee's funding priorities as well as the needs of health 
centers across the country are communicated and realized as a part of 
the fiscal year 2014 funding process.

Conclusion
    We understand this subcommittee will have to make many difficult 
budgetary decisions as you work within the funding limits set for the 
fiscal year 2014 Labor-Health and Human Services-Education 
Appropriations bill.
    As the fiscal year 2014 appropriations process moves forward, we 
urge you to keep in mind that without their local health center, 
medically underserved communities and patients would often be without 
any access to primary care. Health Centers are more than a safety net, 
they have a demonstrated track record of improving the health and well-
being of their patients using a locally-tailored health care home model 
designed to coordinate care and manage chronic disease at the same time 
reducing unnecessary, avoidable and wasteful use of health resources.
    Health centers have continually proven to be a worthwhile 
investment by delivering high quality, affordable health care while 
generating savings to the entire health system. We are extremely 
grateful for your leadership and ask for the subcommittee's continued 
support for the Health Center program.
    We look forward to working with you and thank you for your 
consideration.
---------------------------------------------------------------------------
    \1\ Rust George, et al. ``Presence of a Community Health Center and 
Uninsured Emergency Department Visit Rates in Rural Counties.'' Journal 
of Rural Health Winter 2009 25(1):8-16.
    \2\ NACHC and the Robert Graham Center. Help Wanted: The State of 
Unmet Need for Primary Care in America. March 2012. www.nachc.com/
client//HealthWanted.pdf.
---------------------------------------------------------------------------
                                 ______
                                 
  Prepared Statement of the National Association for State Community 
                           Services Programs

    Chairman Tom Harkin, Ranking Member Thad Cochran, members of the 
committee, thank you for the opportunity to submit this testimony on 
behalf of the National Association for State Community Services 
Programs (NASCSP), the premier national association representing State 
administrators of the Department of Health and Human Services' 
Community Services Block Grant (CSBG) and State directors of the 
Department of Energy's Low-Income Weatherization Assistance Program. We 
thank Congress for its past support of CSBG and look forward to working 
with you to build on the past success and to promote economic mobility 
for all Americans in the years ahead. We appreciate your support and 
need it now more than ever as more Americans face economic insecurity. 
NASCSP seeks continued funding of $713.63 million for CSBG in fiscal 
year 2014 in order to build on the successes of the CSBG Network. With 
level funding, we believe that this already proven network, built on 
local solutions to community issues, is the Nation's answer to the 
economic plight that many Americans experience.

Why CSBG, Why Now
    At a time when over 46 million Americans are living below the 
Federal poverty level ($23,550 a year for a family of four), Americans 
support effective public solutions to this pressing issue. Americans 
need solutions like CSBG to bridge the gap between falling wages, job 
shortages, and high costs of living to keep them from slipping further 
into poverty. The strength of our Nation depends on the prosperity of 
its citizens. CSBG can facilitate that prosperity and opportunity for 
all Americans. The CSBG Network is a proven provider of anti-poverty 
programs, supporting millions of low-income Americans on the path to 
economic security and self-sufficiency. By taking a local approach, the 
CSBG Network uses grassroots, innovative strategies to alleviate 
poverty and provides a significant return on taxpayers' investment. In 
2011, the CSBG Network leveraged $23.43 for every dollar of CSBG 
funding.

Background of CSBG
    CSBG is a federally-funded block grant that supports local anti-
poverty efforts through State-administered networks of more than 1,000 
CAAs that work to eliminate poverty, revitalize low-income communities, 
and empower low-income families to become self-sufficient and 
economically secure. State administrators of CSBG are committed to 
ending poverty and maintaining high accountability standards through 
monitoring and technical assistance. As a conduit between the Federal 
administration and agencies, States build public-private partnerships, 
support innovation, and advance best practices to ensure the most 
effective use of taxpayers' money. Local agencies utilize CSBG funds to 
leverage additional resources and to eliminate poverty through a 
variety of programs and services. While CAAs across the Nation address 
similar issues, local needs determine unique approaches to addressing 
them. Poverty, while a national problem, looks different in every 
community. The CSBG Network strives to find local solutions to these 
community issues by conducting community needs assessments to identify 
with the needs, challenges, and resources in a local community. The 
community needs assessments enables CAAs to provide the most effective 
and efficient programs and services, which fall into nine service 
categories outlined in the CSBG Act; employment, education, income 
management, housing, emergency services, nutrition, linkages, self-
sufficiency, and health.
    National data compiled by NASCSP shows that CSBG serves a broad 
segment of low-income individuals and families. Data from fiscal year 
2011 shows:
  --There are 1,048 CAAs across the country, serving 99 percent of U.S. 
        counties.
  --CSBG serves one out of every five people in America below the 
        Federal Poverty Guideline.
  --The majority of clients are female (58 percent), white (59.1 
        percent), renters (60 percent), and between the ages of 24 to 
        54 years old (36 percent)--the second largest group was seniors 
        over the age of 55 (18 percent).
  --Many of the families served were in ``severe poverty'' (32.3 
        percent), with incomes below 50 percent of the Federal Poverty 
        Guideline.

Successes of the CSBG Network
            Highlights of the CSBG Network
  --CSBG served 18.7 million Americans, including 7.6 million families 
        in fiscal year 2011,
  --Over the past 5 years, the CSBG Network has:
    --Helped over 645,000 people obtain a job,
    --Addressed 18 million barriers to employment through helping 
            people acquire a job, obtain employment supports, and/or 
            receive job training,
    --Expanded 21.5 million community opportunities or resources, which 
            helped to stimulate community and economic development, and
    --Facilitated 17.7 million opportunities for infants, children, 
            youth, parents, and other adults through developmental or 
            enrichment programs.

Success Stories of the CSBG Network
            Job Skills Training in Georgia Leads to Employment--Coastal 
                    Plain Area Economic Opportunity Authority, Inc.
    The Coastal Plain Area Economic Opportunity Authority, Inc. 
(Coastal Plain) contributed to improving the employment outlook in 
their community by creating programs that addressed the needs 
identified through a community needs assessment the agency conducted in 
2010. Coastal Plain found that the number of unemployed individuals in 
their community increased significantly, and that many of those 
unemployed individuals lacked the communication and the job-hunting 
skills necessary to obtain work in a competitive job market. Coastal 
Plain created a job-seeker training program that prepared participants 
for a successful job search by teaching them how to write a 
comprehensive resume and provided interview tactics to best convey 
their experience and knowledge to potential employers.
    Coastal Plain also created linkages with local businesses, which 
donated interview clothing and supplies, and community organizations, 
which offered job leads, career fairs, continuing education 
opportunities, and online job search tools. The agency met childcare 
needs by partnering with the State Department of Family and Children 
Services to secure affordable childcare. In 2011, of the 470 people who 
completed the program, 125 have found employment and the others 
continue to receive assistance with their job searches. As a CAA, 
Coastal Plains had the capacity to look at the needs of the community, 
develop a program to meet those needs, and provide comprehensive 
services to support job-seekers.
            Helping Seniors Maintain Independent Living in Arizona--
                    Community Action Human Resources Agency
    Living at home allows low-income seniors and disabled individuals 
to maintain their independence, which improves their quality of life--
and saves taxpayers money. The Community Action Human Resources Agency 
(CAHRA) created the Home Alone Safe Alone (HASA) program to provide 
Pinal County seniors and disabled individuals with emergency 
notification devices that allowed them to remain independent without 
sacrificing their security and safety. This program is cost-effective 
and successful because it combines CSBG funds together with volunteer 
hours. CAHRA provides an Emergency Alert Pendant at no cost to income-
eligible participants thanks to a partnership with the United Way, who 
covers the costs of the equipment. CSBG-funded CAHRA staff coordinates 
the program, the partners, and trained volunteers who install all 
safety hardware. Since the program began 9 years ago, CAHRA has helped 
nearly 1,000 low-income seniors and disabled individuals remain safe, 
secure, and independent through the HASA program, including providing 
227 devices to needy seniors and disabled individuals in the 2010 
program year.
            Innovative Gardening in New York--Community Action of 
                    Orleans and Genesee, Inc.
    Recognizing that effective use of work release time for individuals 
incarcerated by the criminal justice system provides benefits to both 
the inmate and the local community, Community Action of Orleans and 
Genesee, Inc. reached out to a local prison facility to make efficient 
use of their land and inmate work release time through the Facility 
Garden Project.
    Through this collaboration, inmates plant, weed, and harvest fruits 
and vegetables with facility staff. They distribute these fruits and 
vegetables to the CAA and other nutrition programs. These local 
organizations in turn provide 800 low-income families with both raw 
food and prepared meals. The Facility Garden Project positively impacts 
low-income families and partner agencies in all of Orleans County and 
parts of Genesee County. In fiscal year 2010, agencies across the 
service area helped distribute more than 3,000 pounds of assorted 
vegetables to disabled seniors, soup kitchen customers, emergency food 
customers, and low-income families.
    This innovative partnership yields positive results for the prison, 
community agencies, and low-income residents. CSBG funds were essential 
in creating this collaboration by funding project planners, staff who 
distributed the food to consumers, storage space for the vegetables, 
and space for cooking classes.
Closing Statement
    CAAs funded by the CSBG are an important link in the social safety 
net. They comprise a nationwide, accountable network that has 
experience in developing innovative, high-impact anti-poverty 
strategies and programs that are based on local needs. The CSBG Network 
uses resources to leverage more than $23 for each dollar of CSBG funds 
invested. CSBG bridges the gap between falling wages, job shortages, 
and high costs of living to keep working Americans from slipping 
further into poverty. CSBG already serves one out of every five people 
in America below the Federal Poverty Guideline. Strengthening CSBG is 
an effective, efficient way to meet our Nation's need for a strong and 
successful effort to bring economic opportunity to every American.
                                 ______
                                 
   Prepared Statement of the National Association of County and City 
                            Health Officials

FISCAL YEAR 2014 FUNDING FOR PROGRAMS AT THE CENTERS FOR DISEASE CONTROL
                             AND PREVENTION
                             [$ in millions]
------------------------------------------------------------------------
                                                         Fiscal   NACCHO
                                         Fiscal  Fiscal   Year    Fiscal
                Program                   Year    Year    2014     Year
                                          2012    2013    Pres.    2014
                                                         Budget  Request
------------------------------------------------------------------------
Prevention and Public Health Fund......   1,000     949   1,000    1,000
CDC Public Health Emergency                 666     608     658      715
 Preparedness Grants...................
CDC Community Transformation Grants....     226     146     146      280
CDC Section 317 Immunization Program...     642     528     581      642
CDC National Public Health Improvement       40      37      40       40
 Initiative............................
CDC Food Safety........................      27      26      49       49
------------------------------------------------------------------------

    The National Association of County and City Health Officials is the 
voice of the 2,800 local health departments across the country. These 
city, county, metropolitan, district, and tribal departments work every 
day to ensure the safety of the water we drink, the food we eat, and 
the air we breathe.
    More than 180,000 health department staff across the country are 
responsible for programs that make it easier for people to be healthy. 
The Nation's current financial challenges are compounded by those in 
State and local governments further diminishing the ability of local 
health departments to address community health and safety needs. 
Repeated rounds of budget cuts and lay-offs continue to erode local 
health department capacity. Since 2008, local and State health 
departments have scaled back and eliminated programs that protect the 
public's health and cut more than 50,000 jobs. Sequester cuts will add 
to pressures on local health departments as Federal cuts make their way 
down to the State and local level.
    To help protect the public's health, we urge the subcommittee to 
consider the following fiscal year 2014 funding request for programs at 
the Department of Health and Human Services (HHS) and Centers for 
Disease Control and Prevention (CDC):
Prevention and Public Health Fund (HHS)
NACCHO Request: $1 billion
Fiscal Year 2014 President's Budget: $1 billion
Fiscal Year 2013: $949 million

    The Prevention and Public Health Fund (PPHF) is a dedicated Federal 
investment in programs that prevent disease at the community level. The 
PPHF supports:
  --Early and rapid detection of diseases and injury;
  --Continuous quality improvement in public health practice;
  --Community-based initiatives to stem the epidemic of preventable 
        disease;
  --Immunizations and innovative chronic disease grants to prevent and 
        reduce the rising cost of health care for the leading causes of 
        death; and
  --Local and State public health workforce training.
    In fiscal year 2013 the Obama Administration diverted more than 
$300 million from the PPHF for Navigator grants and health reform 
implementation. NACCHO urges Congress to act to outline an allocation 
for the $1 billion available from the PPHF in fiscal year 2014 that 
adheres to its statutory purpose to prevent disease and promote public 
health.

Public Health Emergency Preparedness
Center: Center for Public Health Preparedness and Response
Funding Line: State and Local Preparedness and Response Capability
Sub-line: Public Health Emergency Preparedness Cooperative Agreements 
        (PHEP)
NACCHO request: $715 million
Fiscal Year 2014 President's Budget: $658 million (fiscal year 2014 
        President's Budget includes PHEP grants in State and Local 
        Preparedness and Response Capability)
Fiscal Year 2013: $608 million

    The Public Health Emergency Preparedness (PHEP) grant program 
protects communities by strengthening local and State public health 
department capacity to effectively respond to public health emergencies 
including terrorist threats, infectious disease outbreaks, natural 
disasters, and biological, chemical, nuclear, and radiological 
emergencies. Local and State health departments work with Federal 
officials, law enforcement, emergency management, health care, 
employers, schools, and religious groups to plan, train, and prepare 
for emergencies so that communities are ready. Local health departments 
protect the public in the following ways:
  --They investigate, detect, and contain outbreaks of disease
  --They educate the public about how to protect themselves; such as by 
        wearing masks, drinking bottled water, or staying indoors.
  --They dispense medications or vaccinations to slow the spread of 
        illness.
    The PHEP program has lost more than a quarter of its funding since 
fiscal year 2004. Sustained funding is essential to make sure that 
communities are protected.
Chronic Disease Prevention
Center: Center for Chronic Disease Prevention and Health Promotion
Funding Line: Community Transformation Grants (CTG)
NACCHO Request: $280 million
Fiscal Year 2014 President's Budget: $146 million
Fiscal Year 2013: $146 million

    The CTG program provides resources for local communities to address 
heart attacks, strokes, cancer, diabetes, and other chronic diseases 
which contribute to the soaring cost of health care. Risk factors like 
obesity and smoking often lead to these diseases and conditions, which 
are responsible for 75 percent of all health care spending--96 cents 
per dollar for Medicare and 83 cents per dollar for Medicaid. CTG 
grantees are charged with a 5 percent reduction in 5 years of death and 
disability due to tobacco use, heart disease and stroke and the rate of 
obesity through nutrition and physical activity. The program seeks to 
improve the health of about 130 million Americans.
Infectious Disease Prevention
317 Immunization Program
Center: National Center for Immunization and Respiratory Diseases
Funding Line: 317 Immunization Program
NACCHO Request: $642 million
Fiscal Year 2014 President's Budget: $581 million
Fiscal Year 2013: $528 million

    Local health departments vaccinate people in their communities, 
providing one of the most successful and cost-effective ways to prevent 
disease and death. Local health departments use innovative methods to 
increase vaccination rates, including ``Vote and Vax'' activities where 
voters receive immunizations at their polling places and conducting 
outreach to families to make sure kids are immunized and ready to 
attend school.
    Local health departments also have a responsibility for ensuring 
that the most vulnerable people in their communities receive protection 
from vaccines. The Section 317 Immunization Program provides funds to 
50 States, six large cities and eight territories for vaccine purchase 
for at-need populations and immunization program operations at the 
local, State, and national levels. Local health departments utilize 
these funds to work with public and private physicians to assure 
effective immunization practices, including proper storage and delivery 
of vaccines. Through the use of vaccine registries administered by 
health departments, savings are achieved by avoiding duplicative 
vaccinations, improved inventory management, and by identifying gaps in 
immunizations in persons and groups.
    Sustained funding for the Section 317 is critical to protecting 
Americans for preventable diseases. NACCHO supports the President's 
request of $25 million within 317 funding to support State and local 
health departments to develop billing and other infrastructure that is 
needed to be reimbursed for clinical services.
Public Health Performance Improvement
Center: Center for Public Health Leadership and Support
Funding Line: National Public Health Improvement Initiative
NACCHO Request: $40 million
Fiscal Year 2014 President's Budget: $40 million
Fiscal Year 2013: $37 million

    The National Public Health Improvement Initiative provides funding 
to 74 State, tribal, local and territorial health departments to make 
changes and enhancements that increase the impact of public health 
services. NPHII strengthens health departments by providing staff, 
training, tools, and capacity-building assistance dedicated to 
establishing performance management and evidence-based practices for 
improved service delivery and better health outcomes.
Food Safety
Center: Center for Emerging and Zoonotic Infectious Diseases
Funding Line: Food Safety
NACCHO Request: $49 million
Fiscal Year 2014 President's Budget: $49 million
Fiscal Year 2013: $26 million

    Foodborne illness affects 48 million Americans every year, 
resulting in 128,000 hospitalizations and 3,000 deaths. CDC's Food 
Safety program seeks to ensure food safety through surveillance and 
outbreak response. Local and State health departments are an essential 
part of the process that ensures that food is safe to eat at home, at 
community events, in restaurants, and in schools. Funding is needed to 
advance implementation of the Food Safety Modernization Act by 
enhancing and integrating disease surveillance, improving outbreak and 
response timeliness and helping address deficits in local capacity to 
prevent and stop illness.
    As the subcommittee drafts the fiscal year 2014 Labor-HHS-Education 
Appropriations bill, NACCHO urges consideration of these 
recommendations for programs critical to protecting the public's 
health.
                                 ______
                                 
    Prepared Statement of the National Congress of American Indians

Introduction

    The National Congress of American Indians (NCAI) is the largest and 
oldest representative organization of American Indian and Alaska Native 
tribal governments. NCAI represents the broad interests of tribes and 
their citizens to advance, and promote the advancement, of tribal 
Sovereignty and Self-Determination. NCAI respectfully submits this 
testimony on the Corporation for Public Broadcasting (CPB) and programs 
in the Department of Labor.

                  CORPORATION FOR PUBLIC BROADCASTING

    In the CPB, NCAI supports an advanced fiscal year 2015 
appropriation of $5 million for American Indian and Alaska Native radio 
stations. This $5 million appropriation would come out of the fiscal 
year 2014 advanced appropriation of $445 million for the overall CPB 
budget.
    For more than 30 years, decisions on the amount of Federal support 
for public broadcasting have been made 2 years ahead of the fiscal year 
in which the funding is allocated. In other words, Congress approves 
the fiscal year 2015 funding level for CPB during the fiscal year 2013 
appropriations process. Thus, where the overall budget for the CPB in 
fiscal year 2014 was $445 million, Indian Country requests an advance 
appropriation of $5 million to fund American Indian and Alaska Native 
radio stations for fiscal year 2015.
    Since 2011, the Native radio system has grown from 33 stations to 
53 stations to provide service to more of Indian Country. CPB funding 
supports 30 of 53 Native radio stations, which collectively reach more 
than 8 percent of the American Indian and Alaska Native populations 
with free radio programming. These stations are funded through a 
variety of sources, including: individual donors, local businesses, 
CPB, tribal governments, and grants. Native-owned and operated radio 
stations are a model of local community service radio, serve as the 
primary and most consistent sole service providers of public safety 
information and cultural and linguistic preservation, and stand as an 
invaluable outlet for local news in tribal communities. Native radio 
stations employ at least 1,000 broadcasters, engineers, station staff, 
consultants, and other local community members.
    Additionally, the Public Broadcasting Act directs CPB to utilize 6 
percent of the appropriation for ``projects and activities that will 
enhance public broadcasting.'' This funding supports the research, 
planning, professional development, and industry consultations that 
guide CPB's decisionmaking in other budget categories. Native Public 
Media and Koahnic Broadcast Corporation are capable to provide valued 
services to develop and maintain the Native radio system and are funded 
from the 6 percent allocation (currently amounting to $1 million over 2 
years). Native Public Media has assisted in filing for 51 new stations 
and secured construction permits for 38 of these new stations.
    Native Public Media also provides education and training for tribal 
broadcasters in digital literacy, journalism, and community-based 
strategies that will broaden the impact of the Native radio system in 
unserved tribal communities across the United States. Koahnic Broadcast 
Corporation produces Native programming and content for radio broadcast 
and oversees Native Voice One--the distribution mechanism that utilizes 
satellite technology to deliver programming and content to Native radio 
stations and other affiliates across the United States.
    Native public radio stations still exist as one of the primary 
sources of public information on tribal lands, and represent 
cornerstones of tribal efforts for information dissemination. Much of 
Indian Country remains disconnected from vital telecommunications 
services, radio should not be counted among them. Radio has always 
existed as a key component of public information and 53 tribal radio 
stations among this country's 566 federally recognized tribes 
illustrates the need for these services in Indian Country. This 
communications tool, though antiquated it may seem compared to other 
technologies available today, provides services of immense cultural 
significance.

                          DEPARTMENT OF LABOR

    Restore the YouthBuild Program funding to a minimum of $102.5 
million, restore the rural and tribal set-aside in the YouthBuild 
program, and reinstate a dedicated 10 percent rural and tribal set-
aside of at least $10.25 million. The YouthBuild program is a workforce 
development program that provides significant academic and occupational 
skills training and leadership development to youth ages 16-24. 
YouthBuild provides services to approximately 7,000 youth annually by 
re-engaging them in innovative alternative education programs that 
provide individualized instruction as they work towards earning either 
a GED or high school diploma, as well as fosters work skills so that 
youth can be competitive candidates in the job market. Youth 
participate in public construction projects while attending classes to 
obtain their high school diploma or GED.
    YouthBuild reports that since it was established as a Federal 
program in 1992, 120,000 YouthBuild students have built 22,000 units of 
affordable housing in low-income communities in 46 States and the 
District of Columbia. When the program was transferred from the 
Department of Housing and Urban Development to the Department of Labor 
in 2007, the 10 percent set-aside for rural and tribal programs was 
eliminated. Additionally, in 2011, due to a 28 percent cut in 
YouthBuild appropriations, over 18,000 applicants to YouthBuild 
programs were turned away.\1\
    The YouthBuild program recruits youth that have been adjudicated, 
aged out of foster care, dropped out of high school, and others at risk 
of not having access to workforce training. In 2010, 4,252 youth 
participated in the program and had a completion rate of 78 percent. 
According to YouthBuild, 60 percent of those that completed the program 
were placed in jobs or further education.\2\ There are a number of 
tribal YouthBuild programs in several States, and at least 4 percent of 
YouthBuild participants are Native. Given the recent reduction in 
tribal YouthBuild programs, significant unemployment and housing 
challenges in Indian Country, and the growing Native youth population, 
it is essential that the 10 percent rural and tribal set-aside be 
restored. 42 percent of the total American Indian and Alaska Native 
population is under 25 \3\, and these workforce development 
opportunities are essential in preparing tribal youth for employment 
and self-sufficiency.
    Fund the Department of Labor's Indian and Native American Program 
(INAP) at a minimum of $60.5 million. Fund the Native American 
Employment and Training Council at $125,000 from non-INAP resources. 
Reducing the education and employment disparity between Native people 
and other groups requires a concentrated effort that provides specific 
assistance to enhance education and employment opportunities, to create 
pathways to careers and skilled employment, and to secure a place for 
Native people within the Nation's middle class. The Workforce 
Investment Act (WIA) Section 166 program serves the training and 
employment needs of over 38,000 American Indians and Alaska Natives via 
a network of 175 grantees through the Comprehensive Service Program 
(Adult) and Supplemental Youth Service Program (Youth), and the Indian 
Employment and Training and Related Services Demonstration Act of 1992, 
Public Law 102-477. Furthermore, the number of American Indians and 
Alaska Natives served through WIA does not fully capture the impact it 
has in Indian Country, as there are many more served by grantees that 
leverage WIA funding, along with other similar federally funded 
employment and training programs, through PL 102-477.
    Any decrease in funding along with the looming discretionary cuts 
will be devastating and severely hamper labor progress in Indian 
Country. According to the Census, the average unemployment rate on 
reservations dropped more than 3 percentage points since 2000 \4\, but 
more still needs to be done as American Indians and Alaska Natives 
still lag significantly behind. With the average unemployment rate in 
Indian Country cited up to 17 percent \5\ and an average joblessness 
rate of nearly 50 percent \6\, the WIA Section 166 program is vital to 
helping reverse these trends.
    Because the WIA Section 166 program is the only Federal employment 
and job training program that serves American Indians and Alaska 
Natives who reside both on and off reservations, it is imperative that 
its funding be maintained. For Native citizens living on remote 
reservations or in Alaska Native villages, it can be difficult to 
access the State and local workforce systems. In these areas, the WIA 
Section 166 program is the sole employment and training provider.
    The Workforce Investment Act (the Act) has been up for 
reauthorization since 2003, and over this ten-year period, the Act has 
not accounted for the population growth of tribal communities, nor the 
economic environment that has drastically changed; according to the 
2010 Census, the population of tribal communities has grown 27 percent 
since the year 2000, compared to 9 percent for the general 
population.\7\ The Act authorizes the INAP to be funded at ``not less 
than $55 million,'' but Section 166 is currently funded at 
approximately $47 million. The Act also authorizes the Native American 
Employment and Training Council to advise the Secretary on the 
operation and administration of INAP, but is funded through the already 
strained and underfunded budget intended for INAP grantees. Since the 
current INAP funding is already below $55 million, the Secretary should 
use other streams of funding to support its advisory council. Without 
an increase in funding and given the large increase in the American 
Indian and Alaska Native population, not enough tribes are able to 
benefit from the support and training activities for employment 
opportunities in Indian Country.
---------------------------------------------------------------------------
    \1\ See https://youthbuild.org/research.
    \2\ Ibid.
    \3\ U.S. Census Bureau, 2010 Census, Summary File 1.
    \4\ US Census Bureau. Census 2000 Summary File 4, 2006-2010, 2009-
2011 American Community Survey.
    \5\ U.S. Census. 2011 American Community Survey.
    \6\ U.S. Department of Interior. Bureau of Indian Affairs. 2005 
American Indian Labor Force Report.
    \7\ U.S. Census Bureau, 2010 Census, Summary File 1.
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                    DEPARTMENT OF EDUCATION PROGRAMS

Introduction
    The National Congress of American Indians (NCAI) is the oldest and 
largest American Indian organization in the United States. Tribal 
leaders created NCAI in 1944 as a response to termination and 
assimilation policies that threatened the existence of American Indian 
and Alaska Native tribes. Since then, NCAI has fought to preserve the 
treaty rights and sovereign status of tribal governments, while also 
ensuring that Native people may fully participate in the political 
system. As the most representative organization of American Indian 
tribes, NCAI serves the broad interests of tribal governments across 
the Nation.
    Investing in the education of American Indian and Alaska Native 
students is not only one most of the most important cornerstones of the 
Federal trust responsibility to tribes, but is also critical to 
economic revitalization for both Indian Country and the Nation as a 
whole. President Obama has repeatedly stressed that improving American 
education is an ``economic imperative,'' and for tribes, the stakes are 
just as high, if not higher. Education provides tribal economies with a 
more highly-skilled workforce while also directly spurring economic 
development and job creation. The profound value of education for 
Native nations extends beyond just economics, however. Education drives 
personal advancement and wellness, which in turn improves social 
welfare and empowers communities--elements that are essential to 
maintaining tribes' cultural vitality and to protecting and advancing 
tribal sovereignty.
    Despite the enormous potential of education for transforming tribal 
communities, Native education is in a state of emergency. American 
Indian and Alaska Native students lag far behind their peers on every 
educational indicator, from academic achievement to high school and 
college graduation rates. For example, in 2011, only 18 percent of 
Native fourth graders and 22 percent of Native eighth graders scored 
proficient or advanced in reading, and only 22 percent of Native fourth 
graders and 17 percent of Native eighth graders scored proficient or 
advanced in math.\8\ The crisis of Indian education is perhaps most 
apparent in the Native high school dropout rate, which is not only one 
of the highest in the country, but is also above 50 percent in many of 
the States with high Native populations.\9\
    To address this urgent situation and provide tribal nations with 
the critical foundation for economic success, the Federal Government 
must live up to its trust responsibility by providing adequate support 
for Native education. The requests below detail the minimum 
appropriations needed to maintain a system that is struggling and 
underfunded. NCAI also fully supports the recommendations of the 
American Indian Higher Education Consortium for tribal colleges.

Education Funding Requests For The Fiscal Year 2014 Labor-HHS-Education 
        Bill
            State-Tribal Education Partnership (STEP) Program
        -- Provide $5 million for the State-Tribal Education 
            Partnership Program.
    Congress appropriated roughly $2 million dollars for the STEP 
program to five participating tribes in fiscal year 2012 and fiscal 
year 2013 under the Tribal Education Department appropriations' line 
that is administered by the Department of Education. In order for this 
program to continue to succeed and thrive, it must receive its own line 
of appropriations in fiscal year 2014. Collaboration between tribal 
education agencies and State educational agencies is crucial to 
developing the tribal capacity to assume the roles, responsibilities, 
and accountability of Native education departments and increasing self-
governance over Native education.
            Impact Aid
        -- Provide $1.395 billion for Impact Aid, Title VIII of the 
            Elementary and Secondary Education Act (ESEA).
    Impact Aid provides direct payments to public school districts as 
reimbursement for the loss of traditional property taxes due to a 
Federal presence or activity, including the existence of an Indian 
reservation. With nearly 93 percent of Native students enrolling in 
public schools, Impact Aid provides essential funding for schools 
serving Native students. Therefore, funding for Impact Aid must not be 
less than this requested amount. Furthermore, Impact Aid should be 
converted to a forward-funded program to eliminate the need for cost 
transfers and other funding issues at a later date.
            Title VII (Indian Education Formula Grants)
        -- Provide $198 million for Title VII of the ESEA.
    This grant funding is designed to supplement the regular school 
program and assist Native students so they have the opportunity to 
achieve the same educational standards and attain equity with their 
non-Native peers. Title VII provides funds to school divisions to 
support American Indian, Alaska Native, and Native Hawaiian students in 
meeting State standards. Furthermore, Title VII funds support early-
childhood and family programs, academic enrichment programs, curriculum 
development, professional development, and culturally-related 
activities.
            Alaska Native Education Equity Assistance Program
        -- Provide $35 million for Title VII, Part C of the ESEA.
    This assistance program funds the development of curricula and 
education programs that address the unique educational needs of Alaska 
Native students, as well as the development and operation of student 
enrichment programs in science and mathematics. This funding is crucial 
to closing the gap between Alaska Native students and their non-Native 
peers. Other eligible activities include professional development for 
educators, activities carried out through Even Start programs and Head 
Start programs, family literacy services, and dropout prevention 
programs.
            Native Hawaiian Education Program
        -- Provide $35 million for Title VII, Part B of the ESEA.
    This program funds the development of curricula and education 
programs that address the education needs of Native Hawaiian students 
to help bring equity to this Native population. Where Native Hawaiians 
once had a very high rate of literacy, today Native Hawaiian 
educational attainment lags behind the general population. The Native 
Hawaiian Education program empowers innovative culturally appropriate 
programs to enhance the quality of education for Native Hawaiians. When 
establishing the Native Hawaiian Education Program, Congress 
acknowledged the trust relationship between the Native Hawaiian people 
and the United States. Additionally, specific educational disparities 
were identified, and targeted for improvement. New grantees in fiscal 
year 2011 alone are estimated to provide educational programs to over 
30,000 Native Hawaiian children and families. These programs strengthen 
the Native Hawaiian culture and improve educational attainment, both of 
which are correlated with positive economic outcomes.
            Tribal Education Departments
        -- Provide $5 million to fund Tribal Education Departments.
    Five million dollars should be appropriated to the Department of 
Education to support tribal education departments (TEDs). This funding 
assists TEDs, which are uniquely situated at the local level to 
implement innovative education programs that improve Native education. 
Because they are administered by tribes, TEDs are best equipped to 
deliver education programs tailored to improve education parity for 
Native students. TEDs would use this much-needed funding to develop 
academic standards, assess student progress, and create math and 
science programs that require high academic standards for students in 
tribal, public, and Bureau of Indian Education schools. Tribes 
exercising self-governance over their citizens' education have been 
very successful because they better understand the circumstances of 
their populations and can develop initiatives that meet local needs. 
Adequately funding TEDs would create the most return on Federal dollars 
spent.
            Vocational Rehabilitation Services Projects for American 
                    Indians with Disabilities
        -- Increase Vocational Rehabilitation Services Projects to $67 
            million and create a line-item of $5 million for providing 
            outreach to tribal recipients.
    According to the Centers for Disease Control and Prevention, 
approximately 30 percent of American Indian and Alaska Native adults 
have a disability--the highest rate of any other population in the 
Nation.\10\ Of those American Indian and Alaska Native adults with a 
disability, 51 percent reported having fair or poor health.\11\ A 
number of issues contribute to this troubling reality, including high 
incidences of diabetes, heart disease, and preventable accidents. As a 
result, tribes have an extraordinary need to support their disabled 
citizens in improving their health and becoming self-sufficient. 
Despite this need, however, tribes have had limited access to funding 
for vocational rehabilitation and job training compared to States. An 
increase in the Vocational Rehabilitation Services Projects to $67 
million would begin to put tribes on par with State governments and 
better equip tribes to provide supports to their disabled citizens.
---------------------------------------------------------------------------
    \8\ National Indian Education Study 2011, NCES 2012-466. National 
Center for Education Statistics, Institute of Education Sciences, 
United States Department of Education.
    \9\ School Year 2010-2011 Four-Year Regulatory Adjusted Cohort 
Graduation Rates, Department of Education.
    \10\ Centers for Disease Control and Prevention. (2011). 
``Disability and Health''. Retrieved on January 2, 2013, from http://
www.cdc.gov/ncbddd/disabilityandhealth/data.html.
    \11\ Ibid.
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                DEPARTMENT OF HEALTH AND HUMAN SERVICES

Introduction
    The National Congress of American Indians (NCAI) is the oldest and 
largest American Indian organization in the United States. Tribal 
governments cannot survive and prosper without healthy and strong 
tribal citizens. The United States Congress has shown a commitment to 
over 300 treaties and the Federal trust responsibility through 
appropriations to programs that support the health and wellness of 
tribal communities. However, American Indians and Alaska Natives 
continue to experience chronically high rates of foster care, suicide, 
diabetes, and obesity.
    Each year NCAI works with national and regional Indian 
organizations to develop budget recommendations and requests for each 
area of the Federal budget. For this subcommittee, NCAI provides the 
recommendations below for some Federal agencies under the Department of 
Health and Human Services (HHS) and fully supports the recommendations 
of the National Indian Child Welfare Association, National Indian 
Health Board, and National Indian Education Association.
Substance Abuse and Mental Health Services Administration (SAMHSA)
    Provide $15 million to fund Substance Abuse and Mental Health 
Services Administration (SAMHSA) for Behavioral Health.--This SAMHSA 
grant program has been authorized to award grants to Indian health 
programs to provide the following services: prevention or treatment of 
drug use or alcohol abuse, promotion of mental health, or treatment 
services for mental illness. To date, these funds have never been 
appropriated. An appropriation of $15 million would provide support to 
Indian health programs to meet the critical substance abuse and mental 
health needs of their citizens.
    Support SAMHSA's Behavioral Health Tribal Prevention Grant program 
at $40 million in fiscal year 2014.--The Behavioral Health Tribal 
Prevention Grant will support behavioral health services that promote 
overall mental and emotion health, in particular substance abuse 
prevention and suicide prevention services. If funded, the grant 
program would be the only source of Federal substance abuse and suicide 
prevention funding exclusively available to tribes.
    Provide a $6 million tribal set-aside for American Indian suicide 
prevention programs under the Garrett Lee Smith Act.--Suicide has 
reached epidemic proportions in some tribal communities. The Garrett 
Lee Smith Memorial Act of 2004 is the first Federal legislation to 
provide specific funding for youth suicide prevention programs, 
authorizing $82 million in grants over 3 years through SAMHSA. 
Currently, tribes must compete with other institutions to access these 
funds. To assist tribal communities in accessing these funds, a line 
item for tribal-specific resources is necessary.

Administration for Children and Families
    Provide full funding for Head Start and Indian Head Start.--Head 
Start has been and continues to play an instrumental role in Native 
education. This vital program combines education, health, and family 
services to model traditional Native education, which accounts for its 
success rate. However, current funding dollars provide less for Native 
populations as inflation and fiscal constraints increase. It is now 
conventional wisdom that there is a return of at least $7 for every 
single dollar invested in Head Start.\12\ Therefore, Congress should 
fully fund Head Start and Indian Head Start to ensure this highly 
successful program serves more Native people.
    Provide $10 million for Esther Martinez Program Native language 
preservation grants.--Native language grant programs are essential to 
revitalizing Native languages and cultures, many of which are at risk 
of disappearing in the next decades. With adequate funding, Esther 
Martinez Program Grants support and strengthen Native American language 
immersion programs. In addition to protecting Native languages, these 
immersion programs have been shown to promote higher academic success 
for participating students in comparison to their Native peers who do 
not participate. This is critical for our Native youth, who have high 
school graduation rates far lower than their non-Native peers.

Administration on Aging
    Provide $30 million for Parts A (Grants for Native Americans) and B 
(Grants for Native Hawaiians) of the Older Americans Act.--Programs 
under Title VI of the Older Americans Act are the primary vehicle for 
providing nutrition and other direct supportive services to American 
Indian, Alaska Native, and Native Hawaiian elders. Approximately two-
thirds of the Part A and Part B grants to tribes or consortia of tribes 
are for less than $100,000. This funding level is expected to provide 
services for a minimum of 50 elders for an entire year. Yet, those 
tribes receiving $100,000 typically serve between 200 and 300 elders. 
As such, many tribes are unable to meet the five-days-a-week meal 
requirement because of insufficient funding and are serving congregate 
meals only two or three days per week. Some Title VI programs are 
forced to close for a number of days each week, unable to provide basic 
services such as transportation, information and referral services, 
legal assistance, ombudsman, respite or adult day care, home visits, 
homemaker services, or home health aide services. Rapidly increasing 
transportation costs also severely limit Title VI service providers' 
ability to deliver meals and related supportive services to home-bound 
Native elders at the current funding level. This funding should be 
significantly increased so that Native elders receive the care that 
they deserve.
    Provide $8.3 million for the Native American Caregiver Support 
Program administered by the Administration on Aging and create a line-
item for training for tribal recipients.--The Native American Caregiver 
Support Program under Part C of the OAA assists American Indian, Alaska 
Native, and Native Hawaiian families caring for older relatives with 
chronic illnesses. The grant program offers many services that meet 
caregivers' needs, including information and outreach, access 
assistance, individual counseling, support groups and training, respite 
care, and other supplemental services. However, this program cannot be 
effective if it is not adequately funded. It should be funded at $8.3 
million, with sufficient resources also allocated to address 
historically unmet tribal training needs.
    Create a tribal set-aside of $2 million under Subtitle B of Title 
VII.--Subtitle B of Title VII of the Older Americans Act authorizes a 
program for tribes, public agencies, or non-profit organizations 
serving Native elders to assist in prioritizing issues concerning elder 
rights and to carry out related activities. While States have been 
funded at more than $20 million per year under this program, tribes 
have never received appropriations for this purpose. Further, tribes 
have no additional source of mandatory Federal funding for elder 
protection activities. As such, a $2 million tribal set-aside should be 
created under Subtitle B to ensure that tribes have access to such 
funds at a comparable level to States.
    Provide $3 million for national minority aging organizations to 
build the capacity of community-based organizations to better serve 
Native seniors.--Language and cultural barriers severely restrict 
Native elder access to Federal programs for which they are eligible. 
Typically, these senior Americans have limited access to and 
participation in programs such as Social Security, Medicare, and 
Medicaid. Funding is needed to build capacity for tribal, minority, and 
other community-based aging organizations to serve Native elders and 
enroll them in programs to which they are entitled. These efforts could 
include training tribal staff on expanding Native elders' access to 
Medicare, Medicaid, housing, congregate meals, and veteran benefits. 
Efforts could also include working with tribal leaders to leverage 
existing funds and programs to sustain support for elders. This funding 
is essential to strengthening local organizations in serving seniors.

National Institutes of Health
    Though NCAI is not requesting additional funding for the National 
Institutes of Health (NIH), we would like to protect current funding 
levels and highlight the significant negative impact the sequestration 
will have on many tribal governments and associate research and 
development projects. Of the major research institutes, the NIH stands 
to take the greatest hit in terms of total dollars lost at nearly $2.4 
billion. This could severely constrain research on diseases that cost 
tribal communities millions of dollars each year to treat, including: 
diabetes, cancer, and heart disease, amongst so many others. It will 
also affect the number of grants NIH awards each year, which may affect 
Native-focused funding mechanisms like the Native American Research 
Centers for Health (NARCH) funded by NIH. NCAI requests that the 
subcommittee work to protect research for and with tribal communities 
as these projects continue to inform policymaking decisions and 
highlight best practices for tribal programs and initiatives.

                               CONCLUSION

    Thank you for your consideration of this testimony. For more 
information, please contact Amber Ebarb, NCAI Budget and Policy 
Analyst, at [email protected], Katie Jones, NCAI Legislative Associate, 
at [email protected], Brian Howard, NCAI Legislative Associate, at 
[email protected], Gerald Kaquatosh, NCAI fellow at [email protected], 
and Terra Branson, NCAI Legislative Associate, at [email protected].
---------------------------------------------------------------------------
    \12\ Mitra, D. (June 2011). ``Pennsylvania's best investment: The 
social and economic benefits of public education.'' Philadelphia, PA: 
Education Law Center. Retrieved on January 8, 2013, from http://
www.elc-pa.org/BestInvestment_Full_Report_6.27.11.pdf.
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                                 ______
                                 
Prepared Statement of the National Council For Diversity in the Health 
                              Professions

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

    1)  $300 million for the Title VII Health Professions Training 
Programs, including:
     --$33.6 million for the Minority Centers of Excellence.
     --$35.6 million for the Health Careers Opportunity Program.
_______________________________________________________________________

    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to present my views before you today. I am Dr. Wanda 
Lipscomb, President of the National Council for Diversity in the Health 
Professions (NCDHP) and the Director of the Center of Excellence for 
Culture Diversity in Medical Education at Michigan State University. 
NCDHP, established in 2006, is a consortium of our Nation's majority 
and minority institutions that once house the Health Resources and 
Services (HRSA) Minority Centers of Excellence (COE) and Health Careers 
Opportunities Programs (HCOP) when there was more funding. These 
institutions are committed to diversity in the health professions. In 
my professional life, I have seen firsthand the importance of health 
professions institutions promoting diversity and the Title VII Health 
Professions Training programs.
    Mr. Chairman, time and time again, you have encouraged your 
colleagues and the rest of us to take a look at our Nation and evaluate 
our needs over the next 10 years. I want to say that minority health 
professional institutions and the Title VII Health Professionals 
Training programs address a critical national need. Persistent and 
severe staffing shortages exist in a number of the health professions, 
and chronic shortages exist for all of the health professions in our 
Nation's most medically underserved communities. Furthermore, our 
Nation's health professions workforce does not accurately reflect the 
racial composition of our population. For example while blacks 
represent approximately 15 percent of the U.S. population, only 2-3 
percent of the Nation's health professions workforce is black. Mr. 
Chairman, I would like to share with you how your committee can help 
NCDHP continue our efforts to help provide quality health professionals 
and close our Nation's health disparity gap.
    There is a well established link between health disparities and a 
lack of access to competent healthcare in medically underserved areas. 
As a result, it is imperative that the Federal Government continue its 
commitment to minority health profession institutions and minority 
health professional training programs to continue to produce healthcare 
professionals committed to addressing this unmet need.
    An October 2006 study by the Health Resources and Services 
Administration (HRSA), entitled ``The Rationale for Diversity in the 
Health Professions: A Review of the Evidence'' found that minority 
health professionals serve minority and other medically underserved 
populations at higher rates than non-minority professionals. The report 
also showed that; minority populations tend to receive better care from 
practitioners who represent their own race or ethnicity, and non-
English speaking patients experience better care, greater 
comprehension, and greater likelihood of keeping follow-up appointments 
when they see a practitioner who speaks their language. Studies have 
also demonstrated that when minorities are trained in minority health 
profession institutions, they are significantly more likely to: 1) 
serve in rural and urban medically underserved areas, 2) provide care 
for minorities and 3) treat low-income patients.
    As you are aware, Title VII Health Professions Training programs 
are focused on improving the quality, geographic distribution and 
diversity of the healthcare workforce in order to continue eliminating 
disparities in our Nation's healthcare system. These programs provide 
training for students to practice in underserved areas, cultivate 
interactions with faculty role models who serve in underserved areas, 
and provide placement and recruitment services to encourage students to 
work in these areas. Health professionals who spend part of their 
training providing care for the underserved are up to 10 times more 
likely to practice in underserved areas after graduation or program 
completion.
    Institutions that cultivate minority health professionals, like the 
NCDHP members, have been particularly hard-hit as a result of the cuts 
to the Title VII Health Profession Training programs in fiscal year 
2006, fiscal year 2007, and fiscal year 2008. Given their historic 
mission to provide academic opportunities for minority and financially 
disadvantaged students, and healthcare to minority and financially 
disadvantaged patients, minority health professions institutions 
operate on narrow margins. The cuts to the Title VII Health Professions 
Training programs amount to a loss of core funding at these 
institutions and have been financially devastating. We have been 
pleased to see efforts to revitalize both COE and HCOP in recent fiscal 
years, but it is important to fully fund the programs at least at the 
fiscal year 2004 level so that more diversity is achieved in our health 
professions.
    Earlier this year with the passage of health reform, the Congress 
showed the importance of the many of the Title VII programs, including 
the Minority Centers of Excellence (COE) and Health Careers 
Opportunities Program (HCOP), by reauthorizing the programs.
    Minority Centers of Excellence.--COEs focus on improving student 
recruitment and performance, improving curricula in cultural 
competence, facilitating research on minority health issues and 
training students to provide health services to minority individuals. 
COEs were first established in recognition of the contribution made by 
four historically black health professions institutions (the Medical 
and Dental Institutions at Meharry Medical College; The College of 
Pharmacy at Xavier University; and the School of Veterinary Medicine at 
Tuskegee University) to the training of minorities in the health 
professions. Congress later went on to authorize the establishment of 
``Hispanic'', ``Native American'' and ``Other'' Historically black 
COEs. For fiscal year 2014, I recommend a funding level of $24 million 
for COEs.
    Health Careers Opportunity Program (HCOP).--HCOPs provide grants 
for minority and non-minority health profession institutions to support 
pipeline, preparatory and recruiting activities that encourage minority 
and economically disadvantaged students to pursue careers in the health 
professions. Many HCOPs partner with colleges, high schools, and even 
elementary schools in order to identify and nurture promising students 
who demonstrate that they have the talent and potential to become a 
health professional.
    Collectively, the absence of HCOPs will substantially erode the 
number of minority students who enter the health professions. Over the 
last three decades, HCOPs have trained approximately 30,000 health 
professionals including 20,000 doctors, 5,000 dentists and 3,000 public 
health workers. For fiscal year 2014, I recommend a funding level of 
$23 million for HCOPs.
    Mr. Chairman, please allow me to express my appreciation to you and 
the members of this subcommittee. With your continued help and support, 
NCDHP member institutions and the Title VII Health Professions Training 
programs can help this country to overcome health and healthcare 
disparities. Congress must be careful not to eliminate, paralyze or 
stifle the institutions and programs that have been proven to work. 
NCDHP seeks to close the ever widening health disparity gap. If this 
subcommittee will give us the tools, we will continue to work towards 
the goal of eliminating that disparity everyday.
    Thank you, Mr. Chairman.
                                 ______
                                 
     Prepared Statement of the National Council of Social Security 
                        Management Associations

    On behalf of the National Council of Social Security Management 
Associations (NCSSMA), thank you for the opportunity to submit this 
testimony regarding the Social Security Administration's (SSA's) fiscal 
year 2014 Appropriation.
    NCSSMA is a membership organization of nearly 3,500 SSA managers 
and supervisors who provide leadership in over 1,200 community-based 
Field Offices (FOs) and Teleservice Centers (TSCs) throughout the 
country. We are the front-line service providers for SSA in communities 
all over the Nation. Since the founding of our organization over forty-
four years ago, NCSSMA has considered our top priority to be a stable 
SSA, which delivers quality and timely community-based service to the 
American public. We also consider it a top priority to be good stewards 
of the taxpayers' monies and the Social Security programs we 
administer.
    We fully support the President's budget request of $12.297 billion 
for SSA's administrative funding in fiscal year 2014. This request 
includes a new Program Integrity Administrative Expenses (PIAE) account 
that will provide new funding in addition to the Limitation on 
Administrative Expenses (LAE) account dedicated to program integrity 
work: medical continuing disability reviews (CDRs) and Supplemental 
Security Income (SSI) redeterminations.
    The PIAE account would provide a reliable stream of mandatory 
funding dedicated to program integrity efforts. In total, the fiscal 
year 2014 SSA budget proposal would provide SSA with $1.5 billion for 
these cost-saving program integrity workloads. SSA estimates that 
medical CDRs provide a return-on-investment of more than $9 for every 
dollar spent, and for SSI redeterminations it saves $5 for every dollar 
spent.
    It is critical SSA receives flexible funding for the LAE and PIAE 
request to respond to the increased requests for assistance from the 
American public as a result of the aging of the baby boom generation, 
the economic downturn, and to fulfill our stewardship responsibilities. 
Without adequate funding, SSA will not be able to provide the high-
quality customer service Americans deserve and will be unable to 
process program integrity workloads, which save taxpayer dollars and 
reduce the Federal budget and deficit.
    SSA TSCs, hearing offices, program service centers (PSCs), 
disability determination services (DDS), and the over 1,200 FOs are in 
critical need of adequate resources to address their growing workloads. 
The fiscal year 2014 budget request would allow SSA to cover 
inflationary increases, continue efforts to reduce hearings and 
disability backlogs, increase deficit-reducing program integrity work, 
and replace some critical staffing losses in SSA's components. It would 
also help to minimize the closure of additional field offices and 
improve public service.
    SSA is challenged by ever-increasing workloads, very complex 
programs to administer, and increased program integrity work with 
diminished staffing and resources. Despite SSA's enormous challenges, 
SSA's fiscal year 2013 appropriation for administrative funding through 
the LAE account was about $370 million below the fiscal year 2012 
enacted level, which includes a reduction of $386 million due to 
sequestration cuts. The fiscal year 2012 appropriation for 
administrative funding through the LAE account was approximately $300 
million below the fiscal year 2011 enacted level after rescissions from 
Carryover Information Technology funds.
    This funding level was over $1 billion below the President's budget 
request and did not allow SSA to cover inflationary costs for fixed 
expenses. It resulted in significant reductions in vital services, 
including a continuation of the hiring freeze in most of SSA; closing 
all FOs to the public one hour earlier (August 2011 one-half hour and 
November 2012 an additional one-half hour); closing of all FOs at noon 
on Wednesdays (effective January 2013); consolidation of 41 FOs and the 
closure of over 500 remote contact stations since fiscal year 2010; 
cancellation of plans to open 8 new hearings offices and a new TSC; 
suspension of mailing annual benefit statements to the public; and 
postponement of electronic service and programmatic efficiency 
initiatives.
    Public service has deteriorated significantly with increased 
waiting times as SSA continues to serve a near record number of 
visitors. Each day, almost 182,000 people visit SSA FOs and more than 
445,000 people call for assistance. The waiting time for visitors to 
date during fiscal year 2013 is nearly 30 percent longer than the same 
time period in fiscal year 2012. During the first 6 months of fiscal 
year 2013, over 2.1 million visitors waited more than one hour to be 
served. The number of visitors leaving without service has increased 10 
percent (over 1.2 million visitors).
    Despite agency online service initiatives and the reduction of 
public service hours, 44.9 million visitors were served by FOs in 
fiscal year 2012, approximately the same as in each of the previous 3 
years. SSA's FO busy rate to answer public telephone calls has 
increased from 7.4 percent in fiscal year 2012 to 14.9 percent (through 
March 2013). TSCs have also experienced a significant degradation of 
service. The agent busy rate has increased from 4.6 percent in fiscal 
year 2012 to 16.8 percent through March 2013. In addition, the time 
someone waits for their call to be answered has increased by 71 
percent.
    The need for resources in SSA FOs is critical to provide vital 
services to the American public. SSA has lost 9,200 employees since the 
beginning of fiscal year 2011--over 10 percent of its workforce. SSA 
will have approximately the same number of employees in fiscal year 
2013 as it did in fiscal year 2007. FO permanent staffing has gone from 
29,481 employees at the end of fiscal year 2010 to 26,298 employees in 
March 2013--a 10.8 percent decrease. In the last 2 years, more than 600 
SSA FOs have lost more than 10 percent of their staff and 16 percent of 
all SSA FOs have had a net attrition loss of over 20 percent.
    Geographic staffing disparities will only increase as ongoing 
attrition spreads unevenly across the country. This leaves many offices 
significantly understaffed and without sufficient capacity to address 
workloads. It is important to note the same SSA FO staff that process 
medical CDRs and SSI redeterminations, are the same employees who 
answer telephone calls, take initial claim applications, and develop 
and adjudicate benefit claims, which are vital in protecting taxpayer 
dollars and prevent improper payments before they occur. The SSA fiscal 
year 2014 budget request would allow SSA to begin replacing critical 
staffing losses and rebalance service, quality, and stewardship 
responsibilities.
    One of the greatest concerns for SSA is the huge increase in 
retirement, survivor, dependent, disability, and Supplemental Security 
Income (SSI) new claims and appeals. Retirement and survivor claims 
will be over 40 percent higher than in 2007. Initial disability claims 
have increased by nearly 25 percent and disability hearings have 
increased by nearly 50 percent since 2007. This increase is driven by 
the nearly 80 million baby boomers who will be filing for Social 
Security benefits by 2030 (an average of 10,000 per day) and by the 
economic downturn.
    In fiscal year 2014, SSA expects to handle over 5.4 million 
retirement, survivors, and Medicare claims; nearly 2.9 million Social 
Security and SSI initial disability claims; and 278,000 SSI aged 
claims. Also in fiscal year 2014, SSA will complete approximately 
725,000 reconsideration requests, 807,000 hearing requests, 16 million 
new and replacement Social Security cards, and 1.1 million Medicare 
prescription drug subsidy applications.
    In fiscal year 2012, disability claims receipts exceeded 3 million 
for the fourth successive year. Since fiscal year 2008, the number of 
claims pending for a disability medical decision rose from 565,286 to 
707,700 in fiscal year 2012--an increase of 142,414, or 25.2 percent. 
Despite the fact disability receipts have exceeded 3 million for four 
successive years, the current staffing level for DDSs is 14,064, 2,129 
(13.1 percent) below the level at the end of fiscal year 2010. A 
continued hiring freeze in DDSs for fiscal year 2013 will not allow SSA 
to complete as many disability claims as received.
    SSA was making progress in addressing the enormous backlog of 
hearings cases, but resource issues have magnified the challenges. 
After December 2008, when the number of pending hearings rose to 
768,540, the backlog was reduced for 19 straight months, to 694,417 in 
June 2010. However, pending hearings began to increase again and as of 
the end of March 2013 stood at 833,353 cases. In fiscal year 2012, 
849,869 hearing requests were filed, which nearly matched the all-time 
high for hearing requests in fiscal year 2011, an increase of over 45 
percent since fiscal year 2006. The number of disability claims pending 
is not acceptable to the millions of Americans who depend on Social 
Security or Supplemental Security Income for their basic income, 
meeting health care costs, and supporting their families.
    Program integrity initiatives save taxpayer dollars and are 
fiscally prudent in reducing the Federal budget and deficit. To address 
program integrity, the President's fiscal year 2014 SSA budget request 
provides a total of $1.5 billion for the two most cost-effective tools 
to reduce improper payments--medical CDRs and SSI redeterminations.
    If SSA would have received the full $1.024 billion requested by the 
President for program integrity initiatives in fiscal year 2013, the 
estimated program savings over the next 10 years would have been $8.1 
billion. However, as a result of the sequester and the current enacted 
fiscal year 2013 budget, SSA will not accomplish those levels of 
program integrity workloads. If the mandatory spending increase 
proposed in the fiscal year 2014 budget continues through 2023 the 
savings will be $37.7 billion.
    For millions of Americans, SSA is the face of the Federal 
Government. Backlogs and delayed services at SSA FOs result in 
inefficiencies and are a source of customer frustration. Last year, FOs 
received nearly 4,000 incidents of threat or violence, and there were 
over 500 incidents in the first three weeks of this year. Untimely 
services can also be economically disastrous to beneficiaries with 
disabilities who attempt to return to work and must report their work 
activity.
    Without question, SSA would have used the President's proposed 
funding for fiscal year 2013 of $11.76 billion for the LAE account to 
address the growing workloads facing the agency. Projecting to fiscal 
year 2014, SSA will require additional funding just to address 
inflationary costs associated with items such as salaries, employee 
benefits, rent, and facility security. SSA would also need additional 
resources to address the backlog of post-eligibility work and medical 
CDRs.
    SSA estimates the effect of sequestration on fiscal year 2013 SSA 
operations will result in pending levels of initial disability claims 
rising by over 140,000 claims; applicants may wait two weeks longer for 
initial disability decisions and nearly a month longer for disability 
hearing decisions; and staffing losses (attrition without replacement) 
of over 3,400 more employees are anticipated. It is essential to 
preserve good service to the American public at SSA. SSA must be 
properly funded to ensure the efficient, accurate, and expeditious 
administration of this vital social program.
    We realize that the fiscal year 2014 funding level outlined above 
is significant, particularly in this difficult Federal budget 
environment. However, Social Security is a key component of America's 
economic safety net for the aged and disabled and is facing 
unprecedented challenges. Even with the President's proposed budget, 
SSA expects an annual growth in their backlog of 2,800 work years. The 
American public expects and deserves SSA's assistance.
    SSA needs sufficient resources to fulfill its stewardship 
responsibilities, process its core workloads, reduce the hearings 
backlog and accomplish critical program integrity workloads, which 
ensure accurate payments, save taxpayer dollars, and is fiscally 
prudent. We are confident this investment in SSA will benefit our 
entire Nation.
    On behalf of NCSSMA members nationwide, thank you for the 
opportunity to submit this written testimony. We respectfully ask that 
you consider our comments, and would appreciate any assistance you can 
provide in ensuring the American public receives the critical and 
necessary service they deserve from the Social Security Administration.
                                 ______
                                 
   Prepared Statement of the National Family Planning & Reproductive 
                           Health Association

    Summary.--Requesting $327 million in funding for fiscal year 2014 
for the national family planning program (Title X of the Public Health 
Service Act).
    My name is Clare Coleman; I'm the President & CEO of the National 
Family Planning & Reproductive Health Association (NFPRHA), a 
membership association representing the Nation's family planning 
provider systems. A majority of NFPRHA's more than 500 members receive 
Federal funding from Medicaid and through Title X of the Public Health 
Service Act, the only dedicated federally funded family planning 
program for the low-income and uninsured. These programs are a part of 
the Nation's public health safety net, and are at the forefront of 
efforts to reduce rates of unintended pregnancy and improve sexual and 
reproductive health outcomes.
    NFPRHA requests that you make a significant investment in the Title 
X family planning program in the fiscal year 2014 bill by supporting 
the President's request and appropriating $327 million. Title X 
sustained significant cuts--$23.6 million--in fiscal years 2011 and 
2012, at a time when the need for publicly subsidized health care is 
growing. As a result of sequestration, it is estimated that the program 
will sustain an additional 5%--9 percent cut. Cuts to Title X health 
systems have led to health center hours being cut and staff layoffs--
which directly led to a sharp drop in the number of patients seen in 
the program in 2011, the last year for which Federal data are 
available.
    Title X-funded centers serve more than 5 million low-income women 
and men annually at nearly 4,400 health centers. Title X services help 
women and men plan the number and timing of pregnancies, helping to 
prevent nearly one million pregnancies a year, which would have likely 
resulted in 432,600 unintended births and 406,200 abortions. In 
addition to providing contraceptive services and supplies, Title X 
health centers provide preventive health services, education, and 
counseling. Title X assists with patient referrals and helps coordinate 
care for individuals who traditionally have lacked access to routine 
care. The services provided at publicly funded health centers not only 
improve public health, they save billions of taxpayer dollars each 
year. In 2008, publicly funded family planning saved Federal and State 
governments $5.1 billion; services provided at Title X-supported 
centers accounted for $3.4 billion in such savings in that same year 
alone. A recent estimate from the Brookings Institution found that 
expanding publicly funded family planning services would produce 
taxpayer savings of $2-$6 for every dollar spent.
    For more than 40 years, Title X has been a critical safety net for 
those living in under-resourced communities across the country. The 
$23.6 million in cuts to Title X in fiscal year 2011 and fiscal year 
2012--a 7.4 percent loss of funding--came after the largest growth of 
patients served by the Title X network in more than a decade, an 
increase of more than 170,000 women, men, and teens between 2008 and 
2010. Unfortunately, the recent funding cuts have reversed this trend, 
and in just 1 year between 2010 and 2011, the program experienced a 
decline of more than 200,000 patients.
    Today, safety-net providers deliver health care to many in need, 
and especially those in vulnerable populations, a role that will 
undoubtedly grow when full ACA coverage expansion begins in 2014. 
Despite the proven cost savings and public support of Title X, the 
program is still under extreme pressure. A funding level of $327 
million would help to stabilize systems following the significant 
damage done by Federal and State budget cuts over the last few years. 
This is essential--if we do not stabilize the system now, this network 
of providers will not be available to serve those in need, including 
the millions of individuals who will gain health coverage through the 
ACA and will seek health care in the safety net.
    Thank you for the opportunity to testify on the role of Title X in 
the public health safety net. NFPRHA stands ready to work with you to 
strengthen America's network of family planning providers and its role 
in helping to ensure that health care reforms are a success.
                                 ______
                                 
       Prepared Statement of the National Head Start Association

    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee, thank you for allowing the National Head Start 
Association (NHSA) to submit testimony on behalf of funding for Head 
Start and Early Head Start in fiscal year 2014 (fiscal year 2014). Head 
Start centers provide critical early education, health, nutrition, 
child care, parent engagement and family support services in return for 
a lifelong measurable impact on the low-income children and families 
who are served. NHSA urges Congress to support robust investment in 
Head Start centers nationwide in order to provide quality school 
readiness opportunities for the most at-risk young children and their 
families--especially as they face greater obstacles today than ever.
    NHSA is grateful for the enduring, bipartisan support of Congress 
and every President for Head Start throughout its 48 year history. We 
are particularly appreciative of the leadership of this subcommittee, 
and hope it gives serious consideration to the President's proposal to 
increase access to high-quality early learning programs. As our 
Nation's flagship early learning program, we believe Head Start can 
serve as the model for expansion. In fiscal year 2014, we believe there 
are important investments that must be made in Head Start and other 
early learning initiatives. First, however, we urge you to consider our 
highest priority: restoring services to the children and families 
across the country we will lose and have lost due to sequestration.
    The 5.27 percent cut that all Head Start grantees were directed to 
make on March 1st has already had disruptive and serious impact. Many 
programs are already in the process of notifying families that their 
children no longer have a place in our classrooms and that families 
will be on their own next school year. Two Indiana programs have 
resorted to a lottery drawing to figure out which families would be cut 
from the program.
    We certainly do not want to cut children, but due to several years 
of continued increases to operating costs, there is no budget cushion. 
During this most recent recession, Head Start and Early Head Start 
directors have had extreme difficulty maintaining their program size, 
resulting in the loss of 7,000 Head Start slots even before 
sequestration took effect. Under sequestration, every program will need 
to cut services for children and families, and therefore staff, to 
absorb the reduction. Nationally, the Department of Health and Human 
Services estimates that sequestration will result in 70,000 fewer 
children receiving Head Start services. NHSA hopes that Members of this 
subcommittee will work with their Senate colleagues towards restoration 
of Head Start cuts in fiscal year 2014.
    Once sequestration is repealed we can then turn to the bold plan to 
dramatically increase access to high quality early learning that 
President Obama has put forth. The Head Start community sees enormous 
potential in the President's fiscal year 2014 Budget proposal to expand 
early learning opportunities for low to middle income children. We also 
see challenges in the areas of quality, workforce needs, and overall 
cost that may hinder success. We are prepared to offer specific 
recommendations to ensure that an expanded system works well for 
children, families, and our taxpayers.
    Specifically, the Head Start community supports the 
Administration's request for an increase of $1.6 Billion to Head Start 
in fiscal year 2014. We propose that within this amount, Head Start and 
Early Head Start programs are first allowed to address their rising 
operating costs, and then are able to expand Early Head Start services 
consistent with the President's proposal. Additionally, we hope the 
subcommittee will consider our suggestions for an expanded pre-
Kindergarten system that could have great impact on our children for 
generations to come.

Head Start Fixed Costs Continue to Rise
    Within the $1.6 billion request for Head Start and Early Head 
Start, the President proposes to give current grantees an additional 
$200 million to help meet rising operating costs. NHSA proposes that 
the Administration instead set aside $419 million to help programs 
`catch up' from previous years; without full adjustments, centers have 
been falling behind. Even before sequestration, the cost of serving 
families has risen at a much faster pace than any increase in funding. 
All grantees have experienced a rapid increase in their fixed costs, 
including maintenance, fuel, transportation, and health insurance. In 
some areas, rent on facilities alone has gone up between 5-10 percent. 
It is an enormous task to keep costs low and still maintain Head 
Start's high-quality comprehensive model. Prior to the 2012-2013 school 
year, programs had already laid off staff, closed facilities and 
consolidated programs to cut costs, and have leaned more than ever on 
community partners to help provide health, employment, and other 
services required by the comprehensive model.
    Increases in fuel costs have impacted programs greatly, especially 
in rural areas where transportation to and from the center is critical 
for families in a sprawling service area. Some rural southern programs 
report that fuel costs have gone up over 64%--affecting transportation, 
waste removal, and food prices. Deferred maintenance of Head Start 
centers poses its challenges as well; centers operating in older 
facilities hope the roof will hold out one more year, or that the 
playground equipment will remain solid and safe. Regardless, the 
centers are judged by frequent monitors who have the ability to demand 
change when they see a potential hazard--with the additional funds 
being requested, Head Start directors could do more to prevent 
potential safety hazards.
    Finally, the significant continuous rise in the cost of health 
insurance has been particularly detrimental for programs across the 
country. Last year in Louisiana, the Iberville Parish Council Head 
Start, which serves 360 children and employs 61 teachers and staff at 6 
centers, struggled to make ends meet because of rising health insurance 
and other costs. Ultimately, the Parish Council voted to relinquish 
control of the program entirely and turn it over to the Federal 
Government rather than tell families they could not serve their 
children because they could not afford to continue subsidizing the 
increasing costs. By prioritizing grantees' ability to meet these costs 
in fiscal year 2014, the subcommittee will ensure that current centers 
can provide a consistently high-quality level of service to their local 
children and families.

Expanded Access to Early Head Start
    NHSA strongly supports the President's vision of increasing 
investments in Early Head Start (EHS). The available research on child 
brain development clearly shows the effectiveness of high-quality early 
interventions. However, high-quality infant care options are extremely 
limited, especially for low-income families. Early Head Start is only 
able to serve a scant 4 percent of eligible infants, about 110,000 
slots. In order to really fully address the continuum, we need to 
invest in access to quality programs, and the President's proposal 
would nearly double the available slots in EHS.
    The President proposes expanding access to programs that are at the 
EHS level of quality, but executed through partnerships with local 
child care (CC) providers. NHSA applauds the Administrations' effort to 
improve both the lack of access to and the overall quality of care for 
infants and toddlers. However, policy makers must understand that the 
missions of CC and EHS are inherently different--and the structure of 
these partnerships must be carefully considered. We propose that a 
multitude of flexible expansion options be eligible, including 
contracts between EHS-CC/Family Child Care (FCC), expansion of existing 
EHS center-based/home-based services, and allowing EHS providers to 
offer training and technical assistance bring area CC providers up to 
EHS standards. Further, innovative program proposals should be 
encouraged by allowing exemptions or a significant ``hold harmless'' 
period from the Designation Renewal System.
    The President's proposal also calls for the conversion of current 4 
year-old Head Start slots into Head Start and Early Head Start slots 
for children birth to age four. We believe this decision should be 
based on community capacity and need, as opposed to a unilateral policy 
decision made in Washington, DC. Head Start should be allowed to 
continue serving both three and 4 year-olds while expanding, rather 
than converting, Early Head Start slots in order to truly serve the 0-5 
continuum. It must also be recognized that the conversion of Head Start 
slots into Early Head Start slots includes significant additional cost, 
time, and challenges, including different staff ratios, facility 
requirements, and stark differences between the credentials required 
for Early Head Start versus Head Start teachers. One program in 
California that recently went through the slot conversion process 
informed NHSA that they converted 166 Head Start slots into an 
equivalent of 70 Early Head Start slots. This is in line with the 
national conversion experience.
    We hope this subcommittee will show its support for current 
initiatives to allow grantees to restructure along a birth-to-five 
continuum. On February 4th, 2013, the Office of Head Start announced 
the first pilot funding for birth to five projects in Detroit, 
Baltimore, Jersey City, Washington, DC, and Mississippi's Sunflower 
County. Each community had been included in the first cohort of 
Designation Renewal System recompetitions, and the Office of Head Start 
saw an opportunity to try a different configuration. The grants are 
meant to encourage applicants to develop comprehensive, flexible, 
seamless birth-to-five programs which incorporate both Head Start and 
Early Head Start funding. By providing a streamlined grant to create a 
tailored local approach, these birth to five pilots will serve as the 
model for a continuum of comprehensive services that meet the diverse 
and challenging needs of families in these communities. We hope the 
subcommittee will recognize the value of this approach and support 
expansion of these models.

Pre-Kindergarten Expansion
    The central component of the President's proposal is the creation 
of a pre-kindergarten program that seeks to partner with and leverage 
State investments so they might take over responsibility for Pre-K 
within 10 years. While this long-term goal is admirable, there are 
several challenges in the areas of quality, workforce pipeline, and 
overall cost that may hinder success. We encourage careful 
consideration of the following six suggestions for the proposed 
expansion of State pre-kindergarten programs over the next 10 years.
    First and foremost, we hope Congress will ensure the creation of a 
diverse and mixed delivery system, rather than creating a duplicative 
system through the school system. Such a strategy would utilize 
existing providers in a community to ensure faster scaling, better 
quality, and locally-appropriate programs. From the Head Start 
perspective, this is the most cost-effective option that allows 
communities to determine what its needs are, and which providers within 
that community can serve these children and families best.
    Further we sincerely hope that this subcommittee will help 
reiterate the importance of two critical components of the Head Start 
model: parent engagement and comprehensive services. New programs under 
this expansion should be required to implement clear, meaningful, 
evidence-based parent and family engagement standards and practices for 
participating States and classrooms. These components work. A study 
released by the National Bureau of Economic Research shows that Head 
Start parents are more actively engaged in their children's academic 
careers long after the child has entered kindergarten, a key ingredient 
of a learning environment that leads to future success.\1\ The 
Baltimore Education Research Consortium (BERC) released findings in 
March 2012 related to chronic absenteeism in Kindergarten--which 
studies have shown to relate to poorer overall academic achievement as 
late as 5th Grade. Pre-school-aged children are completely reliant on 
their parents to prioritize attendance at this stage of life. BERC's 
research shows that students who had attended Head Start showed the 
highest attendance rates in kindergarten and the lowest level of 
chronic absence in first through third grades.\2\
    We also hope that a new expanded pre-k system will include support 
for providing the comprehensive health and development services for the 
children and families who need them. Head Start families with their 
increased health literacy also show immediate health care benefits, 
including lower Medicaid costs--on average $232 per family. The program 
has also reduced mortality rates from preventable conditions for 5-to 
9-year olds by as much as 50 percent.\3\ Studies have shown that the 
program reduces health care costs for employers and individuals because 
Head Start children are less obese,\4\ 8 percent more likely to be 
immunized,\5\ and 19 to 25 percent less likely to smoke as an adult.\6\

Head Start Works
    Looking forward, we hope this subcommittee will continue to support 
Head Start as a high-yield investment. Studies show that for every one 
dollar invested in a Head Start child, society earns at least $7 back 
through increased earnings, employment, and family stability; \7\ as 
well as decreased welfare dependency,\8\ health care costs,\9\ crime 
costs,\10\ grade retention,\11\ and special education.\12\
    Head Start saves tax dollars by decreasing the need for children to 
receive special education services in elementary schools.\13\ Data 
analysis of a recent Montgomery County Public Schools evaluation found 
that a MCPS child receiving full-day Head Start services when in 
Kindergarten requires 62 percent fewer special education services, and 
saves taxpayers $10,100 per child annually.\14\ States can save $29,000 
per year for each person that they don't need to incarcerate because 
Head Start children are 12 percent less likely to have been charged 
with a crime.\15\ These non-test-score findings help illustrate the 
long-term viability of the program--today, more than 27 million Head 
Start graduates are working every day in our communities to make our 
country and our economy strong.
    Again, the Head Start community understands the budgetary pressures 
the Federal Government is facing and is very grateful for the 
commitment shown by Congress and the President to keep early learning, 
and Head Start in particular, as a priority. The research shows that 
the ``achievement gap'' is apparent as early as the age of 18 months--
we will spend substantially more downstream if these same young people 
are not prepared to graduate high-school, attend college and lead 
prosperous lives. We urge the subcommittee to restore the drastic cuts 
to Head Start and Early Head Start, and support increased access to 
high-quality early learning programs for children along the 0-5 
continuum. In doing so, together we will ensure that we have a stable 
and prosperous workforce for generations to come. Thank you for your 
time and consideration.
---------------------------------------------------------------------------
    \1\ National Bureau of Economic Research. (2011, December). 
Children's Schooling and Parents' Investment in Children: Evidence from 
the Head Start Impact Study (Working Paper No. 17704). Cambridge, MA: 
A. Gelber & A. Isen.
    \2\ Baltimore Education Research Consortium (2012, March). Early 
Elementary Performance and Attendance in Baltimore City Schools' Pre-
Kindergarten and Kindergarten. Baltimore, MD: F. Connelly & Olson, L.
    \3\ Ludwig, J. and Phillips, D. (2007) Does Head Start improve 
children's life chances? Evidence from a regression discontinuity 
design. The Quarterly Journal of Economics, 122 (1): 159-208.
    \4\ Frisvold, D. (2006, February). Head Start participation and 
childhood obesity. Vanderbilt University Working Paper No. 06-WG01.
    \5\ Currie, J. and Thomas, D. (1995, June). Does Head Start Make a 
Difference? The American Economic Review, 85 (3): 360.
    \6\ Anderson, K.H., Foster, J.E., & Frisvold, D.E. (2009). 
Investing in health: The long-term impact of Head Start on smoking. 
Economic Inquiry, 48 (3), 587-602.
    \7\ Ludwig, J. and Phillips, D. (2007). The Benefits and Costs of 
Head Start. Social Policy Report. 21 (3: 4); Deming, D. (2009). Early 
childhood intervention and life-cycle skill development: Evidence from 
Head Start. American Economic Journal: Applied Economics, 1(3): 111-
134; Meier, J. (2003, June 20). Interim Report. Kindergarten Readiness 
Study: Head Start Success. Preschool Service Department, San Bernardino 
County, California; Deming, D. (2009, July). Early childhood 
intervention and life-cycle skill development: Evidence from Head 
Start, p. 112.
    \8\ Meier, J. (2003, June 20). Kindergarten Readiness Study: Head 
Start Success. Interim Report. Preschool Services Department of San 
Bernardino County.
    \9\ Frisvold, D. (2006, February). Head Start participation and 
childhood obesity. Vanderbilt University Working Paper No. 06-WG01; 
Currie, J. and Thomas, D. (1995, June). Does Head Start Make a 
Difference? The American Economic Review, 85 (3): 360; Anderson, K.H., 
Foster, J.E., & Frisvold, D.E. (2009). Investing in health: The long-
term impact of Head Start on smoking. Economic Inquiry, 48 (3), 587-
602.
    \10\ Reuters. (2009, March). Cost of locking up Americans too high: 
Pew study; Garces, E., Thomas, D. and Currie, J. (2002, September). 
Longer-term effects of Head Start. American Economic Review, 92 (4): 
999-1012.
    \11\ Barnett, W. (2002, September 13). The Battle Over Head Start: 
What the Research Shows.; Garces, E., Thomas, D. and Currie, J. (2002, 
September). Longer-Term Effects of Head Start. American Economic 
Review, 92 (4): 999-1012.
    \12\ NHSA Public Policy and Research Department analysis of data 
from a Montgomery County Public Schools evaluation. See Zhao, H. & 
Modarresi, S. (2010, April). Evaluating lasting effects of full-day 
prekindergarten program on school readiness, academic performance, and 
special education services. Office of Shared Accountability, Montgomery 
County Public Schools.
    \13\ Barnett, W. (2002, September 13). The Battle Over Head Start: 
What the Research Shows. Presentation at a Science and Public Policy 
Briefing Sponsored by the Federation of Behavioral, Psychological, and 
Cognitive Sciences.
    \14\ NHSA Public Policy and Research Department analysis of data 
from a Montgomery County Public Schools evaluation. See Zhao, H. & 
Modarresi, S. (2010, April). Evaluating lasting effects of full-day 
prekindergarten program on school readiness, academic performance, and 
special education services. Office of Shared Accountability, Montgomery 
County Public Schools.
    \15\ Reuters. (2009, March). Cost of locking up Americans too high: 
Pew study; Garces, E., Thomas, D. and Currie, J. (2002, September). 
Longer-term effects of Head Start. American Economic Review, 92 (4): 
999-1012.
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                                 ______
                                 
           Prepared Statement of the National Health Council

    Dear Chairman Harkin and Ranking Member Moran: On behalf of the 
Nation's leading patient advocacy organizations, thank you for the 
opportunity to submit testimony on the significance of funding for 
Federal health research agencies and other programs that are designed 
to improve the health of our Nation. As work begins on the fiscal year 
2014 Labor-HHS appropriations bill, the NHC urges the subcommittee to 
maximize funding for essential health programs, including those at the 
National Institutes of Health (NIH), Centers for Disease Control and 
Prevention (CDC), Health Resources and Services Administration (HRSA), 
Substance Abuse and Mental Health Services Administration (SAMHSA), and 
the Agency for Healthcare Research and Quality (AHRQ). We urge Congress 
to refrain from shying away from its longstanding commitment to serve 
people with chronic conditions, the individuals who use our health 
system on a daily basis.
    The National Health Council (NHC) is the only organization of its 
kind that brings together all segments of the health care community to 
provide a united voice for the more than 133 million people living with 
chronic diseases and disabilities and their family caregivers. Made up 
of more than 100 national health-related organizations and businesses, 
its core membership includes the Nation's leading patient advocacy 
organizations, which control its governance. Other members include 
professional societies and membership associations, nonprofit 
organizations with an interest in health, and major pharmaceutical, 
medical device, biotechnology, and insurance companies.
    The NHC fully appreciates the challenging fiscal environment facing 
the country and your important role in guiding our Nation through these 
complex and difficult times. The NHC recognizes that Federal resources 
must be carefully allocated so as to ensure that such investments 
produce the greatest good for the American people.
    In turn, let us not forget that Federal support of health programs 
at HHS is moving us closer to making the impossible possible--saving 
medical expenses through effective prevention efforts and new 
treatments, and saving lives in the process.
    The NHC and its member patient organizations cannot overstate that 
Federal support of medical research, prevention programs, and health 
care delivery is vital to people living with chronic diseases and 
disabilities. As we depict in Figure 1, these services should not be 
considered in isolation, but rather serve as essential building blocks 
toward strengthening the collective health care system.
    Investment in biomedical research is leading the discovery of 
biomarkers--physical signs or biological substances that indicate the 
presence of conditions such as osteoarthritis, one of the leading 
causes of disability in the elderly and the most common type of 
arthritis in the U.S., usually affecting middle-aged and older people. 
This type of research will advance our understanding of disease 
progression and earlier detection and aid in expediting clinical trials 
on novel treatments.
    Funds to pay for the study of rare or less common diseases will 
help to greatly improve our understanding of human health--and the more 
common conditions that burden us all. For example, research on alpha-1 
antitrypsin deficiency--a disease affecting no more than 100,000 
people--fueled new areas of investigation on COPD, a respiratory 
condition found in more than 12 million individuals.
    The path to discovery supported by the Federal Government can 
result in cutting-edge, cost-effective programs. A widely-regarded NIH 
clinical trial on diabetes and subsequent translational research found 
that modest weight loss helped prevent type 2 diabetes for 58 percent 
of participants and positive results could be obtained for less than 
$300 per person per year. These findings led to the creation of CDC's 
National Diabetes Prevention Program, which serves individuals with 
prediabetes in local communities across the country.
    Research, prevention efforts, and programs that provide access to 
services and treatments each contribute importantly to enabling 
patients to manage their health. As baby boomers age, the prevalence of 
and deaths from diseases such as Alzheimer's and heart disease are 
projected to increase. Clearly, now is not the time to decrease our 
Nation's investment in research that holds the key to the prevention, 
treatment, and cure of America's leading and most costly causes of 
death.
    The NHC would be happy to provide the subcommittee with numerous 
personal patient stories that demonstrate why appropriate funding of 
research, prevention, and health delivery programs is crucial to the 
millions of men, women, and children in this country living with 
chronic diseases and disabilities. We understand the difficulty you 
face in reaching consensus on a funding level that balances the needs 
of our country with the needs of people with few or possibly no 
treatment options.
    But how do you place a cost figure on people like Debra--a woman 
diagnosed with chronic kidney disease who, after many years of 
dialysis, underwent a successful kidney transplant that was made 
possible because of advancements based on federally funded research? 
She was able to give back to society as a volunteer at Walter Reed Army 
Medical Center, helping others confronted with organ failure to deal 
with the changes in their lives and remain positive.
    If we fail to take aggressive and deliberate action now to 
appropriately fund essential health programs, we will pay a terrible 
cost later--both in terms of health care expenditures and human lives.
    The NHC appreciates the opportunity to submit this written 
testimony to the subcommittee. We understand that you face many hard 
decisions and again urge you to maximize funding for health programs 
that benefit people with chronic diseases and disabilities so that 
patients will be able to live longer, healthier, and more productive 
lives.

   Figure 1. Funding the Continuum of Care for Patients with Chronic 
                       Diseases and Disabilities



      
                                 ______
                                 
  Prepared Statement of the National Indian Child Welfare Association

    The National Indian Child Welfare Association (NICWA) is a national 
American Indian/Alaska Native (AI/AN) organization with over 25 years 
of experience in providing leadership in support of and analysis of 
public policy that affects AI/AN children and families. NICWA regularly 
provides community and program development technical assistance to 
tribal communities regarding the development of effective services for 
this population. Our primary focus will be on Department of Health and 
Human Service programs serving AI/AN children and families. We thank 
the subcommittee for its efforts to honor the Federal trust 
responsibility and provide necessary resources to meet the unique needs 
of tribal children and families.
  dhhs title iv-b subpart 2: promoting safe and stable families (pssf)
    Request.--Increase fiscal year 2014 appropriations for the 
discretionary component of this program to $75 million (fiscal year 
2012 enacted $63 million). This would increase the number of tribes 
eligible (currently 121) and increase allocations for eligible Indian 
tribes. Only tribes who are eligible for grants of $10,000 or more 
under the statutory formula are eligible to apply.

Data and background to justify requests
    PSSF is one of only a few Federal funding streams that can be used 
for services that prevent out-of-home placement and work to strengthen 
families where either the children are at risk of being placed or have 
been placed. These services form the foundation of all tribal child 
welfare programs and are critical to successful outcomes for their 
children and families. The funds are typically used to establish and 
operate integrated, preventive family preservation services and family 
support services for families at risk and/or in crisis. This funding is 
a particularly valuable tool for tribal child welfare because family 
preservation and family reunification work aligns with traditional 
American Indian and Alaska Native (AI/AN) cultures and practices. 
Mainstream approaches to child welfare, which can often be in conflict 
with AI/AN ways of being and healing, often result in disproportionate 
placement of AI/AN children in State systems.

Anecdotes of successes of the Federal investment in tribal programs
    From Tlingit & Haida Tribes.--Our Preserving Native Families (PNF)/
ICWA department received a phone call from the Office of Children's 
Services (OCS) regarding concerns for two children and explained their 
concerns regarding the mother's behavior. OCS was preparing to go into 
the home for an initial investigation.
    Our office did some research and learned that the mother was a TANF 
client. One of our supervisors made a call to our TANF program and 
asked if they would consider using a new assessment tool, created by 
the PNF department, to determine if the woman might be at risk for OCS 
involvement. The TANF worker agreed and based on the score, which was 
high, the TANF child welfare worker was able to engage the woman in PNF 
services quickly. OCS, pleased that PNF services were being offered, 
met with the woman who reported about the PNF services she was involved 
with. OCS determined that her children were safe and that the mother 
was actively engaging in prevention services with PNF. This mother only 
needed someone to reach out to her; she was in need of help, but did 
not know how to ask. This story is successful for two reasons; 
departments collaborated and a tribal family remains together today. It 
is Title IV-B Subpart 2 combined with BIA ICWA Title II funding that 
made this possible by providing the base levels of funding for Tlingit 
& Haida's PNF/ICWA department.

   DHHS CHILD ABUSE PREVENTION AND TREATMENT ACT (CAPTA) CHILD ABUSE 
                        DISCRETIONARY ACTIVITIES

    Request.--Request $10 million increase in appropriations for this 
discretionary grant program to account for the inclusion of tribes as 
eligible applicants; include in the appropriations reporting language 
requirements for better outreach to tribes and AI/AN service providers 
and that funding be provided for tribes and AI/AN service providers.
Data and background to justify requests
    The CAPTA discretionary fund supports a variety of activities, 
including research and demonstration projects that study the causes, 
prevention, identification, assessment and treatment of child abuse and 
neglect. There is little information on the causes and/or risk factors 
for abuse and neglect specific to AI/AN families.\1\ Similarly, 
interventions and assessments that that take into account cultural 
considerations for AI/AN children are lacking.\2\ This is largely due 
to the fact that tribal communities are under resourced and therefore 
unable to engage in evidence-based practices and practice-based 
evidence because there is no national focus on this issue.
    CAPTA discretionary funds can fill this gap by providing tribes the 
necessary monies to support their capacity for research and development 
in the area of child abuse and neglect prevention, identification, 
assessment and treatment. Though the CAPTA Reauthorization Act of 2010 
provides tribes with new funding opportunities under the research and 
demonstration discretionary grant programs, still more can be done to 
increase equitable tribal access to this important source of Federal 
funding.
    Since the inception of these discretionary grant programs, tribal 
children's interests and issues have been given almost no focus in any 
of the grant awards. This lag in attention to tribal children's needs 
has created a vacuum in which accurate data, development, and testing 
of more effective practices in the prevention of child abuse and the 
protection and treatment of AI/AN children has not occurred. An 
accurate and culturally competent understanding of the specific risk 
factors and needs of AI/AN families and communities ensures that 
programs that work with AI/AN children will be the most effective and 
efficient. Appropriations reporting language that increases outreach 
and encourages funding of tribal programs coupled with an overall 
increase in appropriations will begin to fill this vacuum and improve 
services for AI/AN children nationwide.

SAMHSA PROGRAMS OF REGIONAL AND NATIONAL SIGNIFICANCE (CIRCLES OF CARE 
                CHILDREN'S MENTAL HEALTH GRANT PROGRAM)

    Request.--Continue fiscal year 2014 appropriation for Programs of 
Regional and National Significance budget category at fiscal year 2012 
level of $286 million. Funds for the Circles of Care program come out 
of this budget category (typically $3 million per year).

Data and background to justify requests
    The Circles of Care Grant Program is the only children's mental 
health funding program exclusively available to tribes. It is the only 
source of Federal funding that specifically supports the development of 
culturally competent children's mental health service delivery models 
in tribal communities, effective systemic reform and capacity building 
are otherwise impossible due to lack of designated funding.
    The need for continued and increased Circles of Care funding is 
evidenced in available mental health data and the demonstrated and 
measured effectiveness of the program. For example, AI/AN youth 
experience post-traumatic stress disorder at higher rate than the 
national average,\3\ struggle with alcohol use disorders at a higher 
rate than the general youth population,\4\ and have had the highest 
lifetime major depressive episode prevalence and the highest prevalence 
of a major depressive episode in the last year when compared to all 
other youth populations.\5\
    To date, Circles of Care has enabled 38 tribal grantee communities 
to develop culturally competent, community-based children's mental 
service delivery models. Circles of Care yields measurable long-term 
positive outcomes. These grants have significantly increased tribal 
community awareness of the issues that impact their children's mental 
health, facilitated community ownership and responses, and helped 
tribes to develop capacity through leveraging of tribal funds and 
creating new partnerships. Of those tribes that have graduated from the 
Circles of Care program, nearly 1/3 have obtained direct funding 
through the Child Mental Health Initiative (CMHI) program, otherwise 
known as Systems of Care; others have been able to partner with other 
CMHI grantees to implement their models, and remaining graduated sites 
have secured other resources to implement their models to their best 
ability.
     samhsa systems of care children's mental health grant program
    Request.--Continue to fund this program in fiscal year 2014 at the 
fiscal year 2012 level of $117 million. This competitive grant program 
allows eligible States, local governments and tribes to apply for and 
administer a children's mental health services program (tribes at $5--6 
million per year).

Data and background to justify requests
    The current six-year tribal grantees are engaging local 
communities, youth, families, and private and public partners in 
collaborative partnerships to build sustainable children's mental 
health programs and services. National aggregate data on six-year 
Systems of Care programs illustrate the success and continued need for 
Systems of Care program funding: 1) emotional and behavioral problems 
were reduced or remained stable for 89 percent of children and youth 
with co-occurring mental health and substance abuse diagnoses; 2) 
school performance improved or remained the same for 75 percent of 
children and youth served by the grant communities; and 3) almost 91 
percent of children and youth with a history of suicide attempts or 
suicidal ideation improved or remained stable.\6\ Considering these 
positive outcomes and the behavioral health needs of tribal 
communities, continued six-year Systems of Care program funding is 
vital to tribes and their ability to design and implement successful 
children's mental health programs, particularly because tribes remain 
ineligible for direct access to the Mental Health Block Grant and 
Medicaid funding.

Anecdotes of successes of the Federal investment in tribal programs
    From Cherokee Nation.--Cherokee Nation's Behavioral Health Services 
had been working on various children's initiatives for 8 years prior to 
receiving the SAMHSA Systems of Care (SOC) Expansion Planning Grant 
last year. During its 1 year as a SOC Expansion Planning grantee, 
Cherokee Nation accomplished more success in this arena than ever 
before. The funds were used as seed money to plan and lay the 
foundation for expanding and sustaining children's mental health. One 
concrete result of receiving these funds was Cherokee Nation's ability 
to assess and begin to revamp its children's mental health billing 
system. None of this could have been possible without the technical 
assistance (TA) resources provided, the guiding SOC philosophy, and 
systems-wide approach that created space for the larger Cherokee Nation 
and community coalitions to engage actively and benefit from the 
planning process and outcome. Cherokee Nation has since secured funding 
to begin implementing pieces of the strategic plan developed per the 
SOC Expansion Planning funding.
    For more information regarding this testimony, please contact NICWA 
Government Affairs Director David Simmons at [email protected].
---------------------------------------------------------------------------
    \1\ Bigfoot, D.S., Crofoot, T., Cross, T.L., Fox, K., Hicks, S., et 
al. (2005). Impacts of Child Maltreatment in Indian Country: Preserving 
the Seventh Generation through Policies, Programs, and Funding Streams: 
A Report for BIA. Portland, OR: National Indian Child Welfare 
Association.
    \2\ Bigfoot, D.S., Crofoot, T., Cross, T.L., Fox, K., Hicks, S., et 
al. (2005). Impacts of Child Maltreatment in Indian Country: Preserving 
the Seventh Generation through Policies, Programs, and Funding Streams: 
A Report for BIA. Portland, OR: National Indian Child Welfare 
Association.
    \3\ Cooper, J.L., Masi, R., Dababnah, S., Aratani, Y., and Knitzer, 
K. (2007). Strengthening Policy to Support Children, Youth, and 
Families Who Experience Trauma. New York, NY: National Center for 
Children in Poverty, Mailman School of Public Health, Columbia 
University. Retrieved from http://www.nccp.org/publications/
pub_737.html.
    \4\ Office of Applied Studies, Substance Abuse and Mental Health 
Services Administration (SAMHSA) (2007, January 19). Substance use and 
substance use disorders among American Indians and Alaska Natives. The 
National Survey on Drug Use and Health Report. Retrieved from http://
oas.samhsa.gov/2k7/AmIndians/AmIndians.cfm.
    \5\ Urban Indian Health Institute, Seattle Indian Health Board 
(2012). Addressing Depression Among American Indians and Alaska 
Natives: A Literature Review. Seattle, WA: Urban Indian Health 
Institute. Retrieved from http://www.uihi.org/wp-content/uploads/2012/
08/Depression-
Environmental-Scan_All-Sections_2012-08-21_ES_FINAL.pdf.
    \6\ Duclos, C.W., Phillips, M. & LeMaster, Public Law (2004). 
Outcomes and Accomplishment sof the circles of Care Planning Efforts. 
American Indian Alaska Native Mental Health Research Journal. Retrieved 
from http://www.ucdenver.edu/academics/colleges/PublicHealth/research/
centers/CAIANH/journal/Documents/Volume%2011/11(2)_Duclos_Outcomes_and_
Accomplishments_121-138.pdf.
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                                 ______
                                 
          Prepared Statement of the National Kidney Foundation

    The National Kidney Foundation is pleased to submit testimony for 
the written record in support of the Centers for Disease Control and 
Prevention Chronic Kidney Disease Program. We respectively request $2.2 
million be provided for fiscal year 2014.
    End Stage Renal Disease (ESRD), which requires dialysis or 
transplantation for survival, is the only disease-specific coverage 
under Medicare, regardless of age or other disability. At the end of 
2010, the number of Americans with ESRD totaled more than 594,000, 
including 415,000 dialysis patients and almost 180,000 kidney 
transplant recipients. Complicating the cost and human toll is the fact 
that chronic kidney disease (CKD) is a disease multiplier; patients are 
very likely to be diagnosed with diabetes, cardiovascular disease, or 
hypertension (40 percent of ESRD patients had a diagnosis of diabetes). 
In 2010, CKD was present in 8.4 percent of Medicare beneficiaries but 
was responsible for 17 percent of Medicare expenditures.
    Despite this tremendous social and economic impact, no national 
public health program focusing on early detection and treatment existed 
until fiscal year 2006, when Congress provided $1.8 million to initiate 
a Chronic Kidney Disease Program at the Centers for Disease Control and 
Prevention (CDC). Congressional interest regarding kidney disease 
education and awareness also is found in Sec. 152 of the Medicare 
Improvements for Patients and Providers Act of 2008 (MIPPA, Public Law 
110-275), which directed the Secretary to establish pilot projects to 
increase screening for CKD and enhance surveillance systems to better 
assess the prevalence and incidence of CKD. Cost-effective treatments 
exist to potentially slow progression of kidney disease and prevent its 
complications, but only if individuals are diagnosed before the latter 
stages of CKD.
    The CDC program is designed to identify members of populations at 
high risk for CKD, develop community-based approaches for improving 
detection and control, and educate health professionals about best 
practices for early detection and treatment. The President's budget 
request includes provisions calling for the continuation of the 
program, however, does not include a line item. The National Kidney 
Foundation respectfully urges the Committee to maintain line-item 
funding for the Chronic Kidney Disease Program for fiscal year 2014. 
The specific inclusion of a line item will ensure the program is 
appropriately supported and the continuation of these important 
activities. Continued support will benefit kidney patients and 
Americans who are at risk for kidney disease, advance the objectives of 
Healthy People 2020 and the National Strategy for Quality Improvement 
in Health Care, and fulfill the mandate created by Sec. 152 of MIPPA.
    The prevalence of CKD in the United States is higher than a decade 
earlier. This is partly due to the increasing prevalence of the related 
diseases of diabetes and hypertension. It is estimated that CKD affects 
26 million adult Americans \1\ and that the number of individuals in 
this country with CKD who will have progressed to kidney failure, 
requiring chronic dialysis treatments or a kidney transplant to 
survive, will grow to 712,290 by 2015.\2\ Kidney disease is the 9th 
leading cause of death in the U.S. Furthermore, a task force of the 
American Heart Association noted that decreased kidney function has 
consistently been found to be an independent risk factor for 
cardiovascular disease (CVD) outcomes and all-cause mortality and that 
the increased risk is present with even mild reduction in kidney 
function.\3\ Therefore addressing CKD is a way to achieve one of the 
priorities in the National Strategy for Quality Improvement in Health 
Care: Promoting the Most Effective Prevention and Treatment of the 
Leading Causes of Mortality, Starting with Cardiovascular Disease.
    CKD is often asymptomatic, a ``silent disease,'' especially in the 
early stages. Therefore, it goes undetected without laboratory testing. 
In fact, some people remain undiagnosed until they have reached CKD 
Stage 5 and literally begin dialysis within days. However, early 
identification and treatment can slow the progression of kidney 
disease, delay complications, and prevent or delay kidney failure. 
Accordingly, Healthy People 2020 Objective CKD--2 is to ``increase the 
proportion of persons with chronic kidney disease (CKD) who know they 
have impaired renal function.'' Screening and early detection provides 
the opportunity for interventions to foster awareness, adherence to 
medications, risk factor control, and improved outcomes. Additional 
data collection is required to precisely define the incremental 
benefits of early detection on kidney failure, cardiovascular events, 
hospitalization and mortality. Increasing the proportion of persons 
with CKD who know they are affected requires expanded public and 
professional education programs and screening initiatives targeted at 
populations who are at high risk for CKD. As a result of consistent 
congressional support, the National Center for Chronic Disease 
Prevention and Health Promotion at CDC has instituted a series of 
projects that could assist in attaining the Healthy People 2020 
objective. However, this forward momentum will be stifled and CDC's 
investment in CKD to date jeopardized if line-item funding is not 
continued.
    As noted in CDC's Preventing Chronic Disease: April 2006, Chronic 
Kidney Disease meets the criteria to be considered a public health 
issue: (1) the condition places a large burden on society; (2) the 
burden is distributed unfairly among the overall population; (3) 
evidence exists that preventive strategies that target economic, 
political, and environmental factors could reduce the burden; and (4) 
evidence shows such preventive strategies are not yet in place. 
Furthermore, CDC convened an expert panel in March 2007 to outline 
recommendations for a comprehensive public health strategy to prevent 
the development, progression, and complications of CKD in the United 
States.
    The CDC Chronic Kidney Disease program has consisted of three 
projects to promote kidney health by identifying and controlling risk 
factors, raising awareness, and promoting early diagnosis and improved 
outcomes and quality of life for those living with CKD. These projects 
have included the following:
    (a)  Demonstrating effective approaches for identifying individuals 
at high risk for chronic kidney disease through State-based screening 
(CKD Health Evaluation and Risk Information Sharing, or CHERISH).
    (b)  Conducting an economic analysis by the Research Triangle 
Institute, under contract with the CDC, on the economic burden of CKD 
and the cost-effectiveness of CKD interventions.
    (c)  Establishing a surveillance system for Chronic Kidney Disease. 
Development of a surveillance system by collecting, integrating, 
analyzing, and interpreting information on CKD using a systematic, 
comprehensive, and feasible approach will be instrumental in prevention 
and health promotion efforts for this chronic disease. The CDC CKD 
surveillance project has built a basic system from a number of data 
sources, produced a report and created a website program http://
www.cdc.gov/diabetes/projects/kidney/consisting of information on 
preventing and controlling risk factors, the importance of early 
diagnosis, and strategies to improve outcomes. The website, publicly 
available for clinicians, health professionals, public health policy 
makers, and patients, also provides links to a number of publications 
and reports. The next steps include exploring State-based CKD 
surveillance data ideal for public health interventions through the 
State department of health.
    We believe it is possible to distinguish between the CKD program 
and other categorical chronic disease initiatives at CDC, because the 
CKD program does not provide funds to State health departments. 
Instead, CDC has been making available seed money for feasibility 
studies in the areas of epidemiological research and health services 
investigation.
    In summary, undetected Chronic Kidney Disease can lead to costly 
and debilitating irreversible kidney failure. However, cost-effective 
interventions are available if patients are identified in the early 
stages of CKD. With the continued expressed support of Congress, the 
National Kidney Foundation is confident a feasible detection, 
surveillance and treatment program can be established to slow, and 
possibly prevent, the progression of kidney disease.
    Thank you for your consideration of our testimony.
---------------------------------------------------------------------------
    \1\ Josef Coresh, et al. ``Prevalence of Chronic Kidney Disease in 
the United States,'' JAMA, November 7, 2007.
    \2\ D.T. Gilbertson, et al., Projecting the Number of Patients with 
End-Stage Renal Disease in the United States to the Year 2015. J Am Soc 
Nephrol 16: 3736-3741, 2005.
    \3\ Mark J. Sarnak, et al. Kidney Disease as a Risk Factor for the 
Development of Cardiovascular Disease: A Statement from the American 
Heart Association Councils on Kidney in Cardiovascular Disease, High 
Blood Pressure Research, Clinical Cardiology, and Epidemiology and 
Prevention. Circulation 2003: 108: 2154-69.
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                                 ______
                                 
         Prepared Statement of the National League for Nursing

    The National League for Nursing (NLN) is the premiere organization 
dedicated to promoting excellence in nursing education to build a 
strong and diverse nursing workforce to advance the Nation's health. 
With leaders in nursing education and nurse faculty across all types of 
nursing programs in the United States--doctorate, master's, 
baccalaureate, associate degree, diploma, and licensed practical--the 
NLN has more than 1,200 nursing school and health care agency members, 
37,000 individual members, and 24 regional constituent leagues.
    The NLN urges the subcommittee to fund the following Health 
Resources and Services Administration (HRSA) nursing programs:
  --The Title VIII Nursing Workforce Development Programs at $251.099 
        million in fiscal year 2014; and
  --The Title III Nurse-Managed Health Clinics at $20 million in fiscal 
        year 2014.
Nursing Education is a Jobs Program
    According to the U.S. Bureau of Labor Statistics (BLS), the 
registered nurse (RN) workforce will grow by 26 percent from 2010 to 
2020, resulting in 711,900 new jobs. This growth in the RN workforce 
represents the largest projected numeric job increase from 2010 to 2020 
for all occupations. The April 5, 2013, BLS Employment Situation 
Summary--March 2013 likewise reinforces the strength of the nursing 
workforce to the Nation's job growth. While the Nation's overall 
unemployment rate was little changed at 7.6 percent for March 2013, the 
employment in health care increased in March with the addition of 
23,400 jobs at ambula-tory health care services, hospitals, and nursing 
and residential care facilities, amounting to a full 26 percent of all 
jobs added in the month.
    BLS notes that the health care sector is a critically important 
industrial complex in the Nation. It is at the center of the economic 
recovery with the number of jobs climbing steadily, in contrast to the 
erosion in so many other areas of the economy. Growing even when the 
recession began in December 2007, health care jobs are up nationwide by 
10.5 percent. Compare that with all other jobs, which still are down, 
despite recent gains. If the health care economy had not expanded 
during the recession, the national unemployment rate would be 8.8 
percent. Health care has been a stimulus program generating employment 
and income, and nursing is the predominant occupation in the health 
care industry, with more than 3.662 million active, licensed RNs in the 
United States in 2013.
    The Nursing Workforce Development Programs provide training for 
entry-level and advanced degree nurses to improve the access to, and 
quality of, health care in underserved areas. The Title VIII nursing 
education programs are fundamental to the infrastructure delivering 
quality, cost-effective health care. The NLN applauds the 
subcommittee's bipartisan efforts to recognize that a strong nursing 
workforce is essential to a health policy that provides high-value care 
for every dollar invested in capacity building for a 21st century nurse 
workforce.
    The current Federal funding falls short of the health care 
inequities facing our Nation. Absent consistent support, slight boosts 
to Title VIII will not fulfill the expectation of generating quality 
health outcomes, nor will episodic increases in funding fill the gap 
generated by a 15-year nurse and nurse faculty shortage felt throughout 
the U.S. health system.
The Nurse Pipeline and Education Capacity
    Although the recession resulted in some stability in the short-term 
for the nurse workforce, policy makers must not lose sight of the long-
term growing demand for nurses in their districts and States. The NLN's 
findings from its Annual Survey of Schools of Nursing--Academic Year 
2010-2011 cast a wide net on all types of nursing programs, from 
doctoral through diploma, to determine rates of application, 
enrollment, and graduation. Key findings include:
  --Expansion of nursing education programs impeded by shortage of 
        faculty.--In fall 2011, the overall capacity of prelicensure 
        nursing education continued to diminish well short of demand. 
        Associate degree in nursing (ADN) programs rejected 51 percent 
        of qualified applications, compared with 36 percent of 
        baccalaureate of science in nursing (BSN) programs, and 25 
        percent in diploma programs. The Nation's practical nursing 
        (PN) programs turned away 41 percent of qualified applications. 
        With 32.2 percent of pre-licensure RN education programs citing 
        lack of faculty as the main obstacle to expanding capacity, a 
        strong correlation exists between the shortage of nurse faculty 
        and the inability of nursing programs to keep pace with the 
        demand for new RNs. Increasing the productivity of education 
        programs is a high priority in most States, but faculty 
        recruitment is a glaring problem. Without faculty to educate 
        our future nurses, the shortage cannot be resolved.
  --Demand for spots in post-licensure nursing education programs 
        outstripped supply.--The percentage of programs that turned 
        away qualified applicants rose among every post-licensure 
        program type between 2009 and 2011. Most strikingly, the 
        percentage of master's of science in nursing (MSN) programs 
        turning away qualified applicants jumped by 15 percent since 
        2009, i.e., from just one in three programs to almost half in 
        2011. Emerging from program acceptance rates (a.k.a. 
        selectivity rates) was evidence of a scarcity of vacancies in 
        post-licensure nursing programs, thus also indicating that 
        competition was increasing: In 2011, just over one in four MSN 
        programs and about one in six doctoral programs were highly 
        selective. These trends threaten to perpetuate an unsafe cycle, 
        constraining the number of graduates prepared to take on 
        faculty roles in nursing schools.
  --Yield rates continued to grow.--Yield rates--a classic indicator of 
        the competitiveness of college admissions--remain 
        extraordinarily high among pre- and post-licensure nursing 
        programs. A stunning 92 percent of all applicants accepted into 
        ADN programs, and 92 percent of those accepted in PN programs, 
        went on to enroll in 2011. Yield rates among the other program 
        types were nearly as high, averaging 87 percent for RN-to-BSN 
        programs; 88 percent for MSN programs; 89 percent for doctoral 
        programs; 84 percent for RN diploma programs; and 80 percent 
        for BSN programs.
Equally Pressing is Lack of Diversity
    Our Nation is enriched by cultural diversity--37 percent of our 
population identify as racial and ethnic minorities. Yet ethnic, 
cultural, and gender diversity eludes the nursing student and nurse 
educator populations. A survey of nurse educators conducted by the NLN 
and the Carnegie Foundation's Preparation for the Professions Program 
found that only 7 percent of nurse educators were minorities compared 
with 16 percent of all U.S. faculty. The lack of faculty diversity 
limits nursing schools' ability to deliver culturally appropriate 
health professions education. In addition, the NLN survey for the 2010-
2011 academic year reported that:
  --African-American enrollment drops.--The percentage of racial-ethnic 
        minority students enrolled in pre-licensure RN programs has 
        declined steadily over the past 2 years--ultimately dropping 
        from a high of 29 percent in 2009 to 24 percent in 2011. The 
        majority of that decline stems from a steep reduction in the 
        percentage of African-American students enrolled in associate 
        degree nursing programs, which dropped by almost 5 percent to 
        8.6 percent in just 2 years. BSN programs saw a small, but not 
        significant drop, in African-American enrollment, down from 13 
        to 12 percent. Inversely, diploma programs saw a sharp rise in 
        African-American enrollments, but because they represent just 4 
        percent of all basic RN programs, the impact is not great.
  --Hispanic representation, while still lagging, inches upward.--
        Hispanics remain dramatically underrepresented among nursing 
        students. Representing a mere 6 percent of associate degree and 
        baccalaureate nursing students, Hispanics were enrolled in 
        basic nursing programs at less than half the rate at which they 
        were enrolled in undergraduate programs overall. However, the 
        percentage of Hispanics enrolled in post-licensure programs has 
        nearly doubled over the past 2 years at every level. Hispanic 
        enrollment rose from five to 12 percent in RN-to-BSN programs, 
        from 5 to 10 percent in MSN programs, and 3 to 6 percent in 
        doctoral programs. Hispanic enrollment in PN programs also 
        jumped to over 11 percent in 2011.
  --Men's enrollment at historic high.--While significantly less than 
        the proportion in the U.S. population, at 15 percent, men 
        enrolled in basic RN programs remained at the historic high 
        reached at the start of the recession. Across all levels of 
        nursing education, approximately 13 to 15 percent of nursing 
        students were male in 2011, with the exception of doctoral 
        programs where only 9 percent of students were male.
    Besides representing an untapped talent pool to remedy the nursing 
shortage, ethnic, cultural, and gender-diverse minorities in nursing 
are essential to developing a health care system that understands and 
addresses the needs of our rapidly diversifying population. Workforce 
diversity is needed where research indicates that factors such as 
societal biases and stereotyping, communication barriers, limited 
cultural sensitivity and competence, and system and organizational 
determinants contribute to health care inequities.

Title VIII Federal Funding Reality
    Today's undersupply of appropriately prepared nurses and nurse 
faculty does not bode well for our Nation. The Title VIII Nursing 
Workforce Development Programs are a comprehensive system of capacity-
building strategies that provide students and schools of nursing with 
grants to strengthen education programs, including faculty recruitment 
and retention efforts, facility and equipment acquisition, clinical lab 
enhancements, and loans, scholarships, and services that enable 
students to overcome obstacles to completing their nursing education 
programs. A few examples of HRSA's Title VIII data below provide 
perspective on current Federal investments.
    Nurse Education, Practice, Quality, and Retention Grants (NEPQR).--
NEPQR funds projects addressing the critical nursing shortage via 
initiatives to expand the nursing pipeline, promote career mobility, 
provide continuing education, and support retention. Grantees funded to 
support the personal and home health aide purpose of the NEPQR program 
trained 1,366 students during fiscal year 2011; and grantees supporting 
the nursing assistant and home health aide NEPQR purpose supported 
1,810 students.
    Nursing Workforce Diversity (NWD).--NWD grants prepare students 
from disadvantaged backgrounds to become nurses, producing a more 
diverse nursing workforce. Greater diversity among health professionals 
is associated with improved access to care for racial and ethnic 
minority patients, greater patient choice and satisfaction, and better 
patient-clinician communication. In addition, evidence suggests that 
minority health professionals are more likely to serve in areas with a 
high proportion of uninsured and underrepresented racial and ethnic 
groups. In fiscal year 2011, performance data showed that NWD grantees 
provided scholarships to 1,270 students, exceeding the performance 
target by 72 percent.
    Nurse Faculty Loan Program (NFLP).--NFLP supports the establishment 
and operation of a loan fund at participating schools of nursing to 
assist nurses in completing their graduate education to become 
qualified nurse faculty. The NFLP seeks to increase the number and 
diversity of qualified nursing faculty. Faculty diversity is an 
essential ingredient in the efforts to diversify the nursing education 
pipeline and workforce overall. Ongoing NFLP support for faculty 
production is critical to building the pipeline needed to assure the 
full capacity of the Nation's future nursing workforce. Targeting a 
portion of those funds for minority faculty preparation is fundamental 
to achieving that goal. In fiscal year 2011, NFLP grantees provided 
loans to 2,246 students pursuing faculty preparation at the master's 
and doctoral levels, exceeding the program's performance target by 49 
percent.

Nurse-Managed Health Clinics (NMHC)
    NMHCs are defined as a nurse-practice arrangement, managed by 
advanced practice registered nurses, that provides primary care or 
wellness services to underserved or vulnerable populations. NMHCs are 
associated with a school, college, university, or department of 
nursing, federally qualified health center, or independent nonprofit 
health or social services agency.
    NMHCs deliver comprehensive primary health care services, disease 
prevention, and health promotion in medically underserved areas for 
vulnerable and specialized populations (e.g., veterans and/or families 
of active military). Approximately 58 percent of NMHC patients either 
are uninsured, Medicaid recipients, or self-pay. The complexity of care 
for these patients presents significant financial barriers, heavily 
affecting the sustainability of these clinics. While providing access 
points in areas where primary care providers are in short supply, 
expansion of NMHCs also increases the number of structured clinical 
teaching sites available to train nurses and other primary care 
providers. NMHCs continue to collaborate with federally Qualified 
Health Centers, Area Health Education Centers, and rural- and 
community-based clinics to provide training to some 5,000 nursing and 
other health professions students. Appropriating $20 million in fiscal 
year 2014 to NMHCs would increase access to primary care for thousands 
of uninsured people in underserved urban communities.
    The NLN can state with authority that the deepening health 
inequities, inflated costs, and poor quality of health care outcomes in 
this country will not be reversed until the concurrent shortages of 
nurses and qualified nurse educators are addressed. Your support will 
help ensure that nurses exist in the future who are prepared and 
qualified to take care of you, your family, and all those who will need 
our care. Without national efforts of some magnitude to match the 
health care reality facing our Nation today, a hardship in nurse 
education and its adverse effect in health care generally will be 
difficult to avoid.
    The NLN urges the subcommittee to strengthen the Title VIII Nursing 
Workforce Development Programs by funding them at a level of $251.099 
million in fiscal year 2014. We also recommend that the Title III 
Nurse-Managed Health Clinics be funded at $20 million in fiscal year 
2014.
                                 ______
                                 
       Prepared Statement of the National Marfan Foundation (NMF)

NMF Fiscal Year 2014 LHHS Appropriations Recommendations
  --Protect medical research and patient care programs from devastating 
        funding cuts through sequestration and deficit reduction 
        activities.
  --Provide $7.8 billion for CDC, an increase of $1.7 billion over 
        fiscal year 2012, including proportional increases for the 
        National Center for Chronic Disease Prevention and Health 
        Promotion (NCCDPHP) and the National Center on Birth Defects 
        and Developmental Disabilities (NCBDDD) to facilitate life 
        saving awareness and education activities focused on early 
        recognition and proper diagnosis of Marfan syndrome and related 
        heritable connective tissue disorders.
  --Provide $32 billion for NIH, an increase of $1.3 billion over 
        fiscal year 2012, including proportional increases for the 
        National Heart, Lung, and Blood Institute (NHLBI); National 
        Institute of Arthritis and Musculoskeletal and Skin Diseases 
        (NIAMS); National Eye Institute (NEI); National Center for 
        Advancing Translational Sciences (NCATS); Office of Rare 
        Diseases Research (ORDR); Office of the Director (OD); and 
        other NIH Institutes and Centers to facilitate adequate growth 
        in the Marfan syndrome and related heritable connective tissue 
        disorders research portfolio.
    Chairman Harkin, Ranking Member Moran, and distinguished members of 
the subcommittee, thank you for the opportunity to submit testimony on 
behalf of NMF. It is my honor to represent the estimated 200,000 
Americans who are affected by Marfan syndrome or a related heritable 
connective tissue disorder.

About NMF
    NMF is a non-profit voluntary health organization founded in 1981. 
NMF is dedicated to saving lives and improving the quality of life for 
individuals and families affected by the Marfan syndrome and related 
disorders. The Foundation has three major goals: 1) To provide accurate 
and timely information about the Marfan syndrome to affected 
individuals, family members, physicians, and other health 
professionals. 2) To provide a means for those with Marfan syndrome and 
their relatives to share in experiences, to support one another, and to 
improve their medical care. 3) To support and foster research.

About Heritable Connective Tissue Disorders
    Marfan syndrome is a genetic disorder of the connective tissue that 
can affect many areas of the body, including the heart, eyes, skeleton, 
lungs and blood vessels. It is a progressive condition and can cause 
deterioration in each of these body systems. The most serious and life-
threatening aspect of the syndrome is a weakening of the aorta. The 
aorta is the largest artery carrying oxygenated blood from the heart. 
Over time, many Marfan syndrome patients experience a dramatic 
weakening of the aorta which can cause the vessel to dissect and tear.
    Aortic dissection is a leading killer in the United States, and 20 
percent of the people it affects have a genetic predisposition, like 
Marfan syndrome, to developing the complication. Early surgical 
intervention can prevent a dissection and strengthen the aorta and the 
aortic valves, especially when preventive surgery is performed before a 
dissection occurs.

Deficit Reduction and Sequestration
    As you work with your colleagues in Congress on deficit reduction, 
budget, and appropriations issues please support the Marfan syndrome 
community by actively pursuing meaningful funding increases for 
critical medical research and healthcare programs. Our Nation's 
investment in biomedical research, particularly through NIH, is an 
engine that drives economic growth while improving health outcomes for 
patients. NIH currently supports a meaningful research portfolio in 
Marfan syndrome coordinated through NIAMS and NHLBI. The research 
funded through this portfolio is conducted at academic health centers 
across the country, which has a direct impact on local economic 
activity. Further, while more work needs to be done, the commitment to 
NIH's Marfan syndrome and related disorders research portfolio over the 
years has greatly increased our scientific understanding of these 
conditions.
    If Federal funding for Marfan syndrome research is substantially 
reduced, the current effort to capitalize on recent advancements and 
develop treatment options will face a serious setback. Ongoing research 
projects will stall and critical new research projects, particularly 
new activities coordinated by NEI, NCATS, and ORDR will not be 
initiated.
    In addition, reducing support for Federal biomedical research 
efforts sends a powerful message to the next generation about our 
country's lack of commitment to this field. Many talented young people 
interested in biomedical research will seek other career paths. The 
damage done now to the research training and career development 
pipeline could last for decades and undermine this country's entire 
biomedical research industry. It should also be noted that the next 
generation of researchers will face increased competition for their 
talents from foreign competitors who are investing in their biomedical 
research infrastructure.
    The Marfan syndrome community is concerned that if healthcare 
programs endure significant funding cuts, patients will see few 
improvements in health and healthcare over the coming years.

Centers for Disease Control and Prevention
    NMF joins the other voluntary health groups in requesting that you 
support CDC by providing the agency with an appropriation of $7.8 
billion in fiscal year 2014. Such a funding increase would allow CDC to 
undertake critical Marfan syndrome and related connective tissue 
disorders education and awareness activities, which would help prevent 
deadly thoracic aortic aneurysms and dissections.
    In 2010, the American College of Cardiology and the American Heart 
Association issued landmark practice guidelines for the treatment of 
thoracic aortic aneurysms and dissections. NMF is promoting awareness 
of the new guidelines in collaboration with other organizations through 
a new Coalition known as ``TAD''; the Thoracic Aortic Disease 
Coalition. The TAD Coalition is presently comprised of 10 organizations 
that are coordinating efforts to help promote the Guidelines to 
healthcare professionals and to raise public awareness of various 
aortic diseases and the associated risk factors.
    The CDC would be an invaluable partner in the ongoing campaign to 
save lives and improve health outcomes by promoting the new Guidelines 
to healthcare providers and raising public awareness of risk factors. 
In this regard, we ask the subcommittee encourage CDC to identify 
appropriate staff at the NCCDPHP and NCBDDD to participate in TAD 
Coalition activities. It is our hope that involving CDC in the 
activities of the TAD Coalition will lead to a lasting partnership and 
collaboration on critical outreach campaigns.

National Institutes of Health
    NMF joins the broader public health community in requesting that 
you support NIH by providing the agency with an appropriation of $32 
billion in fiscal year 2014. This modest 4 percent funding increase 
would ensure that biomedical research inflation does not result in a 
loss of purchasing power at NIH, critical new initiatives like the 
Cures Acceleration Network (CAN) are adequately supported, and that the 
Marfan syndrome research portfolio can continue to make progress.
    NHLBI.--Critical investment in research activities by NHLBI has 
greatly improved our scientific understanding of Marfan syndrome and 
related heritable connective tissue disorders. These breakthroughs have 
lead to subsequent improvements in healthcare and treatment options.
    NIAMS.--The Marfan syndrome and related connective tissue disorders 
research portfolio at NIAMS has been crucial to the effort to improve 
the lives of individuals living with these conditions. The NIAMS 
research portfolio lead the way in identifying many genetic factors for 
these conditions and still supports major advances in the 
pathophysiology of the disease.
    NEI.--Marfan syndrome is associated with eye problems and vision 
loss. However, we do not currently have a firm understanding of the 
link and NEI is only just beginning to initiate research projects in 
this area.
    NCATS.--The Office of Rare Diseases Research has long supported 
important Marfan syndrome research. Further, emerging programs at NCATS 
intended to ensure that scientific breakthroughs are translated to 
meaningful treatment options hold tremendous promise for the Marfan 
syndrome and heritable connective tissue disorders community.
    Thank you for your time and your consideration of these requests. 
Please contact me if you have any questions or if you would like any 
additional information.
                                 ______
                                 
         Prepared Statement of the National Minority Consortia

    The National Minority Consortia (NMC) submits this statement on the 
fiscal year 2016 advance appropriations for the Corporation for Public 
Broadcasting (CPB) We represent a coalition of five national 
organizations, who, with modest support from CPB, bring authentic 
stories of diversity to the Nation. We bring unique voices and 
perspectives from America's diverse communities into all aspects of 
public broadcasting and other media, including content transmitted 
digitally over the Internet. Our requests are two: 1) That Congress 
direct CPB to meaningfully increase its commitment to diverse 
programming and serving underserved communities; and 2) that at least 
$445 million be provided in advance fiscal year 2016 funding for CPB. 
We ask the Committee to:

(1)  Direct CPB to increase its efforts for diverse programming with a 
commitment for minority programming and for organizations and stations 
located within underserved communities.--We urge Congress in bill and/
or report language to recognize that CPB, while it has enabled 
diversity in public broadcasting, still has very far to go. We suggest 
language such as:

          The Committee recognizes the importance of the partnership 
        CPB has with the National Minority Consortia, which helps 
        develop, acquire, and distribute Public Television programming 
        to serve the needs of African American, Alaska Native, Asian 
        American, Latino, Native American, and Pacific Islander 
        peoples. These stories of diversity transcend statistics and 
        bring universal American stories to all Americans. As 
        communities across the country welcome increased numbers of 
        citizens of diverse ethnic backgrounds, local Public Television 
        stations must strive to meet these viewers' needs. The 
        Committee encourages CPB to support and expand this critical 
        partnership, including instituting funding guidelines that 
        encourage and reward public media that represent and reach a 
        diverse American public.

          CPB has a big responsibility with regard to diversity, yet 
        the five NMC organizations combined receive only $7.5 million 
        in discretionary funds from CPB, an amount less than 2 percent 
        of the CPB budget. And this amount has been decreased by 10 
        percent due to the sequestration.

(2)  Provide fiscal year 2016 advance appropriation for CPB of $445 
million, in order to develop content that reaches across traditional 
media boundaries, such as those separating television and radio.

          While public broadcasting continues to uphold strong ethics 
        of responsible journalism and thoughtful examination of 
        American history, life and culture, it has not kept pace with 
        our rapidly changing demographics. Members of minority groups 
        continue to be underrepresented on programming and oversight 
        levels within and in content production. This is unacceptable 
        in America today, where minorities comprise over 36 percent of 
        the population. This becomes more urgent now that racial and 
        ethnic minorities make up more than half of all children born 
        in the United States today.
          Public broadcasting has the potential to be particularly 
        important for our growing minority and ethnic communities, 
        especially as we transition to a broadband-enabled, 21st 
        century workforce that relies on the skills and talent of all 
        of our citizens. While there is a niche in the commercial 
        broadcast and cable world for quality programming about our 
        communities, it is in the public broadcasting sphere where 
        minority communities and producers should have more access and 
        capacity to produce diverse high-quality programming for 
        national audiences. We therefore, urge Congress to insert 
        strong language in this act to ensure that this is the case and 
        that these opportunities are made available to minorities and 
        other underserved communities.
          About the National Minority Consortia.--With primary funding 
        from the CPB, the NMC serves as an important component of 
        American Public Television content--on air and over the 
        Internet. By developing and funding diverse content, training 
        and mentoring the next generation of minority producers and 
        program managers, as well as brokering relationships between 
        content makers and distributors, we are in a position to ensure 
        the future strength and relevance of Public Television and 
        radio television content from and to our communities.
          Each Consortia organization is engaged in cultivating ongoing 
        relationships with the independent producer community by 
        providing technical assistance and program funding, support and 
        distribution. Often the funding we provide is the initial seed 
        money for a project, that is matched by other public and 
        private sources, providing true economic development. We also 
        provide numerous hours of programming to individual Public 
        Television and radio stations--programming that is beyond the 
        reach of most local stations. To have a real impact, we need 
        funding that recognizes and values the full extent of minority 
        participation in public life. Below is information regarding 
        each of the five NMC organizations.
          Center for Asian American Media (CAAM).--CAAM's mission is to 
        present stories that convey the richness and diversity of Asian 
        American experiences to the broadest audience possible. We do 
        this by funding, producing, distributing and exhibiting works 
        in film, television and digital media. Over CAAM's 33-year 
        history they have provided funding to more than 200 projects, 
        many of which have gone on to win Academy, Emmy and Sundance 
        awards, examples of which are Days of Waiting; Of Civil Rights 
        and Wrongs: The Fred Korematsu Story; Maya Lin: A Strong Clear 
        Vision; The Betrayal (Nerakhoon), Visas and Virtues; and Up the 
        Yangtze. CAAM presents the annual CAAMFest (formerly known as 
        the San Francisco International Asian American Film Festival) 
        and distributes Asian American media to schools, libraries and 
        colleges. CAAM's newest department, Digital Media, is becoming 
        a respected leader in bringing innovative content and audience 
        engagement to public media. CAAM also presented the documentary 
        on ukulele sensation Jake Shimabukuro: Life on Four Strings on 
        national PBS with our partner Pacific Islanders in 
        Communications.
          Latino Public Broadcasting (LPB).--LPB supports the 
        development, production and distribution of public media 
        content that is representative of the diverse Latino community 
        in this country. LPB has provided over 170 hours of engaging 
        Latino programs to the PBS and beyond the broadcast, into 
        communities, colleges and universities through screenings and 
        forums. Emmy nominated The Longoria Affair reached over 20,000 
        participants through forums in 10 States and has become part of 
        the curriculum in 100 colleges. VOCES on PBS is the only series 
        on Public Television that explores the rich diversity of the 
        Latino cultural experience. From its content, LPB creates 
        standards-based curriculum for the PBS Learning Media, a free 
        service into the schools with 850,000 registered teachers. 
        These resources on Latino history and culture enrich the 
        learning experience of young children, particularly Latinos who 
        have one of the Nation's highest drop-out rates. In the Fall of 
        2013, LPB and WETA will present Latino Americans, a 6-part 
        series on the varied history of Latinos who have helped shape 
        the Nation over the last 500-plus years and have become, with 
        more than 50 million people, the largest minority group in the 
        Nation.
          National Black Programming Consortium/Black Public Media 
        works to increase capacity in diverse communities to create, 
        distribute and use public media. Throughout its history, its 
        mission has been two-fold: building capacity in new generations 
        of creators of social issue media and broadening the pool of 
        stakeholders in public media institutions. Over the past 6 
        years, in addition to supporting producers who create 
        programming for Public Television and other platforms, NBPC/
        Black Public Media has convened and mentored over 500 digital 
        media professionals and created the Public Media Corps (PMC) to 
        address an urgent need in our communities at the grassroots 
        level. In 2013, NBPC/Black Public Media presented the fifth 
        season of the critically-acclaimed series AfroPop: the Ultimate 
        Cultural Exchange, which features independent perspectives from 
        the African diaspora, and released the second season of our hit 
        web exclusive series Black Folk Don't, a documentary satire 
        that challenges the common stereotypes. In late March, NBPC/
        Black Public Media premiers 180 Days: A Year Inside an American 
        High School, a PBS Special about the challenges of school 
        reform. ``180 Days'' is connected to CPB's American Graduate 
        initiative to combat the drop out crisis in American public 
        schools.
          Pacific Islanders in Communications (PIC).--PIC's mission is 
        to support, advance, and develop Pacific Island media content 
        and talent that results in a deeper understanding of Pacific 
        Island history, culture, and contemporary challenges. In 
        keeping with the mission, PIC helps Pacific Islander stories 
        reach national audiences through funding support for 
        productions, training and education, broadcast services, and 
        community engagement. Last year alone, PIC provided seven hours 
        of content. In the past 10 years, PIC has produced 
        approximately 65 hours of programming for national broadcast, 
        trained over 350 Pacific Islander filmmakers, and have had over 
        100 community screenings worldwide with more than 54,000 people 
        in attendance. This year, PIC partnered with National 
        Geographic to broadcast The Mystery of Easter Island on NOVA, 
        which refutes earlier claims that the Rapanui people were 
        responsible for their own cultural destruction and Fixing Juvie 
        Justice, which explores the Polynesian model of restorative 
        justice used in the U.S. juvenile criminal system. PIC's series 
        Pacific Heartbeat, reached over 24 million households last 
        year. Its second season begins in May 2013.
          Vision Maker Media (VMM) (formerly Native American Public 
        Telecommunications) shares Native stories with the world that 
        represent the cultures, experiences, and values of American 
        Indians and Alaska Natives. Founded in 1977, Vision Maker Media 
        presented seven Native American documentaries to PBS stations 
        nationwide this year--Grab; Racing the Rez; Standing Bear's 
        Footsteps; POV: Up Heartbreak Hill; America Reframed: My 
        Louisiana Love; Sousa on the Rez; and Need to Know: America by 
        Numbers. We also offered producers and educators numerous 
        workshops across the Nation. Vision Maker Media programming 
        reaches beyond the broadcast with interactive web content, 
        standards-based curriculum, and Viewer Discussion Guides. 
        Vision Maker Media continues to work with local stations to 
        bring new voices into the public broadcasting. We developed 
        community engagement strategies to support CPB's American 
        Graduate initiative.

    Thank you for your consideration of our recommendations. We see new 
opportunities to increase diversity in programming, production, 
audience, and employment in the new media environment, and we thank 
Congress for support of our work on behalf of our communities.
                                 ______
                                 
     Prepared Statement of the National Multiple Sclerosis Society

    Mr. Chairman and Members of the Committee, thank you for this 
opportunity to provide testimony regarding funding of critically 
important Federal programs that impact those affected by multiple 
sclerosis. Multiple sclerosis (MS) is an unpredictable, often disabling 
disease of the central nervous system that interrupts the flow of 
information within the brain, and between the brain and body. Symptoms 
range from numbness and tingling to blindness and paralysis. The 
progress, severity, and specific symptoms of MS in any one person 
cannot yet be predicted, but advances in research and treatment are 
moving us closer to a world free of MS. Most people with MS are 
diagnosed between the ages of 20 and 50, with at least two to three 
times more women than men being diagnosed with the disease.
    The National MS Society sees itself as a partner to the Government 
in many critical areas. As we advocate for NIH research, we do so as an 
organization that funds over $40 million annually in MS research 
through funds generated through the Society's fundraising efforts. And 
as we advocate for Lifespan Respite funding, we do so as an 
organization that works to provide some level of respite relief for 
caregivers. So while we're here to advocate for Federal funding, we do 
it as an organization that commits tens of millions of dollars each 
year to similar or complementary efforts as those being funded by the 
Federal Government. Through these efforts, our goal is to see a day 
when MS has been stopped, lost functions have been restored, and a cure 
is at hand.
    We would like to take this time to highlight for the subcommittee 
the importance of five key agencies/programs that have a direct impact 
on people living with MS as it discusses the fiscal year 2014 budget.

                     NATIONAL INSTITUTES OF HEALTH

    We urge Congress to continue its investment in innovative medical 
research that can help prevent, treat, and cure diseases such as MS by 
appropriating at least $32 billion in fiscal year 2014.
    The NIH is the country's premier institution for medical research 
and the single largest source of biomedical research funding in the 
world. The NIH conducts and sponsors a majority of the MS related 
research carried out in the United States. Approximately $115 million 
of fiscal year 2012 and Recovery Act appropriations (the last available 
data) were directed to MS-related research. An invaluable partner, the 
NIH has helped make significant progress in understanding MS. NIH 
scientists were among the first to report the value of MRI in detecting 
early signs of MS, before symptoms even develop. Advancements in MRI 
technology allow doctors to monitor the progression of the disease and 
the impact of treatment.
    Research during the past decade has enhanced knowledge about how 
the immune system works, and major gains have been made in recognizing 
and defining the role of this system in the development of MS lesions. 
These NIH discoveries are helping find the cause, alter the immune 
response, and develop new MS therapies that are now available to modify 
the disease course, treat exacerbations, and manage symptoms. Twenty 
years ago there were no MS therapies or medications. Now there are 
nine, with the two new oral medications now available and other new 
treatments in the pipeline. The NIH provided the basic research 
necessary so that these therapies could be developed. Had there been no 
Federal investment in research, it's doubtful people living with MS 
would have any therapies available. The NIH also directly supports jobs 
in all 50 States and 17 of the 30 fastest growing occupations in the 
U.S. are related to medical research or health care. More than 83 
percent of the NIH's funding is awarded through almost 50,000 
competitive grants to more than 325,000 researchers at over 3,000 
universities, medical schools, and other research institutions in every 
State.

                CENTERS FOR MEDICARE & MEDICAID SERVICES

Medicare
    Medicare is an extremely important program for many living with MS. 
It is estimated that over 20 percent of the MS population relies on 
Medicare as its primary insurer. The majority of these individuals are 
under the age of 65 and receive the Medicare benefit as a result of 
their disability. While sequestration excluded any cuts that would 
directly impact Medicare beneficiaries, the Society would like to 
remind Congress of the importance of having appropriate reimbursement 
levels for physicians to ensure participation in Medicare, promoting 
policies to allow access to diagnostics and durable medical equipment 
and discouraging overly burdensome cost-sharing for prescription drugs.

Medicaid
    The National MS Society urges Congress to maintain funding for 
Medicaid and reject proposals to cap or block grant the program.
    Medicaid provides comprehensive health coverage to over eight 
million persons living with disabilities, plus six million persons with 
disabilities who rely on Medicaid to fill Medicare's gaps. The latest 
statistics (which are pre-recession) show that about 5-10 percent of 
people with MS have Medicaid coverage. While that is a small figure, 
for these individuals, Medicaid is truly a safety net. The most 
recently available data (2007) reveals that the average annual direct 
and indirect (e.g. lost wages) cost for someone with MS in the U.S. is 
approximately $69,000. After years of paying to manage their disease, 
some people with MS have spent the vast majority of their earnings and 
savings, making their financial situation so dire that they meet 
Medicaid's low income eligibility requirements.
    Some policymakers have proposed capping or block granting Medicaid 
or more recently, placing a ``per capita cap'' whereby the Federal 
Government would limit each State to a fixed dollar amount per 
beneficiary. Any of these proposals would merely shift costs to States, 
forcing States to shoulder a seemingly insurmountable financial burden 
or cut services on which our most vulnerable rely. It could result in 
more individuals becoming uninsured, compounding the current problems 
of lack of coverage, overflowing emergency rooms, limited access to 
long-term services, and increased healthcare costs in an overburdened 
system. Also, by capping funds that support home- and community-based 
care, the proposals could lead to an increased reliance on costlier 
institutional care that contradicts the principles laid forth in the 
1999 U.S. Supreme Court decision Olmstead and integrating and keeping 
people with disabilities in their communities.
    While the economic situation demands leadership and thoughtful 
action, the National MS Society urges Congress to remember people with 
MS and all disabilities, their complex health needs, and the important 
strides Medicaid has made for persons living with disabilities 
particularly in the area of community-based care, and not modify the 
program to their detriment.

                     SOCIAL SECURITY ADMINISTRATION

    The National MS Society urges Congress to provide $12.3 billion for 
the Social Security Administration's (SSA) administrative budget in 
fiscal year 2014.
    Because of the unpredictable nature and sometimes serious 
impairment caused by the disease, SSA recognizes MS as a chronic 
illness or ``impairment'' that can cause disability severe enough to 
prevent an individual from working. During such periods, people living 
with MS are entitled to and rely on Social Security Disability 
Insurance (SSDI) or Supplemental Security Income (SSI) benefits to 
survive. People living with MS, along with millions of others with 
disabilities, depend on SSA to promptly and fairly adjudicate their 
applications for disability benefits and to handle many other actions 
critical to their well-being including: timely payment of their monthly 
benefits; accurate withholding of Medicare Parts B and D premiums; and 
timely determinations on post-entitlement issues, e.g., overpayments, 
income issues, prompt recording of earnings.
    Providing $12.3 billion would allow SSA to cover inflationary 
increases, continue efforts to reduce hearings and disability backlogs, 
increase deficit-reducing program integrity work, and replace some 
critical staffing losses in SSA's components. It would also help to 
minimize the closure of additional field offices. In the last 2 years, 
SSA closed a number of field offices due to limited resources. In many 
cases, applicants for benefits or those approaching retirement age who 
have questions about their eligibility or benefits have been forced to 
travel greater distances to visit a Social Security field office.
    The disability backlog is also an area of serious concern. Since 
fiscal year 2008, the number of claims pending for a disability medical 
decision rose from 565,286 to 707,700--an increase of 142,414, or 25.2 
percent. Despite the fact that claims have exceeded three million for 
four successive years, the current staffing level for DDSs is 14,262, 
which is 1,107 (7.2 percent) below the level at the end of fiscal year 
2011, and 1,831 (11.3 percent) below the level at the end of fiscal 
year 2010. SSA was making progress in addressing the enormous backlog 
of hearings cases, but resource issues have magnified the challenges. 
In June 2010, the number of pending hearings was down to 694,417 but by 
May 2012, it reached an all-time high of 823,828. Even with the 
dramatic increase in the volume of new hearing requests filed over the 
last few years, processing time has been reduced from 491 days in 
fiscal year 2009 to 353 days in September 2012. If SSA does not receive 
adequate funding, this progress will regress and the disability 
hearings backlog will continue to mount, denying people with MS and 
other disabilities timely determinations and dispensing of benefits.

                     LIFESPAN RESPITE CARE PROGRAM

    Up to one quarter of individuals living with MS require long-term 
care services at some point during the course of the disease. Often, a 
family member steps into the role of primary caregiver to be closer to 
the individual with MS and to be involved in care decisions. According 
to a 2011 AARP report, 61.6 million family caregivers provided care at 
some point during 2009 and the value of their uncompensated services 
was approximately $450 billion per year--more than total Medicaid 
spending and almost as high as Medicare spending. Family caregivers 
allow the person living with MS to remain home for as long as possible 
and avoid premature admission to costlier institutional facilities.
    Family caregiving, while essential, can be draining and stressful, 
with caregivers often reporting difficulty managing emotional and 
physical stress, finding time for themselves, and balancing work and 
family responsibilities. A 2012 National Alliance for Caregiving (NAC) 
survey of individuals providing care to people living with MS shows 
that on average, caregivers spend 24 hours a week providing care. Sixty 
4 percent of caregivers were emotionally drained, 32 percent suffered 
from depression and 22 percent have lost a job due to caregiving 
responsibilities. In the broader caregiving community, it has been 
estimated that American businesses lose $17.1 to $33.36 billion each 
year due to lost productivity costs related to caregiving 
responsibilities.
    The Lifespan Respite Care Program, signed into law in 2006 by 
President Bush, provides competitive grants to States to establish or 
enhance statewide lifespan respite programs that better coordinate and 
increase access to quality respite care. Respite offers professional 
short-term help to give caregivers a break from the stress of providing 
care and has been shown to provide family caregivers with the relief 
necessary to maintain their own health and bolster family stability. 
With Lifespan Respite funding, State grantees have developed or 
enhanced statewide databases of respite care services, developed 
person-centered respite service options such as vouchers, and trained 
more volunteer and paid respite providers.
    Perhaps the most critical aspect of the program for people living 
with MS is that Lifespan Respite serves families regardless of special 
need or age--literally across the lifespan. Much existing respite care 
has age eligibility requirements and since MS is typically diagnosed 
between the ages of 20 and 50, Lifespan Respite programs are often the 
only open door to needed respite services. The National MS Society asks 
that Congress preserve funding for the Lifespan Respite program in 
fiscal year 2014 so that people with MS can remain at home, and family 
caregivers can remain productive members of the community and workforce 
and American businesses no longer suffer the monstrous financial impact 
caregiver strain currently has on them. For the past few fiscal cycles, 
Lifespan Respite has received approximately $2.5 million.

                               CONCLUSION

    The National MS Society thanks the Committee for the opportunity to 
provide written testimony and our recommendations for fiscal year 2014 
appropriations. The agencies and programs we have discussed are of 
vital importance to people living with MS and we look forward to 
continuing to working with the Committee to help move us closer to a 
world free of MS. Please don't hesitate to contact me with any 
questions.
                                 ______
                                 
     Prepared Statement of the National Nursing Centers Consortium

    My name is Tine Hansen-Turton, and I am the CEO of the National 
Nursing Centers Consortium (NNCC). On behalf of the NNCC, I would like 
to thank the members of this subcommittee for the opportunity to submit 
testimony regarding the importance of appropriating funds to support 
nurse-managed health clinics. Specifically, NNCC and its members 
request an appropriation of $20 million to support grants to nurse-
managed health clinics through the Nurse Managed Health Clinic Grant 
Program established under Title III of the Public Health Service Act.
    NNCC is a 501(c)(3) member association of nonprofit, nurse-managed 
health clinics, sometimes called nurse-managed health centers or NMHCs. 
The Affordable Care Act (ACA) defines the term `nurse-managed health 
clinic' as a nurse practice arrangement, managed by advanced practice 
nurses, that provides primary care or wellness services to underserved 
or vulnerable populations and that is associated with a school, 
college, university or department of nursing, federally qualified 
health center (FQHC), or independent nonprofit health or social 
services agency.\1\ Currently there are approximately 250 NMHCs in 
operation throughout the United States. The Nurse Managed Health Clinic 
Grant Program was created to provide NMHCs with a stable source of 
Federal funding that would place them on footing similar to other 
safety-net providers. Although authorized, to date the Grant Program 
has received no appropriations.

The Value of NMHCs and the Need for NMHC Grant Funding
    NMHCs Expand Primary Care Workforce Capacity.--The Nation is facing 
a primary care crisis that is about to get worse. According to the 
Association of American Medical Colleges (AAMC), by 2025 there will be 
a dearth of 130,600 physicians, which includes a shortage of 65,800 
primary care physicians.\2\ AAMC data also shows that American medical 
schools are not graduating enough doctors to meet this need. In fact, 
the number of family practice residencies across the Nation has been in 
decline for the past 12 years, and medical schools have not filled 
available family practice residencies in the past 3 years.\3\ The 
Congressional Budget Office estimates the Medicaid expansion called for 
by the ACA will lead to 11 million new enrollees.\4\ As these new 
enrollees establish primary care homes, the burden on the primary care 
workforce is likely to increase dramatically.
    Data from Massachusetts shows just how bad the problem could get. A 
study conducted 2 years after that State expanded its public coverage 
through health care reform legislation found that only 52 percent of 
internists in Massachusetts were accepting new patients and one out of 
every three family physicians was no longer accepting new patients.\5\ 
Another study completed 1 year later, found that the average wait time 
to see a physician in Boston was 49.6 days, the longest in the 
Nation.\6\
    NMHCs are primarily managed by nurse-practitioners which make up 
the fastest growing segment of primary care providers in the 
country.\7\ Currently there are 155,000 NPs in the country and the 
numbers are growing quickly.\8\ Because of their growing numbers, 
policy makers across the country are calling for nurse practitioners 
and NMHCs to assume a greater role in primary care. For example, in its 
report, ``The Future of Nursing, Leading Change, Advancing Health,'' 
the Institute of Medicine (IOM) states, ``advanced practice registered 
nurses should be called upon to fulfill and expand their potential as 
primary care providers across practice settings based on their 
education and competency.'' \9\ When discussing the role of NMHCs, the 
IOM report says, ``Nurse-managed health clinics offer opportunities to 
expand access; provide quality, evidence-based care; and improve 
outcomes for individuals who may not otherwise receive needed care.'' 
\10\
    Along with the IOM, the National Governor's Association (NGA) and 
the National Institute for Health Care Reform (NIHCR) have released 
reports identifying the greater use of nurse practitioners as a 
possible means of alleviating the pressure on the primary care 
workforce. The NGA report titled, ``The Role of Nurse Practitioners in 
Meeting Increasing Demand for Primary Care,'' was published in December 
of 2012. Published in February of 2013, the NIHCR research brief was 
titled, ``Primary Care Workforce Shortages: Nurse Practitioner Scope-
of--Practice Laws and Payment Policies.''
    As safety-net providers, NMHCs offer medically underserved patients 
high quality primary care that is available regardless of the patient's 
ability to pay. Because they already serve a high percentage of 
Medicaid patients, the clinics are perfectly positioned to fill the 
gaps in care that will result from the ACA's proposed Medicaid 
expansion. However, because they often cannot meet the requirements for 
federally-qualified health center (FQHC) funding, many NMHCs are 
struggling financially. The NMHC Grant Program was created to place 
NMHCs on a similar footing with other safety-net providers by giving 
NMHCs an alternative source of Federal funding.
    In order to lessen the primary care crisis, and ensure the 
underserved can take full advantage of the care NMHCs offer, NNCC 
requests that the subcommittee appropriate funding to the NMHC grant 
program. Evidence suggests that doing this will not only expand access 
but also lower the cost of care. In addition to having lower labor 
costs, research shows that NMHCs cut costs by reducing unnecessary 
emergency room visits and hospitalizations.\11\
    NMHCs Help Educate the Health Professionals of Tomorrow.--The main 
reason NMHCs have difficulty qualifying for FQHC funding is because 
many are affiliated with academic schools of nursing. Because 
academically-affiliated NMHCs operate under the jurisdiction of a 
university, most cannot meet FQHC governance requirements without 
breaking their academic connection and giving up their clinical 
programs. Ironically, however, these academic affiliations mean that 
the NMHC model emphasizes the workforce development that is so needed 
with the Medicaid expansion under the Affordable Care Act. NMHCs 
naturally serve as community-based clinical training sites for a 
diverse group of health profession students including registered nurses 
and advance practice nurses (mostly nurse practitioners), medical, 
pharmacy, dental, social work, public health, and other students.
    In October of 2010, HRSA released $14.8 million in Prevention and 
Public Health Fund dollars to fund ten NMHC grants. In addition to 
serving over 27,000 patients and recording more than 72,000 encounters, 
the NMHC grantees have provided interdisciplinary clinical training to 
over 800 health profession students annually.\12\ In 2012, the NNCC 
conducted a survey of its members to measure their contribution to 
health professions education. Twenty-eight NMHCs in a mix of urban, 
rural, and suburban communities reported providing educational 
opportunities for nearly 1,500 students.\13\ The average number of 
students educated by the NMHC grant funded clinics was 80, while the 
clinics participating in the 2012 survey reported educating an average 
of 55 students. This data tells us two important things: 1) the 
contribution of NMHCs to workforce development is undeniable; 2) the 
ability of NMHCs to offer educational opportunities is greatly enhanced 
with increased funding.
    In post-clinical focus groups students have reported being 
``overwhelmingly satisfied'' with their experience in NMHC clinical 
rotations. Other feedback suggested that NMHCs are filling a gap in 
nursing education by providing community-based experience not found in 
other clinical rotations.\14\ The IOM report on the future of nursing 
also specifically praised NMHC clinical programs for their emphasis on 
interprofessional education which is an important factor in future job 
satisfaction, and building a more flexible workforce.
    Despite the benefits of NMHC clinical programs, NMHC leaders are 
often forced to abandon this important piece of the NMHC model in order 
to qualify for FQHC funding. By providing an alternative source of 
funding for NMHCs, the Nurse-Managed Health Clinic grant program helps 
to preserve the contribution of NMHCs to workforce development. Given 
the country's growing need for nurses, NNCC respectfully requests that 
the subcommittee members appropriate funding to support clinical 
programs and place NMHCs on a similar footing with other safety-net 
providers through the NMHC grant program.
    Request.--The 10 NMHC grants distributed in 2010 will expire this 
year if Congress does not move to appropriate funding to the program. 
For all the reasons mentioned above, NNCC respectfully requests an 
appropriation of $20 million in fiscal year 2014 for the Nurse-Managed 
Health Clinic Grant Program, as authorized under Title III of the 
Public Health Service Act.
---------------------------------------------------------------------------
    \1\ Section 5208 of the Affordable Care Act.
    \2\ American Association of Medical Colleges (AAMC) Center for 
Workforce Studies.
    \3\ American Association of Medical Colleges (AAMC) Center for 
Workforce Studies.
    \4\ CBO. Estimates for the Insurance Coverage Provisions of the 
Affordable Care Act Updated for the Recent Supreme Court Decision. 
(July 2012). p 13.Retrieved on February 28, 2013 from http://
www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-
CoverageEstimates.pdf.
    \5\ Massachusetts Medical Society, ``2008 Physician Workforce 
Study: Executive Summary,'' available at:www.massmed.org/workforce.
    \6\ USA Today, ``Wait Times to See Doctors are Getting Longer,'' 
available at: http://usatoday30.usatoday.com/news/health/2009-06-03-
waittimes_N.htm.
    \7\ Statement of A. Bruce Steinwald, Health Care Director, U.S. 
Government Accountability Office, Testimony Before the Committee on 
Health, Labor, Pensions, U.S. Senate, February 12, 2008.
    \8\ 
    \9\ IOM, ``the Future of Nursing: Leading Change, Advancing 
Health,'' page 1-2.
    \10\ IOM, ``the Future of Nursing: Leading Change, Advancing 
Health,'' page c-4.
    \11\ Coddington, J. A. & Sands, L. P. Cost of health are and 
quality outcomes of patients at nurse-managed clinics.Nurs Econ, 26(2), 
75-83. (2008).
    \12\ Special survey of NMHCs funded under the ACA. Conducted by 
NNCC in 2011.
    \13\ 2012 NNCC member survey.
    \14\ Feedback from student focus groups conducted by the Institute 
for Nursing Centers in 2009.
---------------------------------------------------------------------------
                                 ______
                                 
      Prepared Statement of the National Primate Research Centers

    The Directors of the eight National Primate Research Centers 
(NPRCs) respectfully submit this written testimony for the record to 
the Senate Appropriations Subcommittee on Labor, Health and Human 
Services, Education and Related Agencies. The NPRCs appreciate the 
commitment that the Members of this subcommittee have made to 
biomedical research through your support for the National Institutes of 
Health (NIH) and recommends providing at least $32 billion for NIH in 
fiscal year 2014. We believe this amount is the minimum level of 
funding needed to accommodate the rising costs of medical research and 
to help mitigate the effects of sequestration. The NPRCs also encourage 
the subcommittee to work to stop the sequestration cuts to research 
funding that squander invaluable scientific opportunities, threaten 
medical progress and continued improvements in our Nation's health, and 
jeopardize our economic vitality.
    The NPRCs respectfully request that the subcommittee provide strong 
support for the NIH Office of Research Infrastructure Programs (ORIP), 
housed within the NIH Office of the Director, which is the 
administrative home of the NPRCs. This support would help to ensure 
that the NPRCs and other animal research resource programs continue to 
serve effectively in their role as vital national resources.
    The mission of the National Primate Research Centers is to use 
scientific discovery and nonhuman primate models to accelerate progress 
in understanding human diseases, leading to interventions, treatments, 
cures, and ultimately to overall better health of the Nation and the 
world. The NPRCs collaborate as a transformative and innovative network 
to develop and support the best science and act as a resource to the 
biomedical research community as efficiently as possible. There is an 
exceptional return on investment in the NPRC program; ten dollars is 
leveraged for every one dollar of research support for the NPRCs. It is 
important to sustain funding for the NPRC program and the NIH as a 
whole and to continue to grow and develop the innovative plan for the 
future of NIH.
    The NPRCs are particularly concerned with the reduction of Federal 
funds to support research, including the 5 percent cut in NIH funding 
under sequestration. The cuts harm our Nation's ability to advance 
scientific discoveries that improve human health, bolster the economy, 
and help keep our Nation globally competitive. Furthermore, the impact 
of sequestration has been compounded by ongoing funding constraints 
caused by 10 years of flat NIH budgets, which have resulted in a loss 
of purchasing power and affected the ability of NIH-funded scientists 
to pursue promising new avenues of research.
    At the same time that scientists are facing these funding 
challenges, they are poised like never before to capitalize on 
tremendous scientific opportunities and make paradigm-shifting 
discoveries to address our Nation's most pressing public health needs. 
Budget uncertainty is disruptive to training, careers, long-range 
projects, and ultimately, to research progress. To ensure the 
successful and efficient advancement of science, the research engine 
needs predictable, sustained funding that maximizes the Nation's return 
on investment.
    Not only is NIH research essential to advancing health, it also 
plays a key economic role in communities nationwide. Approximately 85 
percent of NIH funding is spent in communities across the Nation, 
creating jobs at more than 2,500 research institutes, universities, 
teaching hospitals, and other institutions. NIH research also supports 
long-term competitiveness for American workers, forming one of the key 
foundations for U.S. industries like biotechnology, medical device and 
pharmaceutical development, and more.

NPRCs' Contributions to NIH Priorities
    The NPRCs' activities are closely aligned with NIH priorities. In 
fact, NPRC investigators conduct much of the Nation's basic and 
translational nonhuman primate research, facilitate additional vital 
nonhuman primate research that is conducted by hundreds of 
investigators from around the country, provide critical scientific 
expertise, train the next generation of scientists, and advance 
cutting-edge technologies.
    As a part of the NIH Office of the Director, the NPRCs see a great 
opportunity to work with all NIH institutes and centers to further 
integrate the consortium as a trans-NIH resource on topics such as 
colony management, training, genetics and genome banking. Also, as the 
National Center for Advancing Translational Sciences (NCATS) identifies 
new approaches to translating basic discoveries into treatments and 
therapeutics, the NPRC consortium will work with the new center to 
bring to the fore the central role of nonhuman primate research in 
developing, and ensuring the effectiveness of, new medical products and 
interventions. Finally, we continue to engage as a resource for the 
Clinical and Translational Science Award (CTSA) network to help 
clinical researchers increase their knowledge of and access to nonhuman 
primates as animal models.
    Outlined below are a few of the overarching goals and priorities 
for the NPRCs, including specifics of how the NPRCs are striving to 
achieve these through programs and activities across the centers.
    Advance Translational Research Using Animal Models.--Nonhuman 
primate models bridge the divide between basic biomedical research and 
implementation in a clinical setting. Currently, seven of the eight 
NPRCs are affiliated and collaborate with an NIH CTSA program through 
their host institution. Specifically, the nonhuman primate models at 
the NPRCs often provide the critical translational link between 
research with small laboratory animals and studies involving humans. As 
the closest genetic model to humans, nonhuman primates serve in the 
process of developing new drugs, treatments, and vaccines to ensure 
safe and effective use for the Nation's public.
    It is neither cost effective nor feasible to reproduce these 
specialized facilities and expertise at every research institution, so 
the NPRCs are a valuable resource to the research community. Major 
areas of research benefiting from the resources of the NPRCs include 
AIDS, avian flu, Alzheimer's disease, Parkinson's disease, autism, 
cardiovascular disease, diabetes, obesity, asthma, and endometriosis. 
To facilitate these and other studies, the NPRC have developed a 
resource of over 26,000 nonhuman primates, 70 percent of which are 
rhesus monkeys, the most widely used nonhuman primate for HIV research 
and a wide range of translational studies.
    Strengthen the Research Workforce.--The success of the Federal 
Government's efforts in enhancing public health is contingent upon the 
quality of research resources that enable scientific research ranging 
from the most basic and fundamental to the most highly applied. 
Biomedical researchers have relied on one such resource--the NPRCs--for 
nearly 50 years for research models and expertise with nonhuman 
primates. The NPRCs are highly-specialized facilities that foster the 
development of nonhuman primate animal models and provide expertise in 
all aspects of nonhuman primate biology. NPRC facilities and resources 
are currently used by over 2,000 NIH funded investigators around the 
country.
    The NPRCs are also supportive of students interested in the 
biomedical research at an early age. For example, the Yerkes NPRC 
supports a program that connects with local high schools and colleges 
in Atlanta, Georgia, and provides high school science students and 
teachers with summer-long internships to participate in research 
projects taking place at their center. Other NPRCs have similar 
programs that help develop a pipeline of aspiring science students and 
teachers.

The Need for Facilities Support
    The NPRC program is a vital resource for enhancing public health 
and spurring innovative discovery. In an effort to address many of the 
concerns within the scientific community regarding the need for funding 
for infrastructure improvements, the NPRCs support the continuation of 
a robust construction and instrumentation grant program at NIH. Animal 
facilities, especially primate facilities, are expensive to maintain 
and are subject to abundant ``wear and tear.'' The NPRCs are dependent 
on strong support for the P51 base grant program which is essential for 
the operational costs, and the C06 and G20 programs which support 
construction and renovation of animal facilities. Without proper 
infrastructure, the ability for animal research facilities, including 
the NPRCs, to continue to meet the high demand of the biomedical 
research community will be unsustainable.
    Thank you for the opportunity to submit this written testimony and 
for your attention to the critical need for primate research and the 
continuation of infrastructure support. We thank you for your support 
of NIH and urge you to provide at least $32 billion for the agency in 
the fiscal year 2014 appropriations bill.
                                 ______
                                 
        Prepared Statement of the National Psoriasis Foundation

                       INTRODUCTION AND OVERVIEW

    The National Psoriasis Foundation (the Foundation) appreciates the 
opportunity to submit written public witness testimony in support of 
$1.2 million in fiscal year 2014 Federal funding for the implementation 
of the psoriasis and psoriatic arthritis public health agenda at the 
National Center for Health Statistics (NCHS) within the Centers for 
Disease Control and Prevention (CDC). The Foundation, the largest 
psoriasis patient advocacy organization and charitable funder of 
psoriatic disease research worldwide, exists to find a cure for 
psoriasis and psoriatic arthritis. Psoriasis, the Nation's most 
prevalent autoimmune disease, affecting as many as 7.5 million 
Americans, is a noncontagious, chronic, inflammatory, painful and 
disabling disease for which there is no cure. It is a systemic disease 
that appears on the skin, most often as red, scaly patches that itch, 
can bleed and require sophisticated medical intervention. Up to 30 
percent of people with psoriasis also develop potentially disabling 
psoriatic arthritis that causes pain, stiffness and swelling in and 
around the joints. There are other serious risks associated with 
psoriasis--for example, diabetes, cardiovascular disease, stroke and 
some cancers. Of serious concern is that beyond its terrible physical 
and psychosocial toll on individuals, psoriasis costs the Nation $11.25 
billion annually.
    From an epidemiology standpoint, psoriasis and psoriatic arthritis 
in the U.S. population is poorly understood. We do not yet understand 
the natural history of these diseases, how it affects various 
populations differently, and how real-world treatments impact disease 
progression. Much of the current understanding of psoriasis 
epidemiology comes from databases from other countries such as the 
United Kingdom or Denmark. However, these populations differ 
significantly from those in the U.S. with regards to patient 
demographics, environmental factors and practice and treatment 
patterns.
    In an effort to address these gaps in understanding, the Foundation 
works with the Nation's research community and policymakers at all 
levels of Government to advance policies and programs that will reduce 
and prevent suffering from psoriasis and psoriatic arthritis. In 2009, 
after examining existing scientific literature, clinical practice and 
other components of psoriasis and psoriatic arthritis research and 
care, the Foundation's medical and scientific advisors recommended the 
creation of a federally-organized public health research program for 
psoriasis and psoriatic arthritis to collect the information necessary 
to address the key scientific questions in the study and treatment of 
psoriatic disease. Responding to this recommendation, recognizing the 
significant economic and social costs of psoriasis and psoriatic 
arthritis and acknowledging the sizeable gap in the understanding of 
these challenging conditions, in fiscal year 2010, Congress provided 
$1.5 million to CDC to commence an effort to identify what gaps exist. 
CDC has been an excellent steward of this Federal funding, working 
diligently to develop a public health agenda for psoriasis while 
stretching these dollars over the course of three fiscal years.
    Thanks to the initial Congressional appropriation, on February 12, 
2013, the CDC released the first-ever public health agenda designed to 
address psoriasis and psoriatic arthritis. The agenda, entitled 
Developing and Addressing the Public Health Agenda for Psoriasis and 
Psoriatic Arthritis, was developed by CDC in collaboration with 
clinical, biomedical and public health experts. Working in partnership, 
these experts identified gaps and developed a list of priorities to be 
addressed by future psoriasis and psoriatic arthritis research efforts. 
The identified priorities include:
  --Improving the way psoriasis and psoriatic arthritis are diagnosed.
  --Examining the relationship between other chronic diseases or 
        comorbidities with psoriasis and psoriatic arthritis.
  --Examining how people with psoriatic diseases access health care, 
        the cost of their treatments and how the diseases impact their 
        ability to work.
  --Studying the effect of psoriasis and psoriatic arthritis on quality 
        of life and other outcomes.
    Investing in these priority areas of study will generate much-
needed public health data that will help scientists understand the 
underlying questions about psoriatic diseases and how they affect a 
large population of people, and, in turn, this insight will help 
identify the most promising areas of new research to find better 
treatments and move the Nation closer to a cure.
    As such, we respectfully request that Congress continue to support 
this important initiative by appropriating $1.2 million in fiscal year 
2014 to enable the NCHS within the CDC to begin to answer the pressing 
questions identified in the psoriasis and psoriatic arthritis public 
health agenda. federally funded efforts are critical to determine 
epidemiology of psoriasis and psoriatic arthritis in Americans, the 
associated comorbidities, and impact of treatments in the U.S. With 
fiscal year 2014 funding, NCHS will be able to develop and validate 
relevant and meaningful questions specific to psoriasis and psoriatic 
arthritis. With rigorous sampling methods and survey administration, we 
will be able to obtain valuable information from a nationally 
representative population to determine the natural history of psoriasis 
and psoriatic arthritis in the U.S. population, the effect of 
environmental factors on disease progression, the impact and 
comorbidities, and the effect of treatments on psoriasis patient 
outcomes.
     the impact of psoriasis and psoriatic arthritis on the nation
    Psoriasis requires steadfast treatment and lifelong attention. 
People with psoriasis have significantly higher health care resource 
utilization, which costs more than that of the general population. As 
noted earlier, of serious and increasing concern is mounting evidence 
that people with psoriasis are at elevated risk for other serious, 
chronic and life-threatening conditions, including cardiovascular 
disease and diabetes. In addition, people with psoriasis experience 
higher rates of depression and anxiety, and they die 4 years younger, 
on average, than people without the disease.
    Despite some recent breakthroughs, many people with psoriasis and 
psoriatic arthritis remain in need of effective, safe, long-term and 
affordable therapies to allow them to function without both physical 
and emotional pain. Due to the nature of the disease, patients often 
have to cycle through available treatments, and while there are an 
increasing number of methods to control the disease, there is no cure. 
Many of the existing treatments can have serious side effects and can 
pose long-term risks for patients (e.g., suppress the immune system, 
deteriorate organ function, etc.). The lack of viable, long-term 
methods of control for psoriasis can be addressed through a robust 
Federal commitment to epidemiological, genetic, clinical and basic 
research. Research holds the key to improved treatment and diagnosis of 
psoriatic disease and, eventually, a cure.

     THE ROLE OF CDC IN PSORIASIS AND PSORIATIC ARTHRITIS RESEARCH

    Despite our increased understanding of the autoimmune underpinnings 
of psoriasis and its treatments, there is a dearth of population-based 
epidemiology data on psoriatic disease. Broadly-representative 
population-based studies of psoriasis reflecting the full spectrum of 
disease are lacking and much-needed because there are still wide gaps 
in our knowledge and understanding of psoriatic disease. CDC's 
implementation of the psoriasis and psoriatic arthritis public health 
agenda will help to provide scientists and clinicians with critical 
information to further their understanding of (a) how early 
intervention can prevent or delay the development of comorbid 
conditions; (b) what factors can trigger flares and remissions; (c) 
some of the underlying causes of disease; (d) how differentiating 
lifestyle and other environmental triggers might lead to approaches 
that minimize exposure to these factors, thus reducing the incidence 
and severity of disease; and (e) best practice treatments, which would 
assist in improving patient care and outcomes, and in turn, help reduce 
health care costs.

           PSORIASIS AND PSORIATIC ARTHRITIS RESEARCH AT NIH

    It has taken nearly 30 years to understand that psoriasis is, in 
fact, not solely a disease of the skin, but also of the immune system. 
Recently, scientists identified some of the immune cells involved in 
psoriasis, and over the last decade we have seen a surge in the 
understanding of these diseases, accompanied by new drug development. 
Scientists are poised, as never before, to make major breakthroughs; to 
facilitate such advancements, we need increased investment in the 
National Institutes of Health (NIH).
    Within the NIH, the National Institute of Arthritis and 
Musculoskeletal and Skin Diseases (NIAMS) is the principal Federal 
Government agency that supports psoriasis research. We commend NIAMS 
for its leadership role and very much appreciate its steadfast 
commitment to supporting and advancing psoriasis research. 
Additionally, we are pleased that research activities that relate to 
psoriasis or psoriatic arthritis also have been undertaken within other 
NIH institutes and centers; this work is critical given the myriad 
comorbidities of psoriasis, as noted earlier. We advocate a strong 
Federal investment in genetic, immunological and clinical studies 
focused on understanding the mechanisms of psoriasis and psoriatic 
arthritis be funded and maintained.
    Given the myriad factors involved in psoriatic disease and its 
comorbid conditions, the Foundation urges Congress to boost funding for 
NIH and NIAMS. We recognize the Nation faces significant budgetary 
challenges; however, we believe an increased Federal investment in 
biomedical research will help strengthen the economy and our 
understanding of psoriatic disease.

                           CONCLUSION/SUMMARY

    On behalf of the more than 7.5 million people with psoriasis and 
psoriatic arthritis, I thank the subcommittee for the opportunity to 
submit written testimony regarding the fiscal year 2014 investments we 
believe are necessary to ensure that our Nation adequately addresses 
the needs of individuals and families affected by psoriatic disease. By 
allocating $1.2 million to implement CDC's psoriasis and psoriatic 
arthritis public health agenda, Congress will help ensure that the 
Nation makes progress in understanding the connection between psoriasis 
and its comorbid conditions, uncovering the biologic aspects of 
psoriasis and other risk factors that lead to higher rates of comorbid 
conditions and identifying ways to prevent and reduce the onset of 
comorbid conditions associated with psoriasis. Please feel free to 
contact the Foundation at any time; we are happy to be a resource to 
subcommittee members and your staff.
                                 ______
                                 
              Prepared Statement of National Public Radio

    Dear Chairman Harkin, Senator Moran and members of the 
subcommittee: My name is Gary E. Knell, and I am the President and CEO. 
Thank you for this opportunity to urge the subcommittee's support for 
an annual Federal investment of $445 million in public broadcasting 
through the Corporation for Public Broadcasting (CPB). With your 
support, every American will continue to have free access to the best 
in news, information, educational and cultural programming.
    As the President and CEO of National Public Radio (NPR), I offer 
this testimony on behalf of the public radio system, a uniquely 
American public service, non-for-profit media enterprise that includes 
NPR, other producers and distributors of public radio programming 
including American Public Media (APM), Public Radio International 
(PRI), the Public Radio Exchange (PRX), and our more than 950 public 
radio station partners , both large and small, that create and 
distribute content through the Public Radio Satellite System (PRSS).
    Funding provided by Congress to the CPB supports the entire 
foundation of a system that has been one of America's most successful 
models of a community-centric grant program. The cost of public 
broadcasting is only 0.01 percent of the entire Federal budget. The 
revenue base provided by Congress enables stations to raise $6 for 
every Federal grant dollar. This Federal financial investment permits 
local stations to invest more deeply in their own local news and 
cultural programming which in turn enables our stations to provide the 
American public with an enduring and daily return on investment that is 
heard, seen, read, and experienced in public radio broadcasts, apps, 
podcasts, and online.
    With support from the CPB's community service grants, each of the 
hundreds of independently-operated public radio stations creates and 
curates the mix of programs that best meets the needs of their local 
community. These stations and their programming choices are as diverse 
as the people who live in the communities they serve. Some have all-
news formats. Others have all-music formats. Others create a blend of 
news, talk, commentary and music into their program offerings. Close to 
thirty percent of our stations' daily programming is locally generated. 
Every year the Federal Government invests roughly ninety million 
dollars in the operation of America's local public radio stations, and 
these stations in turn provide service to all of America's 
congressional districts and States.
    In our congressional testimony last year, we highlighted three 
essential contributions of public radio to Americans: our deeply rooted 
local community connections from which all staffing, management and 
programming decisions are made; public radio's significant and growing 
contributions to music and local music economies; and public radio's 
indispensable role as a lifeline information source during times of 
local and regional crises.
    These unique contributions remain clearly in view as public radio 
adjusts to America's changing demographics and undergoes renewal to 
accommodate the demands of our audience and the opportunities presented 
by the march of technology.
    Mr. Chairman, 2013 marks the twelfth year of armed overseas 
conflict, the longest period of sustained warfare in United States 
history. Some 2.3 million Americans have now served in the wars in Iraq 
and Afghanistan, with more than thirty-two thousand casualties, and 
tens of thousands more enduring the mental strains of combat. Now, with 
the military drawdown taking place, these men and women are returning 
home, with many facing difficult transitions. NPR and its public radio 
station partners are delving deeply into the lives of America's 
veterans to foster an understanding of the impact of war to the public 
and to policymakers. Unique and dedicated reporting projects like 
StoryCorps' Military Voices Initiative allow the stories and lives of 
America's veterans to be heard and preserved. We believe that 
illuminating these stories will deepen the connections between our 
Nation's civilian population and military communities.
    When the storm clouds of Hurricanes Isaac and most recently Sandy 
gathered, so did the reporters of local public radio stations and NPR. 
Stations in the affected areas worked nonstop to deliver updates on 
damage, relief assistance, and places of refuge and safety. The public 
radio system worked together to bring these local struggles and 
challenges to a national audience.
    The work of New York Public Radio (WNYC) perfectly illustrates all 
of public radio's commitment to nonstop coverage during emergencies and 
crises. Despite losing power to its Lower Manhattan headquarters on the 
evening Sandy struck, and later its AM transmitter in New Jersey, WNYC 
stayed on the air with an emergency generator to provide the critical 
news and information its local citizens needed. Its news websites, 
wnyc.org and njpublicradio.org, operated on back-up servers to provide 
up-to-date news and information, such as its interactive maps that 
tracked transit options, flooding and power outages. More than 4.6 
million visitors came to its sites for Sandy information.
    Public radio's coverage following the terrorist bombing attacks at 
the Boston Marathon is another example of the extraordinary power and 
reach of our local-national system based on stations. By using our 
programming interconnection system, Boston-based WBUR's coverage was 
available to all Americans through their local public radio stations.
    The station's round-the-clock coverage is best understood in the 
following summary by Charles Kravitz, General Manager of WBUR, who 
shared this with his station colleagues after that horrible week:
          ``As I'm sure you agree WBUR simply did its job, as any of 
        you have done and will do when a major story develops in your 
        community. That's why we are here. We were writing `the first 
        rough draft of history' that will no doubt be refined and 
        examined for years to come. All of your kind words buoyed us 
        when our energy sagged at the end of some long days.
          ``The city of Boston was the real hero of this story. 
        Countless stories, large and small, of sacrifice and bravery, 
        of loss and grief, painted a tapestry of this complex and 
        beautiful city that many of us had not seen before. Tragedy, as 
        you know, will do that. People held hands, strangers hugged 
        each other and children sang songs which uplifted us. Out of 
        something terrible came something beautiful.
          ``It is in this moment that I am reminded of how fortunate I 
        am, how fortunate we all are, to do the work we do and to serve 
        the public in such a vital and important way. However imperfect 
        we are, we make a difference. It is gratifying.''
    Public radio's commitment to bring news to all Americans during 
emergency events is also reflected in a recent award from the U.S. 
Department of Homeland Security (DHS) and the Federal Emergency 
Management Agency (FEMA) to NPR Labs. This contract will enable the 
demonstration of delivering emergency alerts to deaf or hard-of-hearing 
communities in Gulf Coast States through local public radio stations 
and the PRSS. This is the first-ever effort to deliver real-time 
accessibility-targeted emergency messages, such as weather alerts, 
through radio broadcast texts.
    Mississippi Congressman Steven Palazzo commented on this activity 
by saying:
          ``As we work to promote disaster preparedness and awareness, 
        it is important we remember to equip every member of our 
        communities. This valuable partnership with Mississippi's local 
        public radio stations promises to expand the reach of our 
        disaster alert systems, and I can think of no better place to 
        conduct this trial than the Gulf Coast.''
    We are committed to bringing the breadth of America's diverse 
voices to our programs so that our audience has the benefit of hearing 
the full rundown of ideas, thoughts and policy perspectives that 
populate our country's political, cultural and social conversation. 
Capturing the diversity of these conversations, including political, 
age, racial, ethnic and geographic, is at the center of our mission to 
serve as America's public radio.
    A further commitment to exploring and serving the changing nature 
of America's citizens can be found in our newly launched initiative on 
race, ethnicity and culture. With support from the CPB, NPR has formed 
a new team of six journalists to identify and report on news and issues 
of race and ethnicity, thus presenting new voices that define an 
increasingly diverse America.
    And lastly, Mr. Chairman, at a time when most other American news 
organizations are drawing down on their commitments to cover 
international news, NPR is growing its overseas presence. From Mexico 
City to Berlin, from Shanghai to Dakar, NPR correspondents based in 
eighteen foreign bureaus bring listeners dynamic stories of the world's 
people, politics, economies, and cultures. Our reporters live in these 
areas and are on the ground for breaking news and in-depth, ongoing 
coverage of foreign policy and national security events.
    NPR has permanent bureaus throughout the Middle East in order to 
fully represent the impact of the region: Islamabad, Istanbul, Kabul, 
Beirut, and Jerusalem. Correspondents based in these five cities, along 
with those in Cairo, New Delhi, and Jakarta, bring to life the 
experiences of people in war-torn regions, keep an eye on U.S. military 
engagements abroad, and cover civil uprisings and regime changes.
    Recently, the work of Kelly McEvers and Deborah Amos collected the 
highest honors in journalism, the DuPont-Columbia and Peabody Awards, 
for their coverage of the Syrian conflict. Their recognition truly 
reflects the work of many in what is a total team effort. McEver's 
stories were edited and overseen by senior staff. Show producers 
carefully mixed the stories and the NPR web team wrote compelling text 
and found perfect photographs to illustrate them. This is but a single 
sampling of an ongoing labor of devotion and professional dedication by 
intrepid journalists who are committed to sharing the world's stories, 
events and people with America.
    Mr. Chairman and Senator Moran, NPR and the public radio system are 
committed to being America's public radio where rational, fact-based, 
accurate and civil reporting and conversation are our top priorities. 
We have no political agenda and we do not take sides. Public radio 
plays an important, significant and growing role in news, journalism, 
and music and cultural programming. Our stations are essential to, and 
part of, the communities they serve.
    Public radio stations are reaching audiences wherever they are. 
We're embracing America's changing demographics and using digital media 
to connect better, more quickly and in more diverse ways. Today's 
public radio isn't going away, it's going everywhere--and we are 
working every day to earn the trust of the thirty-eight million 
Americans who rely on us for news and insights that guide and inform.
                                 ______
                                 
          Prepared Statement of the National Respite Coalition

    Mr. Chairman, I am Jill Kagan, Chair of the National Respite 
Coalition (NRC), a network of respite providers, family caregivers, 
national, State and local agencies and organizations who support 
respite. Thirty State respite coalitions are also affiliated with the 
NRC. This statement is presented on behalf of these organizations. The 
NRC also facilitates the Lifespan Respite Task Force, a coalition of 
over 200 national, State and local groups who support the Lifespan 
Respite Program and its continued funding. We are requesting that the 
subcommittee include $2.5 million for the Lifespan Respite Care Program 
administered by ACL/AoA in the fiscal year 2014 Labor, HHS, and 
Education Appropriations bill. This amount, very slightly above current 
sequestration levels, is the same amount appropriated each year since 
2009 and the amount requested by the President in his fiscal year 2014 
budget proposal. This will enable:
  --State replication of best practices in Lifespan Respite to allow 
        all family caregivers, regardless of the care recipient's age 
        or disability, to have access to affordable respite, and to be 
        able to continue to play the significant role in long-term care 
        that they are fulfilling today;
  --Improvement in the quality of respite services currently available;
  --Expansion of respite capacity to serve more families by building 
        new and enhancing current respite options, including 
        recruitment and training of respite workers and volunteers; and
  --Greater consumer direction by providing family caregivers with 
        training and information on how to find, use and pay for 
        respite services.

                           WHO NEEDS RESPITE?

    In 2009, about 61.6 million family caregivers provided care at some 
time during the year. The estimated economic value of their unpaid 
contributions was approximately $450 billion. This amount is more than 
total 2009 Medicaid spending, including both Federal and State 
contributions for health care and long-term services and supports ($361 
billion). Including caregiving for children with special needs in the 
total would add at least 4 to 8 million additional caregivers and 
another $50 to $100 billion to the economic value of family caregiving 
(Feinberg, L.; Reinhard, S., et al, Valuing the Invaluable: 2011 
Update, The Growing Contributions and Costs of Family Caregiving, AARP 
Public Policy Institute, 2011).
    Family caregiving is not just an aging issue, but also a lifespan 
one. While the aging population is growing rapidly, the majority of 
family caregivers are caring for someone under age 75 (56 percent); 28 
percent of family caregivers care for someone between the ages of 50-
75, and 28 percent care for someone under age 50 (National Alliance for 
Caregiving (NAC) and AARP, 2009). Many family caregivers are in the 
sandwich generation--46 percent of women who are caregivers of an aging 
family member and 40 percent of men also have children under the age of 
18 at home (Aumann, Kerstin and Ellen Galinsky, et al. 2008). And 6.7 
million children are in the primary custody of an aging grandparent or 
other relative.
    Families of the wounded warriors, military personnel who returned 
from Iraq and Afghanistan with traumatic brain injuries and other 
serious chronic and debilitating conditions, don't have full access to 
respite. Even with enactment of the new VA Family Caregiver Support 
Program, the need for respite will remain high for all veterans and 
their family caregivers. Caregivers whose veterans have PTSD are about 
half as likely as other caregivers to receive respite (11 percent vs. 
20 percent) (NAC, Caregivers of Veterans--Serving On the Homefront, 
November 2010). Sixty-eight percent of veterans' caregivers reported 
their situation as highly stressful compared to 31 percent of 
caregivers nationally, and three times as many say there is a high 
degree of physical strain (40 percent vs. 14 percent) (NAC, 2010). 
Veterans' caregivers specifically asked for up-to-date lists of respite 
providers in their communities and help to find services, the very 
thing Lifespan Respite is charged to provide (NAC, 2010).
    National, State and local surveys have shown respite to be the most 
frequently requested service of the Nation's family caregivers (The 
Arc, 2011; National Family Caregivers Association, 2011). Other than 
financial assistance for caregiving through direct vouchers payments or 
tax credits, respite is the number one national policy related to 
service delivery that family caregivers prefer (NAC and AARP, 2009). 
Yet respite is unused, in short supply, inaccessible, or unaffordable 
to a majority of the Nation's family caregivers. The NAC 2009 survey 
found that despite the fact that among the most frequently reported 
unmet needs of family caregivers were ``finding time for myself'' (32 
percent), ``managing emotional and physical stress'' (34 percent), and 
``balancing work and family responsibilities'' (27 percent), nearly 90 
percent of family caregivers across the lifespan are not receiving 
respite services at all.
    An estimated 80 percent of all long-term care in the U.S. is 
provided at home. This percentage will only rise in the coming decades 
with greater life expectancies of individuals with disabling and 
chronic conditions living with their aging parents or other caregivers, 
the aging of the baby boom generation, and the decline in the 
percentage of the frail elderly who are entering nursing homes.

          RESPITE BARRIERS AND THE EFFECT ON FAMILY CAREGIVERS

    Barriers to accessing respite include reluctance to ask for help, 
fragmented and narrowly targeted services, cost, and the lack of 
information about respite or how to find or choose a provider. Even 
when respite is an allowable funded service, a critically short supply 
of well-trained respite providers may prohibit a family from making use 
of a service they so desperately need. Lifespan Respite is designed to 
help States eliminate these barriers through improved coordination and 
capacity building.
    While most families take great joy in helping their family members 
to live at home, it has been well documented that family caregivers 
experience physical and emotional problems directly related to their 
caregiving responsibilities. In a 2009 survey of family caregivers, a 
majority (51 percent) who are caring for someone over age 18 have 
medium or high levels of burden of care, measured by the number of 
activities of daily living with which they provide assistance, and 31 
percent were identified as ``highly stressed'' (NAC and AARP, 2009). 
While family caregivers of children with special health care needs are 
younger than caregivers of adults, they give lower ratings to their 
health. Caregivers of children are twice as likely as the general adult 
population to say they are in fair/poor health (26 percent vs. 13 
percent) (Provisional summary Health Statistics for US Adults, National 
Health Interview Survey, 2008, dated August 2009).
    The decline of family caregiver health is one of the major risk 
factors for institutionalization of a care recipient, and there is 
evidence that care recipients whose caregivers lack effective coping 
styles or have problems with depression are at risk for falling, 
developing preventable secondary complications such as pressure sores 
and experiencing declines in functional abilities (Elliott & Pezent, 
2008). Care recipients may also be at risk for encountering abuse from 
caregivers when the recipients have pronounced need for assistance and 
when caregivers have pronounced levels of depression, ill health, and 
distress (Beach et al., 2005; Williamson et al., 2001).
    Supports that would ease family caregiver stress, most importantly 
respite, are too often out of reach or completely unavailable. 
Restrictive eligibility criteria also preclude many families from 
receiving services or continuing to receive services for which they 
once were eligible. Children with disabilities will age out of the 
system when they turn 21 and they will lose many of the services, such 
as respite. A survey of nearly 5000 caregivers of individuals with 
intellectual and developmental disabilities (I/DD) conducted by The Arc 
found: the vast majority of caregivers report that they are suffering 
from physical fatigue (88 percent), emotional stress (81 percent) and 
emotional upset or guilt (81 percent) some or most of the time; 1 out 
of 5 families (20 percent) report that someone in the family had to 
quit their job to stay home and support the needs of their family 
member; and more than 75 percent of family caregivers caring for adult 
children with developmental disabilities could not find respite 
services (The Arc, 2011). Respite may not exist at all in some States 
for individuals with Alzheimer's, those under age 60 with conditions 
such as ALS, MS, spinal cord or traumatic brain injuries, or children 
with serious emotional conditions.

              RESPITE BENEFITS FAMILIES AND IS COST SAVING

    Respite has been shown to be an effective way to reduces stress and 
improve the health and well-being of family caregivers that in turn 
helps avoid or delay out-of-home placements, such as nursing homes or 
foster care, minimizes the precursors that can lead to abuse and 
neglect, and strengthens marriages and family stability. A new study of 
parents of children with autism spectrum disorders found that respite 
care was associated with reduced stress and improved marital quality 
(Harper, Amber, et al, 2013). A U.S. Department of Health and Human 
Services report prepared by the Urban Institute found that higher 
caregiver stress among those caring for the aging increases the 
likelihood of nursing home entry. Reducing key stresses on caregivers, 
such as physical strain and financial hardship, through services such 
as respite would reduce nursing home entry (Spillman and Long, USDHHS, 
2007). In a recent survey of caregivers of individuals with Multiple 
Sclerosis (MS), two-thirds said that respite would help keep their 
loved one at home. When the care recipient with MS also has cognitive 
impairment, the percentage of those saying respite would be helpful to 
avoid or delay nursing home placement jumps to 75 percent (NAC, 2012).
    The budgetary benefits that accrue because of respite are just as 
compelling. Delaying a nursing home placement for just one individual 
with Alzheimer's or other chronic condition for several months can save 
Medicaid and other Government programs thousands of dollars. 
Researchers at the University of Pennsylvania studied the records of 
over 28,000 children with autism ages 5 to 21 who were enrolled in 
Medicaid in 2004. They concluded that for every $1,000 States spent on 
respite services in the previous 60 days, there was an 8 percent drop 
in the odds of hospitalization (Mandell, David S., et al, 2012). In the 
private sector, the Metropolitan Life Insurance Company and the 
National Alliance for Caregivers found that U.S. businesses lose from 
$17.1 billion to $33.6 billion per year in lost productivity of family 
caregivers (MetLife and National Alliance for Caregiving, 2006). 
Respite for working family caregivers could help improve job 
performance and employers could potentially save billions.

                LIFESPAN RESPITE CARE PROGRAM WILL HELP

    The Federal Lifespan Respite program is administered by the 
Administration for Community Living (ACL), Administration on Aging 
(AoA), U.S. Department of Health and Human Services (HHS). ACL/AoA 
provides competitive grants to eligible State agencies in concert with 
Aging and Disability Resource Centers working in collaboration with 
State respite coalitions or respite organizations. Congress 
appropriated $2.5 million each year from fiscal year 2009-fiscal year 
2012 and a slightly lower amount due to sequestration in fiscal year 
2013. Since 2009, thirty States and the District of Columbia have 
received three-year $200,000 Lifespan Respite Grants from AoA. Nine 
States and DC received one-time $150,000 expansion grants to focus on 
direct services, especially for those who are unserved. Last year, 
seven of the original 2009 grantees received 17-month Integration and 
Sustainability grants to continue their important work.
    The purpose of the law is to expand and enhance respite services, 
improve coordination, and improve respite access and quality. States 
are required to establish State and local coordinated Lifespan Respite 
care systems to serve families regardless of age or special need, 
provide new planned and emergency respite services, train and recruit 
respite workers and volunteers and assist caregivers in gaining access 
to services. Those eligible would include family members, foster 
parents or other adults providing unpaid care to adults who require 
care to meet basic needs or prevent injury and to children who require 
care beyond that required by children generally to meet basic needs.
    Lifespan Respite, defined as a coordinated system of community-
based respite services, helps States use limited resources across age 
and disability groups more effectively. Provider pools can be 
recruited, trained and shared, administrative burdens reduced by 
coordinating resources, and savings used to fund new respite services 
for families who do not qualify for any Federal or State program.

          HOW IS LIFESPAN RESPITE PROGRAM MAKING A DIFFERENCE?

    With limited funds, Lifespan Respite grantees are engaged in 
innovative activities such as:
  --In TN and RI, the Lifespan Respite program is building respite 
        capacity by expanding volunteer networks of providers by 
        recruiting University students or Senior Corps volunteers or 
        expanding the national TimeBanks model for establishing 
        voluntary family cooperative respite strategies.
  --In Texas, the Lifespan Respite program has established a statewide 
        Respite Coordination Center, and an online database.
  --In SC, the State respite coalition and the Lifespan Respite program 
        are partnering in new ways with the untapped faith community to 
        provide respite, especially in rural areas.
  --The North Carolina Lifespan Respite Program has challenged each of 
        its 100 counties to improve respite service delivery locally, 
        and has partnered with the Money Follows the Person program to 
        develop family caregiver peer-to-peer support and respite.
  --In NH, new providers have been recruited and trained through 
        partnerships with the NH National Alliance on Mental Illness, 
        New Hampshire Family Voices, and the College of Direct Support 
        with funding from the Department of Labor to expand the pool of 
        respite providers to work with teens and older individuals with 
        mental health conditions or other groups where respite is in 
        short supply.
  --The AZ Lifespan Respite program housed in Division of Aging and 
        Adult Services has partnered with their State's Children with 
        Special Health Care Needs Program to provide respite vouchers 
        to families in need across the age and disability spectrum.
  --The OK Lifespan Respite program partnered with their State's 
        Federal Transit Administration's Section 5310 transportation 
        authority to release a van no longer needed by the program to 
        transport respite volunteers and materials to isolated rural 
        areas to provide respite in church and community center social 
        halls.
    Across the board, States are building respite registries and ``no 
wrong door systems'' in collaboration with State respite coalitions and 
Aging and Disability Resource Centers to help family caregivers access 
respite and funding sources. OK, AL, NV, TN and others are using 
Lifespan Respite grants to expand or implement participant-directed 
respite through coordinated voucher systems so that family caregivers 
have greater control over the type and quality of the respite they 
select. All State grantees secure commitments from partnering State 
agencies to share information and coordinate resources to build a 
seamless Lifespan Respite system for accessing respite.
    Funding must be maintained to help sustain these impressive and 
innovative State efforts. The goal of Lifespan Respite System is to 
coordinate respite services and funding, maximize existing resources 
and leverage new dollars in both the public and private sectors to 
build respite capacity and serve the unserved, but States need more 
time and fiscal support to do so. Maintaining funding for the program 
in fiscal year 2014 could allow several new States to start Lifespan 
Respite Programs and help assist at least a few of the remaining 
grantees to complete the work that they have started. As it is, given 
the limited funding for fiscal year 2013, only 3-5 new States are 
expected to be funded and only up to five of the original twenty-four 
2009 and 2010 grantees will be funded. Most will be cut off before they 
have had a chance to make a lasting impact.
    No other Federal program mandates respite as its sole focus. No 
other Federal program would help ensure respite quality or choice, and 
no current Federal program allows funds for respite start-up, training 
or coordination or to address basic accessibility and affordability 
issues for families. We urge you to include at least $2.5 million in 
the fiscal year 2014 Labor, HHS, Education appropriations bill so that 
Lifespan Respite Programs can be replicated and sustained in the States 
and more families, with access to respite, will be able to continue to 
play the significant role that they are fulfilling today.
                                 ______
                                 
        Prepared Statement of the National Senior Service Corps

    Mr. Chairman, Members of the Committee, my name is Gary Goosman and 
I am Senior Programs Director of the Corporation for Ohio Appalachian 
Development. I testify today on behalf of the National Senior Corps 
Association, representing the interests and ideals of more than 400,000 
senior volunteers and the directors, staff, and friends of local Foster 
Grandparent, Senior Companion, and RSVP programs throughout the 
country.
    For fiscal year 2014, NSCA requests $110,565,000 for the Foster 
Grandparent Program (FGP), $69,300,000 for RSVP (restoring the 20 
percent that was cut in fiscal year 2010), and $46,722,000 for the 
Senior Companion Program (SCP). This level of funding will provide for 
continued support for existing grantees and competition for new 
grantees. Our request is composed of the following goals:
  --Support for Continuing Services--$244,986,540 (FGP--$110,565,000; 
        RSVP--$69,300,000; SCP--$46,722,000). These grant funds allow 
        existing Senior Corps programs and the nearly 400,000 
        volunteers to continue providing critical services, including:
  --Independent living services. SCP volunteers provide companionship 
        and support needed to help frail seniors remain independent and 
        in their own homes at a cost lower than institutional care. 
        RSVP volunteers provide a range of services to frail elders and 
        people with disabilities, and respite to caregivers to help 
        preserve independent living and reduce costly 
        institutionalization.
  --Mobilizing volunteers. RSVP volunteers recruit or manage additional 
        community volunteers to serve in local communities.
  --Serving children and vulnerable families. FGP volunteers tutor 
        children with low literacy skills and mentor troubled teenagers 
        and young mothers. RSVP volunteers tutor thousands of children, 
        and steer disadvantaged children and youth toward a more 
        productive and responsible path.
  --Assisting in disaster preparedness and recovery. Often the first 
        national service participants to respond, RSVP volunteers staff 
        emergency kitchens and shelters, distribute food and clothing, 
        and assist in relocating affected individuals and families.
  --Assisting with clean energy programs. RSVP volunteers provide home-
        based services such as weatherization and handyman assistance 
        to families in need of extra support.
  --Stipend--even though the Kennedy Serve America Act authorizes the 
        increase in the Federal stipend (for Foster Grandparents and 
        Senior Companions) from $2.65 to $3.00 per hour we realize that 
        these are difficult economic times and we would defer this 
        increase until future budgets have the capacity to include a 
        stipend increase.
  --Silver Scholarships. While current legislation does not exclude 
        Senior Corps volunteers from receiving Silver Scholarships, it 
        does not specifically state that they are included. NSCA 
        requests allowing flexibility in rule interpretation to allow 
        Senior Corps program eligibility for Silver Scholarships. 
        Silver Scholarships are $1,000 transferable education awards 
        for adults age 55 and older who serve 350 hours per year. The 
        award may be given to their child or grandchild. NSCA requests 
        $1,000,000 for Silver Scholarships.
    SENIOR CORPS is a federally authorized and funded network of 
national service programs that provides older Americans with the 
opportunity to apply their life experiences to volunteer service. 
Senior Corps is comprised of the Foster Grandparent Program, RSVP, and 
the Senior Companion Program, through which Americans age 55 and older 
provide essential services to cost-effectively address critical 
community needs.
    Foster Grandparent Program.--27,900 Foster Grandparents in 325 
projects provide a cost-effective means to reach and support more than 
232,000 at-risk children with special or exceptional needs annually who 
otherwise may not have the opportunity to receive individual assistance 
and attention from a caring adult. In 2011, Foster Grandparents 
volunteered over 24 million hours.
  --81 percent of children served demonstrated improvements in academic 
        performance. Mentored children have reduced truancy resulting 
        in reduced school costs and, ultimately, reduced high school 
        dropout rates and increased lifetime earnings.
  --90 percent demonstrated increased self-image. This includes 
        improved health outcomes such as reductions in teen pregnancy 
        and reduced or delayed use of tobacco, alcohol, or illicit 
        drugs.
  --56 percent reported improved school attendance leading to increased 
        graduation rates, increased post-secondary education, and 
        higher lifetime earnings.
  --59 percent reported reduction in risky behavior, including reduced 
        juvenile violence and property crimes, saving victim and court 
        expenses, costly treatment of juvenile offenders, costs of 
        adult crime, crime losses of victims and the societal costs of 
        prosecuting and incarcerating adult offenders.
    In 2011, FGP volunteers mentored more than 232,000 children and 
youth, of which 5,400 were children of prisoners at high risk of 
repeating their parent's path. FGP intervention reduced need for social 
services, both short-term costs of counseling and long-term costs of 
public assistance.
    Based on conservative assumptions about outcomes and valuations, 
studies indicate a return benefit of $2.72 for every dollar of 
resources used for mentoring programs. (Analyzing the Social Return on 
Investment in Youth Mentoring Programs, prepared by: Paul A. Anton, 
Wilder Research; and Prof. Judy Temple, University of Minnesota).
    Foster Grandparent Program Profiles.--Ethel Goss turned 92 years 
old this past January. Before beginning the program in 2010 she had 
retired from a receptionist position at a local daycare. When she 
called to inquire about the program she had stated that she was bored 
and needed to be with children. Kinsey Tumblin Head Start teacher) 
writes, ``I have to admit there was a little concern about her age, but 
she reassured me that she walked with a cane only because her son made 
her! Once I met with Ethel those concerns completely disappeared; I 
found her to be quick, alert and full of compassion. As I anxiously 
waited to see the assignment plans and progress reporting, it was not a 
surprise to me that it was very good news.'' Grandma Ethel had two 
children assigned to her, one 3 year old and one 4 year old. The 4 year 
old needed individual help with fine motor skills, interaction with 
familiar adults, building appropriate vocabulary for obtaining wants, 
and to gain positive communication skills. By May; with the one-on-one 
mentoring from Grandma Ethel all goals were met, including the 
programmatic goal for Head Start Programs.
    RSVP.--296,100 RSVP volunteers contributed 62 million hours of 
service in 2011 through 685 projects nationwide working with more than 
65,000 community organizations. The average cost to support one RSVP 
volunteer is approximately $145 a year, whereas the average annual 
value per volunteer is more than $3,000. RSVP volunteers saved local 
communities more than $1.25 billion in 2011.
    RSVP is continually strengthening its leadership role in engaging 
volunteers 55+ by providing nonprofit agencies with volunteers trained 
to recruit and coordinate other community members in support of the 
nonprofits mission and goals. In 2011, RSVP volunteers recruited 38,000 
additional community volunteers.
    RSVP projects demonstrate that their volunteer services increase 
literacy scores for the more than 80,000 children they mentor--the 
National Education Association states the lowest hourly rate for 
teacher aides is $10.31 reflecting a savings of $16,858,623 in remedial 
reading assistance.
  --25,000 RSVP volunteers increased the capacity of the organizations 
        where they serve by enhancing both the quality and quantity of 
        services.
  --In 2011, RSVP volunteers mentored 16,200 children of prisoners at 
        high risk of repeating their parent's path.
  --RSVP volunteers provided 23,300 caregivers with respite services. A 
        recent AARP survey of working caregivers reports that 30 
        percent of family caregivers either quit their jobs or reduce 
        their work hours to take on more care giving responsibilities.
  --RSVP volunteers supported 509,000 with Independent Living Services.
  --30 percent of RSVP volunteers provided at least one service in the 
        area of Health/Nutrition which includes in-home and congregate 
        meals, food distribution/collection, immunization, etc. valued 
        at more than $27 million.
    Senior Companion Program.--13,600 Senior Companions serving in 194 
projects provided 12.2 million hours of service helping 60,940 frail, 
homebound clients in need of assistance in order to remain living 
independently. If all those individuals were instead served in Assisted 
Living facilities it would be at a cost of $2,289,637,680. Senior 
Companion Program services prevented premature and costly 
institutionalization at an annual savings well over $2 billion. The 
national average cost for 1 year in a nursing home is $72,270; the 
assisted living facility yearly average cost is $37,572. One Senior 
Companion volunteer assists 2-6 homebound clients for the annual 
investment of $4,800.
    Senior Companions offered essential respite to nearly 9,000 primary 
caregivers who struggle to remain in the regular workforce while caring 
for their loved one. The Family Caregiver Alliance reports that 
families with long-term care responsibilities miss an average of 7.5 
workdays each year.
    The MetLife Caregiving Cost Study of July 2006 reports the 
estimated cost to employers of full-time employed intense caregivers at 
a total of $17.1 billion in lost productivity annually as well as 
absenteeism, workday interruptions, costs due to crisis in care, 
supervision costs associated with caregiver employees, costs with 
unpaid leave and reducing hours from full-time to part-time.
    Clients have significant, long-term mental health benefits and 
reduced rates of depression saving $50-$75 a month in medication.
    Cost of stress management therapy for one caregiver ($125 per 
session) vs. respite provided by volunteer (4 hours of respite care = 
$10.60 plus mileage average cost of $3).
    Cost for a home health aide after a client's release from the 
hospital is $21 per hour as compared to $2.65 per hour for a Senior 
Companion volunteer (at no cost to clients).
    Senior Companion Program Profile.--Jane H. is in the beginning 
stages of Alzheimer's but still has some of her memory. She has a 
Senior Companion named Barb. She says Barb is a huge help and provides 
personal comfort to her so that she is not alone. Both of her kids work 
and she has no one available thru the day. She is always afraid of 
falling because she is a little clumsy. Her daughter, Sue, is Director 
of the Friendship Center in Carrollton. Sue explained that, ``...having 
Barb there gives me a great peace of mind while I'm at work. Our county 
has limited services and home visitors aren't available.'' She further 
said, ``My brother has a full time job as well and all of his family 
works during the day.'' The family takes turns in the evening hours 
with Jane. ``Mom doesn't want to be in a nursing home so this program 
allows her to stay in her apartment. This is where she is happiest''.
    It has been stated that baby boomer and senior volunteers represent 
our Nation's single and fastest growing resource. During this 
unprecedented economic crisis facing our Nation, the number of baby 
boomer and senior volunteers should be greatly expanded and mobilized 
as solutions to the problems facing our local communities. NSCA's 2014 
budget request will provide the opportunity for thousands more older 
adults to serve in their communities and enhance the lives of those 
most in need, including children with special needs, the frail and 
isolated elderly striving to maintain independence, and expanding the 
services of local non-profit agencies.
    The 2012 national value of one hour of volunteer service was 
estimated at $22.14.
    Senior Corps volunteers' 98.2 million service hours in 2012 = 
$2.174 billion savings
    NSCA recommendations on Re-competition.--While the National Senior 
Corps Association supports the level of funding for Senior Corps in the 
President's 2014 budget, we also express concern regarding language to 
institute re-competition in the Senior Companion and Foster 
Grandparent, and changes the authorized language for RSVP as set forth 
in the Edward M Kennedy Serve America Act. The National Senior Corps 
Association embraces and supports the concept of re-competition for 
Senior Corps grants, we feel strongly the responsibility of changing 
the law governing the Senior Corps programs rests with the Authorizing 
committee. We respectfully request that none of the funds in this Act 
may be used to administer re-competition of Senior Corps programs, 
except as authorized by the Edward M Kennedy Serve America Act as 
enacted.

----------------------------------------------------------------------------------------------------------------
                                                           Fiscal Year                 Fiscal Year
                                             Fiscal Year      2013       Fiscal Year      2014       Fiscal Year
           Senior Corps Program             2012 Enacted   President's  2013 Enacted   President's    2014 NSCA
                                                            Requested                    Request       Request
----------------------------------------------------------------------------------------------------------------
 
Foster Grandparent Program (FGP)..........  $110,565,000  $110,565,000  $111,241,000  $110,565,000  $110,565,000
RSVP......................................    50,204,200    50,299,000    50,511,000    50,204,000    69,300,000
Senior Companion Program (SCP)............    46,722,000    46,810,000    47,007,000    46,722,000    46,722,000
----------------------------------------------------------------------------------------------------------------

                                 ______
                                 
  Prepared Statement of the National Technical Institute for the Deaf 
                                 (NTID)

    Mr. Chairman and Members of the Committee: My name is Dr. Gerard J. 
Buckley, and I am the President of NTID, and the Vice President and 
Dean of RIT. I am pleased to present the fiscal year 2014 budget 
request for NTID, one of nine colleges of RIT, in Rochester, N.Y. 
Created by Congress by Public Law 89-36 in 1965, we provide university 
technical and professional education for students who are deaf and 
hard-of-hearing, leading to successful careers in high-demand fields 
for a sub-population of individuals historically facing high rates of 
unemployment and under-employment. We also provide baccalaureate and 
graduate level education for hearing students in professions serving 
deaf and hard-of-hearing individuals. NTID students live, study and 
socialize with more than 16,000 hearing students on the RIT campus.

Budget Request
    On behalf of NTID, for fiscal year 2014 I would like to request 
$67,422,000 in Operations. I make this request within the context of 
definitive actions taken by NTID to recognize the difficult economic 
times in which we operate. In fiscal year 2012 and the first half of 
fiscal year 2013, NTID operated with essentially the same level of 
Federal support as in fiscal year 2011. In order to manage level 
funding, we significantly reduced equipment purchases and eliminated 37 
positions--a workforce reduction of 6 percent in the midst of record 
enrollments. We have also reduced our budget by an average of 8 percent 
in such areas as building and equipment maintenance, instructional 
supplies, freelance interpreting, professional travel and student 
employment. For several years now, NTID has also postponed requests for 
construction funding for critical and long overdue renovations to a 30-
year old building currently housing three times the number of staff for 
which it was intended. We have continued to increase tuition and fees, 
as these are our primary sources of non-Federal support. From fiscal 
year 2006 to fiscal year 2013, tuition and fees have increased by 49 
percent to offset the rising costs of providing a state-of-the-art 
college education. These non-Federal revenues now represent 27 percent 
of our operating budget--up from 9 percent in 1970. Likewise, from 
fiscal year 2006 to fiscal year 2012, NTID raised almost $19 million in 
support from individuals and organizations.
    Our request of $67,422,000 for Operations would help us balance our 
budget and reduce the damage we have incurred from sequestration. It is 
important to note that this request for fiscal year 2014 is only 3.2 
percent more than the fiscal year 2011 operating appropriation and 
significantly reduced from our original request of $73,819,000 
(including $2,000,000 for construction) submitted to the Department of 
Education in June 2012. Despite the measures we have taken to manage 
level funding, the 5.23 percent reduction from sequestration is 
requiring us to make further cuts in the areas of equipment purchasing, 
interpreting and captioning, scholarship support, building maintenance, 
and, most importantly, in personnel and enrollment. If the 5.23 percent 
reduction stands, we will have to undertake a workforce reduction of up 
to 54 filled positions (about 10 percent of our current headcount). 
This reduction in staff could result in denying as many as 240 
qualified deaf and hard-of-hearing students from enrolling each year. 
These are not the consequences a successful Federal investment should 
face.

Enrollment
    Truly a national program, NTID has enrolled students from all 50 
States. Applications for enrollment in fiscal year 2013 (Fall 2012) 
were up 9 percent, as we experienced one of the highest enrollments in 
our history--1,529 students. Over the last 7 years, our enrollment has 
increased 22 percent. For fiscal year 2014, NTID hopes to maintain this 
high enrollment, if our operational resources allow us to do so. Our 
enrollment history over the last 7 years is shown below:

                                                   NTID ENROLLMENTS: FISCAL YEAR 2007-FISCAL YEAR 2013
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                        Deaf/Hard-of-Hearing Students                Hearing Students
                                                                 -----------------------------------------------------------------------------   Grand
                           Fiscal Year                                                                      Interpreting                         Total
                                                                  Undergrad  Grad RIT    MSSE    Sub-Total     Program      MSSE    Sub-Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
2007............................................................     1,017        47        31      1,095          130         25        155      1,250
2008............................................................     1,103        51        31      1,185          130         28        158      1,343
2009............................................................     1,212        48        24      1,284          135         31        166      1,450
2010............................................................     1,237        38        32      1,307          138         29        167      1,474
2011............................................................     1,263        40        29      1,332          147         42        189      1.521
2012............................................................     1,281        42        31      1,354          160         33        193      1,547
2013............................................................     1,269        37        25      1,331          167         31        198      1,529
--------------------------------------------------------------------------------------------------------------------------------------------------------
MSSE: Master of Science in Secondary Education of Deaf/Hard of Hearing Students.
Grad RIT: other graduate programs at RIT.

NTID Academic Programs
    NTID offers high quality, career-focused associate degree programs 
preparing students for specific well-paying technical careers. NTID 
also is expanding the number of its transfer associate degree programs 
to better serve the higher achieving segment of our student population 
seeking bachelor's and master's degrees. These transfer programs 
provide seamless transition to baccalaureate studies in the other 
colleges of RIT. In support of those deaf and hard-of-hearing students 
enrolled in the other RIT colleges, NTID provides a range of access 
services (including interpreting, real-time speech-to-text captioning, 
and notetaking) as well as tutoring services. One of NTID's greatest 
strengths is our outstanding track record of assisting high-potential 
students to gain admission to, and graduate from, the other colleges of 
RIT at rates comparable to their hearing peers.
    A cooperative education (co-op) component is an integral part of 
academic programming at NTID and prepares students for success in the 
job market. A co-op gives students the opportunity to experience a 
real-life job situation and focus their career choice. Students develop 
technical skills and enhance vital personal skills such as teamwork and 
communication, which will make them better candidates for full-time 
employment after graduation. Almost 300 students last year participated 
in 10-week co-op experiences that augment their academic studies, 
refine their social skills, and prepare them for the competitive 
working world.

Student Accomplishments
    For our graduates, over the past 5 years, an average of 91 percent 
have been placed in jobs commensurate with the level of their 
education. Of our fiscal year 2011 graduates (the most recent class for 
which numbers are available), 54 percent were employed in business and 
industry, 31 percent in education/non-profits, and 15 percent in 
Government.
    Graduation from NTID has a demonstrably positive effect on 
students' earnings over a lifetime, and results in a notable reduction 
in dependence on Supplemental Security Income (SSI) and Social Security 
Disability Insurance (SSDI). In fiscal year 2012, NTID, the Social 
Security Administration, and Cornell University examined earnings and 
Federal program participation data for more than 15,000 deaf and hard-
of-hearing individuals who applied to NTID over our entire history. The 
studies show that NTID graduates over their lifetimes are employed at a 
much higher rate, earn substantially more (therefore paying 
significantly more in taxes), and participate at a much lower rate in 
SSI and SSDI than students who withdrew from NTID.
    Using SSA data, at age 50, 78 percent of NTID deaf and hard-of-
hearing graduates with bachelor degrees and 73 percent with associate 
degrees report earnings, compared to 58 percent of NTID deaf and hard-
of-hearing students who withdrew from NTID. Equally important is the 
demonstrated impact of an NTID education on graduates' earnings. At age 
50, $58,000 is the median salary for NTID deaf and hard-of-hearing 
graduates with bachelor degrees and $41,000 for those with associate 
degrees, compared to $34,000 for deaf and hard-of-hearing students who 
withdrew from NTID. Higher earnings, of course, yield higher tax 
revenues.
    An NTID education also translates into reduced dependency on 
Federal transfer programs, such as SSI and SSDI. At age 40, less than 2 
percent of NTID deaf and hard-of-hearing associate and bachelor degree 
graduates participate in the SSI program compared to 8 percent of deaf 
and hard-of-hearing students who withdrew from NTID. Similarly, at age 
50, only 18 percent of NTID deaf and hard-of-hearing bachelor degree 
graduates and 28 percent of associate degree graduates participate in 
the SSDI program, compared to 35 percent of deaf and hard-of-hearing 
students who withdrew from NTID.

Access Services
    NTID provides an access services system to meet the needs of a 
large number of deaf and hard-of-hearing students enrolled in 
baccalaureate and graduate degree programs in RIT's other colleges as 
well as students enrolled in NTID programs who take courses in the 
other colleges of RIT. Access services also are provided for events and 
activities throughout the RIT community. Access services include sign 
language interpreting, real-time captioning, classroom notetaking 
services, captioned classroom video materials, and Assistive Listening 
Services.
    As enrollments have steadily increased, so has the demand for 
access services. In fiscal year 2012, 129,900 hours of interpreting 
were provided--an increase of 14 percent compared to fiscal year 2008. 
In fiscal year 2012, 19,516 hours of real-time captioning were provided 
to students--a 17 percent increase over fiscal year 2008. The increase 
in demand is partly a result of the increase in the number of students 
enrolled in baccalaureate programs at RIT and the number of students 
with cochlear implants. In fiscal year 2013, there were 551 deaf and 
hard-of-hearing students enrolled in baccalaureate programs at RIT, a 
22 percent increase compared to fiscal year 2008, and 356 students with 
cochlear implants--a 40 percent increase over fiscal year 2008.

Summary
    It is extremely important that our fiscal year 2014 funding request 
be granted in order that we might continue our mission to prepare deaf 
and hard-of-hearing people to enter the workplace and society. NTID has 
shown through hard data that our graduates have higher salaries, pay 
more taxes, and depend less on Federal SSI/SSDI payments than their 
counterparts who do not attend NTID. Our employment rate is 91 percent 
over the past 5 years--even more remarkable given the state of the 
economy. Demand for an NTID education is higher than ever. Therefore, I 
ask that you please consider funding our request of $67,422,000 for 
Operations.
    We are hopeful that the Members of the Committee will agree that 
NTID, with its long history of successful stewardship of Federal funds 
and outstanding educational record of service with people who are deaf 
and hard-of-hearing, remains deserving of your support and confidence. 
Likewise, we will continue to demonstrate to Congress and the American 
people that NTID is a proven economic investment in the future of young 
deaf and hard-of-hearing citizens. Quite simply, NTID is a Federal 
program that works.
                                 ______
                                 
     Prepared Statement of the National Violence Prevention Network

    Thank you for this opportunity to submit testimony in support of 
increased funding for the National Violent Death Reporting System 
(NVDRS), which is administered by the National Center for Injury 
Prevention and Control at the Centers for Disease Control and 
Prevention (CDC). The National Violence Prevention Network, a broad and 
diverse alliance of health and welfare, suicide and violence 
prevention, and law enforcement advocates supports increasing the 
fiscal year 2014 funding level to $25 million to allow for nationwide 
expansion of the NVDRS program. fiscal year 2013 NVDRS funding is $3.5 
million.

Background
    Each year, about 55,000 Americans die violent deaths. Suicide and 
homicide are the fourth and fifth leading causes of death for Americans 
of all ages. In addition, an average of 105 people (22 of which are 
military veterans) take their own lives each day.
    The NVDRS program makes better use of data that are already being 
collected by health, law enforcement, and social service agencies. The 
NVDRS program, in fact, does not require the collection of any new 
data. Instead it links together information that, when kept in separate 
compartments, is much less valuable as a tool to characterize and 
monitor violent deaths. With a clearer picture of why violent deaths 
occurs, law enforcement, public health officials and others can work 
together more effectively to identify those at risk and target 
effective preventive services.
    Currently, NVDRS funding levels only allow the program to operate 
in 18 States, including Alaska, Colorado, Georgia, Kentucky, Maryland, 
Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio, 
Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and 
Wisconsin. Six additional States; Connecticut, Illinois, Maine, 
Minnesota, New York, and Texas plus the District of Columbia, were 
previously approved for participation in the NVDRS, but were unable to 
join due to funding shortfalls. Several other States have expressed an 
interest in joining once new funding becomes available. While NVDRS is 
beginning to strengthen violence and suicide prevention efforts in the 
18 participating States, non-participating States continue to miss out 
on the benefits of this important public health surveillance program.

NVDRS in Action
    Child abuse and other violence involving children and adolescents 
remains a problem in America, and it is only through a comprehensive 
understanding of its root causes that these needless deaths can be 
prevented. Studies suggest that between 3.3 and 10 million children 
witness some form of domestic violence annually. Additionally, 1,560 
children died as a result of abuse or neglect in 2010.
    Children are most vulnerable and most dependent on their caregivers 
during infancy and early childhood. Sadly, NVDRS data has shown that 
young children are at greatest risk of homicide in their own homes. 
Combined NVDRS data from Alaska, Maryland, Massachusetts, New Jersey, 
Oregon, South Carolina, and Virginia determined that African American 
children aged 4 years old and under are more than four times more 
likely to be victims of homicide than Caucasian children, and that 
homicides of children aged four and under are most often committed by a 
parent or caregiver in the home. The data also shows that household 
items, or ``weapons of opportunity,'' were most commonly used, 
suggesting that poor stress responses may be factors in these deaths. 
Knowing the demographics and methods of child abusers can lead to more 
effective, targeted prevention programs.
    Intimate partner violence (IPV) is another issue where NVDRS is 
proving its value. While IPV has declined along with other trends in 
crime over the past decade, thousands of Americans still fall victim to 
it every year. Intimate partner homicides accounted for 30 percent of 
the murders of women and 5 percent of the murders of men in 2006, 
according to the Bureau of Justice Statistics.
    Despite being in its early stages in several States, NVDRS is 
already providing critical information that is helping law enforcement 
and public health officials allocate resources and develop programs in 
ways that target those most at risk for intimate partner violence. For 
example, NVDRS data shows that while occurrences are rare, most murder-
suicide victims are current or former intimate partners of the suspect, 
and a substantial number of victims were the suspect's children. In 
addition, NVDRS data indicate that women are about seven times more 
likely than men to be killed by a spouse, ex-spouse, lover, or former 
lover, and most of these incidents occurred in the women's homes.

NVDRS & VA Suicides
    Although it is preventable, every year more than 38,000 Americans 
die by suicide and another one million Americans attempt it, costing 
more than $36 billion in lost wages and work productivity. In the 
United States today, there is no comprehensive national system to track 
suicides. However, because NVDRS includes information on all violent 
deaths--including deaths by suicide--information from the system can be 
used to develop effective suicide prevention plans at the community, 
State, and national levels.
    The central collection of this data can be of tremendous value for 
organizations such as the Department of Veterans Affairs that are 
working to improve their surveillance of suicides. For instance, CDC 
determined from national NVDRS data that veterans comprised 20 percent 
of all suicide victims. The types of data collected by NVDRS including 
gender, blood alcohol content, mental health issues, physical health 
issues, and intimate partner violence can help prevention programs 
better identify and treat at-risk individuals.

Federal Role Needed
    At an estimated annual cost of $25 million for full implementation, 
NVDRS is a relatively low-cost program that yields high-quality 
results. While State-specific information provides enormous value to 
local public health and law enforcement officials, data from all 50 
States, the U.S. territories and the District of Columbia must be 
obtained to complete the national picture. Aggregating this additional 
data will allow us to analyze national trends and also more quickly and 
accurately determine what factors can lead to violent death so that we 
can devise and disseminate strategies to address those factors.
Strengthening and Expanding NVDRS in Fiscal Year 2014
    In January 2013, President Obama and Vice President Biden released, 
``Now Is The Time: The President's Plan to Protect our Children and our 
Communities by Reducing Gun Violence.'' Recognizing the utility of 
NVDRS in understanding violence, one of the major strategies in the 
report calls for an infusion of $20 million for NVDRS to facilitate its 
nationwide expansion.
    The National Violence Prevention Network, a coalition of national 
organizations that advocate for national violence prevention programs, 
is supporting the Administration's request by calling on Congress to 
provide $25 million for NVDRS in fiscal year 2014. As State funding is 
based on population and violent death rates, significant funding 
increases are necessary to incorporate larger States into the program. 
However, the cost of not implementing the program is much greater: 
without national expansion of the program, thousands of American lives 
remain at risk.
    We thank you for the opportunity to submit this statement for the 
record. The investment in NVDRS has already begun to pay off as the 18 
participating States are adopting effective violence prevention 
programs. We believe that national implementation of NVDRS is a wise 
public health investment that will assist State and national efforts to 
prevent deaths from domestic violence, veteran suicide, teen suicide, 
gang violence and other violence that affects communities around the 
country. We look forward to working with you secure an fiscal year 2014 
NVDRS appropriation of $25 million.
                                 ______
                                 
                     Prepared Statement of Nemours

    Nemours thanks Chairman Harkin, Ranking Member Moran and members of 
the subcommittee for the opportunity to submit written testimony on the 
fiscal year 2014 Labor, Health & Human Services, Education and Related 
Agencies Appropriations bill. Nemours, one of the Nation's leading 
child health systems, is dedicated to improving children's health and 
well-being by offering a spectrum of clinical treatment, research, 
advocacy, educational health, and prevention services extending to 
families in the communities it serves.

About Nemours
    Nemours is an internationally recognized children's health system 
that owns and operates the Alfred I. duPont Hospital for Children in 
Wilmington, Delaware, along with major pediatric specialty clinics in 
Delaware, Florida, Pennsylvania and New Jersey. In October 2012, we 
opened the full-service Nemours Children's Hospital in Orlando, 
Florida. The Nemours promise is to do whatever it takes to treat every 
child as we would our own. We are committed to making family-centered 
care the cornerstone of our health system.
    Established as The Nemours Foundation through the legacy and 
philanthropy of Alfred I. duPont, Nemours offers pediatric clinical 
care, research, education, advocacy and prevention programs to families 
in the communities we serve. We leverage our entire system to improve 
the health of our communities by creating unique models, creating new 
points of access and delivering superlative outcomes. Our investment in 
children is a response to community health needs as Nemours aims to 
fulfill our mission to provide leadership, institutions and services to 
restore and improve the health of children through care and programs 
not readily available.

Community-based Prevention
    As an integrated health system that is very engaged with the 
community, Nemours sees first-hand the impact of chronic disease on our 
Nation's children. We treat obese young children at our clinics, and we 
know that unhealthy habits that contribute to obesity are starting at a 
very young age. In fact, over twenty-seven percent of children ages 2-5 
are obese or overweight--an alarming statistic. We know that much of 
what influences their health is outside the realm of the health care 
system, which is why we have made and will continue to make significant 
investments in community-based prevention, in sectors where children 
learn, live, and play. We believe that investing in clinical and 
community-based prevention is an important way to ensure that children 
grow up to be healthy adults. The Prevention and Public Health Fund 
(Fund) holds the potential to address obesity and chronic disease and 
ultimately reduce our Nation's health care costs over a lifetime.
    We are mindful of the continued efforts to make significant cuts to 
the Fund. However, we believe strongly that crucial elements of health 
care reform and prevention should not be pitted against one another. 
For example, physicians must be enlisted in the fight to prevent 
disease and should be working closely with other community-based 
partners to help families and children lead healthy, active lifestyles, 
as is the case with Nemours-employed physicians. We urge the Committee 
to utilize the resources provided from the Fund to support the 
integration of clinical and community-based prevention and to evaluate 
the outcomes associated with those investments.

The National Early Childcare and Education Learning Collaboratives 
        (CDC)
    The National Early Childcare and Education (ECE) Learning 
Collaboratives program is uniquely focused on working with early child 
care and education providers to help children eat healthy and be 
physically active.
    As one of the Nation's leading child health organizations, with 
significant expertise impacting local, State and national obesity 
prevention initiatives in early care and education settings, Nemours 
and its partners, including the National Initiative for Children's 
Healthcare Quality, Child Care Aware of America, American Academy of 
Pediatrics, and other strategic partners in ECE and public health, will 
implement evidence-based, practice-tested learning collaboratives in 
partnership with six States--Arizona, Florida, Indiana, Kansas, 
Missouri, and New Jersey--reaching over 400,000 children over the 
course of the five-year project.
    Ultimately, the goal is to spread impactful, sustainable program-
level changes to transform early childcare and education programs. In 
particular, continued funding for the ECE project will help early-care 
and education providers (initially ECE centers, and later family child 
care settings as well) in these six States adopt nutrition, 
breastfeeding support, physical activity, and screen time policies and 
practices.
    Through the ECE project, Nemours and its partners also will create 
a new resource, the National ECE Technical Assistance and Support 
Center for Quality Improvement (National TA Center) to provide targeted 
support to the learning collaboratives and participating programs and 
support quality improvement capacity within State ECE systems to 
promote additional spread and sustainability.
    As a Nation, we face daunting economic and fiscal challenges. To a 
large degree, these challenges are driven by high health care costs. 
Preventable chronic diseases account for approximately 75 percent of 
our Nation's annual $2.5 trillion in health care spending. We believe 
Federal investment in approaches that help instill healthy habits early 
in a child's life can help bring down these costs. For these reasons, 
we urge the subcommittee to provide $4.2 million for the ECE program in 
fiscal year 2014, which is consistent with the fiscal year 2012 funding 
level for the program.

Children's Hospital Graduate Medical Education (HRSA)
    Another important priority for Nemours is the health care 
workforce, particularly the pediatric workforce. Children's hospitals 
care for large numbers of children with highly complex medical needs. 
Cutting edge, superior quality clinical care requires that hospitals 
invest time and resources in training residents on how to provide the 
best, most-effective treatments for this population. The Children's 
Hospital Graduate Medical Education program (CHGME) provides support 
for graduate medical education to freestanding children's hospitals 
that train resident physicians. The CHGME program helps address 
shortages in the pediatric workforce in both general (primary care) 
pediatrics and in pediatric sub-specialties.
    The CHGME program has increased the number of pediatric providers, 
addressed critical shortages in pediatric specialty care, and improved 
children's access to care. CHGME ensures that general pediatricians and 
pediatric specialists are trained to care for children in communities 
across the country--metropolitan cities, rural communities, suburbs and 
everywhere in between--covering everything from well-child visits to 
the most complex cardiac surgeries. Today, the children's hospitals 
that receive CHGME, less than 1 percent of all hospitals, train more 
than 49 percent of general pediatricians and 51 percent of pediatric 
specialists.
    Over 300 residents are trained each year at the Alfred I. duPont 
Hospital for Children (AIDHC) in Wilmington, DE. They are on the front 
line for families at our hospital, caring for patients 24 hours a day. 
They are also training to become future clinicians who will practice 
independently in general pediatrics specialties and subspecialties. In 
the outpatient department, they become the primary care physicians 
(under attending supervision) for numerous children. Residents are also 
learning to become researchers and are actively engaged in local 
community and international volunteer efforts to reach medically-
underserved children.
    Unfortunately, the President's fiscal year 2014 budget request once 
again proposes reducing funding for this program to $88 million. We 
urge Congress to reject this ill-advised cut and to continue providing 
adequate support for training the next generation of pediatricians, 
pediatric specialists and pediatric researchers. In fiscal year 2014, 
Nemours urges the subcommittee to provide funding at the fully-
authorized level of $317.5 million. However, in this difficult fiscal 
environment, we urge that funding for the CHGME program not dip below 
$265.2 million, which was the level prior to sequester.

Conclusion
    Nemours appreciates the opportunity to submit written testimony. As 
an integrated child health system, we have prioritized investments in 
clinical and community-based prevention and our workforce because we 
believe that in the long-run these investments will improve health for 
children and bend the health care cost curve. We recognize that the 
Nation's fiscal situation requires a close examination of the programs 
and priorities that the Federal Government funds. As you make these 
critical funding decisions, we hope that prevention and the future 
health care workforce will remain priorities of the subcommittee in 
fiscal year 2014.
                                 ______
                                 
             Prepared Statement of the NephCure Foundation

            SUMMARY OF RECOMMENDATIONS FOR FISCAL YEAR 2014
_______________________________________________________________________

    1)  $32 billion for the National Institutes of Health (NIH) and a 
corresponding increase to the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK).
    2)  Continued support for the Grants for Research in Glomerular 
Diseases Initiative and the Advancing Clinical Research in Primary 
Glomerular Diseases Program at NIDDK, as well as the Nephrotic Syndrome 
Study Network at the Office of Rare Diseases Research (ORDR).
    3)  Expansion of the FSGS/NS Research Portfolio at NIDDK, the 
Office of Rare Diseases Research (ORDR) and the National Institute on 
Minority Health and Health Disparities (NIMHD) by funding more research 
proposals for Primary Glomerular Disease.
_______________________________________________________________________

    Thank you for the opportunity to present the views of the NephCure 
Foundation regarding research on idiopathic focal segmental 
glomerulosclerosis (FSGS) and primary nephrotic syndrome (NS). NephCure 
is the only non-profit organization exclusively devoted to fighting 
FSGS and the NS disease group. Driven by a panel of respected medical 
experts and a dedicated band of patients and families, NephCure works 
tirelessly to support kidney disease research and awareness.
    NS is a collection of signs and symptoms caused by diseases that 
attack the kidney's filtering system. These diseases include FSGS, 
Minimal Change Disease and Membranous Nephropathy. When affected, the 
kidney filters leak protein from the blood into the urine and often 
cause kidney failure, which requires dialysis or kidney 
transplantation. According to a Harvard University report, 73,000 
people in the United States have lost their kidneys as a result of 
FSGS. Unfortunately, the causes of FSGS and other filter diseases are 
poorly understood.
    FSGS is the second leading cause of NS and is especially difficult 
to treat. There is no known cure for FSGS and current treatments are 
difficult for patients to endure. These treatments include the use of 
steroids and other dangerous substances which lower the immune system 
and contribute to severe bacterial infections, high blood pressure and 
other problems in patients, particularly child patients. In addition, 
children with NS often experience growth retardation and heart disease. 
Finally, NS caused by FSGS, MCD or MN is idiopathic and can often 
reoccur, even after a kidney transplant.
    FSGS disproportionately affects minority populations and is five 
times more prevalent in the African American community. In a 
groundbreaking study funded by NIH, researchers found that FSGS is 
associated with two APOL1 gene variants. These variants developed as an 
evolutionary response to African sleeping sickness and are common in 
the African American patient population with FSGS/NS.
    FSGS has a large social impact in the United States. FSGS leads to 
end-stage renal disease (ESRD) which is one of the most costly chronic 
diseases to manage. In 2008, the Medicare program alone spent $26.8 
billion, 7.9 percent of its entire budget, on ESRD. In 2005, FSGS 
accounted for 12 percent of ESRD cases in the U.S., at an annual cost 
of $3 billion. It is estimated that there are currently approximately 
23,000 Americans living with ESRD due to FSGS.
    Research on FSGS could achieve tremendous savings in Federal health 
care costs and reduce health status disparities. For this reason, and 
on behalf of the thousands of families that are significantly affected 
by this disease, we encourage support for expanding the research 
portfolio on FSGS/NS at the NIH.

Encourage FSGS/NS Research at NIH
    There is no known cause or cure for FSGS and scientists tell us 
that much more research needs to be done on the basic science behind 
FSGS/NS. More research could lead to fewer patients undergoing ESRD and 
tremendous savings in health care costs in the United States.
    With collaboration from other Institutes and Centers, ORDR 
established the Rare Disease Clinical Research Network. This network 
provided an opportunity for the NephCure Foundation, the University of 
Michigan, and other university research health centers to come together 
to form the Nephrotic Syndrome Study Network (NEPTUNE). NEPTUNE is 
developing a database of NS patients who are interested in 
participating in clinical trials which would alleviate the problem 
faced by many rare disease groups of not having access to enough 
patients for research. NephCure urges the subcommittee to continue its 
support for RDCRN and NEPTUNE, which has tremendous potential to 
facilitate advancements in NS and FSGS research.
    The NephCure Foundation is also grateful to NIDDK for issuing 
program announcements (PA) that serve to initiate grant proposals on 
primary glomerular disease. Two PAs that have recently been issued 
utilize the R01 and UM1 mechanisms to award funding for primary 
glomerular disease research. NephCure recommends the subcommittee 
encourage NIDDK to continue to issue primary glomerular disease PAs.
    Due to the disproportionate burden of FSGS on minority populations, 
it is appropriate for NIMHD to develop an interest in this research. 
NephCure asks the subcommittee to encourage ORDR, NIDDK and NIMHD to 
collaborate on research that studies the incidence and cause of this 
disease among minority populations. NephCure also asks the subcommittee 
to urge NIDDK and the NIMHD to undertake culturally appropriate efforts 
aimed at educating minority populations about primary glomerular 
disease.
    Thank you again for the opportunity to present the views of the 
FSGS/NS community. Please contact the NephCure Foundation if additional 
information is required.
                                 ______
                                 
        Prepared Statement of the Neurofibromatosis (NF) Network

    Thank you for the opportunity to submit testimony to the 
subcommittee on the importance of continued funding at the National 
Institutes of Health (NIH) for research on Neurofibromatosis (NF), a 
genetic disorder closely linked too many common diseases widespread 
among the American population.
    We respectfully request that you include the following report 
language on NF research at the National Institutes of Health within 
your fiscal year 2014 Labor, Health and Human Services, Education 
Appropriations bill.
    Neurofibromatosis [NF].--The Committee supports efforts to increase 
funding and resources for NF research and treatment at multiple NIH 
Institutes. Children and adults with NF are at significant risk for the 
development of many forms of cancer; the Committee encourages NCI to 
increase its NF research portfolio in fundamental basic science, 
translational research and clinical trials focused on NF. The Committee 
also encourages the NCI to support NF centers, NF clinical trials 
consortia, and NF preclinical mouse models consortia. The Committee 
urges NHLBI to expand its NF research investment based on the increased 
prevalence of hypertension and congenital heart disease in this patient 
population. Because NF causes brain and nerve tumors and is associated 
with cognitive and behavioral problems, the Committee urges NINDS to 
continue to aggressively fund fundamental basic science research on NF 
relevant to nerve damage and repair, learning disabilities and 
attention deficit disorders. In addition, the Committee encourages the 
NICHD and NIMH to expand funding of basic and clinical NF research in 
the area of learning and behavioral disabilities. Children with NF1 are 
prone to severe bone deformities, including scoliosis; the Committee 
therefore encourages NIAMS to expand its NF1 research portfolio. Since 
NF2 accounts for approximately 5 percent of genetic forms of deafness, 
the Committee encourages NIDCD to expand its investment in NF2 basic 
and clinical research. Based on the increased incidence of optic 
gliomas, vision loss, cataracts, and retinal abnormalities in NF, the 
Committee urges the NEI to expand its NF research portfolio. Finally, 
given that NF represents a tractable model system to study the genomics 
of cancer predisposition, learning and behavior problems, and bone 
abnormalities translatable to individualized medicine, the Committee 
encourages NHGRI to increase its investment in NF research.
    On behalf of the Neurofibromatosis (NF) Network, a national 
organization of NF advocacy groups, I speak on behalf of the 100,000 
Americans who suffer from NF as well as approximately 175 million 
Americans who suffer from diseases and conditions linked to NF such as 
cancer, brain tumors, heart disease, memory loss, and learning 
disabilities. Thanks in large measure to this subcommittee's strong 
support, scientists have made enormous progress since the discovery of 
the NF1 gene in 1990 resulting in clinical trials now being undertaken 
at NIH with broad implications for the general population.
    NF is a genetic disorder involving the uncontrolled growth of 
tumors along the nervous system which can result in terrible 
disfigurement, deformity, deafness, blindness, brain tumors, cancer, 
and even death. In addition, approximately one-half of children with NF 
suffer from learning disabilities. NF is the most common neurological 
disorder caused by a single gene and three times more common than 
Muscular Dystrophy and Cystic Fibrosis combined. There are three types 
of NF: NF1, which is more common, NF2, which primarily involves tumors 
causing deafness and balance problems, and schwannomatosis, the 
hallmark of which is severe pain. While not all NF patients suffer from 
the most severe symptoms, all NF patients and their families live with 
the uncertainty of not knowing whether they will be seriously affected 
because NF is a highly variable and progressive disease.
    Researchers have determined that NF is closely linked to heart 
disease, learning disabilities, memory loss, cancer, brain tumors, and 
other disorders including deafness, blindness and orthopedic disorders, 
primarily because NF regulates important pathways common to these 
disorders such as the RAS, cAMP and PAK pathways. Research on NF 
therefore stands to benefit millions of Americans:

Pain Management
    Severe and unmanageable pain is seen in all forms of NF, 
particularly in schwannomatosis, and significantly impacts quality of 
life. Over the past 3 years, Schwannomatosis research has made 
significant advances and new research suggests that the molecular or 
root cause of schwannomatosis pain may be the same as phantom limb 
pain. Understanding what causes this pain, and how it might be treated, 
has been a fast-moving area of NF research over the past few years, and 
CDMRP NFRP funding has been critical in supporting this.

Nerve regeneration
    NF often requires surgical removal of nerve tumors, which can lead 
to nerve paralysis and loss of function. Understanding the changes that 
occur in a nerve after surgery, and how it might be regenerated and 
functionally restored, will have significant quality of life value for 
affected individuals.

Wound Healing, inflammation and blood vessel growth
    Wound healing requires new blood vessel growth and tissue 
inflammation. Mast cells are critical mediators of inflammation in 
wound healing, and they must be quelled and regulated in order to 
facilitate this healing. Mast cells are also important players in NF1 
tumor growth. In the past few years, researchers have gained deep 
knowledge on how mast cells promote tumor growth, and this research has 
led to ongoing clinical trials to block this signaling. The result is 
that tumors grow slower. As researchers learn more about blocking mast 
cell signals in NF, this research could be translated to the management 
of mast cells in wounds and wound healing.

Bone growth and repair/Orthopedic abnormalities and amputation
    At least a quarter of children with NF1 have abnormal bone growth 
in any part of the skeleton. In the legs, the long bones are weak, 
prone to fracture and unable to heal properly; this can require 
amputation at a young age. Adults with NF1 also have low bone mineral 
density, placing them at risk of skeletal weakness and injury. NF1 bone 
defects research has been a fast-moving field in recent years and CDMRP 
NFRP has funded a number of important studies in this area.

Brain Function/Learning Disabilities
    Learning disabilities affect two-thirds of person with NF1, ranging 
from mild to severe, and including attention and social behavior 
deficits. Learning disabilities impact the quality of life for those 
with NF1 more than tumors or any other clinical feature. In recent 
years, research has revealed common threads between NF1 learning 
disabilities, autism and other related disabilities.
    The enormous promise of NF research, and its potential to benefit 
over 175 million Americans who suffer from diseases and conditions 
linked to NF, has gained increased recognition from Congress and the 
NIH. The enormous promise of NF research, and its potential to benefit 
over 175 million Americans who suffer from diseases and conditions 
linked to NF, has gained increased recognition from Congress and the 
NIH. This is evidenced by the fact that eleven institutes are currently 
supporting NF research, and NIH's total NF research portfolio has 
increased from $3 million in fiscal year 1990 to an estimated $24 
million in fiscal year 2012. Given the potential offered by NF research 
for progress against a range of diseases, we are hopeful that the NIH 
will continue to build on the successes of this program by funding this 
promising research and thereby continuing the enormous return on the 
taxpayers' investment.
    We appreciate the subcommittee's strong support for NF research and 
will continue to work with you to ensure that opportunities for major 
advances in NF research are aggressively pursued. Thank you.
                                 ______
                                 
              Prepared Statement of the Nursing Community

    The undersigned organizations representing the Nursing Community, a 
forum comprised of 58 national professional nursing associations, 
respectfully submit this testimony to the Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies. The Nursing Community works collaboratively to build 
consensus and advocate on a wide spectrum of healthcare and nursing 
issues surrounding practice, education, and research. Our organizations 
are committed to promoting America's health through the advancement of 
the nursing profession. Collectively, the Nursing Community represents 
nearly one million registered nurses (RNs), advanced practice 
registered nurses (APRNs-including certified nurse-midwives, nurse 
practitioners, clinical nurse specialists, and certified registered 
nurse anesthetists), nurse executives, nursing students, nursing 
faculty, and nurse researchers.
    For fiscal year 2014, the Nursing Community respectfully requests 
$251 million for the Health Resources and Services Administration's 
(HRSA) Nursing Workforce Development programs (authorized under Title 
VIII of the Public Health Service Act [42 U.S.C. 296 et seq.]), $150 
million for the National Institute of Nursing Research (NINR, one of 
the 27 centers and institutes of the National Institutes of Health), 
and $20 million in authorized funding for the Nurse-Managed Health 
Clinics (NMHCs, Title III of the Public Health Service Act). These 
investments are critical to ensuring that high-quality nursing services 
are delivered nationwide.

The Demand for Nursing Continues to Outgrow Supply
    The U.S. Bureau of Labor Statistics (BLS) projects that the total 
number of additional nurses will rise dramatically. In its report 
Employment Projections: 2010-2020, the BLS reveals that the expected 
number of practicing nurses will grow from 2.74 million in 2010 to 3.45 
million in 2020, an increase of 712,000 or 26 percent. The projections 
further explain the need for 495,500 replacements in the nursing 
workforce, bringing the total number of job openings for nurses due to 
growth and replacements to 1.2 million by 2020.
    Two primary factors contribute to this overwhelming projection. 
First, America's nursing workforce is aging. According to the 2013 HRSA 
report The U.S. Nursing Workforce: Trends in Supply and Demand, of the 
2.8 million RNs currently practicing in our Nation, 34.9 percent are 
over the age of 50, and 8.5 percent are over the age of 60. As the 
economy continues to rebound, many of these nurses will seek 
retirement, leaving behind a significant deficit in the number of 
experienced nurses in the workforce. Secondly, America's Baby Boomer 
population is aging. It is estimated that over 80 million Baby Boomers 
reached age 65 last year. This population will require a vast influx of 
nursing services, particularly in areas of primary care and chronic 
illness management.
    Concurrently, tens of thousands of qualified applicantions are 
turned away from nursing school each year. According to the American 
Association of Colleges of Nursing's 2012-2013 survey on enrollment and 
graduations, 79,659 qualified applications were turned away from entry-
level baccalaureate and graduate nursing programs in 2012 alone. 
Nursing schools report that faculty vacancies, alongside a lack of 
funding and clinical training sites, are a primary reason that prevents 
schools from maximizing student enrollment. Moreover, a special survey 
on nursing faculty vacancy conducted by AACN for the 2012-2013 academic 
year reveals an average vacancy rate of 7.6 percent for full-time 
positions and 6.8 percent for part-time positions within baccalaureate 
and graduate nursing programs across the country.
    A significant investment must be made in the education of new 
nurses to provide the Nation with the nursing services it demands.

How Title VIII Nursing Workforce Development Programs Support the 
        Supply of Nurses
    For nearly five decades, the Nursing Workforce Development programs 
have helped build the supply and distribution of qualified nurses to 
meet our Nation's healthcare demands. The Title VIII programs support 
nursing education at all levels, and are designed to address specific 
needs of patient populations as well as those within the nursing 
workforce.
    These programs are vital to expediting the number of nurses 
entering into the workforce pipeline. AACN's 2012-2013 Title VIII 
Student Recipient Survey, which gathers information about Title VIII 
dollars and their impact on nursing students, demonstrates that Title 
VIII programs played a critical role in persuading students to enroll 
in nursing school. This survey, which included responses from over 
1,100 students, reveals that 74 percent of the respondents receiving 
Title VIII funding are currently attending school full-time. By 
supporting full-time students, these programs help to ensure that 
students enter the workforce without delay.
    Lastly, Title VIII programs help increase access to care in areas 
experiencing shortages in the number of health professionals and health 
services. The Title VIII Student Recipient Survey reveals that nearly 
21 percent of student respondents intend to practice in a community 
hospital, and 22.7 percent of respondents plan to practice in public 
health or in a rural or underserved area upon graduation. Furthermore, 
many of these students also report that due to Title VIII assistance, 
they are able to pursue a career in geographic areas where salary is 
not as competitive, but where the demand for nursing services is great.
    The Nursing Community respectfully requests $251 million for the 
Nursing Workforce Development programs authorized under Title VIII of 
the Public Health Service Act in fiscal year 2014.--The Nursing 
Community recognizes that Congress is faced with difficult decisions 
surrounding Federal deficit reduction, however we believe this amount 
is critical in ensuring the nursing workforce can meet the national 
demand for nursing services.

Advancing Nursing Science through the National Institute of Nursing 
        Research
    Research conducted at the NINR contributes to the advancement of 
nursing science that is translated into evidence-based practice. 
Initiatives funded through NINR center around increasing health 
promotion, reducing rates of chronic illness and transmissible disease, 
and improving patient quality of life. More specifically, NINR 
investigates unique ways to integrate the patient experience into 
health practices that empower patients and their families toward these 
goals. This includes efforts to improve symptom management related to 
chronic disease, reduce suffering at the end of life, and understand 
how genomics impact disease processes for specific populations. While 
other healthcare research focuses on curing disease, a large portion of 
NINR' s work is aimed at preventing disease. This work is fundamental 
to our healthcare system's endeavor of providing high-quality care in a 
cost-effective manner by mitigating burdensome costs associated with 
treatment.
    Moreover, NINR helps to provide needed faculty to support the 
education of future generations of nurses. Training programs at NINR 
develop future nurse-researchers, many of whom also serve as faculty in 
our Nation's nursing schools.
  --The Nursing Community respectfully requests $150 million for the 
        NINR in fiscal year 2014.

Nurse-Managed Health Clinics: Expanding Access to Care
    Run by an APRN and staffed by an interdisciplinary team, NMHCs 
provide essential primary care services in communities across the 
country. These clinics are often associated with a school, college, 
university, department of nursing, federally qualified health center, 
or independent nonprofit healthcare agency. NMHCs can be found in 
medically underserved regions of the country, including rural 
communities, Native American reservations, senior citizen centers, 
elementary schools, and urban housing developments. Nurses and other 
health professionals who work in NMHCs serve as educators to patients 
and their families by teaching healthy lifestyle practices and 
promoting disease prevention. By providing early assessment and 
intervention for patients who are often most vulnerable to co-
morbidities, NMHCs help manage medical conditions that have the 
potential to transpire into acute events. As a result, NMHCs help 
patients out of the emergency room, thereby improving patient outcomes 
and saving the healthcare system millions of dollars annually.
    Furthermore, NMHCs serve as clinical education training sites for 
nursing students and other health professionals--a crucial aspect of 
NMHCs given that a lack of training sites is commonly identified as a 
barrier to nursing school enrollment. An increasing emphasis on 
interdisciplinary care delivery necessitates that health professionals 
begin their training in an environment conducive to collaborative work. 
Many NMHCs serve as clinical training sites for nurses, physicians, 
social workers, public health nurses, and therapists to foster patient-
centered care early on in their practice.
  --The Nursing Community respectfully requests $20 million for the 
        Nurse-Managed Health Clinics authorized under Title III of the 
        Public Health Service Act in fiscal year 2014.
    Without a workforce of well-educated nurses providing evidence-
based care to those who need it most, including our growing aging 
population, the healthcare system is not sustainable. The Nursing 
Community's request of $251 million for the Title VIII Nursing 
Workforce Development programs, $150 million for the National Institute 
of Nursing Research, and $20 million for Nurse-Managed Health Clinics 
in fiscal year 2014 will help ensure access to quality care provided by 
America's nursing workforce.

       MEMBERS OF THE NURSING COMMUNITY SUBMITTING THIS TESTIMONY

Academy of Medical-Surgical Nurses
American Academy of Ambulatory Care Nursing
American Academy of Nursing
American Association of Colleges of Nursing
American Association of Nurse Anesthetists
American Association of Nurse Practitioners
American College of Nurse-Midwives
American Nephrology Nurses' Association
American Nurses Association
American Organization of Nurse Executives
American Pediatric Surgical Nurses Association
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
Association of Community Health Nursing Educators
Association of Nurses in AIDS Care
Association of periOperative Registered Nurses
Association of Public Health Nurses
Association of Rehabilitation Nurses
Commissioned Officers Association of the U.S. Public Health Service
Dermatology Nurses' Association
Gerontological Advanced Practice Nurses Association
Hospice and Palliative Nurses Association
Infusion Nurses Society
International Association of Forensic Nurses
International Society of Psychiatric Nursing
National Association of Clinical Nurse Specialists
National Association of Neonatal Nurse Practitioners
National Association of Neonatal Nurses
National Association of Nurse Practitioners in Women's Health
National Association of Pediatric Nurse Practitioners
National Black Nurses Association
National Nursing Centers Consortium
National Organization for Associate Degree Nursing
National Organization of Nurse Practitioner Faculties
Oncology Nursing Society
Pediatric Endocrinology Nursing Society
Preventive Cardiovascular Nurses Association
Public Health Nursing Section, American Public Health Association
Society of Urologic Nurses and Associates
The Quad Council of Public Health Nursing Organizations
Wound, Ostomy and Continence Nurses Society
      
                                 ______
                                 
        Prepared Statement of the Nurse Practitioner Roundtable

    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee: The Nurse Practitioner Roundtable is comprised of the 
five nurse practitioner associations representing the interests and 
concerns of the more than 155,000 nurse practitioners (NPs) across the 
country. Our organizations advocate for the active role of NPs as 
providers of high quality, cost-effective, comprehensive, patient-
centered healthcare and their patients. NPs have been furnishing 
primary, acute and specialty healthcare to patients of all ages and 
walks of life for nearly half a century. They assess the health care 
needs of patients; order, perform, supervise, and interpret diagnostic 
tests; make diagnoses; and initiate and manage treatment plans 
including prescribing medications. They are the healthcare providers of 
choice for millions of patients. More than 80 percent of NPs are 
educationally prepared as family, adult, gerontologic, pediatric, and 
women's health primary care providers.
    NPs work with organizations representing the rest of the advanced 
practice registered nurse (APRN) and general nursing community to 
support a strong Federal investment in the Nursing Workforce 
Development programs, to secure authorized funding for Nurse-Managed 
Health Clinics, and fund research initiatives at the National Institute 
of Nursing Research (NINR) to ensure that a sufficient supply of the 
highest-quality nursing services is available to meet the Nation's 
increasing need for effective and efficient healthcare.

The Growing Demand for Nurse Practitioners
    As millions of Americans enroll in expanded health insurance 
coverage in 2014, our Nation will face a dramatically increased demand 
for health care providers at a time when many professions face 
shortages and increasing retirements. Policy makers recognize that NPs 
are essential to meeting the demand for primary care services for 
women, children, the uninsured and patients with special needs, yet we 
face a provider shortage that is projected to continue. A significant 
and sustained investment in the education of NPs is needed to produce 
the workforce required to meet our population's demands for health care 
services.
    Nursing education programs are under increased pressure as Congress 
wrestles with reducing the Federal deficit. The six-month continuing 
resolution (H.J. Res. 117) enacted last September extended funding for 
Title VIII nurse education programs at fiscal year 2012 levels, a 
reduction of more than 4 percent from 2011. These programs now face the 
uncertain impact of sequestration, which could eliminate 645 training 
opportunities for advanced practice registered nurses. Funding for 
Advanced Education Nursing in fiscal year 2012 totaled only $64 
million. This is the only Federal funding source for Nurse Practitioner 
education programs.

Title VIII Nursing Workforce Development Programs
    The Nursing Workforce Development programs authorized under Title 
VIII of the Public Health Service Act have provided the resources to 
help educate and prepare nurse practitioners and other qualified nurses 
to meet our Nation's healthcare needs for nearly half a century. Title 
VIII programs reinforce nursing education from entry-level preparation 
through graduate study, and support the institutions that prepare NPs 
and other nurses to practice in rural and medically underserved 
communities. These are the only Federal programs focused on filling the 
gaps in the workforce of health professionals unmet by traditional 
market forces and on producing a workforce capable of caring for the 
Nation's increasingly diverse population.
    Title VIII programs also address the serious need for more nursing 
and Nurse Practitioner faculty. Nursing schools were forced to turn 
away nearly 80,000 qualified applications from entry-level 
baccalaureate and graduate nursing programs in 2012, according to an 
AACN 2012-2013 enrollment and graduation survey, with faculty vacancies 
being a primary reason. The Title VIII Nurse Faculty Loan Program aids 
in increasing nursing school enrollment capacity by supporting students 
pursuing graduate education in exchange for their service as faculty 
for 4 years after graduation. The NP Roundtable urges you to provide 
$251 million for the Nursing Workforce Development programs authorized 
under Title VIII of the Public Health Service Act in fiscal year 2014.

Nurse-Managed Health Clinics
    Nurse-Managed Health Clinics (NMHCs) are health care delivery sites 
managed by Nurse Practitioners and other APRNs, staffed by an 
interdisciplinary team of healthcare providers that may include 
physicians, social workers, public health nurses, and therapists. These 
clinics are often associated with a school, college, university, or 
department of nursing, and occasionally with community health centers 
or independent nonprofit healthcare agencies.
    NMHCs are particularly important threads in the Nation's healthcare 
safety net, caring for patients in medically underserved areas 
including rural communities, Native American reservations, senior 
citizen centers, elementary schools, and urban housing developments. 
Treating populations that are among the most vulnerable to chronic 
illnesses, NMHCs are committed to the management and reduction of acute 
and chronic disease and creating healthier communities by providing 
primary care and other services, as well as counseling and educating 
patients and the community regarding health promotion and disease 
prevention. These clinics also serve as important clinical education 
training sites for NPs, other nursing students and health 
professionals. This is particularly important given the lack of 
clinical training sites that has been recognized as one of the barriers 
to nursing school enrollment. The NP Roundtable requests that you 
provide $20 million for the Nurse-Managed Health Clinics authorized 
under Title III of the Public Health Service Act in fiscal year 2014.

The National Institute of Nursing Research
    As one of the 27 Institutes and Centers at the National Institutes 
of Health (NIH), the National Institute of Nursing Research (NINR) 
funds research that provides the evidence-based foundation for nursing 
practice. Nurse-scientists at NINR examine ways to innovate and improve 
care models to deliver safe, high quality health services in more cost-
effective ways. NINR engages in research on improving the management of 
care for patients during illness and recovery, reducing the risks of 
disease and disability, promoting healthy lifestyles, enhancing the 
quality of life for those with chronic disease, and compassionately 
caring for individuals at the end of life. In addition, NINR provides 
critically needed faculty to support the education of the next 
generations of nurses and Nurse Practitioners; its training programs 
develop the nurse-researchers of the future, many of whom go on to 
serve as faculty in our Nation's nursing schools. The NP Roundtable 
encourages you to provide $150 million for the NINR in fiscal year 
2014.
    Nurse Practitioners recognize that controlling the growth of 
Federal spending is a national priority, but they also know it is 
critical for Congress to provide sustained stable funding to maintain 
nurse practitioner education programs. Without a workforce of well-
educated and clinically prepared NPs providing evidence-based care to 
those in need, our healthcare system will not be sustainable. The NP 
Roundtable respectfully urges you to provide for that workforce by 
committing $251 million for the Title VIII Nursing Workforce 
Development programs, $20 million for Nurse-Managed Health Clinics, and 
$150 million for the National Institute of Nursing Research in fiscal 
year 2014.
    American Association of Nurse Practitioners
    Gerontological Advanced Practice Nurses Association
    National Association of Nurse Practitioners in Women's Health
    National Association of Pediatric Nurse Practitioners
    National Organization of Nurse Practitioner Faculties
                                 ______
                                 
       Prepared Statement of the Ovarian Cancer National Alliance

    The Ovarian Cancer National Alliance (the Alliance) appreciates the 
opportunity to submit comments for the record regarding the Alliance's 
fiscal year 2014 funding recommendations. We believe these 
recommendations are critical to ensure advances to help reduce and 
prevent suffering from ovarian cancer.
    For 16 years, the Alliance has worked to increase awareness of 
ovarian cancer and advocate for additional Federal resources to support 
research that would lead to more effective diagnostics and treatments. 
As an umbrella organization with more than 60 national, State and local 
organizations, the Alliance unites the efforts of survivors, grassroots 
activists, women's health advocates and health care professionals to 
bring national attention to ovarian cancer. The Ovarian Cancer National 
Alliance is the foremost advocate for women with ovarian cancer in the 
United States. To advance the interests of women with ovarian cancer, 
the organization advocates at a national level for increases in 
research funding for the development of an early detection test, 
improved health care practices and life-saving treatment protocols. The 
Ovarian Cancer National Alliance educates health care professionals and 
raises public awareness of the risks, signs and symptoms of ovarian 
cancer.
    Approximately 22,000 women are diagnosed with ovarian cancer every 
year, and more than 14,000 women die from the disease. Ovarian cancer 
is the deadliest gynecologic cancer; fewer than half of women survive 5 
years from diagnosis and only one-third survive 10 years. At this 
point, there is no reliable test we can use to screen women or catch 
the disease early. There are some known risk factors, including a 
genetic risk of breast/ovarian cancer, hormone replacement therapy and 
aging. Factors that decrease the risk of developing ovarian cancer 
include use of oral contraceptives, breastfeeding and removal of the 
fallopian tubes/ovaries. The majority of women with the disease have at 
least one recurrence, and for many of them, treatment eventually stops 
working. Ovarian cancer is the fifth leading cause of cancer deaths 
among women in the United States. That is why research and public 
health programs are so important for ovarian cancer.
    The National Cancer Institute and the Centers for Disease Control 
and Prevention both do significant and valuable work around ovarian 
cancer. We are grateful for the Committee's continued support of these 
agencies, and the programs they undertake to lower the burden of 
ovarian cancer.
    The NCI is the single largest nonprofit funder of ovarian cancer 
research domestically, funding approximately 75 percent of all 
nonprofit ovarian cancer research done in the United States. In fiscal 
year 2011, the NCI spent approximately $110 million on ovarian cancer 
research, including large grants to cancer centers and cooperative 
groups as well smaller grants for research on topics including 
overcoming drug resistance, angiogenesis--cutting off blood supply to 
tumors, and exploring the link between high density breasts and risk 
for ovarian cancer.
    Recent highlights of NCI funded research include: a large trial of 
a new ovarian cancer drug, Avastin, which was shown to improve the time 
women's cancer stayed in remission; studies showing that prophylactic 
surgery for high risk women, including the removal of just a woman's 
fallopian tubes, significantly reduces the odds of developing ovarian 
cancer; and a study showing that screening average risk women with our 
current tools does not reduce mortality. The results of The Cancer 
Genome Atlas--another study funded by NCI--showed us how important 
personalized medicine is for ovarian cancer. The Atlas told us that 
each case of ovarian cancer is genetically unique, so we are going to 
have our work cut out for us to identify targets and develop and test 
drugs.
    The CDC has two programs directly related to ovarian cancer. The 
first raises awareness of the risks and symptoms of gynecologic cancers 
through advertising and educational materials. As of December 2012, 
PSAs about gynecologic cancer had generated 2.62 billion audience 
impressions and paid media generated 187 million audience impressions. 
Studies conducted by the CDC have shown that both women and health 
providers are unaware of the symptoms of ovarian cancer and current 
recommendations against screening. This data shows the clear need for 
continued education.
    The second CDC program is focused on epidemiological research. 
Current research includes an evidence review of birth control as an 
intervention for those at high risk of developing ovarian cancer, a 
study of barriers to determine why women don't see specialists for 
surgery, as well as analyses of data on disparities and other patterns 
of survival.
    While we clearly have a long way to go, we have made progress in 
our understanding of ovarian cancer. We have seen new treatments 
developed over the past twenty years, and we have a better 
understanding of where ovarian cancer develops and who is at risk for 
this deadly disease. In addition, we have a larger and stronger network 
of survivors and family members who can support one another.
    The Alliance maintains a long-standing commitment to work with 
Congress, the Administration and other policy makers and stakeholders 
to improve the survival rate for women with ovarian cancer through 
education, public policy, research and communication. Please know we 
appreciate and understand that our Nation faces many challenges, 
including limited resources. We thank you for continuing to support 
programs that help women and health providers better understand and 
treat ovarian cancer. We know these programs have reduced suffering. We 
know women whose lives have been saved by knowing they were at high 
risk or who got new treatments that kept their cancer at bay. We 
respectfully request that you maintain support for these critical 
activities.

    ONE VOICE AGAINST CANCER FISCAL YEAR 2014 APPROPRIATIONS REQUESTS
------------------------------------------------------------------------
                                                                Amount
                          Program                             (millions)
------------------------------------------------------------------------
National Institutes of Health..............................    32,632
    National Cancer Institute..............................     5,349
    National Institute on Minority Health and Health              283
     Disparities...........................................
Centers for Disease Control and Prevention.................       515
    Comprehensive Cancer Control Initiative................        50
    Cancer Registries......................................        65
    National Breast & Cervical Cancer Early Detection             275
     Program...............................................
    Colorectal Cancer......................................        70
    Skin Cancer............................................         5
    Prostate Cancer........................................        25
    Ovarian Cancer.........................................        10
    Geraldine Ferraro Blood Cancer Program.................         4.67
    Johanna's Law: The Gynecologic Cancer Education and            10
     Awareness Act.........................................
    Office of Smoking and Health...........................       197
------------------------------------------------------------------------

                    ONE VOICE AGAINST CANCER MEMBERS

Alliance for Prostate Cancer Prevention
American Academy of Dermatology Association
American Association for Cancer Research
American Cancer Society Cancer Action Network
American College of Surgeons Commission on Cancer
American Congress of Obstetricians and Gynecologists
American Social Health Association
American Society of Clinical Oncology
American Society for Radiation Oncology
Asian & Pacific Islander American Health Forum
Association of American Cancer Institutes
Bladder Cancer Advocacy Network
Cancer Support Community
Charlene Miers Foundation for Cancer Research
Colon Cancer Alliance
CureSearch for Children's Cancer
Fight Colorectal Cancer
Friends of Cancer Research
Intercultural Cancer Council Caucus
International Myeloma Foundation
LIVESTRONG
Leukemia & Lymphoma Society
Malecare Prostate Cancer Support
Men's Health Network
National Alliance of State Prostate Cancer Coalitions
National Association of Chronic Disease Directors
National Brain Tumor Society
National Cervical Cancer Coalition
National Coalition for Cancer Research (NCCR)
National Coalition for Cancer Survivorship
National Patient Advocate Foundation
Oncology Nursing Society
Ovarian Cancer National Alliance
Pancreatic Cancer Action Network
Pennsylvania Prostate Cancer Coalition
Prevent Cancer Foundation
Preventing Colorectal Cancer
Sarcoma Foundation of America
Society of Gynecologic Oncology
Susan G. Komen for the Cure Advocacy Alliance
Us TOO International Prostate Cancer Education and Support Network
      
                                 ______
                                 
          Prepared Statement of the Parkinson's Action Network

    Dear Chairman Harkin and Ranking Member Moran: The Parkinson's 
Action Network (PAN) appreciates the opportunity to comment on the 
fiscal year 2014 appropriations for the U.S. Department of Health and 
Human Services. Our comments will focus on the importance of Federal 
investment in biomedical research at the National Institutes of Health 
(NIH) and the Brain Research through Advancing Innovative 
Neurotechnologies (BRAIN) Initiative. PAN supports at least $32 billion 
in funding for the NIH and the President's budget request of 
approximately $100 million for the BRAIN Initiative in fiscal year 
2014, $40 million of which will come from the NIH.
    PAN is the unified voice of the Parkinson's community advocating 
for better treatments and a cure. In partnership with other Parkinson's 
organizations and our powerful grassroots network, we educate the 
public and Government leaders on better policies for research and 
improved quality of life for the estimated 500,000 to 1.5 million 
Americans living with Parkinson's, for whom there is no treatment 
available that slows, reverses, or prevents progression.
    As the second most common neurological condition after Alzheimer's 
disease, Parkinson's disease is projected to grow substantially over 
the next few decades as the size of the elderly population grows and 
will have a direct impact on the health care system and economy. A 
recent study published in Movement Disorders estimated that the 
economic burden of Parkinson's disease is at least $14.4 billion a year 
in the United States, and the prevalence of Parkinson's will more than 
double by the year 2040.\1\ In addition, the study calculated an 
additional $6.3 billion in indirect costs such as missed work or loss 
of a job for the patient or family member who is helping with care, 
long-distance travel to see a neurologist or movement disorder 
specialist, as well as costs for home modifications, adult day care, 
and personal care aides. A second study also published in Movement 
Disorders projected that if Parkinson's progression were slowed by 50 
percent, there would be a 35 percent reduction in excess costs, 
representing a dramatic reduction in cost of care spread over a longer 
expected survival.\2\ Both studies highlight the enormous economic 
implications of this devastating disease, and make it abundantly clear 
that increased research funding is a wise investment on the front end 
to help significantly lower or eliminate costs on the back end.
    Sustained growth for the NIH should be an urgent national priority. 
The NIH supports research grants in all fifty States designed to 
identify and develop medical discoveries that improve people's health, 
understand disease, and save lives. More than 80 percent of its 
research dollars go to universities, research institutions, and small 
businesses, which directly create thousands of jobs and grow local 
economies across the country. In 2012, NIH funding supported more than 
402,000 jobs and generated more than $57.8 billion in economic 
activity. NIH remains the largest funder of Parkinson's research, 
supporting more than $154 million in funding for Parkinson's disease in 
fiscal year 2012.
    Under sequestration, instead of increasing research budgets to 
tackle the diseases of the future, NIH has been cut by more than $1.5 
billion. While funding cuts may not be felt immediately or all at once, 
they will delay years of critical research on a cure for Parkinson's 
and other diseases. For instance, the National Institute of 
Neurological Disorders and Stroke (NINDS), which is the primary 
supporter of the Parkinson's research portfolio at NIH, will be unable 
to expand the NINDS Parkinson's Disease Biomarkers Program, which 
brings together multiple stakeholders dedicated to finding diagnostic 
and progression biomarkers for Parkinson's disease, as planned. A 
Parkinson's biomarker could hasten new treatments and improve diagnosis 
of the disease in the future.
    By investing in biomedical research both at the Federal level and 
in the private sector, and creating results-driven public-private 
partnerships, the scientific community can develop more innovative 
treatments and, one day, a cure for Parkinson's. That is why PAN is 
supportive of the new BRAIN Initiative, which aims to revolutionize our 
understanding of the human brain by bringing together the NIH, the 
Defense Advanced Research Projects Agency, and the National Science 
Foundation as well as key private sector partners, like the Allen 
Institute for Brain Research. We are supportive of the President's 
request for approximately $100 million of fiscal year 2014 funds to 
jumpstart this exciting new effort, with $40 million coming from the 
NIH. We are hopeful that this cross-cutting and targeted effort can 
answer questions and create tools that will be directly applicable to 
the millions of people living with neurological diseases.
    PAN urges the subcommittee to prioritize biomedical research 
funding by supporting at least $32 billion for the NIH overall and 
supporting the President's request of $40 million at the NIH for the 
BRAIN Initiative. We look forward to working with the subcommittee as 
the fiscal year 2014 appropriations process moves forward.
---------------------------------------------------------------------------
    \1\ ``The Current and Projected Economic Burden of Parkinson's 
Disease in the United States,'' Movement Disorders, Vol. 000, No. 000, 
2013.
    \2\ ``An Economic Model of Parkinson's Disease: Implications for 
Slowing Progression in the United States,'' Movement Disorders, Vol. 
00, No. 00, 2012.
---------------------------------------------------------------------------
                                 ______
                                 
  Prepared Statement of the Physician Assistant Education Association 
                                 (PAEA)

    On behalf of the 174 accredited physician assistant (PA) education 
programs in the United States, the Physician Assistant Education 
Association (PAEA) is pleased to submit these comments on the fiscal 
year 2014 appropriations for PA education programs that are authorized 
through Title VII of the Public Health Service Act. PAEA supports 
funding of at least $264.4 million in fiscal year 2014 for the health 
professions education programs authorized under Title VII of the Public 
Health Service Act and administered through the Health Resources and 
Services Administration (HRSA) and requests $7.65 million in support of 
PA programs operating across the country This is the only designated 
source of Federal funding for PA education and is crucial to the 
education system's ability to meet the demand for training and to 
continue to produce highly skilled physician assistants ready to enter 
the health care workforce in an average of 26 months.

Need for Increased Federal Funding
    The unmet need for primary care services in the United States is 
well documented, and only expected to grow as Baby Boomers age and the 
Affordable Care Act is fully implemented. The very parameters of access 
and health care quality are rapidly evolving. Yet the one constant in 
our health care system remains the need for qualified health care 
providers in numbers sufficient to meet demand, and primary care has 
been clearly identified as the critical entry point into the health 
care system where that access must be guaranteed. PAs stand ready for 
the challenges in primary care, and could play an even larger role with 
appropriate financial support and through innovations in the PA 
education system.
    Like physicians, the PA profession also faces shortages that will 
hinder its ability to help address the primary care issue in the United 
States. Without new solutions, at the current output of approximately 
6500 graduates from PA programs per year, these shortages will persist, 
particularly in the rural and underserved communities where care is 
needed the most. Title VII funding is the only opportunity for PA 
programs to apply for Federal funding and plays a crucial role in 
developing and supporting the PA education system's ability to produce 
the next generation of these critical advanced practice clinicians.

Background on the Profession
    Since the 1960s, PAs have consistently demonstrated they are 
effective partners in health care, readily adaptable to the needs of an 
ever-changing delivery system. Physician assistants are licensed health 
professionals with advanced education in general medicine. PAs practice 
medicine as members of a team working with supervising physician. They 
exercise autonomy in medical decisionmaking and provide a broad range 
of medical and therapeutic services to diverse populations in rural and 
urban settings. In all 50 States, PAs carry out physician-delegated 
duties that are allowed by law and within the physician's scope of 
practice and the PA's training and experience, including prescriptive 
authority in all 50 States, the District of Columbia, and Guam. The 
combination of medical training, advanced education and hands-on 
experience allows PAs to practice with significant autonomy, and in 
rural and other medically underserved areas where they are often the 
only full-time medical provider. The profession is well established, 
yet young enough to embrace new models of care, adopt innovative 
approaches to training and education, and adapt to health system 
challenges as they arise. The PA practice model is, by design, a team-
based approach to patient-centered care where the PA works in tandem 
with a physician and other health professionals. This PA practice 
approach to quality care is uniquely aligned with the patient-centered, 
collaborative, interprofessional and outcomes-based care models 
expected to transform the U.S. health care system.

PA Education: The Pipeline for Physician Assistants
    There are currently 174 accredited PA education programs in the 
United States--a 23 percent increase over the past 5 years; together 
these programs graduate nearly 6,422 PA students each year. PAs are 
educated as generalists in medicine and their flexibility allows them 
to practice in more than 60 medical and surgical specialties. More than 
one third of PA program graduates practice in primary care.
    The average PA education program is 26 months in length and 
typically, 1 year is devoted to classroom study and approximately 12 
months is devoted to clinical rotations. Most curricula include 340 
hours of basic sciences and nearly 2,000 hours of clinical medicine.
    As of today, approximately 65 new PA programs are in the pipeline 
at various stages of development, moving toward accredited status. The 
growth rate in the applicant pool is even more remarkable. Since its 
inception in 2001 until the most recent application cycle, the 
Centralized Application Service (CASPA) used by most programs grew from 
4,669 applicants to over 19,000. In March 2009, there were a total of 
12,216 applicants to PA education programs; as of March 2013, there 
were 18,900 applicants to PA education programs. This represents a 54 
percent increase in CASPA applicants over the past 5 years.
    The PA profession is expected to continue to grow as a result of 
the projected shortage of physicians and other health care 
professionals, the growing demand for care driven by an aging 
population, and the continuing strong PA applicant pool. The Bureau of 
Labor Statistics projects a 39 percent increase in the number of PA 
jobs between 2008 and 2018. The way that PAs are trained in America--
the caliber of our institutions and the expertise of our educators--is 
the gold-standard throughout the world and that must be maintained. 
With its relatively short initial training time and the flexibility of 
generalist-trained PAs, the PA profession is well-positioned to help 
fill projected shortages in the numbers of health care professionals--
if appropriate resources are available to support the education system 
behind them.

                          AREAS OF ACUTE NEED

Faculty Shortages
    Faculty development is one of the profession's critical needs and 
educators are an often overlooked element to developing an adequate 
primary care workforce. Nearly half of PA program faculty are 50 years 
or older and the PA teaching profession faces large numbers of 
retirements in the next 10-15 years. An interest in education must be 
developed early in the educational process to ensure a continuous 
stream of educators and we must alleviate the significant loan burdens 
that prevent many physician assistants from entering academia. In order 
to attract the most highly qualified individuals to teaching, PA 
education programs must have the resources to start that process, and 
train faculty in academic skills, such as curriculum development, 
teaching methods, and laboratory instruction. Most educators come from 
clinical practice and these non-clinical professional skills are 
essential to a successful transition from clinical practice to a 
classroom setting. Without Federal support, we will continue to cycle 
through existing faculty and face an impending shortage of teachers who 
are prepared for and committed to the critical teaching role in PA 
student education.

Clinical Site Shortages
    Outside of the classroom, the PA education faces additional 
challenges in meeting demand. A lack of clinical sites for PA education 
is hampering PA programs' ability to produce the next generation of PAs 
at the pace needed to meet the demand for primary care in the U.S. This 
shortage is caused by two main factors: a shortage of medical 
professionals willing to teach students as they are cycling through 
their clinical rotations (preceptors), and a lack of sites with the 
physical space to teach.
    This phenomenon is experienced throughout the health professions, 
and is particularly acute in primary care. It has created unintentional 
competition for clinical sites and preceptors within and among PAs, 
physicians and advance practice nurses. Federal funding can help 
incentivize practicing clinicians to both offer their time as 
preceptors, and volunteer their clinical operations as training grounds 
for PAs and other health professionals to directly interact with 
patients. PAEA believes that interprofessional clinical training and 
practice are necessary for optimum patient care and will be a defining 
model of health care in the U.S. in the 21st century. We can only make 
that a reality if we begin to build a sufficient network of health 
professionals who are willing to teach the next generation of primary 
care professionals--that approach will benefit PAs as well as the 
future physicians and nurses that comprise the full primary care team.

Enhancing Diversity
    Generalist training, workforce diversity, and practice in 
underserved areas are key priorities identified by HRSA and are 
consistent with those of PAEA. It is increasingly important for patient 
care quality that the health workforce better represents America's 
changing demographics, as well as addresses the issues of disparities 
in health care. PA programs have been committed to attracting students 
from underrepresented minority groups and disadvantaged backgrounds 
into the profession, through programs such as the National Health 
Service Corps (NHSC), Scholarships for Disadvantaged Students (SDS) and 
the Health Careers Opportunity Program (HSCOP). Studies have found that 
health professionals from underserved areas are three to five times 
more likely to return to underserved areas to provide care and PA 
programs are looking for unique ways to recruit diverse individuals 
into the profession, and sustain them as leaders in the education 
field. If we can provide resources to schools that are particularly 
poised to improve their diversity recruitment efforts and replicate or 
create best practices, we can begin to address this systemic need.
    Efforts to increase workforce diversity in the PA profession are 
enhanced when colleges and universities are able to leverage primary 
care training funds with other Federal programs that specifically 
target recruitment and retention of underrepresented minorities. PAEA 
therefore supports the restoration of funding for the Health Careers 
Opportunity Program (HCOP), and increased funding for the Scholarships 
for Disadvantaged Students and National Health Service Corps. 
Historically, access to higher education has been constrained for 
individuals from disadvantaged backgrounds. Funding for HCOP that 
targets the physician assistant profession and scholarship programs 
that provide support for students with limited financial resources 
helps to provide a clear path for students who might not otherwise 
consider a physician assistant career.

Veterans
    The first physician assistant class of 1965 was comprised of Navy 
corpsman who served during the Vietnam War. Veterans with medical 
backgrounds are excellent potential candidates for PA programs and 
special incentives for both the schools and students can help expedite 
the process of matriculation into the educational system. Over the past 
18 months, PAEA has been involved in initiatives to create a pathway 
for veterans interested in becoming physician assistants. PAEA is 
currently partnering with the American Academy of Physician Assistants, 
the National Commission on Certification of Physician Assistants, and 
the Accreditation Review Commission on Education for the Physician 
Assistant (ARC-PA ) to promote the opportunities for veterans that 
exist in the PA profession. PAEA has also created two groups tasked 
with identifying best practices in PA education and ways to quantify 
military experiences for academic credit.
    The Recruitment and Training group is working to develop and employ 
outreach methods to engage military personnel and veterans who are 
seeking careers in health care. The Vet 2 PA workgroup was formed with 
the goal of identifying PA programs with bridge programs instituted to 
help military service members more easily transition into PA training 
programs. In addition, there was a special priority created in the last 
PA Primary Care Training Grant competition for programs that provided 
supportive services for veterans, including academic support and 
mentoring services, among others. Eleven out of the 12 PA education 
program grantees, all members of PAEA, had a veteran-specific 
initiative in their training grant application.

Title VII Funding
    Title VII funding fills a critical need for curriculum development, 
faculty development, clinical site expansion and diversification of the 
primary care workforce. These funds enhance clinical training and 
education, assist PA programs with recruiting applicants from minority 
and disadvantaged backgrounds, and enables innovative programs that 
focus on educating a culturally competent workforce. Title VII funding 
increases the likelihood that PA students will practice in medically 
underserved communities with health professional shortages. The absence 
of this funding would result in the loss of care to patients with the 
most urgent need for access to care.
    Title VII support for PA programs was strengthened in 2010 when 
Congress enacted a 15 percent allocation in the appropriations process 
specifically for PA programs working to address the health provider 
shortage. This funding will enhance capabilities to train a growing PA 
workforce and is likely to increase the pool for faculty positions as a 
result of PA programs now being eligible for faculty loan repayment.
    Here we provide several examples of how PA programs have used Title 
VII funds to creatively expand care to underserved areas and 
populations, as well as to develop a diverse PA workforce.
  --One Texas program has used its PA training grant to support the 
        program at a distant site in an underserved area. This grant 
        provides assistance to the program for recruiting, educating, 
        and training PA students in the largely Hispanic South Texas 
        and mid-Texas/Mexico border areas and supports new faculty 
        development.
  --A Utah program has used its PA training grant to promote 
        interprofessional teams--an area of strong emphasis in the 
        Patient Protection and Affordable Care Act. The grant allowed 
        the program to optimize its relationship with three service-
        learning partners, develop new partnerships with three service-
        learning sites, and create a model geriatric curriculum that 
        includes didactic and clinical education.
  --An Alabama program used its PA training grant to update and expand 
        the current health behavior educational curriculum and HIV/STD 
        training. They were also able to include PA students from other 
        programs who were interested in rural, primary care medicine 
        for a four-week comprehensive educational program in HIV 
        disease diagnosis and management.

Recommendations on fiscal year 2014 Funding
    The Physician Assistant Education Association requests the 
Appropriations Committee support funding for Title VII health 
professions programs at a minimum of $264.4 million for fiscal year 
2014.This level of funding is crucial to support the Nation's ability 
to produce and maintain highly skilled primary care practitioners, 
particularly those who will practice in medically underserved areas and 
serve vulnerable populations. Additionally, we ask for the 15 percent 
allocation for PA education programs in the Primary Care cluster as 
mandated in the Affordable Care Act. This $7.65 million will enable the 
education system to produce 1,400 more primary care PAs over 5 years. 
We thank the members of the subcommittee for their support of the 
health professions and look forward to your continued commitment to 
finding solutions to the Nation's health workforce shortage. We 
appreciate the opportunity to present the Physician Assistant Education 
Association's fiscal year 2014 funding recommendation.
                                 ______
                                 
Prepared Statement of the Population Association of America/Association 
                         of Population Centers

                              INTRODUCTION

    Thank you, Chairman Harkin, Ranking Member Moran, and other 
distinguished members of the subcommittee, for this opportunity to 
express support for the National Institutes of Health (NIH) and the 
National Center for Health Statistics (NCHS). The Population 
Association of America (PAA) and Association of Population Centers 
(APC) are pleased to endorse funding recommendations made by the Ad Hoc 
Group for Medical Research Funding and Friends of National Center for 
Health Statistics for NIH and NCHS, respectively. Specifically, we urge 
the Committee to provide the NIH with $32 billion in fiscal year 2014 
and to provide the NCHS with the Administration's request, $181.5 
million. Further, we encourage the subcommittee to stop the pernicious 
cuts to research funding and statistical agencies that squander 
invaluable scientific opportunities and threaten the ability of our 
members to continue making important contributions towards improving 
the health and well being of the American people, to train the next 
generation of population scientists, and to prevent the permanent loss 
of key longitudinal survey data.

           BACKGROUND ON THE PAA/APC AND DEMOGRAPHIC RESEARCH

    The Population Association of America (PAA) 
(www.populationassociation.org) is a scientific organization comprised 
of over 3,000 population research professionals, including 
demographers, sociologists, statisticians, and economists. The 
Association of Population Centers (APC) (www.popcenters.org) is a 
similar organization comprised of over 40 universities and research 
groups nationwide that foster collaborative demographic research and 
data sharing, translate basic population research for policy makers, 
and provide educational and training opportunities in population 
studies.
    Demography is the study of populations and how or why they change. 
Demographers, as well as other population researchers, collect and 
analyze data on trends in births, deaths, and disabilities as well as 
racial, ethnic, and socioeconomic changes in populations. A key 
component of the NIH mission is to support biomedical, social, and 
behavioral research that will improve the health of our population. The 
health of our population is fundamentally intertwined with the 
demography of our population. Recognizing the connection between health 
and demography, NIH supports extramural population research programs 
primarily through the National Institute on Aging (NIA) and the 
National Institute of Child Health and Human Development (NICHD). Below 
are examples of the important population research activities that these 
Institutes support.

                      NATIONAL INSTITUTE ON AGING

    According to the U.S. Census Bureau, the number of people age 65 
and older will more than double between 2010 and 2050 to 88.5 million 
or 20 percent of the population; and those 85 and older will increase 
three-fold, to 19 million. To inform the implications of our rapidly 
aging population, policymakers need objective, reliable data about the 
antecedents and impact of changing social, demographic, economic, 
health and well being characteristics of the older population. The NIA 
Division of Behavioral and Social Research (BSR) is the primary source 
of Federal support for basic research on these topics.
    In addition to supporting an impressive research portfolio, that 
includes the prestigious Centers of Demography of Aging, the NIA BSR 
Division also supports several large, accessible data surveys. These 
surveys include a new nationally representative study, the National 
Health and Aging Trends Study (NHATS), which has enrolled 8,000 
Medicare beneficiaries with the goal of studying trends in late-life 
disability trends and dynamics. The study also includes a supplement to 
examine informal caregivers and their impact on the long-term care 
utilization of people with chronic disabilities. NHATS is enabling 
researchers to continue important research on late-life disability 
trends and those factors (socio-economic, demographic, health) that may 
influence changes in disability across different populations.
    Another NIA survey, the Health and Retirement Study (HRS), has 
become one of the seminal sources of information to assess the health 
and socioeconomic status of older people in the U.S. Since 1992, the 
HRS has tracked 27,000 people, providing data on a number of issues, 
including the role families play in the provision of resources to needy 
elderly and the economic and health consequences of a spouse's death. 
HRS is so respected that the study is being replicated currently in 30 
other countries, providing important data on how the U.S. compares with 
other countries whose populations are aging more rapidly. In March 
2012, HRS posted genetic data collected voluntarily from over half of 
the HRS participants to dbGAP, the NIH's online genetics database. 
These data are now available for analysis by qualified researchers to 
track the onset and progression of diseases and disabilities affecting 
the elderly. In the last year, HRS data were used to report a number of 
findings, including a significant study published in The New England 
Journal of Medicine in April 2013, which identified the costs of 
dementia. The study found that caring for people with dementia in the 
United States in 2010 costs between $159 billion to $215 billion, and 
these costs could rise dramatically with the increase in the numbers of 
older people in coming decades. The researchers found these costs of 
care comparable to, if not greater than, those for heart disease and 
cancer.
    As members of the Friends of the NIA, PAA and APC endorse the 
coalition's recommendation that NIA receive $1.4 billion in fiscal year 
2014.

  EUNICE KENNEDY SHRIVER NATIONAL INSTITUTE ON CHILD HEALTH AND HUMAN 
                              DEVELOPMENT

    Since its establishment in 1968, the Eunice Kennedy Shriver NICHD 
Center for Population Research has supported research on population 
processes and change. As a result of the Institute's recent 
reorganization, this research is now housed in the Population Dynamics 
Branch. This branch supports research in three broad areas: demography, 
HIV/AIDs, other sexually transmitted diseases, and other reproductive 
health; and population health, with focus on early life influences and 
policy.
    NICHD is the major supporter of the national studies that track the 
health and well being of children and their families from childhood 
through adulthood. These studies include Fragile Families and Child 
Well Being, the first scientific study to track the health and 
development of children born to unmarried parents; the National 
Longitudinal Study of Youth, a multigenerational study of health and 
development; and the National Longitudinal Study of Adolescent Health 
(Add Health), tracing the effects of childhood and adolescent exposures 
on later health. NICHD supports the prompt and widespread release of 
demographic data collected with NIH and other Federal Government 
funding through the Demographic Data Sharing and Archiving project.
    One of the most important population research programs the NICHD 
supports is the Research Infrastructure for Demographic and Behavioral 
Population Science (DBPop). This program promotes innovation, supports 
interdisciplinary research, translates scientific findings into 
practice, and develops the next generation of population scientists, 
while at the same time providing incentives to reduce the costs and 
increase the efficiency of research by streamlining and consolidating 
research infrastructure within and across research institutions. DBPop 
supports research at 24 private and public research institutions 
nationwide, the focal points for the demographic research field for 
innovative research and training and the development and dissemination 
of widely used large-scale databases.
    NIH-funded demographic research provides critical scientific 
knowledge on issues of greatest consequence for American families: 
marriage and childbearing, childcare, work-family conflicts, and family 
and household behavior. Demographic research is having a large impact 
in public health, particularly on issues such as infant and child 
health and development, and adolescent and young adult health, and 
health disparities. Research supported by the Population Dynamics 
branch has revealed the critical role of marriage and stable families 
in ensuring that children grow up healthy, achieving developmental and 
educational milestones. Branch-supported researchers have published a 
number of recent findings, including a study, based on Add Health data, 
which concluded that women who are overweight or obese years during the 
transition from adolescence to adulthood are more likely to later 
deliver babies with a higher birth weight, putting the next generation 
at a higher risk of obesity-related health outcomes. In another 
published study, researchers using genetic and survey data from the 
Fragile Families and Child Well Being Study, found that post-partum 
depression was most likely among women with both at-risk genetic 
profiles and low educational levels.
    As members of the Friends of the NICHD, PAA and APC endorse the 
coalition's recommendation that the Institute receive $1.2 billion in 
fiscal year 2014.

                 NATIONAL CENTER FOR HEALTH STATISTICS

    Located within the Centers for Disease Control (CDC), the National 
Center for Health Statistics (NCHS) is the Nation's principal health 
statistics agency, providing data on the health of the U.S. population 
and backing essential data collection activities. Most notably, NCHS 
funds and manages the National Vital Statistics System, which contracts 
with the States to collect birth and death certificate information. 
NCHS also funds a number of complex large surveys to help policy 
makers, public health officials, and researchers understand the 
population's health, influences on health, and health outcomes. These 
surveys include the National Health and Nutrition Examination Survey 
(NHANES), National Health Interview Survey (HIS), and National Survey 
of Family Growth. Together, NCHS programs provide credible data 
necessary to answer basic questions about the state of our Nation's 
health. The wealth of data NCHS collects makes the agency an invaluable 
resource for population scientists.
    Despite recent steady funding increases, NCHS continues to feel the 
effects of long-term funding shortfalls, compelling the agency to 
undermine, eliminate, or further postpone the collection of vital 
health data. For example, in 2009, sample sizes in HIS and NHANES were 
cut, while other surveys, most notably the National Hospital Discharge 
Survey, were not fielded. In 2009, NCHS proposed purchasing only ``core 
items'' of vital birth and death statistics from the States (starting 
in 2010), effectively eliminating three-fourths of data routinely used 
to monitor maternal and infant health and contributing causes of death. 
Fortunately, Congress and the new Administration worked together to 
give NCHS adequate resources and avert implementation of these 
draconian measures. Also, funding from the Prevention and Public Health 
Fund has been an invaluable source of support for the agency since 
fiscal year 2011, providing much needed funding to, for example, add 
components to NHANES, purchase updated vital statistics data from the 
States, and facilitate the implementation of electronic birth records 
in the all States. With funding from the NIH, the agency is also 
working to expedite the release of mortality data from the National 
Death Index. However, the progress NCHS has made is threatened if the 
agencies that it relies on for support (through funding from the HHS 
evaluation tap and via interagency agreements) continue to be cut.
    Thank you for considering the importance of these agencies under 
your jurisdiction that benefit the population sciences. Despite 
challenges facing the subcommittee, we urge you to support $32 billion 
for NIH and $181.5 million for NCHS in fiscal year 2014. Further, we 
urge you to work to reverse the impact sequestration and years of 
funding levels below inflation have had on the entire public health 
continuum, which includes NIH and NCHS.
                                 ______
                                 
            Prepared Statement of Prevent Blindness America

                        FUNDING REQUEST OVERVIEW

    Prevent Blindness America appreciates the opportunity to submit 
written testimony for the record regarding fiscal year 2014 funding for 
vision and eye health related programs. As the Nation's leading non-
profit, voluntary health organization dedicated to preventing blindness 
and preserving sight, Prevent Blindness America maintains a long-
standing commitment to working with policymakers at all levels of 
Government, organizations and individuals in the eye care and vision 
loss community, and other interested stakeholders to develop, advance, 
and implement policies and programs that prevent blindness and preserve 
sight. Prevent Blindness America respectfully requests that the 
subcommittee provide the following allocations in fiscal year 2014 to 
help promote eye health and prevent eye disease and vision loss:
  --Provide at least $508,000 million to maintain vision and eye health 
        efforts at the Centers for Disease Control and Prevention 
        (CDC).
  --Support the Maternal and Child Health Bureau's (MCHB) National 
        Center for Children's Vision and Eye Health (Center).
  --Provide at least $640 million in fiscal year 2014 to sustain 
        programs under the Maternal and Child Health (MCH) Block Grant.
  --Provide $730 million to the National Eye Institute (NEI) in order 
        to bolster efforts to identify the underlying causes of eye 
        disease and vision loss, improve early detection and diagnosis, 
        and advance prevention and treatment efforts.

                       INTRODUCTION AND OVERVIEW

    Vision-related conditions affect people across the lifespan from 
childhood through elder years. Good vision is an integral component to 
health and well-being, affects virtually all activities of daily 
living, and impacts individuals physically, emotionally, socially, and 
financially. Loss of vision can have a devastating impact on 
individuals and their families. An estimated 80 million Americans have 
a potentially blinding eye disease, three million have low vision, more 
than one million are legally blind, and 200,000 are more severely 
visually blind. Vision impairment in children is a common condition 
that affects five to 10 percent of preschool age children. Vision 
disorders, including amblyopia (``lazy eye''), strabismus (``cross 
eye''), and refractive error are the leading cause of impaired health 
in childhood.
    Alarmingly, while half of all blindness can be prevented through 
education, early detection, and treatment, the NEI reports that ``the 
number of Americans with age-related eye disease and the vision 
impairment that results is expected to double within the next three 
decades.'' \1\ Among Americans age 40 and older, the four most common 
eye diseases causing vision impairment and blindness are age-related 
macular degeneration (AMD), cataract, diabetic retinopathy, and 
glaucoma.\2\ Refractive errors are the most frequent vision problem in 
the U.S.--an estimated 150 million Americans use corrective eyewear to 
compensate for their refractive error.\3\ Uncorrected or under-
corrected refractive error can result in significant vision 
impairment.\4\
    To curtail the increasing incidence of vision loss in America, 
Prevent Blindness America advocates sustained and meaningful Federal 
funding for programs that help promote eye health and prevent eye 
disease, vision loss, and blindness; needed services and increased 
access to vision screening; and vision and eye disease research. In a 
time of significant fiscal constraints, we recognize the challenges 
facing the subcommittee and urge you to consider the ramifications of 
decreased investment in vision and eye health. Vision loss is often 
preventable, but without continued efforts to better understand eye 
diseases and conditions, and their treatment, through research, to 
develop the public health systems and infrastructure to disseminate and 
implement good science and prevention strategies, and to protect 
children's vision, millions of Americans face the loss of independence, 
loss of health, and the loss of their livelihoods, all because of the 
loss of their vision. We thank the subcommittee for its consideration 
of our specific fiscal year 2014 funding requests, which are detailed 
below.

 VISION AND EYE HEALTH AT THE CDC: HELPING TO SAVE SIGHT AND SAVE MONEY

    The CDC serves a critical national role in promoting vision and eye 
health. Since 2003, the CDC and Prevent Blindness America have 
collaborated with other partners to create a more effective public 
health approach to vision loss prevention and eye health promotion. The 
CDC works to:
  --Promote eye health and prevent vision loss.
  --Improve the health and lives of people living with vision loss by 
        preventing complications, disabilities, and burden.
  --Reduce vision and eye health related disparities.
  --Integrate vision health with other public health strategies.
    Prevent Blindness America requests at least $508,000 million in 
fiscal year 2014 to maintain vision and eye health efforts of the CDC. 
Adequate fiscal year 2014 resources will allow the CDC to continue to 
address the growing public health threat of preventable chronic eye 
disease and vision loss among at-risk and underserved populations 
through increased coordination and integration of vision and eye health 
at State and local health departments, and through community health 
centers and rural services.

    INVESTING IN THE VISION OF OUR NATION'S MOST VALUABLE RESOURCE--
                                CHILDREN

    While the risk of eye disease increases after the age of 40, eye 
and vision problems in children are of equal concern. If left 
untreated, they can lead to permanent and irreversible visual loss and/
or cause problems socially, academically, and developmentally. Although 
more than 12.1 million school-age children have some form of a vision 
problem, only one-third of all children receive eye care services 
before the age of six.\5\
    In 2009, the MCHB established the National Center for Children's 
Vision and Eye Health (the Center), a national vision health 
collaborative effort aimed at developing the public health 
infrastructure necessary to promote eye health and ensure access to a 
continuum of eye care for young children.
    The Center has established a National Advisory Committee of experts 
in ophthalmology, optometry, pediatrics, public health, childcare, 
academia, family advocacy, and others who have a stake in the field of 
children's vision. Members of the National Advisory Committee provide 
recommendations toward national guidelines for quality improvement 
strategies, vision screening and developing a continuum of children's 
vision and eye health. In addition, they serve as advisors to the 
Center as it pursues its goals and objectives. With this support the 
Center, will continue to:
  --Provide national leadership in dissemination of best practices, 
        infrastructure development, professional education, and 
        national vision screening guidelines that ensure a continuum of 
        vision and eye health care for children;
  --Advance State-based performance improvement systems, screening 
        guidelines, and a mechanism for uniform data collection and 
        reporting; and
  --Provide technical assistance to States in the implementation of 
        strategies for vision screening, establishing quality 
        improvement measures, and improving mechanisms for 
        surveillance.
    Prevent Blindness America also requests at least $640 million in 
fiscal year 2014 to sustain programs under the MCH Block Grant. The MCH 
Block Grant enables States to expand critical health care services to 
millions of pregnant women, infants and children, including those with 
special health care needs. In addition to direct services, the MCH 
Block Grant supports vital programs, preventive and systems building 
services needed to promote optimal health.

            ADVANCE AND EXPAND VISION RESEARCH OPPORTUNITIES

    Prevent Blindness America calls upon the subcommittee to provide 
$730 million for the NEI to bolster its efforts to identify the 
underlying causes of eye disease and vision loss, improve early 
detection and diagnosis of eye disease and vision loss, and advance 
prevention and treatment efforts. Research is critical to ensure that 
new treatments and interventions are developed to help reduce and 
eliminate vision problems and potentially blinding eye diseases facing 
consumers across the country.
    Through additional support, the NEI will be able to continue to 
grow its efforts to:
  --Expand capacity for research, as demonstrated by the significant 
        number of high-quality grant applications submitted in response 
        to the American Recovery and Reinvestment Act opportunities.
  --Address unmet need, especially for programs of special promise that 
        could reap substantial downstream benefits.
  --Fund research to reduce healthcare costs, increase productivity, 
        and ensure the continued global competitiveness of the United 
        States.
    By providing additional funding for the NEI at the NIH, essential 
efforts to identify the underlying causes of eye disease and vision 
loss, improve early detection and diagnosis of eye disease and vision 
loss, and advance prevention, treatment efforts and health information 
dissemination will be bolstered.

                               CONCLUSION

    On behalf of Prevent Blindness America, our Board of Directors, and 
the millions of people at risk for vision loss and eye disease, we 
thank you for the opportunity to submit written testimony regarding 
fiscal year 2014 funding for the CDC's vision and eye health efforts, 
the MCHB's National Center for Children's Vision and Eye Health, and 
the NEI. Please know that Prevent Blindness America stands ready to 
work with the subcommittee and other Members of Congress to advance 
policies that will prevent blindness and preserve sight. Please feel 
free to contact us at any time; we are happy to be a resource to 
subcommittee members and your staff. We very much appreciate the 
subcommittee's attention to--and consideration of--our requests.
---------------------------------------------------------------------------
    \1\ ``Vision Problems in the U.S.: Prevalence of Adult Vision 
Impairment and Age-Related Eye Disease in America,'' Prevent Blindness 
America and the National Eye Institute, 2008.
    \2\ Ibid.
    \3\ Ibid
    \4\ Ibid.
    \5\ ``Our Vision for Children's Vision: A National Call to Action 
for the Advancement of Children's Vision and Eye Health, Prevent 
Blindness America,'' Prevent Blindness America, 2008.
---------------------------------------------------------------------------
                                 ______
                                 
   Prepared Statement of the Pulmonary Hypertension Association (PHA)

PHA fiscal year 2014 LHHS Appropriations Recommendations:
  --Protect Federal medical research and patient care programs from 
        devastating funding cuts through sequestration and deficit 
        reduction activities.
  --$7 billion for HRSA, an increase of $500 million over fiscal year 
        2012.
  --$7.8 billion for CDC, an increase of $1.7 billion over fiscal year 
        2012, including a proportional increase for the National Center 
        for Chronic Disease Prevention and Health Promotion (NCCDPHP).
  --$32 billion for NIH, an increase of $1.3 billion over fiscal year 
        2012, including proportional increases for the National Heart, 
        Lung, and Blood Institute (NHLBI); National Center for 
        Advancing Translational Sciences (NCATS); Office of Rare 
        Diseases Research (ORDR); Office of the Director (OD); and 
        other NIH Institutes and Centers to facilitate adequate growth 
        in the PH research portfolio.
    Chairman Harkin, Ranking Member Moran, and distinguished members of 
the subcommittee, thank you for the opportunity to submit testimony on 
behalf of PHA. It is my honor to represent the hundreds of thousands of 
Americans who are affected by the devastating disease pulmonary 
hypertension (PH).
    PHA has served the PH community for over 20 years. In 1990, three 
PH patients found each other with the help of the National Organization 
for Rare Disorders and shortly thereafter founded PHA. At that time, 
the condition was largely unknown amongst the general public and within 
the medical community; there were fewer than 200 diagnosed cases of the 
disease. Since then, PHA has grown into a nationwide network of over 
20,000 members and supporters, including over 240 support groups across 
the country.
    PHA is dedicated to improving treatment options and finding cures 
for PH, and supporting affected individuals through coordinated 
research, education, and advocacy activities. Since 1996, nine 
medications for the treatment of PH have been approved by the Food and 
Drug Administration (FDA), eight of those since 2001. These innovative 
treatment options represent important steps forward in the medical 
understanding of PH and the care of PH patients, but more needs to be 
done to end the suffering caused by this disease. PH remains a serious 
and life-altering condition.
    PH is a debilitating and often fatal condition where the blood 
pressure in the lungs rises to dangerously high levels. In PH patients, 
the walls of the arteries that take blood from the right side of the 
heart to the lungs thicken and constrict. As a result, the right side 
of the heart has to pump harder to move blood into the lungs, causing 
it to enlarge and ultimately fail. Symptoms of PH include shortness of 
breath, fatigue, chest pain, dizziness and fainting.
    PH can be idiopathic, and occur without a known cause, or be 
secondary to other conditions, such as HIV, scleroderma, lupus, blood 
clots, sickle cell, and liver disease. While PH impacts individuals of 
all races, genders, and ages, preliminary data from the Registry to 
Evaluate Early and Long Term Pulmonary Arterial Hypertension Disease 
Management (REVEAL Registry) suggests that women develop PH at a 4:1 
ratio to men.
    PH is a chronic condition that is costly in terms of quality of 
life and healthcare expenditures. The symptoms of PH are frequently 
misdiagnosed, leaving patients with the false impression that they have 
a minor pulmonary or cardiovascular condition. By the time many 
patients receive an accurate diagnosis, the disease has progressed to a 
late stage, which makes it difficult if not impossible to treat, even 
with drastic action such as a heart or lung transplant. While PH 
remains incurable with a poor survival rate, new treatment options are 
improving lives and enabling some patients to manage their condition 
for 20 years or longer.
    I would like to extend my sincere gratitude to the subcommittee for 
your historic support of PH programs at HRSA, CDC, and NIH. Thanks to 
your leadership, the PH research portfolio at NIH has advanced and 
improved our understanding of the disease, and awareness of PH by the 
general public has led to earlier diagnosis and improved health 
outcomes for patients. Please continue to support PH activities moving 
forward.

Deficit Reduction and Sequestration
    Our Nation's investment in biomedical research, particularly 
through NIH, is an engine that drives economic growth while improving 
health outcomes for patients. NIH supports a significant research 
portfolio in pulmonary hypertension with critical research activities 
conducted at academic health centers across the country. The Federal 
commitment to this research portfolio has been the catalyst behind 
major breakthroughs that have improved our scientific understanding of 
PH and led to better health and healthcare for PH patients.
    While meaningful progress has been made, PH remains a fatal 
condition and researchers across the country continue to work towards 
the goal of finding a cure. If Federal funding for NIH is substantially 
reduced, the current effort to capitalize on recent advancements and 
improve treatment options will face a serious setback. Ongoing research 
projects, including those being conducted at academic health centers 
across the country, will stall and critical new research projects will 
not be initiated.
    In addition, reducing support for Federal biomedical research 
efforts sends a powerful message to the next generation about our 
country's lack of commitment to this field. Many talented young people 
interested in biomedical research will seek other career paths. Those 
who become the next generation of researchers will face increased 
competition for their talents from foreign competitors who are 
investing in their biomedical research infrastructure.
    Over the past 15 years, 9 therapies indicated to treat PH have been 
developed by industry and approved by FDA. PH is a chronic, disabling, 
and often fatal condition and the advent of current therapies has 
extended life and improved quality of life for individuals with the 
disease. However, the treatments are complex and come with significant 
side effect profiles. Moreover, current therapies do not completely 
restore affected individuals, which means that a life with PH can be 
difficult for both patients and caregivers.
    More work is in progress in this area, but if healthcare programs 
endure significant funding cuts, PH patients may see few improvements. 
Funding cuts to discretionary health programs have the potential to 
drastically limit resources at FDA, undermining the agency's efforts to 
facilitate expeditious treatment development and potentially impair 
current oversight activities. Further, any cuts to the Centers for 
Medicare and Medicaid Services (CMS) have the potential to jeopardize 
access to care for PH patients by creating cost-driven barriers to 
available therapies.
    As you work with your colleagues in Congress on deficit, budget, 
and appropriations issues please support the PH community by actively 
pursuing meaningful funding increases for critical medical research and 
healthcare programs.

Health Resources and Services Administration
    PHA asks that you support HRSA by providing the agency with a 
meaningful funding increase of $500 million in fiscal year 2014. Such a 
funding increase would allow the agency to initiate important new 
activities such as partnering with the PH experts to improve the 
criteria for determining lung and heart-lung transplantation for PH 
patients. We ask for your leadership in encouraging HRSA, specifically 
the United Network for Organ Sharing, to engage in active and 
meaningful dialogue with medical experts at the REVEAL Registry. Such a 
dialogue has the potential to improve the methodology used to determine 
lung transplantation eligibility for PH patients and to improve 
survivability and health outcomes following a transplantation 
procedure.

Centers for Disease Control and Prevention
    PHA joins other voluntary health groups in requesting that you 
support CDC by providing the agency with an appropriation of $7.8 
billion in fiscal year 2014. Such a funding increase would allow CDC to 
undertake critical PH education and awareness activities, which would 
promote early detection and appropriate intervention for PH patients.
    We are grateful to the subcommittee for providing past support of 
PHA's Pulmonary Hypertension Awareness Campaign. We know for a fact 
that Americans are dying due to a lack of awareness of PH and a lack of 
understanding about the many new treatment options. This unfortunate 
reality is particularly true among minority and underserved populations 
and citizens in rural areas remote from medical centers with PH 
expertise. More needs to be done to educate both the general public and 
healthcare providers if we are to save lives.
    To that end, PHA has utilized the funding provided through the CDC 
to 1) launch a successful media outreach campaign focusing on both 
print and online outlets 2) expand our support programs for previously 
underserved patient populations and 3) establish PHA Online University, 
an interactive curriculum-based website for medical professionals that 
targets pulmonary hypertension experts, primary care physicians, 
specialists in pulmonology/cardiology/rheumatology, and allied health 
professionals. The site is continually updated with information on 
early diagnosis and appropriate treatment of pulmonary hypertension. It 
serves as a center point for discussion among PH-treating medical 
professionals and offers Continuing Medical Education and CEU credits 
through a series of online classes.
    Early diagnosis of PH and timely intervention with innovative 
therapies can significantly improve health outcomes for PH patients. In 
some instances, early intervention can mitigate the need for more 
drastic treatment and costly treatment options, like heart-lung 
transplantation. In order to promote early recognition and accurate 
diagnosis, PHA asks the subcommittee to provide CDC with additional 
funding in fiscal year 2014 so that important PH education and 
awareness activities can be initiated through NCCDPHP.

National Institutes of Health
    PHA joins the public health community in requesting that you 
support NIH by providing the agency with an appropriation of $32 
billion in fiscal year 2014. This modest funding increase would ensure 
that biomedical research inflation does not result in a loss of 
purchasing power at NIH, critical new initiatives like the Cures 
Acceleration Network (CAN) are adequately supported, and the PH 
research portfolio can continue to progress.
    Less than two decades ago, a diagnosis of PH was essentially a 
death sentence, with only one approved treatment for the disease. 
Thanks to advancements made through the public and private sector, 
patients today are living longer and better lives with a choice of nine 
FDA approved medications. Sustained investment in basic, translational, 
and clinical research can ensure that we capitalize on recent 
advancement and emerging opportunities to speed the discovery of 
improved treatment options and cures.
    Expanding clinical research remains a top priority for patients, 
caregivers, and PH investigators. We are particularly interested in 
establishing a pulmonary hypertension research network. Such a network 
would link leading researchers around the United States, providing them 
with access to a wider pool of shared patient data. In addition, the 
network would provide researchers with the opportunities to collaborate 
on studies and to strengthen the connections between basic and clinical 
science in the field of pulmonary hypertension research. Such a network 
is in the tradition of the NHLBI, which, to its credit and to the 
benefit of the American public, has supported numerous similar networks 
including the Acute Respiratory Distress Syndrome Network and the 
Idiopathic Pulmonary Fibrosis Clinical Research Network. We ask that 
you provide NHLBI with sufficient resources and encouragement to move 
forward with the establishment of a PH network in fiscal year 2014.
    We applaud the recent establishment of NCATS at NIH. Housing 
translational research activities at a single Center at NIH will allow 
these programs to achieve new levels of success. Initiatives like CAN 
are critical to overhauling the translational research process and 
ensuring that more breakthroughs in basic research are developed into 
meaningful diagnostic tools and treatment options that directly benefit 
patients. In addition, new efforts like taking the lead on drug 
repurposement hold the potential to speed new treatment to patients, 
particularly patients who struggle with rare or neglected diseases. We 
ask that you support NCATS and provide adequate resources for the 
Center in fiscal year 2014.
    Thank you for your time and your consideration of our requests. 
Please contact me if you have any questions or if you require any 
additional information.
                                 ______
                                 
 Prepared Statement of the Research Working Group of the Federal AIDS 
                     Policy Partnership--April 2013

    Chairman Harkin, Ranking Member Moran, and Members of the 
Committee, thank you for the opportunity to provide testimony on the 
National Institutes of Health (NIH) budget overall and for AIDS 
research in fiscal year 2014 (fiscal year 2014). Tomorrow's scientific 
and medical breakthroughs depend on your vision, leadership, and 
commitment to robust NIH funding this year. To this end, the Research 
Working Group (RWG) urges this Committee to support--at minimum--a 
funding target of $35.98 billion in fiscal year 2014 to maintain the 
United States' position as the world leader in medical research and 
innovation.
    Investments in health research via the NIH have paid enormous 
dividends in the health and wellbeing of people in the U.S. and around 
the world. NIH-funded HIV and AIDS research has supported innovative 
basic science for better drug therapies, evidence-based behavioral and 
biomedical prevention interventions, and vaccines that have saved and 
improved the lives of millions, and holds great promise for 
significantly reducing HIV infection rates and providing more effective 
treatments for those living with HIV/AIDS in the coming decade.
    Despite these advances, the number of new HIV/AIDS cases continues 
to rise in various populations in the U.S. and around the world. There 
are over one million HIV-infected people in the U.S., the highest 
number in the epidemic's 31-year history; additionally over 50,000 
Americans become newly infected every year. The evolving HIV epidemic 
in the U.S. disproportionately affects the poor, sexual and racial 
minorities, and the most disenfranchised and stigmatized members of our 
communities. However, with proper funding coupled with the promotion of 
evidence-based policies, we can capitalize on the ongoing scientific 
progress in prevention science, vaccines, and finding a cure for HIV, 
as well as addressing the comorbid illnesses such as viral hepatitis 
and tuberculosis that affect patients with HIV.
    Major advances over the last few years in HIV prevention 
technologies--in particular with microbicides, HIV vaccines, 
circumcision, antiretroviral treatment as prevention, and pre-exposure 
prophylaxis (PrEP) using antiretrovirals--demonstrate that adequately 
resourced NIH programs can transform our lives. Federal support for 
AIDS research has also led to new treatments for other diseases, 
including cancer, heart disease, Alzheimer's, hepatitis, osteoporosis, 
and a wide range of autoimmune disorders. Over the years, the NIH has 
sponsored the evaluation of a host of vaccine candidates, some of which 
are advancing to efficacy trials. The successful iPrEx and HPTN 052 
trials have shown the potential of antiretroviral drugs to prevent HIV 
infection. Moreover, increased funding will support the future testing 
of new microbicides and therapeutics in the pipeline via the 
implementation of a newly restructured, cross-cutting HIV clinical 
trials network that translates NIH-funded scientific innovation into 
critical quality-of-life gains for those most affected with HIV.
    It is also essential to note that NIH-funded HIV pathogenesis and 
clinical research has contributed substantially to our understanding of 
potential curative approaches. These include, but are not limited to, 
therapeutic vaccines and other immune-system modulators, gene 
therapies, and drugs that can purge HIV from its various reservoirs in 
the body. These candidates, many of which are now being further 
explored in human studies, are the culmination of nearly three decades 
of steadfast public support for basic science and pilot-phase 
research--support that must continue if we are to end the epidemic once 
and for all.
    Increased funding for the NIH in fiscal year 2014 makes good 
bipartisan economic sense, especially in shaky times. Robust funding 
for the NIH overall will enable research universities to pursue 
scientific opportunity, advance public health, and create jobs and 
economic growth. In every State across the country, the NIH supports 
research at hospitals, universities, private enterprises, and medical 
schools. This includes the creation of jobs that will be essential to 
future discovery. Sustained investment is also essential to train the 
next generation of scientists and prepare them to make tomorrow's HIV 
discoveries. NIH funding puts 350,000 scientists to work at research 
institutions across the country. According to the NIH, each of its 
research grants creates or sustains six to eight jobs, and NIH-
supported research grants and technology transfers have resulted in the 
creation of thousands of new, independent private-sector companies. 
Strong, sustained NIH funding is a critical national priority that will 
foster better health and economic revitalization.
    Since 2003, funding for the NIH has failed to keep up with our 
existing research needs--damaging the success rate of approved grants 
and leaving very little money to fund promising new research. The real 
value of the increases prior to 2003 has been precipitously reduced 
because of the relatively higher inflation rate for the cost of 
research and development activities undertaken by the NIH. According to 
the Biomedical Research and Development Price Index, which calculates 
how much the NIH budget must change each year to maintain purchasing 
power, between fiscal year 2003 and fiscal year 2011, the cost of NIH 
activities increased by 32.8 percent. By comparison, the overall NIH 
budget increased by $3.6 billion, or 13.4 percent, over fiscal year 
2003. So in real terms, the NIH has already sustained budget decreases 
of close to 20 percent over the past decade due to inflation alone. As 
such, any further cuts to NIH on top of sequestration will have the 
clear and devastating effects of undermining our Nation's leadership in 
health research and our scientists' ability to take advantage of the 
expanding opportunities to advance health care. The race to find better 
treatments and a cure for cancer, heart disease, AIDS, and other 
diseases, and for controlling global epidemics like AIDS, tuberculosis, 
and malaria, all depend on a robust long-term investment strategy for 
health research at NIH.
    In conclusion, the RWG calls on Congress to continue the bipartisan 
Federal commitment towards combating HIV as well as other chronic and 
life-threatening illnesses by increasing funding for the NIH to $35.98 
billion in fiscal year 2014, including funds for transfer to the Global 
Fund for HIV/AIDS, Tuberculosis and Malaria. A meaningful commitment to 
stemming the epidemic and securing the well being of people with HIV 
cannot be met without prioritizing the research investment at the NIH 
that will lead to tomorrow's lifesaving vaccines, treatments, and 
cures. Thank you for the opportunity to provide these written comments.
                                 ______
                                 
               Prepared Statement of Rotary International

    Chairman Harkin, members of the subcommittee, Rotary International 
appreciates this opportunity to submit testimony in support of the 
polio eradication activities of the U. S. Centers for Disease Control 
and Prevention (CDC). The Global Polio Eradication Initiative (GPEI) is 
an unprecedented model of cooperation among national Governments, civil 
society and UN agencies working together to reach the most vulnerable 
children through a safe, cost-effective public health intervention of 
polio immunization, one which is increasingly being combined with 
opportunistic, complementary interventions such as the distribution of 
life-saving vitamin A drops. For fiscal year 2014 Rotary International 
is seeking $146.3 million for the polio eradication efforts of the CDC 
to support full implementation of the polio eradication strategies and 
innovations outlined in the new Polio Eradication and Endgame Strategic 
Plan (2013-2018).

Progress in the Global Program to Eradicate Polio
    Significant strides were made toward polio eradication in 2012 
thanks to this committee's leadership in appropriating funds for the 
polio eradication activities of the CDC.
  --India has not had a case of polio for more than 2 years.
  --Eradication efforts have led to more than a 99 percent decrease in 
        cases since the launch of the GPEI in 1988. In 2012 there were 
        fewer cases in fewer places than at any point in recorded 
        history with only 223 cases of polio--a 65 percent decrease 
        compared to 2011. All but six of these cases were in the three 
        remaining polio endemic countries of Afghanistan, Pakistan, and 
        Nigeria. Countries will remain at risk for outbreaks until 
        polio has been eradicated in the remaining places where it 
        persists.
  --As of 1 May 2013, only 24 cases of polio have been reported in 2013 
        (50 percent the level of 2012).
  --Incidence of type 3 polio is at historically low levels. Pakistan 
        has not reported a case of type 3 polio for 1 year and Nigeria 
        is now the only country with type 3 poliovirus circulation.
  --Angola and the Democratic Republic of Congo, two of four countries 
        considered to have reestablished transmission of polio, 
        reported no cases of polio in 2012. Chad, another of the 
        reestablished transmission countries has not reported a case of 
        polio since June of 2012.
    A new Polio Eradication and Endgame Strategic Plan (2013-2018) lays 
out the strategies for the certification of the eradication of wild 
poliovirus by 2018 at a total global cost of U.S. $5.5 billion. This 
new plans builds on the lessons learned from the successful eradication 
of polio to date and the substantial advances in technology in 2012. 
The timely availability of funds remains essential to the achievement 
of a polio free world. The United States has been the leading public 
sector donor to the Global Polio Eradication Initiative. Members of 
U.S. Rotary clubs appreciate the United States' generous support. 
However, this support has declined as a proportion of the GPEI 
expenditures from approximately 19 percent just 5 years ago to 13 
percent in 2012. A resumption of funding to the earlier 19 percent 
level would ensure vital funding for the GPEI and send a strong signal 
of continued leadership and commitment by the United States as the new 
strategic plan is implemented. Notably, funding provided by the polio 
affected countries themselves and by private sector donors--led by 
Rotary International and the Bill & Melinda Gates Foundation, has 
increased in recent years. The ongoing support of donor countries, like 
the United States, is essential to assure the necessary human and 
financial resources are made available to polio-endemic and at risk 
countries to take advantage of the window of opportunity to forever rid 
the world of polio. Continued leadership of the United States is 
essential to capitalize on past progress and certify the world polio 
free by the end of 2018.

The Role of Rotary International
    Rotary International, a global association of more than 34,000 
Rotary clubs in more than 170 countries with a membership of over 1.2 
million business and professional leaders (more than 345,000 of which 
are in the U.S.), has been committed to battling polio since 1985. 
Rotary International has contributed more than U.S. $1.2 billion toward 
a polio free world--representing the largest contribution by an 
international service organization to a public health initiative ever. 
Rotary also leads the United States Coalition for the Eradication of 
Polio, a group of committed child advocates that includes the March of 
Dimes Foundation, the American Academy of Pediatrics, the Task Force 
for Global Health, the United Nations Foundation, and the U.S. Fund for 
UNICEF. These organizations join us in thanking you for your support of 
the GPEI.

The Role of the U.S. Centers For Disease Control and Prevention
    Rotary commends CDC for its leadership in the global polio 
eradication effort, and greatly appreciates the subcommittee's support 
of CDC's polio eradication activities. The United States is the leader 
among donor nations in the drive to eradicate this crippling disease. 
Congressional support, in fiscal year 2012 and fiscal year 2013 enabled 
CDC to:
  --continue engagement of the Emergency Operations Center (EOC) to 
        harness agency-wide technical expertise to implement the 
        agency's polio response in a rapid and efficient manner;
  --develop a ``dash board'' monitoring system to collect, analyze, and 
        visualize key indicators of campaign performance in real time 
        to identify and address issues in advance to ensure high 
        quality campaigns. This system, modeled on lessons from India 
        and Pakistan, was piloted in Nigeria in July 2012 in 11 States 
        and then fully implemented during the October campaigns.
  --implement a nomad strategy in Nigeria which identified more than 
        560,000 children under 5 years old through census taking 
        activities; reached more than 22,000 settlements with polio 
        vaccine; and identified more than 4,000 settlements never 
        visited by a vaccination team.
  --provide the trained and experienced human resources to strengthen 
        detection of polioviruses through the Stop Transmission of 
        Polio (STOP) volunteer consultants. Since the December 2, 2011 
        EOC activation, the STOP program has deployed more than 500 
        individuals in 33 countries. CDC also developed the National 
        STOP program (NSTOP) to build local capacity by recruiting 
        highly trained public health professionals to work at the State 
        and local levels to support polio eradication. In Nigeria, 
        NSTOP is an innovative strategy that has deployed 70 staff 
        across northern polio affected States.
  --purchase 195 million doses of oral polio vaccine for use in polio 
        campaigns in 2012;
  --conduct AFP surveillance reviews, and support WHO Expanded Program 
        on Immunization (EPI) reviews; and
  --provide technical and programmatic assistance to the global polio 
        laboratory network through the Polio Laboratory in CDC's 
        Division of Viral Diseases. CDC's labs provide critical 
        diagnostic services and genomic sequencing of polioviruses to 
        help guide disease control efforts. CDC will continue to serve 
        as the global reference laboratory, while expanding 
        environmental surveillance in countries to serve as a ``safety 
        measure'' to detect any polioviruses circulating in areas 
        without cases.
    Continued funding will allow CDC to fully capitalize on the 
resources of the Emergency Operation Center to provide direct support 
and build capacity to continue intense supplementary immunization 
activities in the remaining polio-affected countries, continue 
leadership on data management to drive evidence-based decisionmaking, 
and continue to implement strategies to increase effective management 
and accountability. These funds will also help maintain essential 
certification standard surveillance.

Benefits of Polio Eradication
    Since 1988, over 10 million people who would otherwise have been 
paralyzed are walking because they have been immunized against polio. 
Tens of thousands of public health workers have been trained to manage 
massive immunization programs and investigate cases of acute flaccid 
paralysis. Cold chain, transport and communications systems for 
immunization have been strengthened. The global network of 145 
laboratories and trained personnel established by the GPEI also tracks 
measles, rubella, yellow fever, meningitis, and other deadly infectious 
diseases and will do so long after polio is eradicated.
    A study published in the November 2010 issue of the journal Vaccine 
estimates that the GPEI could provide net benefits of at least $40-50 
billion. Polio eradication is a cost-effective public health investment 
with permanent benefits. On the other hand, as many as 200,000 children 
could be paralyzed in the next 10 years if the world fails to 
capitalize on the more than $9 billion already invested in eradication. 
Success will ensure that the significant investment made by the U.S., 
Rotary International, and many other countries and entities, is 
protected in perpetuity.

  ROTARY INTERNATIONAL AND THE ROTARY FOUNDATION PUBLIC DISCLOSURE OF FEDERAL GRANT FUNDS RECEIVED FROM OCTOBER
                                            2008 TO JANUARY 31, 2013
              [Funds reported in the fiscal year they were received, in thousands of U.S. dollars]
----------------------------------------------------------------------------------------------------------------
                                     Agency/
         Organization              Subcontract         Program       Contract Term,      Fiscal Year     Funding
                                    Agreement                         Value, Period      (July-June)    Received
----------------------------------------------------------------------------------------------------------------
Rotary International..........  Open World        Open World        Annual, budget    \1\ Fiscal year        160
                                 Leadership        Program.          submitted and     2009.                 240
                                 Center.                             approved         Fiscal year 2010       231
                                                                     annually.        Fiscal year 2011       289
                                                                                      Fiscal year 2012        20
                                                                                      \2\ Fiscal year
                                                                                       2013.
                                                                                                       ---------
      Total...................  ................  ................  ................  ................       940
----------------------------------------------------------------------------------------------------------------
Rotary International..........  U.S. Agency for   Supportive        45 months         Fiscal Year 2011        --
                                 International     Environments      commencing May   Fiscal Year 2012       123
                                 Development.      for Health        2011; Award      \2\ Fiscal Year         95
                                (Cost              (WASHPlus).       ceiling           2013.
                                 Reimbursable                        $667,292;
                                 Subagreement                        contract ending
                                 with FHI                            January 2015.
                                 Development 360
                                 LLC).
                                                                                                       ---------
      Total...................  ................  ................  ................  ................       218
----------------------------------------------------------------------------------------------------------------
Rotary International..........  U.S. Agency for   Environmental     18 months         \1\ Fiscal Year         59
                                 International     Health            commencing May    2009.                 102
                                 Development.      Indefinite        2008, $215,000;  Fiscal Year 2010        54
                                (Task Order        Quantity          contract         Fiscal Year 2011
                                 Subcontract       Contract.         completed in
                                 agreement with   (EH IQC). CLIN 3   November 2010.
                                 CDM               Water
                                 International     Sanitation and
                                 Inc).             Hygiene
                                                   Technical
                                                   Assistance
                                                   (WASHTA).
                                                                                                       ---------
      Total...................  ................  ................  ................  ................       215
----------------------------------------------------------------------------------------------------------------
Rotary International..........  U.S. Agency for   World Peace       One year          \1\ Fiscal Year         25
                                 International     Fellow Pilot      commencing        2009.                  25
                                 Development.      Internship        September 2008,  Fiscal Year 2010
                                                   Program.          $50,000;
                                                                     contract
                                                                     completed in
                                                                     September 2009.
                                                                                                       ---------
      Total...................  ................  ................  ................  ................        50
----------------------------------------------------------------------------------------------------------------
Total funding by Fiscal Year                                                          \1\ Fiscal Year        244
 for Rotary International and                                                          2009.                 367
 The Rotary Foundation:.                                                              Fiscal Year 2010       285
                                                                                      Fiscal Year 2011       412
                                                                                      Fiscal Year 2012       115
                                                                                      \2\ Fiscal Year
                                                                                       2013.
                                                                                                       ---------
                                                                                                           1,423
----------------------------------------------------------------------------------------------------------------
\1\ Fiscal Year 2009 figures starting October 1, 2008.
\2\ Fiscal Year 2013 figures as of January 31, 2013.

      
                                 ______
                                 
    Prepared Statement of the Ryan White Medical Providers Coalition

Introduction

    My name is James L. Raper, DSN, CRNP, JD, FAANP, FAAN; Director, 
1917 HIV/AIDS Outpatient Clinic at the University of Alabama at 
Birmingham; and Immediate Past Co-Chair of the Ryan White Medical 
Providers Coalition. I respectfully submit testimony on behalf of the 
1917 HIV/AIDS Outpatient Clinic at the University of Alabama at 
Birmingham and the Ryan White Medical Providers Coalition, which I co-
chaired from 2010-2013. Thank you for the opportunity to describe the 
lifesaving HIV/AIDS care and treatment provided by Ryan White Part C 
funded programs, including my own clinic.
    The 1917 Clinic is a dedicated, not-for profit outpatient HIV/AIDS 
medical and dental clinic established in 1988 at the University of 
Alabama at Birmingham. Ryan White Part C funding provides critical 
assistance in helping the clinic meet the needs of our patients. Today, 
35 percent of the 1917 Clinic's patients are uninsured and would be at 
risk for losing access to lifesaving services without Ryan White 
Program funding.
    The 1917 Clinic provides comprehensive outpatient HIV primary care 
services to residents of Jefferson, Walker, Winston, Cullman, Blount, 
St. Clair, and Shelby counties. Although our service area technically 
includes only these seven counties, we serve people with HIV/AIDS 
throughout Alabama and its neighboring States. In February 2013, the 
1917 Clinic absorbed 800+ new patients from the previously Ryan White 
Part C funded Cooper Green Hospital's St. Georges' Clinic, which closed 
on January 31, 2013. The 1917 Clinic is now providing care to 30 
percent of all known adults living with HIV/AIDS in Alabama.
    The clinic offers the range of primary care and social services 
critical to successful HIV treatment, including primary medical and 
oral health care; on-site case management; mental health and substance 
abuse treatment services; onsite access to clinical trials; adherence, 
spiritual, risk reduction, and nutrition counseling; infusion therapy, 
coordination of hospital discharge planning, and home health care/
hospice referral. To avoid emergency room visits, the 1917 Clinic 
provides `sick call' services five days a week. Subspecialty care is 
available at the University's Kirklin Clinic--which is located just two 
blocks from the 1917 Clinic.
    In addition to critical funding that Ryan White Part C provides 
through direct Federal grants for comprehensive medical care programs 
like the 1917 Clinic, most Ryan White Part C clinics (including the 
1917 Clinic) also receive support from other parts of the Ryan White 
Program. Those funds help provide access to medication, additional 
medical care, dental services; and key support services, such as case 
management and transportation, all of which are essential components of 
highly effective Ryan White HIV care that results in excellent outcomes 
for our patients.
    Adequate funding of the Ryan White Program is essential to 
providing both effective and efficient care for individuals living with 
HIV/AIDS, and I thank the subcommittee for its support of the Ryan 
White Part C Program. And while I am grateful for this support, and 
understand that times are tough, I request $236.6 million for Ryan 
White Part C programs in fiscal year 2014. While I know that this is a 
lot of funding, it is in fact well below the estimated need. Ryan White 
medical providers will spend these dollars effectively and efficiently 
caring for patients and achieving excellent health and cost outcomes.

Ryan White Part C Programs Support Comprehensive, Expert and Effective 
        HIV Care
    Part C of the Ryan White Program funds comprehensive, expert and 
effective HIV care and treatment--services that are directly 
responsible for the dramatic decrease in AIDS-related mortality and 
morbidity over the last decade. The Ryan White Program supported the 
development of expert HIV care and treatment programs that have become 
patient-centered medical homes for individuals living with this 
serious, chronic condition. In 2011, a ground-breaking clinical trial--
named the ``scientific breakthrough of the year'' by Science magazine--
found that HIV treatment not only saves the lives of people with HIV, 
but also reduces HIV transmission by more than 96%--proving that HIV 
treatment is also HIV prevention.
    The comprehensive, expert HIV care model that is supported by the 
Ryan White Program has been highly successful at achieving positive 
clinical outcomes with a complex patient population.\1\ In a 
convenience sample of eight Ryan White-funded Part C programs ranging 
from the rural South to the Bronx, retention in care rates ranged from 
87 to 97 percent. In estimates from the Centers for Disease Control and 
Prevention (CDC)--only 37 percent of all people with HIV are in regular 
care nationally.\2\ Once in care, patients served at Ryan White-funded 
clinics do well--with 75 to 90 percent having undetectable levels of 
the virus in their blood. This is much higher than the estimate from 
the CDC that just 25 percent of all people living with HIV in the U.S. 
are virally suppressed.

Investing in Ryan White Part C Programs Saves Both Lives and Money
    Early and reliable access to HIV care and treatment both helps 
patients with HIV live relatively healthy and productive lives and is 
more cost effective. One study from the 1917 Clinic found that patients 
treated at the later stages of HIV disease required 2.6 times more 
health care dollars than those receiving earlier treatment meeting 
Federal HIV treatment guidelines. On average it costs $3,501 per person 
per year to provide the comprehensive outpatient care and treatment 
available at Part C funded programs. The comprehensive services 
provided often include lab work, STI/TB/Hepatitis screening, ob/gyn 
care, dental care, mental health and substance abuse treatment, and 
case management.

Current Challenges--Future Promise
    However, this effective and comprehensive HIV care model is not 
completely supported by Medicaid or most private insurance. While many 
Ryan White Program clients have some form of insurance coverage, 
without the Ryan White Program, they would risk falling out of care. 
Barriers include poor reimbursement rates; benefits designed for 
healthier populations that fail to cover critical services, such as 
care coordination; and inadequate coverage for other important 
services, such as extended medical visits, mental health and substance 
use treatment. Full implementation of the Patient Protection and 
Affordable Care Act plus continuation of the Ryan White Program will 
dramatically improve health access and outcomes for many more people 
living with HIV disease.

Ryan White Programs Are Struggling to Meet Demand
    Additionally, as a result of funding cuts and shortfalls, as well 
as increased patient demand, a 2012 Ryan White Medical Providers 
Coalition (RWMPC) survey of over 100 Ryan White Part C providers 
nationwide demonstrated that approximately half of the programs 
surveyed had to make cuts or other program changes. More specifically:
  --54 percent reported that they reduced or cut services, including 27 
        percent that reduced or cut support for medications, and 19 
        percent that reduced coverage for laboratory monitoring;
  --40 percent report longer wait times for new and/or existing patient 
        appointments;
  --31 percent laid off staff and 30 percent froze hiring.
  --8 percent closed their clinics to new patients.
    Upon the implementation of sequestration and other funding cuts, 
Ryan White Part C clinics indicated in the RWMPC survey that they would 
need to make additional reductions, including:
  --66 percent of clinics further cutting or reducing services;
  --57 percent further cutting staff; and
  --13 percent closing their clinics to new patients.

Fully Funding and Maintaining Ryan White Part C Programs Is Essential
    Because of both the inadequacy of insurance coverage for people 
with complex conditions like HIV and the fact that some individuals 
will remain uncovered, even after Patient Protection & Affordable Care 
Act implementation, fully funding and maintaining the Ryan White 
Program is essential to providing comprehensive, expert and effective 
HIV care nationwide.
    While RMWPC understands the difficulty of the current economic 
climate, reducing funding for HIV care and treatment is not cost-
effective, will hamper the ability of Ryan White Part C programs to 
achieve the best possible patient outcomes and may fail to prevent new 
infections thereby jeopardizing our Nation's ability to capitalize on 
recent scientific breakthroughs that could move us toward an AIDS-free 
generation. Without ready access to comprehensive, expert, and 
effective HIV care and treatment, patients will use expensive emergency 
care more, and receive less effective treatment at later stages of HIV 
disease. Restricted access to effective HIV care and treatment also 
will result in reduced rates of retention in care, resulting in 
increased patient viral loads and increased numbers of HIV infections. 
And most importantly, there will be those who will lose their lives 
because they are not able to access these lifesaving services.

Conclusion
    These are challenging economic times. While we recognize the 
significant fiscal constraints Congress faces in allocating limited 
Federal dollars, the significant financial and patient pressures that 
we face in our clinics throughout the United States propel us to make 
the fiscal year 2014 request of $236.6 million for Ryan White Part C 
programs. This funding would help to support medical providers 
nationwide in delivering life-saving, effective HIV/AIDS care and 
treatment to their patients, and save millions is wasted health care 
dollars treating patients too late or in inappropriate, higher cost 
settings.
    Thank you so much for your time and consideration of this request. 
If you have any questions, please do not hesitate to contact me at 
[email protected] or the Ryan White Medical Providers Coalition Convener, 
Jenny Collier, at [email protected].
---------------------------------------------------------------------------
    \1\ See Improvement in the Health of HIV-Infected Persons in Care: 
Reducing Disparities at http://cid.oxfordjournals.org/content/early/
2012/08/24/cid.cis654.full.pdf+html.
    \2\ See CDC's HIV in the United States: The Stages of Care http://
www.cdc.gov/nchhstp/
newsroom/docs/2012/Stages-of-CareFactSheet-508.pdf.
---------------------------------------------------------------------------
                                 ______
                                 
             Prepared Statement of the Safe States Alliance

    The Safe States Alliance, the national membership association 
representing public health injury and violence prevention 
professionals, appreciates the opportunity to provide testimony in 
support of the Centers for Disease Control and Prevention (CDC). Safe 
States Alliance supports the President's request to increase funding 
for the CDC's National Center for Injury Prevention and Control (Injury 
Center) including $20 million for the National Violent Death Reporting 
System (NVDRS), $10 million for firearm violence prevention research, 
and $5 million to evaluate the Rape Prevention and Education Program. 
Additionally, Safe States requests an additional $13 million to support 
the Core Violence and Injury Prevention Program (VIPP), as well as 
restoration of CDC's Preventive Health and Health Services Block Grant 
(Prevent Block Grant) to $100 million.
    In 1985, the Institutes of Medicine (IOM) first called attention to 
the lack of recognition and funding for injury and violence prevention 
(IVP) as a public health issue in the United States.\1\ Although some 
progress has been made in subsequent years, injuries and violence 
continue to have a significant impact on the health of Americans and 
the healthcare system, as injuries remain the leading cause of death 
for Americans ages one to 44.\2\ As a result of injuries and violence, 
more than 29 million people are treated in emergency departments each 
year, two million are hospitalized, and approximately 180,000 people 
die--one person every three minutes. Every 45 minutes, one of those 
preventable deaths is a child.2 In a single year, injuries and violence 
will ultimately cost $406 billion in medical costs and lost 
productivity.\3\ In 2009, CDC estimates that injuries accounted for 
nearly half of all deaths among Americans from age one to 44. This is 
more than deaths from non-communicable diseases and infectious diseases 
combined.\4\
    At the Federal level, the CDC Injury Center serves as the focal 
point for the public health approach to injury and violence prevention. 
Despite the enormous toll of injuries and violence and the existence of 
cost-effective interventions, there is no dedicated and ongoing 
Federal, State, or local funding to adequately respond to these 
problems. The CDC Injury Center only receives 2 percent of the CDC/
Agency for Toxic Substances and Disease Registry (ATSDR) budget to 
address the significant burden of injuries and violence nationwide. In 
fiscal year 2012, the total Injury Center budget was only $137.7 
million, down from $147.8 million in fiscal year 2010. The 5.1 percent 
cut imposed by sequestration further reduces the Injury Center's 
funding by an additional $7 million. The net impact is a 12 percent cut 
to the Injury Center since fiscal year 2010 and a funding level below 
fiscal year 2000 levels.
    Given its limited budget, the CDC Injury Center currently provides 
capacity building grants to only 20 State health departments (SHDs) 
through the Core Violence and Injury Prevention Program (VIPP). Core 
VIPP is comprised of multiple components including: Basic Prevention 
(20 States); Regional Network Leaders (five States); Surveillance 
Quality Improvement (four States); Older Adult Falls Prevention (three 
States); and Motor Vehicle/Child Injury Prevention (four States). With 
an additional investment of just $13 million, the CDC Injury Center 
would be able to support injury and violence prevention programs in all 
States and territories, much as it does for other key public health 
issues, such as infectious and chronic diseases.
    The National Violent Death Reporting System (NVDRS) is a State-
based surveillance system that uses information from a variety of 
States and local agencies and sources--medical examiners, coroners, 
police, crime labs and death certificates--to form a more complete 
picture of the circumstances that surround violent deaths. As a result, 
NVDRS has enabled States to plan and implement more effective violence 
prevention programs informed by evidence and NVDRS data. The CDC Injury 
Center currently funds 18 States to implement NVSRS. Safe States 
Alliance supports the President's proposal \5\ to invest an additional 
$20 million to expand NVDRS to all States.
    For more than 30 years, the Prevent Block Grant has remained an 
essential source of Federal support, providing States with the autonomy 
to address their own unique health priorities and needs. In fiscal year 
2011, more than 20 percent of the Prevent Block Grant was used by 
States to support injury and violence prevention efforts and emergency 
medical services. According to a recent survey conducted by Safe States 
Alliance, 29 States reported receiving an average of $329,000 from the 
Prevent Block Grant for injury and violence prevention efforts.\6\ The 
Prevent Block Grant is a critical source of funding for SHD injury and 
violence prevention programs, representing 9.4 percent of total funding 
in 2011. The Prevent Block Grant was used to support two of the five 
top injury areas addressed by State health departments in 2011--fall 
injury and poisonings, including prescription drug overdoses. Safe 
States Alliance supports restoration of the Prevent Block Grant at the 
$100 million level.
    The Safe States Alliance believes that all SHDs must have a 
comprehensive injury and violence surveillance and prevention program, 
similar to other public health programs for chronic disease and 
infectious disease prevention. SHDs provide significant leadership to 
reduce injuries and injury-related health care costs by: informing the 
development of public policies through data and evaluation; designing, 
implementing, and evaluating injury and violence prevention programs in 
cooperation with other agencies and organizations; collaborating with 
partners in health care and throughout the State; collecting and 
analyzing injury and violence data to identify high-risk groups; 
disseminating effective practices; and providing technical support and 
training to injury prevention partners and local-level public health 
professionals. The following are examples of how SHDs have utilized the 
Core VIPP, NVDRS, and Prevent Block Grant to prevent injuries and 
protected the lives of Americans:
  --An estimated 3,143 lives have been saved since 1998 as a result of 
        CDC-funded smoke alarm installation and fire safety education 
        programs in high-risk communities. In funded States, more than 
        487,800 smoke alarms have been installed in approximately 
        250,000 homes. High-risk homes that were targeted by the 
        program included children ages five and younger and adults ages 
        65 and older.
  --NVDRS data helped Oregon to develop suicide prevention programs for 
        high-risk groups of older adults. Almost 50 percent of men and 
        60 percent of women ages 65 years or older who died by suicide 
        were reported to have a depressed mood before death. However, 
        only a small proportion were receiving treatment for their 
        depression before they died. These findings suggest that 
        screening and treatment for depression may have saved lives. In 
        response to these findings, Oregon developed and is 
        implementing a State Older Adult Suicide Prevention Plan to 
        improve primary care integration with mental health services so 
        suicidal behavior and ideation is diagnosed and older adults 
        receive appropriate treatment.
  --In response to the growing epidemic of prescription drug overdoses 
        in Ohio, the Ohio Core VIPP and the Ohio Injury Prevention 
        Partnership developed a multidisciplinary Prescription Drug 
        Abuse Action Group (PDAAG). Together, the group developed 
        consensus-based recommendations for policymakers. In May 2011, 
        the Ohio legislature passed a law containing many of the PDAAG 
        policy recommendations including: licensure of pain management 
        clinics; in-office dispensing limits; a Medicaid lock-in 
        program; and Prescription Drug Monitoring Program changes.
  --The Massachusetts Department of Public Health Injury and Violence 
        Prevention Program (MDPH IVPP) worked in collaboration with 
        partners to provide support and technical assistance to schools 
        across the State to implement recent regulations on the 
        identification and management of concussion in school sports 
        during the 2011-2012 school year. To date, 262 school 
        districts, 17 charter schools, and 31 private schools have 
        confirmed that they have put in place policies complying with 
        MDPH regulations. This represents 78 percent of the schools and 
        school districts required to provide confirmation.
    Injuries and violence also place a large financial burden on 
mandatory spending programs. The U.S. population is aging rapidly: 
currently, 35 million Americans are 65 years of age or older, and by 
2020 this number is expected to reach 77 million. The majority of 
adults over age 64 are covered under the Medicare Federal health 
insurance program. In 2005, about 22 percent of community-dwelling 
Medicare beneficiaries reported falling in the previous year.\7\ These 
fall injuries accounted for 17 percent of emergency department visits 
and 8 percent of hospital admissions. About one quarter of fall 
injuries were fractures; 4 percent were hip fractures.\8\
    According to the CDC, fall injuries are one of the 20 most 
expensive medical conditions. After adjusting for inflation, the direct 
medical costs of older adult fall injuries in 2011 totaled $36.4 
billion.\9\ Medicare costs in the first year after a fall averaged 
between $12,150 and $18,009. About 58 percent of direct medical costs 
were for inpatient hospitalizations, with 16 percent for home health 
care, 10 percent for medical office visits, 8 percent for hospital 
outpatient visits, 6 percent for emergency room visits, and 1 percent 
each for prescription drugs and dental visits. Of these costs, about 78 
percent were reimbursed by Medicare.\8\ In 2011 dollars adjusted for 
inflation, the annual cost of falls in 2020 is estimated to be $61.6 
billion.\10\
    Preventable injuries exact a heavy burden on Americans through 
premature deaths, disabilities, pain and suffering, medical and 
rehabilitation costs, disruption of quality of life for families, and 
disruption of productivity for employers. Strengthening investments in 
public health injury and violence prevention programs is a critical 
step to keep Americans safe and productive for the 21st century. The 
Safe States Alliance would like to thank the Committee for 
consideration of this testimony.
---------------------------------------------------------------------------
    \1\ National Research Council. Injury in America: A Continuing 
Public Health Problem. Washington, DC: The National Academies Press, 
1985.
    \2\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS) [online] (2007) [accessed 2013 Feb 15]. 
Available from URL: http://www.cdc.gov/injury/wisqars.
    \3\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS) [online] (2007) [accessed 2013 Feb 15]. 
Available from URL: http://www.cdc.gov/injury/wisqars
    \4\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. [online][accessed 2013 Feb 15]. 
Available from URL: http://www.cdc.gov/injury/overview/
leading_cod.html.
    \5\ NOW IS THE TIME: The President's plan to protect our children 
and our communities by reducing gun violence. Washington, DC: White 
House; 2013.
    \6\ State of the States: 2011 Report. Atlanta, GA: Safe States 
Alliance; 2013.
    \7\ Stevens JA, Ballesteros MF, Mack KA, et al. Gender differences 
in seeking care for falls in the aged Medicare population. Am J Prev 
Med 2012;59-62.
    \8\ Carroll NV, Slattum PW, Cox FM. The cost of falls among the 
community-dwelling elderly. Journal of Managed Care Pharmacy 
2005;11(4):307-16.
    \9\ Stevens JA, Corso PS, Finkelstein EA, Miller TR. Cost of fatal 
and nonfatal falls among older adults. Inj Prev 2006;12(5):290-95.
    \10\ Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of 
slip and fall injuries. Journal of Forensic Science 1996;41(5):733-
46.trial. The Gerontologist 1994;34(1):16-23.
---------------------------------------------------------------------------
                                 ______
                                 
            Prepared Statement of the Scleroderma Foundation

Fiscal Year 2014 Appropriations Recommendations:
  --Provide $32 billion for the National Institutes of Health in fiscal 
        year 2014, with corresponding increases to the National 
        Institute of Arthritis, Musculoskeletal and Skin Disease, the 
        National Heart, Lung and Blood Institute, the National 
        Institute of Allergy and Infectious Diseases, and the National 
        Institute of Minority Health and Health Disparities.
  --The Committee recommendation for the National Institute of 
        Arthritis, Musculoskeletal and Skin Disease to provide 
        sustained investment in the Scleroderma research portfolio 
        which has a proven success in providing insight to the medical 
        and research community's understanding of the disease, as well 
        as other connective tissue diseases.
  --The Committee's encouragement of the National Heart, Lung and Blood 
        Institute to expand research related to the pulmonary 
        complications of Scleroderma patients with Systemic sclerosis.

The Scleroderma Foundation:
    My name is Robert Riggs, and I am the Chief Executive Officer. On 
behalf of the Scleroderma Foundation and the estimated 300,000 
Americans impacted by the disease, I appreciate the opportunity to 
submit written testimony to the Senate Labor, Health and Human 
Services, Education and Related Agencies Appropriations Subcommittee 
regarding the Foundation's recommendations for fiscal year 2014 
Appropriations for the Department of Health and Human Services.
    Given the work of this subcommittee to accommodate the crippling 
parameters of budget sequestration, long term deficit reduction and 
recent cuts to non-defense, discretionary spending, I greatly respect 
the Committee's continued commitment in support of investments in 
medical research to enhance patient care and sustained funding support 
for health programs that benefit patients with rare, costly and 
difficult to treat diseases like Scleroderma.
    Based in Danvers, Massachusetts, the Scleroderma Foundation is a 
non-profit, national organization committed to providing support to the 
thousands of patients and their families with the disease, promoting 
public awareness and education for medical professionals and the public 
about the condition, and supporting both Federal and private research 
into finding the cause, treatment options and hopefully, a cure for 
Scleroderma and other connective tissue diseases.
    With a network of 23 chapters, more than 150 support groups and a 
toll-free helpline for patients and their families, the Foundation 
strives to provide high quality support through peer counseling, 
physician referrals and educational information. The Foundation 
supports nearly $1 million per year in research funding, providing seed 
money for new and established Scleroderma investigators. Determined by 
our Peer Research Review Committee of medical experts, this annual 
investment, which is the largest single expenditure of the Foundation, 
backs high quality and innovative research at universities, hospitals 
and laboratories.

Scleroderma:
    Scleroderma is a rare, progressive disease that involves the 
hardening and tightening of the skin and connective tissues. Considered 
both a rheumatic and connective tissue disorder, patients experience an 
overproduction of collagen in the skin, tissue and underlying muscle 
(localized Scleroderma). Severe cases of Scleroderma also impact 
internal organs such as the heart, lungs, kidneys, intestines as well 
as internal systems and blood vessels (Systemic Scleroderma).
    Localized Scleroderma primarily impacts the skin, but can also 
affect the associated tissue and muscles. In localized cases, thickened 
areas of skin appear lighter or darker than surrounding skin and can 
develop in patches, which is a type classified as ``morphea.'' 
Thickened skin can also appear in abnormally thick bands, or in a 
``linear'' pattern on the arms, legs or face (termed``Scleroderma en 
coup de sabre''). Most patients with the localized form of the disease 
improve over time, while a darkened skin appearance and localized 
muscle weakness, may remain permanently.
    Systemic Scleroderma (SSc), which is experienced by approximately 
one-third of Scleroderma patients, affects the internal organs and 
systems, blood vessels, as well as the skin. In limited cutaneous 
systemic sclerosis or CREST syndrome, both the internal and external 
tightening occurs in strictly the face, hands, forearms, lower legs and 
feet and patients experience CREST symptoms. CREST symptoms include:
  --Cacinosis, calcium deposits form in the connective tissues of the 
        hands, face, abdominal area and arms.
  --Raynaud's phenomenon, blood vessels in the hands, but also in the 
        feet contract due to stress, anxiety or cold temperature 
        appearing white or blue.
  --Esophageal dysfunction, muscle weakness is experienced in the 
        esophagus resulting in patients experiencing trouble swallowing 
        or heartburn.
  --Sclerodctyly, rigid fingers caused by thickened or tight skin, 
        cause patients difficulty in bending or straitening their 
        digits.
  --Telegiectasia, the appearance of red spots in the hands and face.
    Diffuse cutaneous scleroderma affects large areas of skin as wells 
as the esophagus, gastrointestinal tract, lungs, kidneys, heart, and 
joints and occurs with a sudden onset. Given the impact of the fibrous 
collagen development and the long term impact within the associated 
internal organs, individuals with the diffuse form of Scleroderma often 
experience more serious long term patient prognoses and life 
threatening complications. These patients are at risk of developing 
pulmonary fibrosis or hypertension, heart issues such as 
cardiomyopathy, arrhythmia or myocarditis, kidney disease, and 
gastrointestinal issues in the esophagus and intestines. While 
Scleroderma can affect anyone regardless of age, race, ethnicity or 
gender, there is an increased incidence amongst women and minorities. 
Typically women are three times more likely to experience Scleroderma 
and African Americans, Native Americans and other minority patient 
communities are more likely to be diagnosed with Systemic Scleroderma. 
In most cases, the localized form of the disease is more common to 
children and the average onset of the disease is between the ages of 25 
and 55-years-old.
    Given the different types, unpredictable and sometimes swift 
progression of the disease, and its rarity, Scleroderma, like many 
other autoimmune diseases is difficult for medical practitioners to 
accurately diagnose. Diagnosis requires specialized tests and 
consultation with rheumatologists, dermatologists and other specialists 
depending on the disease progression. Furthermore, given the unique 
experience of each patient's disease progression, treatments are 
determined on a patient-by-patient basis depending on the experienced 
symptoms.
    As there is no cure for the Scleroderma, physicians are left 
offering treatments which minimize the impact of the disease's 
progression and alleviate the symptoms. Skin softening agents, anti-
inflammatory medication and exposure to heat, are used for typical skin 
and tissue symptoms. For patients experiencing the internal effects of 
the systemic class, physicians work to mitigate the long term impact of 
the disease on internal organs through specialized and personalized 
treatments. While researchers and medical experts have yet to determine 
the cause of Scleroderma, preliminary findings point to a 
susceptibility gene which indicates a predisposition likely tied to 
familial history of rheumatic disease. Scleroderma patients however 
rarely have relatives, either immediate or extended, who also have the 
disease.

The Importance of Federal Investment in Scleroderma:
    Despite this Committee's likely limited 302 (b) allocation and 
efforts to reduce Federal debt and deficit spending, Federal funding 
for science and medical research at the National Institutes of Health 
has remained a bi-partisan, widely supported, critical national 
investment. As the Committee faces increased pressure due to the 
effects of budget sequestration, I urge your continued support of the 
historical commitment this Committee has made to providing adequate 
funding for the NIH.
    In fiscal year 2012 and the current fiscal year, the National 
Institutes of Health's estimated research portfolio for Scleroderma 
remains $25 million and consists of grants funded predominantly at the 
National Institute of Arthritis, Musculoskeletal and Skin Disease 
(NIAMS) as well as through the National Heart, Lung and Blood 
Institute, the National Institute of Allergy and Infectious Diseases, 
and the National Institute of Minority Health and Health Disparities. 
Like many successful research portfolios, the proven success of the NIH 
supported Scleroderma portfolio, has provided translational knowledge 
into connective tissue diseases along with the medical community's 
increased understanding of Scleroderma.
    The Committee's investment has provided hope to the millions of 
patients with diseases like Scleroderma which are difficult to 
diagnose, treat and currently without a cure. I know that within her 
lifetime, Scleroderma patients like Cynthia Cervantes, a high school 
junior that was afforded the opportunity to testify before this 
committee 5 years ago, will benefit from tangible advancements 
delivered through NIH findings.
    As this Committee makes the difficult determination of 
discretionary spending, I urge your continued support of important 
health related research and patient care programs at NIH. Thank you 
again for providing the opportunity to submit written testimony on 
behalf of the Scleroderma Foundation.
                                 ______
                                 
            Prepared Statement of the Sleep Research Society

    Chairman Harkin and distinguished members of the subcommittee, as 
you begin to craft the fiscal year 2014 (fiscal year 2014) Labor-HHS-
Education appropriation bill, the Sleep Research Society (SRS) is 
pleased to submit this statement for the record asking you to provide 
$32 billion for NIH, including a proportional increase for the National 
Heart, Lung, and Blood Institute (NHLBI), $1 million in funding for 
sleep disorders awareness and surveillance at the Centers for Disease 
Control and Prevention (CDC), full support for the National Center on 
Sleep Disorders Research (NCSDR), and implementation of the 2011 NIH 
Sleep Disorders Research Plan. These actions will ensure increased 
awareness of the importance of sleep and circadian rhythms and further 
the advancements being made by sleep researchers to better understand 
the relationship between sleep and health.

                         SLEEP RESEARCH SOCIETY

    SRS was established in 1961 by a group of scientists who shared a 
common goal to foster scientific investigations on all aspects of sleep 
and sleep disorders. Since that time, SRS has grown into a professional 
society comprising over 1,300 researchers nationwide. From promising 
trainees to accomplished senior level investigators, sleep research has 
expanded into areas such as psychology, neuroanatomy, pharmacology, 
cardiology, immunology, metabolism, genomics, and healthy living. SRS 
recognizes the importance of educating the public about the connection 
between sleep and health outcomes. We promote training and education in 
sleep research, public awareness, and evidence-based policy, in 
addition to hosting forums for the exchange of scientific knowledge 
pertaining to sleep and circadian rhythms.
    According to an Institute of Medicine's report entitled, ``Sleep 
Disorder and Sleep Deprivation: An Unmet Public Health Problem'' 
(2006), chronic sleep and circadian disturbances and disorders are a 
very real and relevant issue in today's society as they affect 50-70 
million Americans across all demographic groups. Sleep deprivation is a 
major safety issue, particular in reference to drowsy driving, where it 
is a factor in 20 percent of motor vehicle injuries. The high 
prevalence of sleep disorders in every age group poses widespread 
effects on public health, extending from poor academic performance in 
children and adolescents to an increased risk of most major illnesses 
including: obesity, diabetes, hypertension, cardiovascular disease, 
stroke, depression, bipolar disorder, and substance abuse.
    Sleep-disordered breathing, including obstructive sleep apnea, is a 
detrimental condition affecting 15 percent of the population. Sleep 
apnea results in excessive daytime somnolence, impaired cognition, an 
increased frequency of road traffic accidents, hypertension, and 
cardiovascular disease. Studies show that 85 percent of 725 troops 
returning home from Afghanistan and Iraq had a sleep disorder and the 
most common was obstructive sleep apnea (51 percent). Troops also 
suffer from insomnia, disrupted sleep-wake rhythms, and fatigue related 
to post-traumatic stress disorder and traumatic brain injury.

                     NATIONAL INSTITUTES OF HEALTH

    Due to the fact that sleep affects, and is affected by most 
behavioral and biological systems, many institutes and centers at NIH 
utilize a portion of their funding to support sleep and circadian 
research. The majority of sleep research is coordinated by NHLBI, 
particularly the National Center on Sleep Disorders Research. An 
appropriation of $32 billion for NIH is needed to facilitate the 
continued growth and advancement in the sleep/circadian research 
portfolio.
    The reason NCSDR is housed at NHLBI is due to the important link 
between sleep disorders and cardiovascular health. NCSDR supports 
research, health education, and research training related to sleep-
disordered breathing and the fundamental function of sleep and 
circadian rhythms. Furthermore, NCSDR coordinates sleep research across 
NIH and with other Federal agencies and outside organizations.
    NCSDR's coordinating role between institutes is made possible 
through adequate funding. These research activities also have far 
reaching effects, beginning with training grants targeted towards 
undergraduate students and continuing to career development 
opportunities attracting top research talent in doctoral programs. 
Sequestration has the potential to disrupt the research training 
pipeline designed to train future investigators who are pursuing 
research in sleep disorders and circadian rhythms, by reducing the 
amount of F, T, and K series awards.
    It is also important to recognize that by increasing the Federal 
commitment to sleep and circadian research, we can improve the health 
of those brave Americans who have served in uniform and are suffering 
from sleep disorders. Both obstructive sleep apnea and insomnia have a 
high prevalence among active-duty U.S. Armed Forces and among Veterans. 
Post-traumatic stress disorder and/or depression are highly prevalent 
in returning Iraq and Afghanistan combat Veterans. Sleep disturbance is 
a prominent symptom in these disorders. Traumatic brain injury is 
increasingly common in modern combat, and sleep disruption in the 
aftermath of TBI may have negative effects on long-term recovery of 
normal brain function.
    The Department of Veterans Affairs (VA) has shown a commitment to 
collaborating with NIH on sleep research related to Post-Traumatic 
Stress Disorder (PTSD), Traumatic Brain Injury (TBI), and Gulf War 
Illness (GWI). This is highlighted in the fiscal year 2014 (fiscal year 
2014) President's budget request detailing research initiatives in PTSD 
and TBI. The ``Longitudinal Health Study of Gulf War Era Veterans'' is 
one of the largest scientific research studies on chronic diseases and 
multi-symptom illnesses, including Gulf War Illness. Researchers found 
that prazosin, an inexpensive drug already used by millions of 
Americans for hypertension and prostate problems, improves sleep and 
reduces nightmares for veterans with PTSD. They continue to pursue 
activities such as the difference between female and male veterans with 
PTSD and possible intervention strategies to help veterans with TBI 
return to daily activities. One study described in the Veteran's Health 
Administration report State of VA Research 2012, found that 96 percent 
of veterans with chronic multi-symptom illnesses experienced sleep 
disordered breathing. By using continuous positive airway pressure 
(CPAP) these veterans reported reductions in pain and fatigue and 
improvements in cognitive function. It is important to fund NIH in 
fiscal year 2014 so that we can continue these advancements in sleep 
and circadian research.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

    CDC gathers important data on sleep disorders through their 
surveillance efforts under the Chronic Disease Prevention and Health 
Promotion program. Most notably, CDC hosts a National Sleep Awareness 
Roundtable (NSART) by promoting the importance of sleep through the 
production of State fact sheets, updating the CDC website, and 
disseminating information on sleep related topics. CDC also promotes 
awareness of sleep disorders and the dangers associated with sleep 
deprivation for the benefit of millions of Americans. Currently 
population-based data on the prevalence of circadian disruption and its 
relationship to disease risk is relatively limited. Please fund CDC at 
$7.8 billion including an allocation of $1 million solely for sleep 
awareness and surveillance activities within the Chronic Disease 
Prevention and Health Promotion program so that progress can continue 
in the areas of sleep disorders and disturbances, sleep awareness, and 
education to the public community.

                   NIH SLEEP DISORDERS RESEARCH PLAN

    NCSDR published the NIH Sleep Disorders Research Plan in November 
of 2011 highlighting the implementation of pertinent sleep research 
goals to enable further advancements in the realm of sleep and 
circadian rhythm disorders. A Joint Task Force between the two leading 
organizations representing the sleep medicine and research community, 
Sleep Research Society (SRS) and American Academy of Sleep Medicine 
(AASM), has identified research opportunities within the plan that will 
have the highest impact on health, including:
  --Reducing the societal impact of sleep deficiency and circadian 
        dysfunction on health
  --Identifying key effective treatments for sleep and circadian 
        disorders across the lifespan
  --Enhancing the training pipeline for future sleep and circadian 
        researchers
  --Developing academic sleep and circadian research networks
    Research activities and stakeholders addressed by the plan benefit 
from the encompassing range of NIH research, training and outreach 
programs. Over the past 2 years, steps have been taken to implement 
portions of this research plan, but additional work needs to be done. 
SRS encourages you to recommend that this research plan continue to be 
implemented during fiscal year 2014.
    Thank you for the opportunity to submit the views of the sleep 
research community. Please do not hesitate to contact us should you 
have any questions or require additional information.
                                 ______
                                 
     Prepared Statement of the Society for Maternal-Fetal Medicine

    On behalf of the Society for Maternal-Fetal Medicine (SMFM), I am 
pleased to submit testimony in support of funding for the Eunice 
Kennedy Shriver National Institute of Child Health and Human 
Development (NICHD). We urge your support of at least $32 billion for 
NIH, including $1.37 billion for NICHD in fiscal year 2014.
    Established in 1977, SMFM is dedicated to improving maternal and 
child outcomes and raising the standards of prevention, diagnosis, and 
treatment of maternal and fetal disease. Maternal-fetal medicine 
specialists, known as MFM specialists, perinatologists, or high-risk 
pregnancy physicians, are highly trained obstetricians/gynecologists 
with advanced expertise in obstetric, medical, and surgical 
complications of pregnancy and their effects on the mother and fetus. 
The complex problems faced by some mothers may lead to death as well as 
short-term or life-long problems for both mothers and their babies. 
Such complications be understood, treated, prevented and eventually 
solved through research.
    NICHD's mission is to ensure that every child is born healthy and 
that women suffer no harmful effects from reproductive processes. 
NICHD-supported basic, clinical, translational, and multidisciplinary 
research studies address a myriad of issues in pregnancy including:
    Preterm birth.--Delivery before 37 weeks' gestation is associated 
with increased risks of death in the immediate newborn period as well 
as in infancy, and can cause long-term complications. About 20 percent 
of premature babies die within the first year of life, and although the 
survival rate is improving, many preterm babies have life-long 
disabilities including cerebral palsy, mental retardation, respiratory 
problems, and hearing and vision impairment. Preterm birth costs the 
U.S. $26 billion annually.
    Stillbirth.--Defined as the death of a fetus at 20 or more weeks of 
gestation, stillbirth complicated nearly 26,000 pregnancies in the 
United States in 2005. Stillbirth is more than twice as common among 
African Americans as Caucasian women. Other maternal risk factors for 
stillbirth include advanced age, obesity, and co-existing medical 
disorders such as diabetes or hypertension. The impact of environmental 
exposures on stillbirth risk remains unknown. Of known stillbirth 
causes, the most common are genetic abnormalities, alterations in the 
number or structure of the chromosomes, maternal infection, hemorrhage, 
and problems with the umbilical cord or placenta. However, the cause 
remains unknown in about half of all stillbirths.
    Hypertensive diseases in pregnancy.--High blood pressure 
(hypertension) during pregnancy is the second leading cause of maternal 
death in the United States, accounting for 15 percent of all deaths. 
For the mother, it is associated with increased need for delivery 
because of pregnancy complications, stroke, pulmonary or heart failure, 
and death. The likelihood and severity of these complications increases 
as the severity of the hypertension increases, and if preeclampsia 
develops. Preeclampsia is characterized by high blood pressure and the 
presence of protein in the urine. Its cause remains one of the greatest 
mysteries in obstetrics and is a major cause of maternal, fetal, and 
neonatal mortality worldwide.
    Pregestational and gestational diabetes.--The hormonal changes of 
pregnancy can seriously worsen preexisting diabetes and often bring 
about a diabetic state (gestational diabetes) in predisposed women. 
Whether diabetes mellitus existed before conception or gestational 
diabetes develops during pregnancy, maternal glucose intolerance can 
have significant medical consequences for both mother and baby. Poorly 
controlled diabetes is associated with miscarriage, congenital 
malformations, abnormal fetal growth, stillbirth, obstructed labor, 
increased cesarean delivery, and neonatal complications. Up to 200,000 
pregnancies are affected by gestational diabetes each year.
    Great strides are being made through NICHD-supported research to 
address the complex situations faced by mothers and their babies. One 
of the most successful approaches for testing research questions is the 
NICHD research networks which allow researchers from across the country 
to collaborate and coordinate their work to change the way we think 
about pregnancy complications and change medical practice across the 
country. These networks deal with different aspects of pregnancythe 
problem of preterm birth and its consequence.
    The Stillbirth Collaborative Research Network (SCRN) was created to 
study the extent and causes of stillbirth in the United States, and is 
conducting a geographic population-based determination of the incidence 
of stillbirth and is determining the causes of stillbirth using a 
standardized protocol that includes clinical histories, autopsies and 
pathologic examinations of the fetus and placenta as well as other 
postmortem tests to illuminate genetic, maternal and environmental 
influences. The information from this Network will benefit families who 
have experienced a stillbirth, women who are pregnant or who are 
considering pregnancy, and obstetric care providers. In addition, the 
knowledge gained from this Network will support future research aimed 
at improving preventive and therapeutic interventions and at 
understanding the mechanisms that lead to fetal death.
    Another important network is the Maternal-Fetal Medicine Units 
Network (MFMU), established in 1986 to achieve a greater understanding 
and pursue development of effective treatments for the prevention of 
preterm births, low birth weight infants and medical complications 
during pregnancy. The MFMU Network has identified new effective 
therapies and will put an end to practices that are not useful. It is 
the only national research infrastructure capable of performing the 
much needed large trials that provide the evidence on which sound 
medical practice is based. The MFMU Network is also the ideal vehicle 
to collaborate with other NIH networks, as well as international 
networks in order to improve global health. Since its inception, the 
Network has made several exciting scientific advancements and has been 
able to rapidly turn laboratory and clinical research into diagnostic 
examinations and treatment procedures that directly benefit those 
affected:
    Following a series of studies in the 1970s and 1980s, an MFMU 
Network clinical trial showed that progesterone treatment resulted in a 
substantial reduction in the rate of preterm delivery among women who 
had a previous preterm birth, reduced the risk of newborn 
complications, and was effective in both African American and Non-
African American women. The MFMU Network conducted the largest, most 
comprehensive trial to date to test whether magnesium sulfate given to 
a woman in labor with a premature fetus (24 to 31 weeks out of 40) 
would result in a reduction in cerebral palsy. In August 2008, NIH 
announced that magnesium sulfate, when administered to women at risk of 
imminently delivering preterm, reduces the risk of cerebral palsy in 
surviving preterm infants by 45 percent.
    The MFMU Network provided the first conclusive evidence that 
treating pregnant women who have even the mildest form of gestational 
diabetes can reduce the risk of common birth complications among 
infants, as well as blood pressure disorders among mothers. These 
findings will change clinical practice and lead to better outcomes for 
both mothers and babies. Vigorous support of the MFMU Network is needed 
so that therapies and preventive strategies that have significant 
impact on the health of mothers and their babies will not be delayed. 
Until new options are created for identifying those at risk and 
developing cause specific interventions, preterm birth will remain one 
of the most pressing problems in obstetrics.
    The NuMoM2b network was developed to use current genomic and 
proteomic techniques in combination with traditional markers for the 
prediction of adverse pregnancy outcomes, including preterm birth, 
preeclampsia, fetal growth restriction, and stillbirth in first 
pregnancies, since adverse pregnancy outcomes are at increased risk for 
complications in future pregnancies and over 40 percent of pregnancies 
in the United States are first pregnancies. The NuMoM2b study of 10,000 
women provides the infrastructure for additional multicenter study of 
sleep disordered breathing in pregnancy. Epidemiologic studies have 
shown that a woman's health status during pregnancy is associated with 
her long-term health after pregnancy, suggesting that findings in 
pregnancy may be a better indicator for determining a woman's future 
health status than traditional risk factors. The NuMoM2b study could 
serve as the basis for long-term studies to determine the relationships 
between adverse pregnancy outcomes and long-term maternal health.
    Opportunities for future study include collaborative work by NICHD, 
NHLBI and NIDDK to more closely study these epidemiologic findings in 
an effort to identify predictive markers during pregnancy for 
subsequent heart disease and diabetes; develop tests to evaluate health 
after pregnancy; and test interventions both during and after pregnancy 
that may mitigate risk. Research is the cornerstone for improving our 
understanding of the physiology and pathophysiology of pregnancy, the 
interrelationship between the mother and fetus, the impact of medical 
conditions on pregnancy and the impact of medical diseases and 
pregnancy outcomes on the long term health of both mother and child. 
With your support, researchers can continue to peel away the layers of 
complex problems of pregnancy that have such devastating consequences.
                                 ______
                                 
           Prepared Statement of the Society for Neuroscience

    Mr. Chairman and members of the subcommittee, my name is Larry 
Swanson, Ph.D. I am the Milo Don and Lucille Appleman Professor of 
Biological Sciences at University of Southern California. Over the past 
30 years my work has focused on the structure and organization of 
neural structures involved in motivated and emotional behaviors, as 
well as the development and wiring diagram of the nervous system more 
generally. This statement is in support of increased funding for the 
National Institutes of Health (NIH) for fiscal year 2014.
    On behalf of the nearly 42,000 members of the Society for 
Neuroscience (SfN), thank you for your past support of neuroscience 
research at the NIH. SfN's mission is to advance the understanding of 
the brain and the nervous system; provide professional development 
activities, information and educational resources; promote public 
information and general education; and inform legislators and other 
policymakers.
    This is an exciting time to be a part of the neuroscience field. 
Advances in understanding brain development, imaging, genomics, circuit 
function, computational neuroscience, neural engineering, and many 
other disciplines are leading to discoveries that were impossible even 
a few years ago. These will no doubt help us better understand and 
treat traumatic brain injury, Alzheimer's disease, Parkinson's disease, 
Down syndrome, schizophrenia, epilepsy, and post-traumatic stress 
disorder to name just a few. All told, there are more than 1,000 
debilitating neurological and psychiatric diseases that strike over 100 
million Americans each year, costing an estimated $750 billion a year.
    SfN is appreciative that President Obama recognizes brain science 
as one of the great scientific challenges of our time. The recently 
announced Brain Research through Application of Innovative 
Neurotechnologies (BRAIN) Initiative would enable NIH and other Federal 
agencies to develop initial tools and conduct further planning that 
will help accelerate fundamental discoveries and improve the health and 
quality of life for millions of Americans.
    The field of neuroscience is poised to make revolutionary advances 
thanks to decades of global investment and path-breaking research. 
However, realizing this potential means today's critical seed funds 
must be backed by sustained, robust investment in the scientific 
enterprise in the coming decade. SfN is encouraged by the President's 
request for a modest increase to the budget of NIH. However, flat 
funding over the last decade has led to the loss of approximately 20 
percent of NIH's purchasing power due to inflation, thus hampering the 
pursuit of the knowledge needed to uncover the mysteries behind 
biological function, causes of disease, and potential therapies.
    Now is the time to take advantage of scientific momentum, to pave 
the way for improved human health, to advance scientific discovery and 
innovation, and to promote America's near-term and long-range economic 
strength. That requires robust investments in NIH that reverse the tide 
of stagnant and shrinking funding. These investments contribute to the 
economic growth of local communities in every State as part of the 
approximately 85 percent of the NIH budget that goes to funding 
extramural research. In 2012 alone, NIH supported more than 402,000 
jobs and $57.8 billion in economic output nationwide. Moreover, 
adequate funding will help preserve and expand America's role as a 
preeminent leader in biomedical research, supporting public and private 
institutions and fostering activity in the pharmaceutical, 
biotechnology, and medical device industries.
    Seizing this moment can only happen if labs are able to pursue 
promising leads and innovative ideas can move forward. A constricted 
fiscal environment--compounded by sequestration--will stand in the way 
of that progress. It's impossible to say what breakthroughs will go 
undiscovered, but there is no doubt that this fiscal environment will 
result in delayed discoveries, with potentially huge opportunity costs 
for human health.
    Last year, the Society stood with others in the research community 
in requesting at least $32 billion for NIH. Today, the need is no less 
as the funding situation is even more precarious, and the Society urges 
Congress to reverse the current course and find ways to invest more in 
biomedical research. We urge Congress to act before sequestration takes 
full effect, further eroding the short and long-term capacity for 
discovery. Let's work to put biomedical research on a trajectory of 
sustained growth that recognizes its promise and opportunity as a tool 
for economic growth and, more importantly, for advancing the health of 
Americans.

                     BRAIN RESEARCH AND DISCOVERIES

    NIH-funded basic (also known as fundamental) research continues to 
be essential for discoveries that will inspire scientific pursuit and 
medical progress for generations to come. Past NIH supported projects 
have helped neuroscientists make tremendous strides in diagnosing and 
treating neurological and psychiatric disorders. Given the long-term 
path of basic science and industry's need for shorter-term return on 
investment, private industry depends on federally-funded research to 
create a strong foundation for applied research. More than ever, it is 
important to support and fund research at levels from the most basic to 
translational.
    The following are just three of the many basic research success 
stories in neuroscience emerging now thanks to strong historic 
investment in NIH and other research agencies:

A New Model for Complex Brain Disease
    A new development from basic science shows tremendous potential for 
improving understanding of complex diseases such as Alzheimer's, which 
affects 5.4 million Americans and costs the United States $200 billion 
in direct costs annually.
    Traditionally, human disease is modeled by identifying and studying 
single gene mutations that run in families. Brain cells from mice 
genetically engineered to express this mutated gene can be studied to 
help illuminate the complex interactions that produce the disease.
    Unfortunately for the ease of understanding these diseases, single 
gene mutations are not the only way to develop most diseases. With 
Alzheimer's disease, most cases are likely caused by mutations in many 
different genes. Thus, current models of Alzheimer's likely paint an 
incomplete picture of the disease.
    New developments in stem cell technology are changing this picture. 
Stem cells are special cells that have the potential to become any 
other type of cell in the body. Due to advances in genetic engineering, 
scientists can now trick almost any cell into becoming a stem cell. 
This technique can be used to turn skin cells from patients with 
idiopathic Alzheimer's disease into brain cells. These cells are 
ostensibly identical to the cells in that person's brain, complete with 
that person's unique genetic risk profile. Research with these cells 
could potentially help identify subgroups of patients who will respond 
differently to treatment in clinical trials.
    For now, it is not clear whether the brain cells made from this 
technique are completely identical to the 70-year-old neurons in the 
brain of a patient with Alzheimer's disease. In addition, these cells 
are currently prohibitively difficult to create, making them unlikely 
to replace embryonic stem cells in other applications in the near 
future. Continued research funding will allow scientists to begin 
addressing these and other outstanding questions. This research 
exemplifies the powerful potential to apply basic research well beyond 
its original intent.

The ``Connectome''
    Current knowledge about the intricate patterns connecting brain 
cells (the ``connectome'') is extremely limited. Yet identifying these 
patterns and understanding the fundamental wiring diagram or 
architectural principles of brain circuitry is essential to 
understanding how the brain functions when healthy and how it fails to 
function when injured or diseased. Recent research suggests that some 
brain disorders, like autism and schizophrenia, may result from errors 
in the development of neural circuits. This research suggests a new 
category of brain disorders called ``disconnection'' syndromes.
    Advanced technologies, along with faster and more data-efficient 
computers, now make it possible to trace the connections between 
individual neurons in animal models providing us with greater insight 
into brain dysfunction in mental health disorders and neurological 
disease. Scientists have already used these technologies to examine 
disease-related circuitry in rodent studies of Parkinson's disease. 
Their findings helped explain how a new treatment called deep brain 
stimulation works in people, and are being explored for treatments of 
other diseases.

Genetics of Schizophrenia
    Antipsychotic drugs and improved therapeutic techniques represent 
great advances in the treatment of schizophrenia, but they do not help 
everyone. Even when successful, they typically mitigate only psychotic 
effects, leaving many severely disabled due to other symptoms.
    One promising line of research deals with the genetics of 
schizophrenia. In recent years, neuroscientists have found numerous 
mutations linked to schizophrenia. However, no single mutation seems to 
directly lead to schizophrenia, making a genetic test for the condition 
unlikely for now. Rather, multiple, rare mutations seem to combine to 
make someone susceptible. These genes seem to affect neural development 
and neural plasticity--the ability of the brain to reshape its 
connections as needed.
    One of these genes is the Disrupted-In-Schizophrenia-1 (DISC1) 
gene. DISC1 helps maintain signaling levels of a key chemical in the 
brain called glutamate. Mice with a mutant form of DISC1 have reduced 
glutamate signaling and behavioral abnormalities. There is evidence 
that this deficit is the result of alterations during development which 
nonetheless have lasting effects later in life.
    Knowing the mechanisms by which individual genes may raise or lower 
the risk of developing certain diseases is an important first step in 
identifying the pathways involved in those diseases. Future research is 
needed to probe the complex interactions of multiple genes within a 
system. Once pathways are identified, they can provide direction for 
development of new treatments.

                     THE FUTURE OF AMERICAN SCIENCE

    As the subcommittee considers this year's funding levels, please 
consider that significant advancements in the biomedical sciences often 
come from young investigators. The current funding environment is 
taking a toll on the energy and resilience of these young people. 
America's scientific enterprise--and its global leadership--has been 
built over generations. Without sustained investment, we will quickly 
lose that leadership. The culture of entrepreneurship and curiosity-
driven research could be hindered for decades.
    We live at a time of extraordinary opportunity in neuroscience. A 
myriad of questions once impossible to consider are now within reach 
because of new technologies, an ever-expanding knowledge base, and a 
willingness to embrace many disciplines.
    To take advantage of the opportunities in neuroscience we need an 
NIH appropriation that allows for sustained reliable growth. That, in 
turn, will lead to improved health for the American public and will 
help maintain American leadership in science worldwide. Thank you for 
this opportunity to testify.
                                 ______
                                 
     Prepared Statement of the Society for Women's Health Research

    The Society for Women's Health Research (SWHR) is pleased to have 
the opportunity to submit the following testimony urging renewed 
Federal investment in biomedical research, specifically women's health 
and sex differences research, within the Department of Health and Human 
Services (HHS). We request that for fiscal year 2014, Congress fund the 
following agencies and the office of women's health programs at:
  --Agency for Healthcare and Research Quality (AHRQ)--$430 million
  --National Institutes of Health (NIH)--$32 billion
  --Office of Research on Women's Health (ORWH)--$43.3 million
  --HHS Office of Women's Health--$34.7 million
  --CDC Office of Women's Health--$478,000
    SWHR is the thought leader in research on biological differences in 
disease and is dedicated to transforming women's health through 
science, advocacy, and education. We believe that sustained funding of 
a Federal research agenda that is inclusive of biomedical and women's 
health research programs is absolutely essential if the U.S. is to meet 
the needs of its citizens, especially women. SWHR realizes that the 
Federal Government is focused on reducing our Federal deficit; however, 
proper and sustained investment in health research will ultimately save 
valuable dollars that are currently wasted on inappropriate treatments 
and procedures.
    Past investments in biomedical research propelled the U.S. into the 
position of world leader in biomedical research. These investments 
resulted in the mapping of the human genome and made it possible for 
scientists to discover the biological and physiological differences 
between women and men. The study of how these differences impact health 
and medicine, known as sex based biology has been a fundamental part of 
SWHR's mission since its inception. This research confirms that 
biological sex plays an important role in disease susceptibility, 
prevalence, time of onset and severity. Sex differences are evident in 
cancer, obesity, heart disease, immune dysfunction, mental health 
disorders, and many other diseases. Medications can have different 
effects in woman and men, based on sex specific differences in 
absorption, distribution, metabolism and elimination. When translated 
into medical practice, this research will result in a personalized 
approach to medicine, which will transform medical practice in the U.S.
    National Institutes of Health.--In the past decade; NIH has faced a 
20.8 percent decrease in buying power as a direct result of budgetary 
cuts. More than 83 percent of NIH funding is spent in communities 
across the Nation, creating jobs at more than 3,000 universities, 
medical schools, teaching hospitals, and other research institutions in 
every State. The number of new grants funded by NIH has dropped 
steadily with declining budgets; and in 2012, the NIH Director, Francis 
Collins, reported that grant funding was at an all-time low of 20 
percent .
    A shrinking number of available grants put American scientists out 
of work. With a limited avenue to secure research funding, scientists 
will have little choice than to pursue opportunities outside of 
academic research, resulting in the loss of skilled bench scientists 
and researchers to countries like China, who continue to heavily invest 
in research. The U.S. desperately needs these researchers and scientist 
to meet the needs and challenges of an aging U.S. population. 
Innovation, which can take years to bear fruit, only occurs with 
continual research investment. It is estimated that U.S. health 
spending will account for nearly one-fifth of the U.S. economy by 
2021.Given this timeframe, investments made today will just be coming 
onto the market. Rather than implementing across the board budget cuts 
that will limit future treatments, SWHR believes that Congress should 
invest in specific areas of cost savings that will lower the overall 
cost of healthcare, which is the largest driver of the Federal deficit. 
Research into new and innovative strategies that are proven to prevent, 
treat, or cure chronic conditions is perhaps the single most cost 
effective strategy in reducing our Federal deficit.
    SWHR recommends that Congress set, at a minimum, a budget of $32 
billion for NIH for fiscal year 2014. Further we recommend that NIH, 
with the funds provided, be mandated to report sex/gender differences 
in all research findings, including those studying a single sex but 
with explanation and justification. Additionally, NIH's mandate should 
be expanded to include women in all phases of basic, clinical and 
medical research. Current practice only mandates sufficient female 
subjects only in Phase III research, and researchers often miss out on 
the chance to look for variability by sex in the early phases of 
research, safety and effectiveness is determined.
    Office of Research on Women's Health.--ORWH is the focal point for 
coordinating women's health and sex differences research at NIH, and 
supports innovative interdisciplinary initiatives that focus on women's 
health and sex differences research. ORWH works in collaboration with 
NIH Institutes and Centers (IC's) to implement their programs and co-
fund research that incorporates sex and gender differences into their 
ongoing studies. ORWH also promotes opportunities for and support of 
recruitment, retention, re-entry and advancement of women in biomedical 
careers.
  --The Building Interdisciplinary Research Careers in Women's Health 
        (BIRCWH) is an innovative, trans-NIH career development program 
        that provides protected research time for junior faculty by 
        pairing them with senior investigators in an interdisciplinary 
        mentored environment. To date, over 490 scholars have been 
        trained in 39 centers, and 80 percent of those scholars have 
        been female. These centers have produced over 4,800 
        publications, and have been awarded 346 NIH research grants.
  --Specialized Centers of Research on Sex and Gender Factors Affecting 
        Women's Health (SCOR) are designed to integrate basic and 
        clinical approaches to sex and gender research across 
        scientific disciplines. These programs have resulted in over 
        665 articles, reviews, abstracts, book chapters and other 
        publications.
  --The Advancing Novel Science in Women's Health Research (ANSWHR) 
        program promotes innovative new concepts and interdisciplinary 
        research in women's health research and sex/gender differences. 
        ORWH partners with 23 NIH IC's, to broaden all areas of women's 
        health and sex differences research.
  --Administrative Supplements for Research on Sex and Gender 
        Differences, is a new trans-NIH initiative to broaden the field 
        of sex and gender differences research. It allows ORWH to 
        leverage on-going grants by adding new dimension to the study.
    To allow ORWH's programs and research grants to continue make their 
impact on research and the public, Congress must direct that NIH 
continue its support of ORWH and provide it with a $1 million dollar 
budget increase, bringing its fiscal year 2014 total to $43.3 million.
    Health and Human Services' Office of Women's Health.--The HHS OWH 
is the Government's champion and focal point for women's health issues. 
It works to redress inequities in research, health care services, and 
education that have historically placed the health of women at risk. 
Without OWH's actions, the task of translating research into practice 
would be only more difficult and delayed. Considering the impact of 
women's health programs from OWH on the public, we urge Congress to 
provide an increase of $1 million for this office, a total of $34.7 
million for fiscal year 2014.
    Under HHS, the agencies currently with offices, advisors or 
coordinators for women's health or women's health research include the 
Food and Drug Administration (FDA), Centers for Disease Control and 
Prevention (CDC), Agency for Healthcare Quality and Research (AHRQ), 
Indian Health Service (INS), Substance Abuse and Mental Health Services 
Administration (SAMHSA), Health Resources and Services Administration 
(HRSA). These offices do important work, both individually and in 
collaboration with other offices and Federal agencies to ensure that 
women receive the appropriate care and treatments in a variety of 
different areas. In a time of limited budgetary dollars, Congress 
should invest in offices that promote working in collaboration with 
other agencies, which shares much needed expertise while avoiding 
unnecessary duplication. SWHR recommends that they are sufficiently 
funded to ensure that these programs can continue and be strengthened 
in fiscal year 2014.
    In conclusion, Mr. Chairman, we thank you and this Committee for 
its support for medical and health services research and its commitment 
to the health of the Nation. We look forward to continuing to work with 
you to build a healthier future for all Americans.
                                 ______
                                 
           Prepared Statement of the Spina Bifida Association

                        BACKGROUND AND OVERVIEW

    On behalf of the estimated 166,000 individuals and their families 
who are affected by all forms of Spina Bifida--Spina Bifida Association 
(SBA) appreciates the opportunity to submit public written testimony 
for the record regarding fiscal year 2014 funding for the National 
Spina Bifida Program housed at the National Center on Birth Defects and 
Developmental Disabilities at the Centers for Disease Control and 
Prevention (CDC) and other related Spina Bifida initiatives. SBA is a 
national patient advocacy organization, working on behalf of people 
with Spina Bifida and their families through education, advocacy, 
research and service. SBA stands ready to work with Members of Congress 
and other stakeholders to ensure our Nation mounts and sustains a 
comprehensive effort to reduce and prevent suffering from Spina Bifida.
    Spina Bifida, a neural tube defect (NTD), occurs when the spinal 
cord fails to close properly within the first few weeks of pregnancy. 
As the fetus grows--the spinal cord is exposed to the amniotic fluid, 
which increasingly becomes toxic. It is believed that the exposure of 
the spinal cord to the toxic amniotic fluid erodes the spine and 
results in Spina Bifida. There are varying forms of Spina Bifida 
occurring from mild--with little or no noticeable disability--to 
severe--with limited movement and function. In addition, within each 
different form of Spina Bifida the effects can vary widely. 
Unfortunately, the most severe form of Spina Bifida occurs in 96 
percent of children born with this birth defect.
    The result of this NTD is that most people with it suffer from a 
host of physical, psychological, and educational challenges--including 
paralysis, developmental delay, numerous surgeries, and living with a 
shunt, which helps to relieve cranial pressure associated with spinal 
fluid that does not flow properly. As we have testified previously, the 
good news is that after decades of poor prognoses and short life 
expectancy, children with Spina Bifida are now living into adulthood 
and increasingly into their advanced years. These gains in longevity 
are due to breakthroughs in research, combined with improvements in 
health care and treatment. However, with this extended life expectancy, 
people with Spina Bifida now face new challenges, such as finding adult 
health care providers, education, job training, independent living, 
health care for secondary conditions, and aging concerns, among others. 
Fortunately, with the creation of the National Spina Bifida Program in 
2003, individuals and families affected by Spina Bifida now have a 
program at the CDC that relates to their needs.
    The daily consumption of 400 micrograms of folic acid by women of 
childbearing age, prior to becoming pregnant and throughout the first 
trimester of pregnancy, can help reduce the incidence of Spina Bifida, 
by up to 70 percent. The CDC calculates that there are approximately 
3,000 NTD births each year, of which an estimated 1,500 are Spina 
Bifida, and, as such, with the aging of the Spina Bifida population and 
a steady number of affected births annually, the Nation must take 
additional steps to ensure that all individuals living with this 
complex birth defect can live full, healthy, and productive lives.

                          COST OF SPINA BIFIDA

    It is important to note that the lifetime costs associated with a 
typical case of Spina Bifida--including medical care, special 
education, therapy services, and loss of earnings--are as much as $1 
million. The total societal cost of Spina Bifida is estimated to exceed 
$750 million per year, with just the Social Security Administration 
payments to individuals with Spina Bifida exceeding $82 million per 
year. Moreover, tens of millions of dollars are spent on medical care 
paid for by the Medicaid and Medicare programs. Efforts to reduce and 
prevent suffering from Spina Bifida will help to not only save money, 
but will also save--and improve--lives.

  IMPROVING QUALITY-OF-LIFE THROUGH THE NATIONAL SPINA BIFIDA PROGRAM

    Since 2001, SBA has worked with Members of Congress and staff at 
the CDC to help improve our Nation's efforts to prevent Spina Bifida 
and diminish suffering--and enhance quality-of-life--for those 
currently living with this condition. With appropriate, affordable, and 
high-quality medical, physical, and emotional care, most people born 
with Spina Bifida will likely have a normal or near normal life 
expectancy. The CDC's National Spina Bifida Program works to improve 
quality-of-life for those living with Spina Bifida.
    The National Spina Bifida Program helps provide information and 
support to help ensure that individuals, families, and other 
caregivers, such as health professionals, have the most up-to-date 
information about effective interventions for the myriad primary and 
secondary conditions associated with Spina Bifida. Among many other 
activities, the program helps individuals with Spina Bifida and their 
families learn how to treat and prevent secondary health problems, such 
as bladder and bowel control difficulties, learning disabilities, 
depression, latex allergies, obesity, skin breakdown, and social and 
sexual issues. Children with Spina Bifida often have learning 
disabilities and may have difficulty with paying attention and 
executive function skills such as math. These problems can be treated 
or prevented, but only if those affected by Spina Bifida--and their 
caregivers--are properly educated to provide the skills leading to the 
highest level of health and well-being possible. The National Spina 
Bifida Program's secondary prevention activities represent a tangible 
quality-of-life difference to the estimated 166,000 individuals living 
with all forms of Spina Bifida, with the goal being living well with 
Spina Bifida.
    An important resource to better determine best clinical practices 
and the most cost effective treatments for Spina Bifida is the National 
Spina Bifida Patient Registry, now in its third year. A total of 17 
sites throughout the Nation have collated over 3000 patient records 
from which lifesaving data about treatment and care can be extracted.
    SBA understands that the Congress and the Nation face unprecedented 
budgetary challenges. However, the progress being made by the National 
Spina Bifida Program must be sustained to ensure that people with Spina 
Bifida--over the course of their lifespan--have the support and access 
to quality care they need and deserve. To that end, SBA respectfully 
urges the subcommittee to Congress allocate $5.812 million (level 
funding) in fiscal year 2014 to the program, so it can continue its 
current its current scope of work, increase its folic acid awareness/
Spina Bifida prevention efforts, further develop the National Spina 
Bifida Patient Registry, and ensure that patients and their clinicians 
receive the most up-to-date information--all efforts that help improve 
quality of life and fulfill unmet needs for an estimated 166,000 
Americans currently living with Spina Bifida.

         SUSTAIN AND SEIZE SPINA BIFIDA RESEARCH OPPORTUNITIES

    Our Nation has benefited immensely from our past Federal investment 
in biomedical research at the NIH. SBA joins with other in the public 
health and research community in advocating that NIH receive increased 
funding in fiscal year 2014. This funding will support applied and 
basic biomedical, psychosocial, educational, and rehabilitative 
research to improve the understanding of the etiology, prevention, cure 
and treatment of Spina Bifida and its related conditions. In addition, 
SBA respectfully requests that the subcommittee include the following 
language in the report accompanying the fiscal year 2014 LHHS 
appropriations measure:

        ``The Committee encourages NIDDK, NICHD, and NINDS to study the 
        causes and care of the neurogenic bladder in order to improve 
        the quality of life of children and adults with Spina Bifida; 
        to support research to address issues related to the treatment 
        and management of Spina Bifida and associated secondary 
        conditions, such as hydrocephalus; and to invest in 
        understanding the myriad co-morbid conditions experienced by 
        children with Spina Bifida, including those associated with 
        both paralysis and developmental delay.''

                               CONCLUSION

    Please know that SBA stands ready to work with the subcommittee and 
other Members of Congress to advance policies and programs that will 
reduce and prevent suffering from Spina Bifida. Again, we thank you for 
the opportunity to present our views regarding fiscal year 2014 funding 
for programs that will improve the quality-of-life for the estimated 
166,000 Americans and their families living with all forms of Spina 
Bifida.
                                 ______
                                 
            Prepared Statement of the Transplant Roundtable

    Dear Chairman Harkin and Ranking Member Moran: On behalf of the 
Transplant Roundtable, a coalition of organ transplant patients, 
professionals, and related organizations, the undersigned organizations 
offer our strong support for Federal funding for the organ donation and 
transplantation programs run by the Division of Transplantation (DoT) 
within the Health Resources and Services Administration (HRSA).
    We applaud you for your many years of unwavering commitment to 
these programs and ask again for your assistance. While we recognize 
the serious challenges regarding the Federal budget, it is critical 
that the Federal Government retain its strong commitment to these 
programs. As such, we ask that you preserve, at a minimum, a level 
budget of $24 million for these DoT programs from fiscal year 2013 to 
fiscal year 2014.
    The DoT serves a unique and irreplaceable function and if 
discretionary funds are available, an increase in funding (i.e., $3 
million) for fiscal year 2014 would make a huge difference and 
ultimately save lives. DoT provides oversight and funding for the 
Nation's organ procurement, allocation, and transplantation system 
through the Organ Procurement and Transplantation Network (OPTN). It 
coordinates all organ and tissue donation activities and funds donation 
research. Further, through the National Living Donor Assistance Center 
(NLDAC), it provides funding for travel and subsistence expenses of 
living donors whose low income may otherwise prohibit them from 
donating. These and other programs funded through DoT are very worthy 
of additional Federal investment as they produce a major return on this 
investment, year after year.
    DoT reports that each day, an average of 79 people receive organ 
transplants; however, an average of 18 people die each day waiting for 
transplants that do not occur because of the shortage of donated 
organs. As of February 2013, the national patient waiting list for 
organ transplants contained more than 127,000 listings. The total 
number of transplants from January to November of 2012 was 
approximately 26,000, with nearly 13,000 donors during that same time 
period.
    Congressional, agency and private sector support has resulted in 
transplantation that has saved and enhanced the lives of more than 
600,000 people in the United States, helped to greatly reduce the 
number of deaths on the waiting list, and generated substantial savings 
to the Medicare program through foregone need for dialysis. As a 
country, we do very well in facilitating and providing these life-
saving services, but we need sustained Federal commitment and resources 
to continue this mission.
    Your leadership has been exemplary over many years on 
transplantation and organ donation activities. On behalf of transplant 
patients and their families, we ask that you again champion Federal 
organ donation and transplantation programs run through HRSA.
    Sincerely,
                    Alliance for Paired Donation, American Association 
                            of Kidney Patients, American Association 
                            for the Study of Liver Diseases, American 
                            Society of Nephrology, American Society of 
                            Pediatric Nephrology, American Society of 
                            Transplantation, American Society of 
                            Transplant Surgeons, American Transplant 
                            Foundation, Association of Organ 
                            Procurement Organizations, Dialysis Patient 
                            Citizens, Eye Bank Association of America, 
                            NATCO, The Organization for Transplant 
                            Professionals, National Kidney Foundation, 
                            PKD (Polycystic Kidney Disease) Foundation, 
                            Renal Physicians Association, Texas 
                            Transplant Society, Transplant Recipients 
                            International Organization, United Network 
                            for Organ Sharing.
                                 ______
                                 
                Prepared Statement of the Trevor Project

    Dear Chairman Harkin and Representative Moran: My name is Abbe 
Land, and I am the Executive Director and CEO. The Trevor Project 
appreciates the opportunity to submit a statement on the critical and 
timely issue of funding for children's mental health initiatives. We 
strongly encourage you to support our Nation's youth by funding these 
vital programs:
  --Increase and continue to fund SAMHSA Mental Health Programs: $1.101 
        billion
  --Continue to fund and reauthorize the Garrett Lee Smith Memorial 
        Act, and increase funding by $2 million to each program ($44 
        million total, SAMHSA)
  --Now is the Time Programs (Departments of Justice, Education, HHS):
    --Authorize $150 million for the Comprehensive School Safety 
            Program
    --Authorize $80 million to help create safer and healthier school 
            climates
    --Fully fund Project Aware--$155 million (Department of Education, 
            HHS)
  --Continue to support and fund the Elementary and Secondary School 
        Counseling Program (Department of Education): $52.3 million
  --Continue to fund and reauthorize the Runaway and Homeless Youth Act 
        and increase funding to $165 million (Department of Housing and 
        Urban Development)
  --Continue to fund the Prevention and Public Health Fund (Departments 
        of Health and Human Services, SAMHSA):
    --Behavioral Health Screening and Integration with Primary Health--
            $70 million
    --Public Health Workforce--$45 million
  --Restore and augment funding to the Centers for Disease Control and 
        Prevention, Division of Adolescent and School Health: $50 
        million
    The Trevor Project is the leading national organization providing 
crisis intervention and suicide prevention services to lesbian, gay, 
bisexual, transgender and questioning (LGBTQ) young people under 24. 
The Trevor Project saves young lives through its free and confidential 
lifeline, a secure instant messaging service providing live help, in-
school workshops, educational materials, online resources and advocacy. 
Recognized by the President as a Model of Pride, The Trevor Project has 
been an innovator in suicide prevention since 1998.
    The recent tragic and senseless loss of life in Newtown, 
Connecticut, has highlighted the need for action to address the serious 
mental health concerns that continue to face our Nation. President 
Obama has brought further attention to this critical issue through his 
``Now is the Time'' Presidential plan,\1\ which emphasizes the 
importance of both mental health care and safe schools as part of an 
effort to protect our youth and communities. We thank the Committee for 
taking a thorough look at the funding mechanisms that support our 
Nation's youth mental health programs, and we hope that this letter 
will identify the critical programs that exist to protect our most 
vulnerable youth.
    While Congress has sought to increase access to appropriate mental 
health care in recent years through the passage of laws such as the 
Mental Health Parity and Addiction Equity Act and the Affordable Care 
Act, there unfortunately remain substantial barriers to accessing 
mental health care, particularly for young people.
    According to the National Survey of Children's Health, up to 20 
percent of young people have a diagnosable mental illness, but only 60 
percent of those in need of mental health care receive the treatment 
they require.\2\ In fact, half of all individuals with mental illness 
experience onset of the disorder by age 14, but do not seek treatment, 
on average, until the age of 24.\3\ For youth, the consequences of 
untreated mental illness vary and include increased suicide risk, 
school failure, involvement in the criminal justice system, 
unemployment, substance abuse, and homelessness. Among stigmatized 
populations such as LGBTQ young people, these negative outcomes can be 
exacerbated by prejudice, fear, and hate experienced in homes, schools, 
and communities.
    Suicidality is closely associated with mental illness; more than 90 
percent of those who die by suicide have a diagnosable mental 
disorder.\4\ Therefore suicide prevention is an essential component of 
a comprehensive mental health system. Among young people ages 10 to 24, 
suicide is the second leading cause of death.\5\ This issue is 
especially critical for LGBTQ youth populations. Research has shown 
that LGB youth are 4 times more likely to attempt suicide than their 
straight peers, and questioning youth are 3 times more likely.\6\ 
Nearly half of young transgender people have seriously thought about 
taking their lives and one quarter report having made a suicide 
attempt.\7\ While these statistics are tragic, it is important to 
remember that together we can prevent suicide through education and 
awareness.
    The Trevor Project recommends the following appropriations to 
improve access to effective mental health care and reduce suicide risk 
for young people:

                  MENTAL HEALTH BLOCK GRANTS (SAMHSA)

    SAMHSA operates the only Federal programs dedicated to improving 
systems of care for youth in juvenile justice and special education 
programs. Through SAMHSA's block grant programs, States provide 
necessary services to youth and adults facing mental illness and 
addiction who would not otherwise be able to seek help and get 
treatment.
  --Congress should allocate a minimum of $1.101 billion in total 
        fiscal year 2013 funding for mental health programs to sustain 
        and improve necessary initiatives.
            garrett lee smith memorial act (s. 116) (samhsa)
    Suicide prevention programs for young people are a life-saving and 
effective means to address the daunting issue of youth suicide. We can 
help avoid tragedy by appropriately funding programs that focus on 
extreme harming behaviors and mental illness in young people. Garrett 
Lee Smith funding currently supports suicide prevention programs in 40 
States, 38 tribes, and 85 colleges.
  --Ensure the Suicide Prevention Resource Center that houses the 
        National Best Practices Registry and also the evidence base in 
        suicide prevention continues to be funded at $5 million 
        annually.
  --Increase authorization for State and tribal programs to $32 million 
        annually, an increase of $2 million.
  --Increase authorization for higher education programs to $7 million 
        annually, an increase of $2 million.

                        NOW IS THE TIME PROGRAMS

     (departments of justice, education, health and human services)
    The President's Now is the Time plan is a profound affirmation of 
this Administration's commitment to addressing school safety and youth 
mental health. These programs must be adequately funded in order to 
fulfill the promise of making our schools and communities safe for all 
young people.
  --Authorize $150 million for the Comprehensive School Safety Program. 
        This valuable program will help ensure that every student feels 
        supported and safe, by helping school districts hire 1,000 new 
        school mental health professionals and resource officers.
  --Authorize $80 million to help schools create safer and healthier 
        school climates through comprehensive emergency management, and 
        new monitoring systems.
  --Fully fund Project AWARE--$155 million
    --Support innovative, State-based strategies for improving mental 
            health training and responsiveness to mental health 
            emergencies;
    --Put more trained teachers and mental health professionals on the 
            ground;
    --Help school districts make sure students get the referrals they 
            need;
    --Underscore the importance of prevention by offering students 
            mental health services for trauma or anxiety, conflict 
            resolution programs, and other school-based violence 
            prevention strategies.
           elementary and secondary school counseling program
                       (department of education)
    The Department of Education plays a vital role in ensuring that at-
risk youth communities have consistent access to mental health services 
in schools. Congress should support these services through allocation 
of funding to new mental health in schools initiatives, as well as 
through a recommitment to programs that have already been successful.
  --The Elementary and Secondary School Counseling Program is the only 
        Federal program that helps school districts put mental health 
        professionals in schools. Congress should continue to fund this 
        critical program at current levels ($55.3 million).
                  runaway & homeless youth act (rhya)
             (department of housing and urban development)
    An estimated 40 percent of all homeless youth are LGBTQ-identified, 
often because they are thrown out of their homes or face family 
rejection. Nearly 2/3 of these young people are likely to attempt 
suicide at least once. Funding for the RHYA has not significantly 
increased since 2008, despite a growing population desperately in need 
of the services provided by this Act. Through the RHYA, Congress 
ensures funding for community outreach programs, transitional housing 
and support services, and counseling and reunification guidance for 
families to be reconnected.
  --Congress should fully fund the Runaway and Homeless Youth Act, 
        providing $165 million to help keep our vulnerable youth safe 
        and healthy.
                   prevention and public health fund
               (department of health and human services)
    Preventative care results in better health outcomes, and it is 
cheaper and more cost effective than downstream alternatives. This is 
especially true for issues relating to mental health and suicide 
prevention. The Prevention and Public Health Fund represents an 
opportunity to recognize mental health as a public health issue, and to 
take meaningful action to give States the support services and 
infrastructure necessary to treat it as such.
  --Congress should continue to fund Behavioral Health Screening and 
        Integration with Primary Health ($70 million), which in part 
        goes towards expanding suicide prevention activities and 
        screening for substance use disorders, and towards assisting 
        communities with integrating primary care services into 
        publicly-funded community mental health and behavioral health 
        settings.
  --Congress should continue to provide funding for the Public Health 
        Workforce ($45 million) to help communities train public health 
        providers who will advance preventive medicine and improve the 
        access to and quality of health services in medically 
        underserved communities.
         division of adolescent and school health funding (cdc)
    The Centers for Disease Control and Prevention (CDC)'s Division of 
Adolescent and School Health (DASH) provides crucial support services 
nationally. DASH helps administer the Youth Risk Behavior Surveillance 
System (YRBSS)--the only instrument utilized at the Federal level to 
assess the health and education needs of middle and secondary school 
students in the United States. This survey collects important 
information about the health and well-being of our Nation's youth, data 
that helps advocates and policymakers to make better-informed and more 
effective decisions on behalf young people.
  --Congress should fully restore funding to DASH for $50 million so 
        that important data continue to be collected about at-risk 
        youth and essential student health programs can continue.

                               CONCLUSION

    We thank the Committee for taking the time to fully assess our 
Nation's mental health care system, and we appreciate the opportunity 
to provide a written statement. We strongly support efforts to increase 
access to mental health care for young people, and we urge the 
Committee to fully support these critical programs.
    If you should have any questions regarding this statement, please 
contact myself or Elliot Kennedy, Government Affairs Counsel, by email 
at [email protected].
---------------------------------------------------------------------------
    \1\ The White House, Now is the Time: The President's plan to 
protect our children and communities by reducing gun violence (2013).
    \2\ 2007 National Survey of Children's Health, Data Resource Center 
for Child & Adolescent Health, Child and Adolescent Health Measurement 
Initiative, http://www.nschdata.org (last visited May 2009).
    \3\ Ronald C. Kessler et al., Lifetime Prevalence and Age-of-Onset 
Distributions of DSM-IV Disorders in the National Co-morbidity Survey 
Replication (NCSR), 62 General Psychiatry 593 (2005); and Philip S. 
Wang et al., Failure and Delay in Initial Treatment Contact After First 
Onset of Mental Disorders in the National Co-morbidity Survey 
Replication (NCS-R), 62 General Psychiatry 603 (2005).
    \4\ Suicide in the U.S.: Statistics and Prevention, National 
Institute of Mental Health, available at http://www.nimh.nih.gov/
health/publications/suicide-in-the-us-statistics-and-prevention/
index.shtml#Moscicki-Epi (last visited Mar. 14, 2013).
    \5\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control, Web-Based Injury Statistics Query and 
Reporting System (WISQARS), available at http://www.cdc.gov/ncipc/
wisqars (last visited Mar. 14, 2013).
    \6\ Laura Kann et al., Sexual Identity Sex of Sexual Contacts, and 
Health-Risk Behaviors Among Students in Grades 9-12--Youth Risk 
Behavior Surveillance, Selected Sites, United States, 2001-2009, 
60(SS07) MMWR 1 (2011), available at http://www.cdc.gov/mmwr/preview/
mmwrhtml/ss6007a1.htm (last visited Mar. 14, 2013).
    \7\ Arnold H. Grossman & Anthony R. D'Augelli, Transgender Youth 
and Life-Threatening Behaviors, 37(5) Suicide Life Threat Behav. 527 
(2007).
---------------------------------------------------------------------------
                                 ______
                                 
           Prepared Statement of the Tri-Council for Nursing

    The Tri-Council for Nursing, comprising the American Association of 
Colleges of Nursing, the American Nurses Association, the American 
Organization of Nurse Executives, and the National League for Nursing, 
respectfully requests $251.099 million for the Nursing Workforce 
Development programs authorized under Title VIII of the Public Health 
Service Act (42 U.S.C. 296 et seq.) in fiscal year 2014.
    The Tri-Council is a long-standing nursing alliance focused on 
leadership and excellence in the nursing profession. As the Nation 
restructures its health care system through expanding access to some 
30+ million new patients, decreasing cost, and improving quality, an 
investment must be made to strengthen the nursing workforce. The U.S. 
Bureau of Labor Statistics (BLS) projects that the profession of 
registered nurse (RN) will grow 26 percent for the 10-year timeframe 
between 2010 and 2020, compared to the average growth rate of 14 
percent for all occupations.
    Notwithstanding our slowed economic recovery, the BLS projects 
there will be 2 million health care jobs created between 2010 and 2020. 
This workforce growth is expected to continue as demand for nursing 
care accelerates in traditional acute care settings and in non-hospital 
settings such as home care and long-term care. The BLS projections 
further explain the need for 495,500 replacements in the nursing 
workforce, bringing the total number of job openings for nurses due to 
growth and replacements to 1.2 million by 2020.
    As our Nation regains its economic foothold, the Tri-Council urges 
the subcommittee to focus on the larger context of building the nursing 
capacity needed to meet the rising health care demands of our Nation's 
population. Starting on January 1, 2011, Baby Boomers began turning 65 
at the rate of 10,000 a day. With them comes the amplified call for 
health care and services of an aging population, which will swell the 
pressure on the health care system, especially when coupled with near 
epidemic growth in childhood obesity, diabetes, and other chronic 
diseases experienced among the country's populations.
    Moreover, the acute nurse faculty shortage is one significant 
reason why schools of nursing across the country turn away thousands of 
qualified applications each year. The demand for nurses and the faculty 
who educate them is a serious impediment to improving the Nation's 
health care needs. Nurses continue to be the largest group of health 
care providers whose services are directly linked to quality and cost-
effectiveness. The Tri-Council is grateful to the subcommittee for your 
past commitment to Title VIII funding and respectfully asks that you 
continue to make the long-term investment that will build the nursing 
workforce necessary to deliver the quality, affordable care envisioned 
in health reform.

A Proven Solution: Nursing Workforce Development Programs
    The Nursing Workforce Development programs, authorized under Title 
VIII of the Public Health Service Act, have helped build the supply and 
distribution of qualified nurses to meet our Nation's health care needs 
since 1964. Over these past 49 years, the original programs, newly 
added and expanded programs have addressed all aspects of supporting 
the workforce--education, practice, retention, and recruitment. They 
have bolstered nursing education at all levels--from entry-level 
preparation through graduate study--and have provided support for 
institutions that educate nurses for practice in rural and medically 
underserved communities. A description of the Title VIII programs and 
their impact are included below.
  --Advanced Nursing Education (ANE) Programs (Sec. 811) fund a number 
        of grant activities--including several traineeships--that aim 
        to increase the size and quality of the advanced nursing 
        workforce. Supporting the preparation of RNs in master's and 
        doctoral nursing programs, the ANE grants help prepare our 
        Nation's nurse practitioners, clinical nurse specialists, nurse 
        midwives, nurse anesthetists, nurse educators, nurse 
        administrators, nurses in executive practice, public health 
        nurses, and other nursing specialists requiring advanced 
        nursing education. In fiscal year 2011, these grants supported 
        the education of over 7,800 students--exceeding the program's 
        performance target by 25 percent. The ANE-funded traineeships 
        comprise the Advanced Education Nursing Traineeships (AENT) and 
        the Nurse Anesthetist Traineeships (NAT). Where AENTs aim to 
        increase the number of advanced education nurses trained to 
        practice as primary care nurse practitioners or nurse midwives, 
        the NATs seek to address the misdistribution of primary care 
        nurse anesthetists in the United States. Performance data for 
        fiscal year 2011 showed that grantees of the AENT and NAT 
        programs provided direct financial support to 11,242 nursing 
        and nurse anesthesia students, exceeding the performance target 
        of 2,910.
  --Nursing Workforce Diversity (NWD) Grants (Sec. 821) prepare 
        students from disadvantaged backgrounds to become nurses, 
        producing a more diverse nursing workforce. This outcome will 
        help meet the increasing need for culturally aligned, quality 
        health care for the Nation's rapidly diversifying population 
        and help close the gap in health disparities. This program 
        awards grants and contract opportunities to schools of nursing 
        for a variety of clinical training facilities to address 
        nursing educational needs for not only disadvantaged students 
        but also racial and ethnic minorities underrepresented in the 
        nursing profession. Also, the reauthorization of the NWD 
        program under the Patient Protection and Affordable Care Act 
        added the authority to support advanced nursing education. The 
        persistent underrepresentation of racial/ethnic minority groups 
        prompts an initiative targeting efforts to diversify the ranks 
        of nursing faculty. In fiscal year 2011, the program 
        performance data showed that NWD grantees provided scholarships 
        to 1,270 students, exceeding the performance target by 72 
        percent.
  --Nurse Education, Practice, Quality and Retention (NEPQR) Grants 
        (Sec. 831, and Sec. 831 A) help schools of nursing, academic 
        health centers, nurse managed health centers, State and local 
        governments to strengthen nursing education programs thereby 
        increasing the size and quality of the nursing workforce. The 
        purposes of the NEPQR are broad and flexible, allowing the 
        program to address emerging needs in nursing workforce 
        development. For example, projects to develop and disseminate 
        collaborative practice models that incorporate the full range 
        of health care workers in team-based care are of certain 
        interest. NEPQR supports infrastructure development to enhance 
        the coordination and capacity building of interprofessional 
        practice and education among health professions across the 
        United States and particularly in medically underserved areas. 
        For other interests, a number of grant activities have been 
        funded to support several legislative purposes such as 
        expanding the size of academic programs that are able to confer 
        a baccalaureate degree of science in nursing (BSN); recruiting 
        and educating individuals as qualified personal and home care 
        aides in occupational shortage and/or high demand areas; 
        training qualified nursing assistants and home health aides to 
        meet the growing health care needs of the aging population; 
        and/or supporting nurse managed health clinics that serve as 
        primary care access points in areas where primary care 
        providers are in short supply. A total of 5,127 BSN students 
        were supported during fiscal year 2011, exceeding the program's 
        performance target by 5 percent. Grantees funded to support the 
        personal and home health aide purpose of the NEPQR program 
        trained a total of 1,366 students during fiscal year 2011; and 
        grantees supporting the nursing assistant and home health aide 
        NEPQR purpose supported a total of 1,810 students.
  --NURSE Corps (formerly known as the Nursing Education Loan Repayment 
        and Scholarship Program) (Sec. 846, Title VIII, PHSA) provides 
        monies to students that pay up to 85 percent of a student's 
        loan in return for at least 3 years of service in a designated 
        health shortage area or in an accredited school of nursing. The 
        NURSE Corps Loan Repayment Program (LRP) is a financial 
        incentive program under which individual RNs and advanced 
        practice RNs (APRNs) enter into a contractual agreement with 
        the Federal Government to work full-time in a health care 
        facility with a critical shortage of nurses, in return for 
        repayment of qualifying nursing educational loans. The Patient 
        Protection and Affordable Care Act of 2010 amended the NURSE 
        Corps LRP to extend loan repayment to nurse faculty. These 
        awards assist in the recruitment and retention of nurse faculty 
        at accredited schools of nursing by decreasing economic 
        barriers that may be associated with pursuing a career in 
        academic nursing. The NURSE Corps Scholarship Program (SP) 
        offers scholarships to individuals attending accredited schools 
        of nursing in exchange for a service commitment payback in 
        health care facilities with a critical shortage of nurses. The 
        NURSE Corps SP award reduces the financial barrier to nursing 
        education for all levels of professional nursing students, thus 
        increasing the pipeline. A first funding preference is given to 
        qualified applicants who have zero expected family contribution 
        and who are enrolled full-time in an undergraduate nursing 
        program or a Master's nurse practitioners program.
  --Nurse Faculty Loan Program (NFLP) (Sec. 846 A, Title VIII, PHSA) 
        provides up to 85 percent of loan cancellation if the student 
        agrees to a 4-year teaching commitment in a school of nursing. 
        In fiscal year 2011, NFLP grantees provided loans to a total of 
        2,246 students pursuing faculty preparation at the master's and 
        doctoral level, exceeding the program's performance target of 
        1,510 by 49 percent. NFLP performance data showed that, of the 
        students supported in fiscal year 2011, over 400 graduated at 
        the end of academic year, exceeding the performance target of 
        275 by 45 percent.
  --Comprehensive Geriatric Education Program (CGEP) Grants (Sec. 855, 
        Title VIII, PHSA) provide support to nursing students 
        specializing in care for the elderly. These grants may be used 
        to educate RNs who will provide direct care to older Americans, 
        develop and disseminate geriatric curriculum, prepare faculty 
        members, and provide continuing education. Through continuing 
        education activities, fiscal year 2011 grantees of the CGEP 
        program reached over 8,200 trainees and delivered over 1,700 
        hours of instruction. Performance data showed that CE offerings 
        primarily focused on topics such as geriatric education for 
        direct care providers, palliative and end-of-life care, and 
        health care and older adults.
    Our Nation is faced with a growing health care crisis that must be 
addressed on many fronts. Nurses are an important part of the solution 
to the crisis of cost, burden of disease, and access to quality care. 
To meet this challenge, funding of proven Federal programs such as 
Title VIII will help ease the demand for RNs. The Tri-Council 
respectfully requests your support of $251.099 million for the Title 
VIII Nursing Workforce Development Programs in fiscal year 2014.
                                 ______
                                 
          Prepared Statement of the Trust for America's Health

    Trust for America's Health (TFAH), a nonprofit, nonpartisan 
organization dedicated to saving lives by protecting the health of 
every community and working to make disease prevention a national 
priority, would like to thank you for this opportunity to submit 
written testimony regarding fiscal year 2014 appropriations. We would 
also like to give special thanks to Senator Harkin for decades of 
tireless work to support for prevention and wellness programs in both 
his roles as Chairman of the Senate Health, Education, Labor, and 
Pensions (HELP) Committee but this subcommittee as well.
    As you craft the fiscal year 2014 Labor, Health & Human Services, 
Education and Related Agencies (LHHS) appropriations bill, I urge you 
to include adequate funding for prevention and preparedness programs at 
the Centers for Disease Control and Prevention (CDC) and other public 
health agencies.
    As a Nation, we face daunting economic and fiscal challenges. To a 
large degree, these are driven by high health care costs. Indeed, we 
spend roughly 75 percent of our Nation's annual $2.5 trillion in health 
care spending on preventable chronic diseases. Despite this expenditure 
of scarce resources, we are managing sickness, not preventing it--and 
are faced with the grim prospect that, if we remain on our current 
trajectory, our children may be the first in U.S. history to live 
shorter, less healthy lives than their parents.
    Fortunately, the vast majority of our chronic disease burden is 
preventable through proven approaches that focus primarily on increased 
physical activity, improved nutrition, and reduced tobacco use. A 
recent TFAH report estimates that if average body mass index were 
reduced by five percent, in just 5 years the United States would save 
$30 billion and prevent millions of cases of diabetes, heart disease, 
stroke, arthritis, and cancer. The Prevention and Public Health Fund 
and National Prevention Strategy provide an important framework on 
which we can build efforts to put greater emphasis on prevention, turn 
our ``sick care'' system into one that provides true health care, and 
help Americans lead longer, more productive, healthier lives.
    The future health of the Nation depends on supporting both 
investments within the health sector that promote prevention inside and 
outside the clinic, as well as partnerships between health and crucial 
partners in education, transportation, housing, and other sectors, and 
we must maintain our investment in Federal wellness and prevention 
programs.
    We also cannot forget the critical role that CDC and State and 
local health departments play in protecting us from communicable 
diseases, bioterrorist threats and natural disasters. That core 
capacity has been diminished in recent years because of Federal budget 
cuts and the economic downturn, resulting in a 20 percent loss (48,000 
jobs) in the State and local health department workforce.
    Meeting these twin challenges of preventing disease and protecting 
the American people from natural and man-made threats can only occur 
with continued support for key programs at the CDC--ranging from the 
Prevention and Public Health Fund and Community Transformation Grant 
program to preparedness programs and other funding streams that assure 
that all health departments have the foundational capabilities to 
respond to all health threats.

            CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

    Cuts to the CDC, our Nation's lead public health agency and a 
critical partner in our long-term efforts to prevent disease and 
illness have already been stark. Compared to fiscal year 2010, with 
sequestration the CDC will have seen its budget authority cut by 18 
percent over just 3 years. These cuts have played a big part in the 
aforementioned workforce cuts. Overall, scarce resources means CDC will 
be forced to make extremely tough, sometimes life and death choices.

                 THE PREVENTION AND PUBLIC HEALTH FUND

    Significant cuts to the Fund contained in the Middle Class Tax 
Relief and Job Creation Act of 2012 will be compounded with additional 
cuts under sequestration. To date, the Fund has invested $2.25 billion 
since fiscal year 2010 to support State and local public health efforts 
to transform and revitalize communities, build epidemiology and 
laboratory capacity to track and respond to disease outbreaks, train 
the Nation's public health and health workforce, prevent the spread of 
HIV/AIDS, expand access to vaccines, reduce tobacco use, and help 
control the obesity epidemic.
    Unfortunately, we learned last month that of $949 million remaining 
under the Prevention Fund for fiscal year 2013, a significant portion 
of funding will be diverted to support outreach and education efforts 
for the federally-administered Heath Insurance Marketplace. TFAH 
supports insurance enrollment as a critical opportunity to ensure 
people gain access to life-saving and life-extending services, 
including essential preventive services. However, it is just as 
important that people have access to the support they need outside the 
doctor's office to become and remain healthy to potentially avoid those 
life-threatening health situations. We are concerned that further cuts 
to the Prevention Fund will compromise our ability to make progress on 
cost containment, public health modernization and wellness promotion.
    As a result, we urge this subcommittee and Congress to fully 
allocate fiscal year 2014 Prevention and Public Health dollars towards 
evidence-based programs, include the Community Transformation Grant 
program (see below), aimed at promoting primary prevention and public 
heath promotion.

                    COMMUNITY TRANSFORMATION GRANTS

    The Community Transformation Grants (CTG) program, administered by 
the CDC, is one of our best prevention opportunities. CTG grants 
empower States and localities to address the drivers of chronic 
disease. Most importantly, it requires communities to create 
partnerships to achieve sustainable solutions to help make the healthy 
choice the easy choice. CTGs must deploy strategies that are evidence-
based and all grantees have rigorous health outcomes improvement goals 
that must be met. It is important to note, that as required by law, at 
least 20 percent of CTG funds must be targeted to reach rural or 
frontier communities. Even with current levels of funding, only about 4 
in 10 Americans are reached by the CTG program. We recommend the 
Committee allocate $300 million from the Prevention Fund for the CTG 
program in fiscal year 2014, which will allow the program to reach 
millions more Americans.

  NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION

    Over the past several years, the Chronic Disease Center at CDC has 
made progress in an effort to move away from the traditional 
categorical approach to funding chronic disease prevention and towards 
more coordinated, cross-cutting strategies. In 2011, CDC awarded 
coordinated chronic disease State grants to all 50 States to begin to 
build a core capacity to address common risk factors and implement 
comprehensive strategies for promoting health. While funding is no 
longer available for those grants, the Chronic Disease Center at CDC 
recently released a new funding opportunity announcement (FOA) aimed at 
integrating prevention approaches for addressing heart disease, 
obesity, school health, and diabetes.
    Diminishing Federal dollars for CDC has meant that not all 50 
States receive funding under our existing categorical grants. 
Coordinated approaches like this can help to ensure that we fund all 
State health departments to achieve cross-cutting, core chronic disease 
prevention capacity. Past proposals from President Obama and others 
have included plans to consolidate budget lines for the Center, another 
approach that could further aid coordination of national and State 
chronic disease prevention. However, consolidation would need to be 
thoughtfully designed so it meaningfully improves our chances of 
improving health, not just serve as a budget gimmick that will further 
harm our ability to address our growing chronic disease burden.

            NATIONAL CENTER FOR ENVIRONMENTAL HEALTH (NCEH)

    Critical programs conducted at the CDC National Center for 
Environmental Health support our chronic disease prevention and public 
health preparedness efforts. However, it remains one of the most 
critically underfunded parts of CDC. Since fiscal year 2009, NCEH 
funding has been cut approximately 25 percent. In fiscal year 2012, for 
example, the CDC Healthy Homes and Lead Poisoning Prevention program 
was nearly eliminated, putting 600,000 children at risk of the terrible 
effects of lead poisoning. We recommended that you fund NCEH at 
$146.151 million in fiscal year 2014 to help begin to rebuild the lead 
control program and ensure that no additional ground is lost in 
addressing the environmental causes of disease.

                  PUBLIC HEALTH EMERGENCY PREPAREDNESS

    The State & Local Preparedness & Response Capability program at the 
CDC supports health departments in preparing for, and responding to, 
all types of disasters, including bioterror attacks, natural disasters, 
and infectious disease outbreaks. The centerpiece is the Public Health 
Emergency Preparedness (PHEP) Cooperative Agreements. PHEP grants 
support 15 core capabilities, including biosurveillance, community 
resilience, countermeasures and mitigation, incident management, 
information management, and surge management. These capabilities are 
tiered so that grantees can identify areas of greatest need and target 
their resources accordingly.
    TFAH recommends providing $657.4 million for the CDC State and 
Local Preparedness line for fiscal year 2014 in line with the 
authorized amount included in the recently-passed reauthorization of 
the Pandemic and All-Hazards Preparedness Act (PAHPA). Cuts mean the 
loss of highly-trained frontline public health preparedness workers, 
reduction of the number of high-level laboratories, defunding academic 
and research centers, and eroding training, exercise, planning, 
epidemiology, and surveillance capacity. Preparedness is dependent on 
maintaining a well-trained public health workforce, and inconsistent 
funding results in serious gaps in our ability to respond to new health 
threats. It is unreasonable to expect our first responders to continue 
to be able to confront more threats with fewer resources.

                               CONCLUSION

    Investing in disease prevention is the most effective, common-sense 
way to improve health and help address our long-term deficit. Hundreds 
of billions of dollars are spent each year via Medicare, Medicaid, and 
other Federal health care programs to pay for health care services once 
patients develop an acute illness, injury, or chronic disease and 
present for treatment in our health care system. A sustained and 
sufficient level of investment in public health and prevention efforts 
is essential to reduce high rates of disease and improve health in the 
United States.
    Should you have any questions regarding this written testimony, 
please do not hesitate to contact: Rebecca Salay, Director of 
Government Relations, Trust for America's Health, 1730 M Street, NW, 
Suite 900, Washington, DC 20036, email [email protected].
                                 ______
                                 
          Prepared Statement of the United Nations Foundation

    Chairman Tom Harkin, Ranking Member Jerry Moran, and members of the 
subcommittee, the American Red Cross and the United Nations Foundation 
appreciate the opportunity to submit testimony in support of measles 
control activities of the U.S. Centers for Disease Control and 
Prevention (CDC). The American Red Cross and the United Nations 
Foundation recognize the leadership that Congress has shown in funding 
CDC for these essential activities. We sincerely hope that Congress 
will continue to support the CDC during this critical period in measles 
control.
    In 2001, CDC--along with the American Red Cross, the United Nations 
Foundation, the World Health Organization, and UNICEF--founded the 
Measles Initiative, a partnership committed to reducing measles deaths 
globally. In 2012, the Initiative expanded to include rubella control 
and adopted a new name, the Measles & Rubella Initiative (the 
Initiative). The Initiative aims to reach elimination goals for 
measles, rubella and congenital rubella syndrome. The current UN goal 
is to reduce global measles deaths by 95 percent by 2015 compared to 
2000 estimates, and three of six WHO regions have set rubella control 
or elimination targets. The Initiative is committed to reaching these 
goals by providing technical and financial support to governments and 
communities worldwide.
    The Measles & Rubella Initiative has achieved ``spectacular'' \1\ 
results by supporting the vaccination of more than 1.1 billion 
children. Largely due to the Measles & Rubella Initiative, global 
measles mortality dropped 71 percent, from an estimated 548,000 deaths 
in 2000 to 158,000 in 2011 (the latest year for which data is 
available). During this same period, measles deaths in Africa fell by 
84 percent. About 430 children still die from measles each day from a 
virus that can be countered with an effective, inexpensive vaccine; and 
each year more than 110,000 children are born with congenital rubella 
syndrome. In May 2012, the 194 member States of the World Health 
Assembly resolved to endorse the Global Vaccine Action Plan, which 
affirmed the elimination of measles and rubella by 2020 in at least 
five of six WHO regions as global goals.

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


    Working closely with host governments, the Measles & Rubella 
Initiative has been the main international supporter of mass measles 
immunization campaigns since 2001. The Initiative mobilized more than 
$1 billion and provided technical support in more than 80 developing 
countries on vaccination campaigns, surveillance and improving routine 
immunization services. From 2000 to 2011, an estimated 10 million 
measles deaths were averted as a result of these accelerated measles 
control activities at a donor cost of less than $200/death averted, 
making measles mortality reduction one of the most cost-effective 
public health interventions.
    Nearly all the measles vaccination campaigns have been able to 
reach more than 90 percent of their target populations. Countries 
recognize the opportunity that measles vaccination campaigns provide in 
accessing mothers and young children, and ``integrating'' the campaigns 
with other life-saving health interventions has become the norm. In 
addition to measles vaccine, vitamin A (crucial for preventing 
blindness in under nourished children), de-worming medicine (reduces 
malnutrition), and insecticide-treated bed nets (ITNs) for malaria 
prevention are distributed during vaccination campaigns. The scale of 
these distributions is immense. The Initiative and its partners have 
supported the distribution of more than 245 million doses of vitamin A, 
113 million doses of de-worming medicine, 41 million insecticide-
treated bed nets, and 137 million doses of polio vaccine. Doses of oral 
polio vaccines are frequently distributed during measles campaigns in 
polio endemic and high risk countries. The delivery of polio vaccines 
in conjunction with measles vaccines in these campaigns strengthens the 
reach of elimination and eradication efforts of these diseases. The 
delivery of multiple child health interventions during a single 
campaign is far less expensive than delivering the interventions 
separately, and this strategy increases the potential positive impact 
on children's health from a single campaign.
    The extraordinary reduction in global measles deaths contributed 
nearly 25 percent of the progress to date toward Millennium Development 
Goal #4 (reducing under-five child mortality). However, large outbreaks 
in several African, European and Asian countries in 2011 and 2012 have 
put the 2015 measles elimination goals at risk. These outbreaks 
highlight the fragility of the last decade's progress. If mass 
immunization campaigns are not continued, measles deaths will increase 
rapidly with more than half a million deaths estimated for 2013 alone.
    To achieve the 2015 goal and avoid a resurgence of measles the 
following actions are required:
  --Fully implementing activities, both campaigns and strengthening 
        routine measles coverage, in India since it is the greatest 
        contributor to the global burden of measles.
  --Sustaining the gains in reduced measles deaths, especially in 
        Africa, by strengthening immunization programs to ensure that 
        more than 90 percent of infants are vaccinated against measles 
        through routine health services before their first birthday as 
        well as conducting timely, high quality mass immunization 
        campaigns.
  --Accelerating the introduction of a second dose of measles 
        containing vaccine into the routine immunization program of 
        eligible countries with support from the GAVI Alliance.
  --Securing sufficient funding for measles and rubella-control 
        activities both globally and nationally. The Measles & Rubella 
        Initiative faces a funding shortfall of an estimated U.S. $171 
        million for 2013-2015. Implementation of timely measles 
        campaigns is increasingly dependent upon countries funding 
        these activities locally. The decrease in donor funds available 
        at a global level to support measles elimination activities 
        makes increased political commitment and country ownership of 
        the activities critical for achieving and sustaining the goal 
        of reducing measles mortality by 95 percent.
    If these challenges are not addressed, the remarkable gains made 
since 2000 will be lost and a major resurgence in measles deaths will 
occur.
    By controlling measles and rubella cases in other countries, U.S. 
children are also being protected from the diseases. Measles can cause 
severe complications and death. A resurgence of measles occurred in the 
United States between 1989 and 1991, with more than 55,000 cases 
reported. This resurgence was particularly severe, accounting for more 
than 11,000 hospitalizations and 123 deaths. Since then, measles 
control measures in the United States have been strengthened and 
endemic transmission of measles cases have been eliminated here since 
2000. However, importations of measles cases into this country continue 
to occur each year, particularly from Europe. The costs of these cases 
and outbreaks are substantial, both in terms of the costs to public 
health departments and in terms of productivity losses among people 
with measles and parents of sick children. Studies show that a single 
case of measles in the United States can cost between $100,000 and 
$200,000 to control. The U.S. had 222 measles cases in 2011, the 
highest in 15 years and Canada experienced a large outbreak of over 800 
cases.

The Role of CDC in Global Measles Mortality Reduction
    Since fiscal year 2001 and until 2013, Congress has provided 
between $43.6 and $49.3 million annually in funding to CDC for global 
measles control activities. These funds were used toward the purchase 
of measles vaccine for use in large-scale measles vaccination campaigns 
in more than 80 countries in Africa and Asia, and for the provision of 
technical support to Ministries of Health. Specifically, this technical 
support includes:
  --Planning, monitoring, and evaluating large-scale measles 
        vaccination campaigns;
  --Conducting epidemiological investigations and laboratory 
        surveillance of measles outbreaks; and
  --Conducting operations research to guide cost-effective and high 
        quality measles control programs.
    In addition, CDC epidemiologists and public health specialists have 
worked closely with WHO, UNICEF, the United Nations Foundation, and the 
American Red Cross to strengthen measles control programs at global and 
regional levels, and will continue to work with these and other 
partners in implementing and strengthening rubella control programs. 
While it is not possible to precisely quantify the impact of CDC's 
financial and technical support to the Measles & Rubella Initiative, 
there is no doubt that CDC's support--made possible by the funding 
appropriated by Congress--was essential in helping achieve the sharp 
reduction in measles deaths in just eleven years.
    The American Red Cross and the United Nations Foundation would like 
to acknowledge the leadership and work provided by CDC and recognize 
that CDC brings much more to the table than just financial resources. 
The Measles & Rubella Initiative is fortunate in having a partner that 
provides critical personnel and technical support for vaccination 
campaigns and in response to disease outbreaks. CDC personnel have 
routinely demonstrated their ability to work well with other 
organizations and provide solutions to complex problems that help 
critical work get done faster and more efficiently.
    In fiscal year 2011 and fiscal year 2012, Congress appropriated 
approximately $49 million each year to fund CDC for global measles 
control activities. This amount represents a $2.7 million decrease from 
2010. The American Red Cross and the United Nations Foundation 
respectfully request a return to fiscal year 2010 funding levels ($52 
million) for fiscal year 2014 for CDC's measles and rubella control 
activities to protect the investment of the last decade, and prevent a 
global resurgence of measles and a loss of progress toward Millennium 
Development Goal #4.
    Your commitment has brought us unprecedented victories in reducing 
measles mortality around the world. In addition, your continued support 
for this initiative helps prevent children from suffering from this 
preventable disease both abroad and in the United States.
    Thank you for the opportunity to submit testimony.
---------------------------------------------------------------------------
    \1\ Unpublished data from Measles & Rubella, Annual Report 2012, 
page 11 (April 2013).
---------------------------------------------------------------------------
                                 ______
                                 
   Prepared Statement of the the US Hereditary Angioedema Association

              SUMMARY OF FISCAL YEAR 2014 RECOMMENDATIONS
_______________________________________________________________________

    1)  $32 billion for the National Institutes of Health (NIH) at an 
increase of $1 billion over fiscal year 2012.
    2)  Continued Focus on Hereditary Angioedema Research and Education 
at NIH.
    3)  Funding to create and support the Centers For Disease Control 
and Prevention's (CDC) to increase awareness efforts for Hereditary 
Angioedema at CDC.
_______________________________________________________________________

    Chairman Harkin, thank you for the opportunity to present the views 
of the US Hereditary Angioedema Association (US HAEA) regarding the 
importance of Hereditary Angioedema (HAE) public awareness activities 
and research.
    The US HAEA is a non-profit patient advocacy organization founded 
in 1999 to help those suffering with HAE and their families to live 
healthy lives. The Association's goals were, and remain, to provide 
patient support, advance HAE research and find a cure. The US HAEA 
provides patient services that include referrals to HAE knowledgeable 
health care providers, disease information and peer-to-peer support. US 
HAEA also provides research funding to scientific investigators to 
increase the HAE knowledge base and maintains an HAE patient registry 
to support ground-breaking research efforts. Additionally, US HAEA 
provides disease information materials and hosts forums to educate 
patients and their families, health care providers, and the general 
public on HAE.
    HAE is a rare and potentially life-threatening inherited disease 
with symptoms of severe, recurring, debilitating attacks of edema 
(swelling). HAE patients have a defect in the gene that controls a 
blood protein called C1-inhibitor, so it is also more specifically 
referred to as C1-inhibitor deficiency. This genetic defect results in 
production of either inadequate or nonfunctioning C1-inhibitor protein. 
Because the defective C1-inhibitor does not adequately perform its 
regulatory function, a biochemical imbalance can occur and produce an 
unwanted peptide--called bradykinin--that induces the capillaries to 
release fluids into surrounding tissues, thereby causing swelling.
    People with HAE experience attacks of severe swelling that affect 
various body parts including the hands, feet, face, airway (throat) and 
intestinal wall. Swelling of the throat is the most life-threatening 
aspect of HAE, because the airway can close and cause death by 
suffocation. Studies reveal that more than 50 percent of patients will 
experience at least one throat attack in their lifetime.
    HAE swelling is disfiguring, extremely painful and debilitating. 
Attacks of abdominal swelling involve severe and excruciating pain, 
vomiting, and diarrhea. Because abdominal attacks mimic a surgical 
emergency, approximately one third of patients with undiagnosed HAE 
undergo unnecessary surgery. Untreated, an average HAE attack lasts 
between 24 and 72 hours, but some attacks may last longer and be 
accompanied by prolonged fatigue.
    The majority of HAE patients experience their first attack during 
childhood or adolescence. Most attacks occur spontaneously with no 
apparent reason, but anxiety, stress, minor trauma, medical, surgical, 
and dental procedures, and illnesses such as colds and flu have been 
cited as common triggers. ACE Inhibitors (a blood pressure control 
medication) and estrogen-derived medications (birth control pills and 
hormone replacement drugs) have also been shown to exacerbate HAE 
attacks.
    HAE's genetic defect can be passed on in families. A child has a 50 
percent chance of inheriting the disease from a parent with HAE. 
However, the absence of family history does not rule out the HAE 
diagnosis; scientists report that as many as 25 percent of HAE cases 
today result from patients who had a spontaneous mutation of the C1-
inhibitor gene at conception. These patients can also pass the 
defective gene to their offspring. Worldwide, it is estimated that this 
condition affects between 1 in 10,000 and 1 in 30,000 people.

   PUBLIC AWARENESS AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION

    HAE patients often suffer for many years and may be subject to 
unnecessary medical procedures and surgery prior to receiving an 
accurate diagnosis. Raising awareness about HAE among healthcare 
providers and the general public will help reduce delays in diagnosis 
and limit the amount of time that patients must spend without treatment 
for a condition that could, at any moment, end their lives.
    Once diagnosed, many individuals are able to piece together a 
family history of mysterious deaths and episodes of swelling that 
previously had no name. In some families, over many years, this 
condition has come to be accepted as something that must simply be 
endured. Increased public awareness is crucial so that these patients 
understand that HAE often requires emergency treatment and disabling 
attacks no longer need to be passively accepted. While HAE cannot yet 
be cured, intelligent use of available treatments can help patients 
lead a productive life.
    In order to prevent deaths, eliminate unnecessary surgeries, and 
improve patients' quality of life, it is critical that CDC pursue 
programs to educate the public and medical professionals about HAE in 
fiscal year 2014.

           RESEARCH THROUGH THE NATIONAL INSTITUTES OF HEALTH

    In years past, HAE research was conducted at the National 
Institutes of Health (NIH) through the National Institute of Allergy 
and Infectious Diseases, the National Institute of Neurological 
Disorders and Stroke, the National Heart Lung and Blood Institute, the 
National Institute of Child Health and Human Development, National 
Center for Research Resources, and the National Institute on Diabetes 
and Digestive and Kidney Diseases. However, NIH has not engaged in HAE-
specific research since 2009, and there is no longer any Federal 
research as it relates to HAE.
    As it may provide greater opportunities for HAE research, we 
applaud the recent establishment of the National Center for Advancing 
Translational Sciences (NCATS) at NIH. Housing translational research 
activities at a single Center at NIH will allow these programs to 
achieve new levels of success. Initiatives like the Cures Acceleration 
Network are critical to overhauling the translational research process 
and overcoming the challenges that plague treatment development. In 
addition, new efforts like taking the lead on drug repurposing have the 
potential to speed access to new treatments, particularly to patients 
who struggle with rare or neglected diseases. As a rare disease 
community, HAE patients may also benefit from the Therapeutics for Rare 
and Neglected Diseases (TRND) program, housed at NCATS, as well 
coordination with the Office of Rare Diseases Research (ORDR). We ask 
that you support NCATS and provide adequate resources for the Center in 
fiscal year 2014.
    In order to reinvigorate HAE research at NIH, it is vital that NIH 
receive increased support in fiscal year 2014. US HAEA recommends an 
overall funding level of $32 billion for NIH in fiscal year 2014 and 
the inclusion of recommendations emphasizing the importance of HAE 
research to learn more about this rare disease and new pathways for 
appropriate treatment.
    Thank you for the opportunity to present the views of the HAE 
community.
                                 ______
                                 
             Prepared Statement of the United States Senate

Hon. Tom Harkin,
Chairman, Senate Appropriations Subcommittee on Labor,
Health and Human Services and Education,
131 Dirksen Senate Office Building,
Washington, DC 20510

Hon. Jerry Moran,
Ranking Member, Senate Appropriations Subcommittee on Labor,
Health and Human Services and Education,
156 Dirksen Senate Office Building,
Washington, DC 20510

    Dear Chairman Harkin and Ranking Member Moran: We are writing to 
thank you for your support for the Office of Museum Services (OMS) at 
the Institute of Museum and Library Services (IMLS) and to urge the 
Subcommittee to support robust funding for OMS in the Fiscal Year 2014 
Labor, Health and Human Services and Education Appropriations bill. The 
Office of Museum Services is currently authorized to receive $38.6 
million annually.
    The demand for museum services is greater than ever. At a time when 
school resources are strained and many families cannot afford to travel 
or make ends meet, museums are working overtime to fill the gaps--
providing more than 18 million instructional hours to schoolchildren, 
bringing art and cultural heritage, dynamic exhibitions and living 
specimens into local communities, partnering with other nonprofits to 
encourage national service and volunteerism, and offering free or 
reduced admission. Museums are part of a robust nonprofit community 
working to address a wide range of our Nation's greatest challenges, 
from conducting medical research to hosting supervised visits for the 
family court system, and from creating energy efficient public 
buildings to collecting food for needy families.
    Unfortunately, museums are struggling significantly in these 
difficult economic times. They are being forced to cut back on hours, 
educational programming, community services and jobs. And according to 
the 2005 Heritage Health Index, at least 190 million artifacts are at 
risk, suffering from light damage and harmful and insecure storage 
conditions. Many museums also rely heavily on philanthropic donations 
to keep admission rates low and provide new exhibitions for their 
communities.
    The Institute of Museum and Library Services (IMLS) is the primary 
Federal agency that serves the Nation's more than 17,500 museums, and 
its Office of Museum Services' funding has decreased in recent years. 
Although the agency has been successful in creating and supporting 
advancements in areas such as technology, lifelong community learning 
and conservation and preservation efforts, only a small fraction of the 
Nation's museums are currently being reached, and many highly rated 
grant applications go unfunded each year.
    In 2010, the Institute of Museum and Library Services was 
unanimously reauthorized by both the House and Senate. The agency is 
highly accountable, and its competitive, peer-reviewed grants serve 
every State. The reauthorization contained several provisions to 
further support museums, particularly at the State level, but much of 
the recently authorized activities cannot be accomplished without 
sustained funding.
    We urge the subcommittee to support robust funding for the IMLS 
Office of Museum Services for Fiscal Year 2014 to support the important 
work museums are doing in our communities. This vital funding will aid 
museums of all types--aquariums, arboretums, archaeological museums, 
art museums, botanical gardens, children's museums, culturally specific 
museums, historic sites, history museums, maritime museums, military 
museums, natural history museums, nature centers, planetariums, science 
and technology centers, zoological parks, and other types of museums--
and enable them to continue serving our schools and communities and 
preserving our cultural heritage for future generations.
    Again, we appreciate the subcommittee's prior support for OMS and 
request this investment to strengthen and sustain the work of our 
Nation's museums.
            Sincerely,
                    Kirsten E. Gillibrand, Jack Reed, Patrick J. Leahy, 
                            Frank R. Lautenberg, Christopher A. Coons, 
                            Angus S. King Jr., Richard Blumenthal, 
                            Richard J. Durbin, Jeanne Shaheen, Tim 
                            Johnson, Martin Heinrich, Charles E. 
                            Schumer, Carl Levin, Sherrod Brown, Joe 
                            Manchin III, Bernard Sanders, Ron Wyden, 
                            Mazie K. Hirono, Christopher Murphy, Debbie 
                            Stabenow, Benjamin L. Cardin, Sheldon 
                            Whitehouse, Brian Schatz, Elizabeth 
                            Warren.--United States Senators
                                 ______
                                 
       Prepared Statement of the United Tribes Technical College

    For 44 years, with the most basic of funding, United Tribes 
Technical College (UTTC) has provided postsecondary career and 
technical education, job training and family services to some of the 
most impoverished, high risk Indian students from throughout the 
Nation. With such challenges, some colleges might despair, but we have 
consistently had excellent retention and placement rates and are a 
fully accredited institution. We are proud to be equipping our students 
to take part in the new energy economy in North Dakota and proud to be 
part of building a strong middle class in Indian Country by training 
the next generation of law enforcement officers, educators, medical 
technicians and ``Indianpreneurs.'' We are governed by the five tribes 
located wholly or in part in North Dakota. We are not part of the North 
Dakota State college system and do not have a tax base or State-
appropriated funds on which to rely. Section 117 Carl Perkins Act funds 
represent a significant portion of our operating budget and provide for 
our core instructional programs. The request of the UTTC Board for 
fiscal year 2014 is:
  --$10 million for base funding authorized under Section 117 of the 
        Carl Perkins Act for the Tribally Controlled Postsecondary 
        Career and Technical Institutions program (20 U.S.C. Section 
        2327). This is $1.8 million above the fiscal year 2012 level. 
        These funds are awarded competitively and are distributed via 
        formula.
  --$30 million as requested by the American Indian Higher Education 
        Consortium for Title III-A (Section 316) of the Higher 
        Education Act (Strengthening Institutions program). This is $5 
        million above the fiscal year 2012 enacted level.
  --Maintain Pell Grants at the $5,635 maximum award level.

A Few Things of Note About United Tribes Technical College. We have:
  --Renewed unrestricted accreditation from the North Central 
        Association of Colleges and Schools, for July 2011 through 
        2021, with authority to offer all of our full programs on-line. 
        We have 26 Associate degree programs, 20 Certificate and three 
        Bachelor degree programs (Criminal Justice; Elementary 
        Education; Business Administration).
  --Services including a Child Development Center, family literacy 
        program, wellness center, area transportation, K-8 elementary 
        school, tutoring, counseling, family and single student 
        housing, and campus security.
  --A projected return on Federal investment of 20-1 (2005 study).
  --A semester retention rate of 85 percent and a graduate placement 
        rate of 77 percent. Over 45 percent of our graduates move on to 
        four-year or advanced degree institutions.
  --Students from 75 tribes; 85 percent of our undergraduate students 
        receive Pell Grants.
  --An unduplicated count of undergraduate degree-seeking students and 
        continuing education students of 1200 and a workforce of 360.
  --A dual-enrollment program targeting junior and senior high school 
        students, providing them an introduction to college life and 
        offering high school and college credits.
  --A critical role in the regional economy. Our presence brings at 
        least $34 million annually to the economy of the Bismarck 
        region A North Dakota State University study reports in that 
        the five tribal colleges in North Dakota made a direct and 
        secondary economic contribution to the State of $181,933,000 in 
        2012.
    Positioning our Students for Success.--UTTC is dedicated to 
providing American Indians with postsecondary and technical education 
in a culturally diverse environment that will provide self-
determination and economic development for all tribal nations. This 
means offering a rich cultural education and family support system 
which emphasizes enhancement of tribal peoples and nations, while 
simultaneously evaluating and updating our curricula to reflect the 
current job market. The ramifications of the North Dakota Bakken oil 
boom are seen throughout the State. We saw the need for more certified 
welders in relation to the oil boom and so expanded our certified 
welding program. We are now able to train students for good paying, in-
demand welding jobs. Similarly, our online medical transcription 
program was designed to meet the growing need for certified medical 
support staff. Other courses reflect new emphasis on energy auditing 
and Geographic Information System Technology.
    We are in the midst of opening up a distance learning center in 
Rapid City, SD, where there are some 16,000 American Indians in the 
area. We are also working toward establishment of an American Indian 
Specialized Health Care Training Clinic.

                            FUNDING REQUESTS

    Section 117 Perkins Base Funding.--Funds requested under Section 
117 of the Perkins Act above the fiscal year 2012 level are needed to: 
1) maintain 100 year-old education buildings and 50 year-old housing 
stock for students; 2) upgrade technology capabilities; 3) provide 
adequate salaries for faculty and staff (who have not received a cost 
of living increase for the past year and who are in the bottom quartile 
of salary for comparable positions elsewhere); and 4) fund program and 
curriculum improvements.
    Perkins funds are central to the viability of our core 
postsecondary educational programs. Very little of the other funds we 
receive may be used for core career and technical educational programs; 
they are competitive, often one-time supplemental funds which help us 
provide the services our students need to be successful. Our Perkins 
funding provides a base level of support (averaging over the past 5 
years in excess of 40 percent of our core operating budget) while 
allowing the college to compete for desperately needed discretionary 
funds leading to additional resources annually for the college's 
programs and support services.
    Title III-A (Section 316) Strengthening Institutions.--Among the 
Title III-A statutorily allowable uses is facility construction and 
maintenance. We are constantly in need of additional student housing, 
including family housing. We would like to educate more students but 
lack of housing has at times limited the admission of new students. 
With the completion this year of a new Science, Math and Technology 
building on our South Campus on land acquired with a private grant, we 
urgently need housing for up to 150 students, many of whom have 
families.
    While we have constructed three housing facilities using a variety 
of sources in the past 20 years, approximately 50 percent of students 
are housed in the 100-year-old buildings of what was Fort Abraham 
Lincoln, as well as housing that was donated by the Federal Government 
along with the land and Fort buildings in 1973. These buildings require 
major rehabilitation. New buildings are actually cheaper rehabilitating 
the old buildings that now house students.
    Pell Grants.--We support maintaining the Pell Grant maximum to at 
least a level of $5,635. This resource makes all the difference in 
whether most of our students can attend college. As mentioned above 85 
percent of our undergraduate students are Pell Grant recipients. We are 
glad to learn of the February 6, 2013 report of the Congressional 
Budget Office that the Pell Grant program is currently financially 
healthy and can support full funding the maximum award levels for 
fiscal years 2013 and 2014.

                GOVERNMENT ACCOUNTABILITY OFFICE REPORT

    As you know, the Government Accountability Office (GAO) in March of 
2011 issued two reports regarding Federal programs which may have 
similar or overlapping services or objectives (GAO-11-318SP of March 1 
and GAO-11-474R of March 18). Funding from the Bureau of Indian 
Education (BIE) and the Perkins Act for Tribally Controlled 
Postsecondary Career and Technical Institutions were among the programs 
listed in the supplemental report of March 18, 2011. The GAO did not 
recommend defunding these or other programs; in some cases 
consolidation or better coordination of programs was recommended to 
save administrative costs. We are not in disagreement about possible 
consolidation or coordination of the administration of these funding 
sources so long as funds are not reduced.
    Perkins funds represent on average over 40 percent of UTTC's core 
operating budget. These funds supplement, but do not duplicate, the BIE 
funds. It takes both sources of funding to frugally maintain the 
institution. Even these combined sources do not provide the resources 
necessary to operate and maintain the college. Therefore, UTTC actively 
seeks alternative funding to assist with curricula, deferred 
maintenance, and scholarship assistance, among other things
    We reiterate that UTTC and other tribally-chartered colleges are 
not part of State educational systems and do not receive State-
appropriated general operational funds for their Indian students. The 
need for postsecondary career and technical education in Indian Country 
is so great and the funding so small, that there is little chance for 
duplicative funding.
    There are only two institutions targeting American Indian/Alaska 
Native career and technical education and training at the postsecondary 
level--United Tribes Technical College and Navajo Technical College. 
Combined, these institutions received less than $15 million in fiscal 
year 2012 Federal operational funds ($8 million from Perkins; $7 
million from the BIE). That is a very modest amount for two campus-
based institutions which offer a broad (and expanding) array of 
training opportunities.
    UTTC offers services that are catered to the needs of our students, 
many of whom are first generation college attendees and many of whom 
come to us needing remedial education and services. Our students 
disproportionately possess more high risk characteristics than other 
student populations. We also provide services for the children and 
dependents of our students. Although BIE and Section 117 funds do not 
pay for remedial education services, we make this investment through 
other sources to ensure our students succeed at the postsecondary 
level.
    Thank you for your consideration of our requests.
                                 ______
                                 
 Prepared Statement of the University of North Dakota and North Dakota 
                            State University

    On behalf of the University of North Dakota (UND) and North Dakota 
State University (NDSU), thank you for the opportunity to submit our 
written testimony regarding the fiscal year 2014 funding for the 
National Institutes of Health (NIH) Institutional Development Award 
(IDeA) program. We respectfully request your support of no less than 
$310.0 million for this critically important program. We further 
request that the subcommittee give serious consideration to legislative 
language which would direct that future NIH budgets include funding for 
the IDeA program that reaches no less than 1 percent of the total NIH 
budget. IDeA was authorized by the 1993 NIH Revitalization Act (Public 
Law 103-43) and funds only merit-based, peer-reviewed research that 
meets NIH research objectives in the 23 IDeA States and Puerto Rico.
    The States eligible for IDeA funding are defined as ``all states/
commonwealths with a success rate for obtaining NIH grant awards of 
less than 20 percent over the period of 2001-2005 or received less than 
an average of $120 million per year during that time period.'' 
Currently this includes 23 States and Puerto Rico--nearly half of the 
States. Funding from this capacity-building program has been a key part 
of the growth in research capacity and impact at the two North Dakota 
research universities in recent years.
    Funding for the IDeA program in fiscal year 2013 was $ 277.65 
million. The total budget for NIH in fiscal year 2013 was $29.6 
billion; thus in fiscal year 2013, the IDeA program--funding 
competitively awarded biomedical research in nearly half the nation--
comprised only 0.94 percent of the entire NIH budget. The IDeA program 
exists because the 23 eligible States overall receive less than 20 
percent of NIH's extramural funding. The proposed reduction in the 
President's fiscal year 2014 budget request of $52.1 million represents 
a staggering 18.8 percent cut to the budget of the IDeA program, but 
represents only 0.18 percent of the entire proposed NIH budget. Making 
such a serious, disproportionate cut to a program designed to aid 
small, rural States is manifestly unfair. This program is small in the 
overall scheme of things at NIH, but huge for the States that compete 
for these funds. Our requested funding level of $310.0 million 
represents only 0.99 percent of the President's total fiscal year 2014 
budget request for NIH.
    Our State, North Dakota, has benefited immensely from the 
competitive funding available through the IDeA program in the form of 
COBRE (Center for Biomedical Research Excellence) and INBRE (IDeA 
Networks of Biomedical Research Excellence) grants, and UND and NDSU 
anticipate submitting a joint proposal in fiscal year 2014 for a new 
INBRE grant.
    At the University of North Dakota, we have been awarded funding for 
three phases of a COBRE grant supporting research on neurodegenerative 
diseases. We received funding for Phase III, the final phase of a COBRE 
project, during fiscal year 2013. North Dakota has one of the largest 
populations of the extremely old in the Nation (second only to Florida 
in the percentage of its citizens over 85 years of age), and high rates 
of neurodegenerative diseases such as Alzheimer's, Parkinson's, and 
multiple sclerosis. As an example of the impact of this funding and the 
research capacity it has built, externally funded research at the 
University of North Dakota's School of Medicine and Health Sciences 
(SMHS) has grown substantially. Prior to COBRE funding, in fiscal year 
2002, the SMHS received about $12 million in external funding; by 
fiscal year 2011, this had increased to $20.5 million, an increase of 
71 percent. In 2010, when UND developed a new strategic plan for 
research, neuroscience was identified as an existing strength on which 
to build.
    Thus, the neurobiology COBRE grant is achieving its intended 
purpose of expanding our research capacity and our ability to compete 
for Federal funding. That research is directed at problems of direct 
interest to our citizenry, but also to the rest of the United States.
    The University of North Dakota has submitted a proposal for an 
additional COBRE grant on the topic of epigenetics. Epigenetics is the 
study of how environmental factors influence the expression of our 
genes; in many cases these changes in gene expression can then be 
inherited by the next generation. We have been notified that the 
submitted grant is a highly competitive one that addresses a burgeoning 
area of research interest and importance. Despite this, fiscal year 
2013 funding cuts and further reductions due to the sequester mean it 
is unlikely that the grant will be funded.
    North Dakota State University has received COBRE grants to fund 
research at its Center for Protease Research and the Center for Visual 
and Cognitive Neuroscience. COBRE funding supported important chemical 
and biological research at the Center for Protease Research relating to 
the roles played by enzymes that break down proteins in cancer and 
asthma.
    COBRE funding at NDSU's Center for Visual and Cognitive 
Neuroscience facilitated research illuminating and ameliorating 
conditions such as disordered perception, cognition, emotion, attention 
and executive function, which are hallmarks of debilitating and costly 
disease syndromes (e.g., ADHD, ARMD, agnosia, amblyopia, autism, 
depression, dementia, dyslexia, hemi neglect, multiple sclerosis, 
Parkinson's disease, PTSD, and schizophrenia).
    COBRE funding has contributed to the success that both NDSU's 
Centers have achieved in obtaining competitive grants from privates 
sources and a variety of Federal agencies. Additionally, the COBRE 
grants led to the publication of NDSU's research findings in 
international, refereed publications and have aided in the recruitment 
of new faculty and increased enrollments in related graduate and 
undergraduate programs.
    Another important IDeA program is INBRE, which provides funding to 
build the biomedical workforce through activities ranging from outreach 
to elementary school children to creating opportunities for 
undergraduates to engage in research. This program has provided support 
for undergraduate students at two- and four-year colleges in North 
Dakota to participate in research during the summer at their home 
institutions. This program includes two tribal colleges and serves 
between 70 and 100 students each year. Another program at the 
University of North Dakota serves about 60 undergraduates per year and 
applications routinely exceed the number of slots that are available. 
These programs are essential for keeping students in the pipeline for 
the STEM (science, technology, engineering, and math) workforce. 
Studies have repeatedly shown that engaging undergraduates in original 
research is a powerful tool for retaining students in college so that 
they graduate in a timely way.
    A major emphasis has been on outreach programs to Native American 
students, the minority group that is most under-represented in the 
fields of science, engineering, and math. Between 25 and 35 Native 
American students in grades 7-12 participate each year in a program 
that uses traditional Native American tools to teach science. As many 
as 40 students from tribal colleges are funded each year to visit UND 
and learn about opportunities to transfer to the University and 
complete their four-year degrees. INBRE provides support for transfer 
students from tribal colleges through the Pathway program, a six-week 
summer program that prepares participants for advanced coursework in 
science. Pathway students can also receive tuition waivers from the 
University. INBRE funding is also provided to support the American 
Indian Health Research Forum on the UND campus each year; this forum 
attracts attendees from across the Nation.
    North Dakota, with a population of 672,591 according to the 2010 
Census, is the smallest of all the IDeA States. Yet, our School of 
Medicine and Health Sciences graduates a disproportionately large 
number of primary care physicians who practice in rural areas, and 20 
percent of all Native American physicians in the U.S. are graduates of 
the University of North Dakota. This medical school is clearly making 
important contributions to health care for underserved populations. 
Like all medical schools, it must have a healthy research program 
underpinning its training of physicians, and funding from the IDeA 
program is critical to the health of that program and to building 
research capacity for the future.
    The IDeA States produce STEM graduates at the same per capita rate 
as States with larger populations and larger research portfolios. The 
students from IDeA States need and deserve the same exposure to 
research as students in larger States. If the proposed reductions in 
the President's fiscal year 2014 budget request for the IDeA program 
are not rejected, North Dakota and other small, mostly rural States, 
will receive a major setback in their efforts to increase their 
capacity to undertake biomedical research and to train the next 
generation of scientists who are vital to the health of our Nation and 
economy.
    The IDeA program is absolutely critical not only for the University 
of North Dakota and North Dakota State University, but also for the 
biomedical research capacity and capability of research institutions 
nationwide. We sincerely appreciate the subcommittee's ongoing support 
of the IDeA program and request that you give full consideration to our 
recommendations and fiscal year 2014 request of no less than $310.0 
million for the National Institutes of Health IDeA program. We further 
request that the subcommittee consider legislative language directing 
that future NIH budgets include funding for the IDeA program that 
reaches no less than 1 percent of the total NIH budget.
                                 ______
                                 
       Prepared Statement of the World Molecular Imaging Society

    The World Molecular Imaging Society (WMIS) is dedicated to 
developing and promoting all aspects of preclinical and clinical 
multimodal medical molecular imaging to understand and effectively 
treat life-threatening oncological, neurological, cardiovascular, 
inflammatory, metabolic, infectious and other diseases. The WMIS is 
gravely concerned with the continued negative impacts to the U.S. 
research enterprise resulting from the significant decline in research 
funding, particularly due to sequestration coming on the heels of years 
of flat-funding. A higher level of research in medical molecular 
imaging is required in the U.S. to increase our knowledge about disease 
processes, disease detection, and therapy management, with the long-
term goal of improving the health of U.S. citizens that will provide 
savings of billions of dollars.
    The U.S. has, until now, been the leading force in medical 
molecular imaging. Molecular imaging plays a central role in health 
care as it significantly contributes to improved patient outcome and 
cost-efficient healthcare in all major diseases. This high-impact field 
is finding transformative applications in the understanding, detection, 
and treatment of nearly all diseases. However, the impetus of this 
multidisciplinary transformative field is under severe threat due to 
declining funding that is impacting the U.S. economy in multiple ways:
  --Rapid erosion of an exceptional workforce of highly trained 
        molecular imaging scientists that represent the culmination of 
        significant monetary and intellectual investments, often 
        supported in part by public grants, aid, etc. The opportunity 
        cost of their departure, therefore, is a profound;
  --Decline of the U.S. as the world-leader in medical molecular 
        imaging sciences, and the emergence of China and other nations 
        as leaders in this field;
  --Exploitation of U.S. intellectual property in medical molecular 
        imaging by nations with little or no research enterprise, 
        effectively discouraging complementary private research 
        investment in the U.S.;
  --Falling attendance at scientific conferences directly impacting 
        local economies in host cities in the U.S., and undermining the 
        interactions among scientists from diverse fields, at all 
        stages of their careers (including students and young faculty), 
        cutting short the next round of game-changing technologies and 
        innovations; and
  --Decreased market and student confidence in science-related fields 
        and infrastructure--entire industries that support the 
        scientific and imaging infrastructure are on the decline 
        resulting in major loss of jobs and trainees.
    Molecular imaging is truly a poster child for the success of the 
U.S.'s long history of investments in research. It represents a 
confluence of hard sciences and life sciences; medicine, physics, 
chemistry, computer science and anatomy. Out of decades of advances in 
each of these fields, molecular imaging is changing the way medicine is 
practiced, and it is just scratching the surface. Our field owns a 
generous global competitive advantage in this area--one that promises 
not just clinical impact but commercial as well. However, we cannot 
continue to see our seed funding for research dry up, and our 
scientists take their knowledge abroad. Other countries are waiting and 
willing to reap the benefits--both public and private--that we've 
already expended to bring us to this exciting point in scientific 
discovery. We cannot lose it.
    Because of this, the WMIS strongly supports an increase in the NIH 
budget by at least 3 percent in fiscal year 2014. We also offer a plea 
to Appropriators to join with their colleagues in the Senate to replace 
the harmful sequester with a policy that does not seek to balance the 
budget on the backs of productive discretionary programs like medical 
research and science--which have remained essentially flat in nominal 
dollars for the past decade.
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