[Senate Hearing 113-768]
[From the U.S. Government Publishing Office]




 
  DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
          RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2015

                              ----------                              


                         WEDNESDAY, MAY 7, 2014

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:02 a.m., in room SD-138, Dirksen 
Senate Office Building, Hon. Tom Harkin (chairman) presiding.
    Present: Senators Harkin, Durbin, Reed, Mikulski, Shaheen, 
Moran, Shelby, Alexander, and Johanns.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

STATEMENT OF TIMOTHY LOVE, CHIEF OPERATING OFFICER, 
            CENTERS FOR MEDICARE AND MEDICAID SERVICES

                OPENING STATEMENT OF SENATOR TOM HARKIN

    Senator Harkin. The Appropriations Subcommittee on Labor, 
Health and Human Services, Education and Related Agencies will 
please come to order.
    Each year this subcommittee questions the Secretaries of 
agencies under our jurisdiction. But because Secretary Sebelius 
has resigned and the nominee to serve as the next HHS 
Secretary, Mathews Burwell, has not yet been confirmed, we are 
sort of in an odd situation, so we decided on a different 
approach for HHS this year.
    We have before us today leaders from each of the HHS 
operating divisions that have the large proposals in the 
President's budget, new programs as well as programs with 
proposals for significant increases and/or cuts.
    So this is a great opportunity for this subcommittee to get 
answers from the leaders most responsible for implementing our 
bills, so I look forward to this. Each of your agencies 
administers at least one program that holds special interest 
for me, and I am sure for others on this committee.
    Overall, the budget request for HHS is $1.5 billion less 
than last year. The budget request is consistent with the 
overall funding levels in the Bipartisan Budget Act. That 
agreement partially restored cuts from sequestration and 
prevented further cuts to nondefense discretionary programs in 
2014 and 2015.
    However, as this budget request shows, this committee knows 
all too well that cuts to nondefense discretionary spending 
over the last several years have forced some very difficult 
decisions.
    The Administration for Children and Families (ACF), I have 
been deeply committed to expanding access to high-quality early 
learning programs for most of my career. I am pleased with the 
budget's proposed $270 million increase for Head Start and the 
$57 million increase for the Child Care and Development Block 
Grant. This bill honors significant investments this committee 
made in those programs just last year.
    I am particularly interested in hearing more today about 
the ACF work in implementing the $500 million provided last 
year to expand Early Head Start, including the establishment of 
new Early Head Start-Child Care Partnerships.
    At the same time, I am deeply concerned about proposed cuts 
to the Community Services Block Grant program and LIHEAP (Low 
Income Home Energy Assistance Program).
    For CDC (Centers for Disease Control and Prevention), Dr. 
Frieden and I have had conversations about the importance of 
public health. The challenge of public health is that when it 
is working well, no one should notice it. We in the U.S. notice 
it least because the Centers for Disease Control and Prevention 
is a world-class public health institute.
    In fact, that is why I was pleased to allocate funding in 
2014 to create a program to help other countries create their 
own CDCs to organize their health systems around public health 
and data.
    So I look forward, Dr. Frieden, to hearing about progress 
on that effort.
    Dr. Wakefield, it is nice to have you back on Capitol Hill, 
where you are no stranger here. You spent most of your career 
here with both Senator Burdick and Senator Conrad, both of whom 
were great leaders in rural health and rural healthcare. Your 
career has demonstrated your commitment to delivering high-
quality care to those who need it most, and I can think of no 
greater calling and no greater mission than HRSA's (Health 
Resources and Services Administration), which is to increase 
access to comprehensive primary care services for medically 
underserved communities.
    So that is why I am deeply troubled by the repeated budget 
proposals to cut or delay health center openings and to reduce 
the number of pediatricians and nurses that we train. I will 
also have a question about integrative medicine and how we are 
doing with that.
    Last but not least, the Centers for Medicare and Medicaid 
Services (CMS). Although Ms. Tavenner is unable to attend 
today--her mother passed away just last evening--I want to 
congratulate CMS, its leaders and staff, on the latest 
enrollment estimates, including 8 million people who signed up 
for coverage in the State and Federal exchanges, close to 5 
million in Medicaid and the Children's Health Insurance 
Program. So despite a rocky start with that Web site, the 
Affordable Care Act remains the most significant human services 
legislation in decades. It is giving millions of men, women, 
and children affordable insurance options for the first time.
    So I look forward to hearing from you, Mr. Love, about the 
steps CMS is taking to ensure that the people who signed up for 
coverage have access to and receive quality care.
    I am particularly interested in hearing about two things: 
CMS's continued efforts to reduce healthcare fraud and abuse. 
As we know from our data, for every $1 we spend in that area, 
we are getting $8 returned to the Treasury in savings. So that 
work is critical to ensuring that Medicare is available for 
millions of Americans for generations to come.

                           PREPARED STATEMENT

    The other is, again, the provision of prevention and 
wellness programs under CMS and how that is being implemented 
in the Affordable Care Act.
    So I hope that the format of this hearing will give us 
renewed appreciation for the breadth of human needs that HHS 
serves every year. So I look forward to all of your testimony.
    Before Senator Moran starts his statement, Chairwoman 
Mikulski submitted a statement to be inserted for the record.
    [The statement follows:]
          Prepared Statement of Chairwoman Barbara A. Mikulski
    Today we are here to discuss the fiscal year 2015 budget request 
for the Department of Health and Human Services. I would like to thank 
Chairman Harkin and Ranking Member Moran who worked so hard to enact 
the 2014 Omnibus. By negotiating with their House counterparts, we were 
able to ensure HHS would no longer have to operate under a continuing 
resolution or sequestration.
    This hearing is part of the Senate Appropriation Committee's 
mission to hold more than 60 hearings in a span of 6 weeks and to 
complete all of our appropriations work by October 1. We will begin the 
process of marking up our bills on May 22, and hope to consider this 
subcommittee's bill sometime in June.
    It saddens me to acknowledge that this will be the last LHHS 
appropriations bill authored by Senator Harkin. However, it should also 
inspire us to get the LHHS bill to the Senate floor for the first time 
in 7 years. It would be a fitting way to pay tribute to Senator Harkin, 
who has either chaired or served as the ranking member of this 
subcommittee for the past two decades.
    I look forward to hearing from our panel of witnesses, which 
represent HHS' Administration for Children & Families (ACF); Centers 
for Disease Control and Prevention (CDC); Centers for Medicare & 
Medicaid Services (CMS) and Health Resources and Services 
Administration (HRSA).
    I hope all of you touch on how the Health and Human Services' 
budget will help to create jobs and support innovation, while 
protecting the public's health and providing kids with quality 
healthcare, child care and a jump start on education.
    Mr. Greenberg, I will want to discuss two areas of ACF's budget 
request with you: Child Care Development Block Grants (CCDBG) and 
Unaccompanied Alien Children.
    Senator Burr and I worked together on a bipartisan reauthorization 
of the CCDBG program that followed regular order and had an open 
amendment process on the Senate floor. We were able to make important 
reforms that improved the quality of care children receive. I was 
thrilled to see our bill pass with overwhelming bipartisan support and 
a vote of 96-2.
    I appreciate that your fiscal year 2015 request increases funding 
levels for CCDBG, but additional funding will still be needed to ensure 
that the reforms in our bill are implemented effectively. Kids must be 
taken off waiting lists and provided with the child care they deserve.
    While your requests for CCDBG give reason for optimism, I am very 
disappointed with the budget you have requested to tackle the issue of 
Unaccompanied Alien Children. You have asked for level funding even 
though you had to transfer millions of dollars to this program in 
fiscal year 2014 in order to fulfill your needs.
    I am worried because these are some of our most vulnerable 
children. They have left their countries and travelled thousands of 
miles to enter the United States, often fleeing violence to avoid 
becoming victims of abuse or organized crime.
    Their journey here is often riddled with danger--these kids put 
their life, health and safety in jeopardy. Along the way, they risk 
being subjected to trafficking and the violence they were attempting to 
escape. These brave children deserve our consideration.
    On April 22, I convened a bipartisan, bicameral staff level meeting 
with various Federal agencies that are responsible for these 
unaccompanied alien children. We learned that the number of 
unaccompanied children entering the United States is rising.
    In fiscal year 2012 there were 14,000. In fiscal year 2013 there 
were 25,000 and that number is projected to balloon to 60,000 for 
fiscal year 2014. This issue is not going away--we expect tens of 
thousands more to enter the country in fiscal year 2015--and we need to 
keep these children in mind when appropriating our resources.
    What I need from you is a better estimate of the budget you will 
need to provide these kids with proper services so you don't have to 
transfer funds in the future.
    Dr. Frieden, as America's chief public health officer, I look 
forward to hearing your plans for new and existing initiatives.
    How do you plan to continue the creation of blue zones, which were 
supported by $80 million in Community Prevention Grants?
    I hope you will delve into how you plan to use the $45 million in 
funding to improve global health security. What will your approach be 
in helping other countries build and strengthen their own Centers for 
Disease Control as well as improve early detection and response to 
epidemics?
    You have also requested $30 million to combat antibiotic resistance 
by quickly identifying deadly microbes and use common sense practices 
to protect patients from infection. I encourage you to work with Dr. 
Peter Pronovost of Johns Hopkins, his checklist has proven very 
effective in reducing central line infections.
    Lastly Dr. Frieden, I am keen to hear more about the $16 million 
budgeted to address prescription painkiller abuse.
    Administrator Wakefield, I look forward to hearing about your work 
to strengthen the healthcare work force and increase the number of 
primary care doctors, nurses, pediatricians and dental providers in 
underserved communities.
    I am also interested in hearing how communities, families and 
patients are benefiting from the additional funding dedicated to health 
reform and community health centers.
    Finally, Mr. Love, I have particular interest in CMS because it 
employs over 4,200 in my home State of Maryland. CMS does important 
work to process Medicare claims, increase access to health insurance, 
prevent fraud and abuse, help States expand their Medicaid programs, 
support new healthcare delivery innovations and implement healthcare 
reform.
    I want to hear how this budget will enable you to fulfill those 
crucial responsibilities. I also want to know what specific plans you 
have to increase health insurance enrollment; improve the functionality 
and operation of the Federal health insurance exchange; and help States 
expand their own Medicaid programs.
    I understand that there are some proposals in this budget that will 
not be universally supported across the aisle--that's the nature of any 
bill or budget. We all have things we like and things we don't like, 
but we must try to refrain from making any one issue a ``deal 
breaker.''
    It is my hope, however, that we can work together to come to an 
agreement. I think we all recognize that sequesters and continuing 
resolutions are not an effective way to run a Federal agency like the 
Department of Health and Human Services. Our Nation is better off when 
we work together and govern together.

    Senator Harkin. I will now turn to our ranking member, 
Senator Moran, for his opening statement.

                    STATEMENT OF SENATOR JERRY MORAN

    Senator Moran. Mr. Chairman, thank you very much.
    Before I give my remarks, let me express my condolences to 
Marilyn Tavenner and her family. We have a good, solid working 
relationship with Marilyn, and I really do express my sincere 
concern and care for her loved ones. We are sorry for the loss 
of her mother.
    I am, Mr. Chairman, disappointed that the Secretary of 
Health and Human Services is not here today. In my view, she 
declined, refused to testify, to talk about and defend the 
budget request.
    I know there were numerous press accounts last week about 
this issue, and what I know about it is that our staff invited 
all Cabinet Secretaries under the purview of this committee 
with the option of certain dates. We asked those Cabinet 
Secretaries to accept one of those dates, and we do it in 
whoever accepts first gets that date.
    And Secretary Sebelius accepted the opportunity to testify 
at a hearing to be held on April 2, and then at her request, we 
moved her opportunity to testify to May 7, to accommodate her 
schedule.
    The Department of Health and Human Services budget requests 
nearly $70 billion for fiscal year 2015, and I would expect the 
head of any Department, regardless of its budget size, 
regardless of its budget request, to appear before the Senate 
Appropriations Committee to discuss and defend, for our 
consideration, their thoughts on that budget.
    More closely, the total discretionary and mandatory budget 
combined of Health and Human Services for fiscal year 2015 is 
$1.02 trillion. That is more than the amount of the 
discretionary budget cap for the entire Federal Government. And 
so we get the view of how big Health and Human Services is.
    And I, certainly, appreciate the individuals who are here 
to testify today. I know that you have expertise and 
experience.
    But none of you can testify to the overall strategy or 
management of the Department. Not one person on the panel 
before us can explain the give-and-take that goes into 
determining how funding is allocated throughout the entire 
budget. Not one witness here with us today can answer the 
questions regarding the priorities of the Department as a 
whole. And not one of the panelists can speak to why specific 
decisions were made.
    All of these questions would be answered by a Secretary. 
And in that role, I believe she should be here. And I am 
disappointed that she declined to appear before our panel 
today.
    I have worked hard to be a valuable and hardworking member 
of the Appropriations Committee. I have praised Barbara 
Mikulski and her leadership of our Appropriations Committee. 
There has been a great desire to get us back to regular order. 
Her leadership, along with Senator Shelby, has been very much 
appreciated by me and I assume by all members of the 
Appropriations Committee.
    And I wanted to make certain that the circumstance we find 
ourselves into today doesn't become a norm for the 
Appropriations Committee. In my view, regular order would 
require that a Cabinet Secretary be here to discuss and defend 
his or her budget.
    And I want the committee's work to be responsible and 
received well and to be respected. And I think we lose 
something if we easily forgo the opportunity to have a 
conversation with a Cabinet Secretary.
    My colleagues tell me, who have been here longer than I 
have, that no one can remember a Cabinet Secretary declining to 
appear before their appropriations subcommittee. Whether or not 
that fact is exactly true or not, I am not certain. But at 
least for those who have told me, there is no recollection of 
that not being the case.
    And I want to make clear from my perspective, and I hope 
this is not a Republican/Democrat perspective, is the 
Appropriations Committee is deserving of the respect of a 
Cabinet Secretary to be here in front of us to have the 
conversations necessary for us to make decisions, to elucidate 
the facts surrounding the appropriations request, and to make 
sure that we do our jobs as appropriators as best as we can to 
our abilities.
    So, Mr. Chairman, I used my opportunity in my opening 
statement to, certainly, express my respect for the folks who 
are in front of us, but to indicate my disappointment at the 
absence of the Secretary.
    Thank you, Mr. Chairman.
    Senator Harkin. Thanks, Senator Moran.
    Again, I just want to make it clear, in statements referred 
to last week, and since I made the statements, I want to 
respond in kind. I want to make it very clear that as the chair 
of this subcommittee, I never formally asked or invited the 
Secretary to appear. Staff started working this stuff out, 
trying to figure out dates and all that kind of stuff, when it 
is mutually agreeable.
    In between time, Secretary Sebelius submitted her 
resignation. And then the President nominated Ms. Burwell to be 
the head of HHS. Budget hearings, these kinds of budget 
hearings, look forward. They look at what is coming. That is 
what the budget is about, next year.
    Secretary Sebelius is not going to be here next year. But 
Ms. Burwell hasn't taken over yet. And so we were sort of in a 
kind of limbo.
    I will admit that this is my idea, to have the heads of the 
agencies under HHS that have the lion's share of the funding to 
come here.
    I said earlier to the group, I said a lot of times if I 
were asked to appear and testify on something under my 
jurisdiction, I would have all my staff in back of me, backing 
me up, because they are the repository of the knowledge. They 
are the ones who carry out this.
    Secretaries, Senators, we have sort of a broader vision of 
things. And so I thought it would be interesting, and perhaps 
even hopefully maybe a precedent to have the people here who 
actually do the work, and who carry out the bulk of the 
spending of the money that we appropriate.
    And so there is nothing sinister or anything other than 
that. If we were having an oversight hearing over the past, 
yes, you would have someone like that here who was responsible 
for implementing things in the past. But that is not why we are 
here. We are talking about the budget for the future and what 
that is going to be about. And that is why I set this up in 
this way.
    Each of you here, your statements will be made a part of 
the record in their entirety. We will start left to right. We 
will start with Mr. Love, if you can sum up in 5 minutes, also 
Mr. Greenberg, Dr. Frieden, Dr. Wakefield. And then we will 
start our rounds of questioning.
    So, Mr. Love, please start, and if you can just sum it up 
in 5 minutes.

                   SUMMARY STATEMENT OF TIMOTHY LOVE

    Mr. Love. Thank you, Mr. Chairman.
    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee, thank you for the invitation to discuss the 
Centers for Medicare and Medicaid Services' discretionary 
budget request included in the President's fiscal year 2015 
budget.
    I am appearing today on behalf of Administrator Tavenner, 
who the chairman and ranking member graciously acknowledged her 
loss last night. I will do the best I can as her understudy.
    My name is Tim Love, and I was appointed CMS's chief 
operating officer in January of this year. As a career public 
servant, I have spent nearly 3 decades in public service, 
including the United States Navy, a Peace Corps volunteer, and 
over 22 years in CMS.
    I would like to begin by saying that our agency is 
committed to strengthening and modernizing the Nation's 
healthcare system to provide access to high-quality care and 
improved care at lower costs for beneficiaries and consumers 
enrolled in our programs.
    I would like to thank the subcommittee for the support you 
have provided CMS that allows us to carry out this important 
work.
    Our fiscal year 2015 budget request allows CMS to build on 
the successes we have achieved in helping more Americans obtain 
healthcare coverage while improving the quality and value of 
the care provided.
    CMS has led efforts to expand affordable health insurance 
coverage to Americans through the health insurance marketplace. 
We are pleased to report that at the end of the first 
enrollment period, 8 million Americans have signed up for 
private health insurance. An additional 4.8 million Americans 
have enrolled in a State Medicaid program during this period.
    In addition to the marketplace, CMS continues to serve 54 
million Americans through Medicare, 65 million through 
Medicaid, and nearly 6 million through the Children's Health 
Insurance Program, also known as CHIP.
    Our fiscal year 2015 program management budget request 
enables reforms in healthcare delivery, while continuing to 
support the ongoing Medicare, Medicaid, and CHIP programs, as 
well as the marketplace.
    The CMS budget supports fraud prevention and the reduction 
of improper payments, which are top priorities for the 
administration. The program integrity investments in the budget 
are projected to yield $13.5 billion in savings for Medicare 
and Medicaid over the next 10 years.
    Our budget includes a package of Medicare legislative 
proposals that will save $407 billion over 10 years, while more 
closely aligning payments with actual costs of care, 
strengthening provider payment incentives to promote high-
quality care, and by creating incentives for beneficiaries to 
seek high-value services.

                           PREPARED STATEMENT

    Together, these measures will extend the hospital insurance 
trust fund solvency by 5 years.
    Our budget reflects the administration's commitment to 
fiscal responsibility while providing CMS with the resources it 
needs to support demographic trends in Medicare, Medicaid, and 
CHIP, and continued administration and oversight of the 
marketplace.
    We look forward to continuing our work with this 
subcommittee, and I would like to thank you for your time this 
morning.
    [The statement follows:]
                   Prepared Statement of Timothy Love
    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee, thank you for the invitation to discuss the Centers for 
Medicare & Medicaid Services discretionary budget request included in 
the President's fiscal year 2015 budget. Our request will allow us to 
build on the successes we have achieved in helping more Americans 
access healthcare coverage and improving the quality and value of care 
provided across our delivery system.
    In fiscal year 2014, CMS led efforts to expand affordable health 
insurance coverage to Americans through the Health Insurance 
Marketplace. We are pleased to report that 8 million Americans have 
signed up for private health insurance through the Marketplace and more 
than 4.8 million more Americans enrolled in Medicaid and the Children's 
Health Insurance Program (CHIP). Additionally outside experts estimate 
that millions more enrolled directly with insurers for new high-quality 
coverage. In 2015, we will continue our work to expand quality, 
affordable coverage to millions of Americans. In addition to the 
Marketplace, CMS continues to serve 54 million Americans through 
Medicare, 65 million through Medicaid, and nearly 6 million through 
CHIP.
    Fixing America's healthcare system doesn't stop with guaranteeing 
that everyone has coverage. To address the rising costs of healthcare, 
we must improve the way that healthcare is delivered, including the 
coordination and safety of care. We are working closely with providers, 
hospitals, and others to improve our healthcare delivery system for all 
patients. Already, we have made significant progress. For the second 
consecutive year, overall health costs grew more slowly than the 
economy as a whole. We have also seen low spending growth per enrollee 
in 2012 for Medicare (0.7 percent), Medicaid (1.3 percent), and private 
health insurance premiums (2.7 percent).
    We began tying Medicare payments for hospitals to their readmission 
rates, and saw the 30-day, all-cause readmission rate decline in both 
2012 and 2013. In 2012, Medicare Accountable Care Organizations (ACOs) 
began participating in the Shared Savings Program that encourages 
providers to invest in redesigning care for higher quality and more 
efficient service delivery, without restricting patients' freedom to go 
to the Medicare provider of their choice. The program is off to a 
strong start with 338 Medicare ACOs participating in the Shared Savings 
Program. We are encouraged by the interim results and we look forward 
to final performance year one results later this year.
                           program management
    The budget for CMS Program Management enables reforms in healthcare 
delivery while continuing to support the ongoing Medicare, Medicaid, 
and CHIP programs in CMS, as well as the recently implemented Health 
Insurance Marketplace. The request also accommodates substantial 
increases in CMS' workload because of demographic trends and program 
changes driving higher Medicare and Medicaid enrollment and implements 
responsibilities assigned in the Affordable Care Act and other 
legislation related to Medicare, Medicaid, and CHIP. The fiscal year 
2015 discretionary budget request for CMS Program Management is $4.2 
billion, an increase of $108 million above fiscal year 2014. This 
request will allow CMS to continue to effectively administer Medicare, 
Medicaid, and the Children's Health Insurance Program (CHIP), as well 
as new health insurance reforms contained in the Affordable Care Act.
    With Medicare enrollment projected to grow to 55 million 
beneficiaries in fiscal year 2015, CMS will require additional 
resources to effectively oversee the programs. For example, the budget 
requests an additional $49 million in Survey and Certification funds to 
conduct mandated Federal inspections of key facilities--such as nursing 
homes--serving beneficiaries. This increase is needed to complete 
surveys at frequencies consistent with statutory and policy 
requirements, given continued growth in the number of participating 
facilities, increased survey responsibility, and inflation. The budget 
improves survey frequencies for dialysis facilities, nonaccredited 
hospitals, ambulatory surgical centers, and other providers. 
Additionally, this budget requests funding to survey community mental 
health centers for the first time.
                 private insurance and the marketplaces
    The Affordable Care Act provides vital new protections for 
consumers receiving or shopping for private health insurance. New 
reforms ensured that essential care will become a standard part of most 
private health insurance plans, and that consumers can continue to rely 
upon their insurance when they become ill. Consumers are able to 
purchase more efficient coverage due to rate review and medical loss 
ratio protections. By providing one-stop shopping, the Marketplace has 
helped individuals better understand their insurance options and 
assisted them in shopping for, selecting, and enrolling in high-quality 
private health insurance plans.
    The budget includes $629 million for CMS activities and 
administrative expenses to support Marketplace operations in fiscal 
year 2015. For the federally facilitated Marketplace (FFM), CMS 
performs eligibility and appeals work, certification and oversight of 
qualified health plans, payment and financial management functions, and 
operates the Small Business Health Options Program (SHOP). As a part of 
this work, CMS operates a number of IT systems to support the 
Marketplaces, such as the system that operates FFM functions including 
eligibility, and plan management. The data services hub provides 
eligibility verification services to all Marketplaces through 
interfaces with trusted data sources in other Federal departments. 
Other IT costs include hosting services and data management systems.
    Additionally, CMS oversees operations of State-based Marketplaces 
and provides technical assistance as needed. To help individuals better 
understand their coverage options, CMS provides Marketplace consumer 
assistance through a call center and website for the FFM, as well as 
in-person support through Navigator grants.
                           program integrity
    The fiscal year 2015 budget supports fraud prevention and the 
reduction of improper payments, which are top priorities of the 
administration. For fiscal year 2015, the budget invests a total of 
$428 million in new Health Care Fraud and Abuse Control Program (HCFAC) 
and Medicaid program integrity funds. Together the program integrity 
investments in the budget will yield $13.5 billion in gross savings for 
Medicare and Medicaid over 10 years. The budget also proposes 
legislative changes to give HHS important new tools to enhance program 
integrity oversight; cut fraud, waste, and abuse in Medicare, Medicaid, 
and Children's Health Insurance Program (CHIP); and generate an 
additional $1 billion in program savings over 10 years.
    The HCFAC investment supports efforts to reduce the Medicare fee-
for-service improper payment rate and initiatives of the joint HHS-DOJ 
Health Care Fraud Prevention and Enforcement Action Team task force, 
including Strike Force teams in cities where intelligence and data 
analysis indicate high levels of fraud, and the Health Care Fraud 
Prevention Partnership between the Federal Government, private 
insurers, and other stakeholders. CMS will also make further 
investments in innovative prevention initiatives, such as the Fraud 
Prevention System that analyzes all Medicare FFS claims using 
sophisticated algorithms to identify suspicious behavior. In fiscal 
year 2015 and beyond, CMS will continuously refine these technologies 
to better combat fraud, waste, and abuse in Medicare, Medicaid, and 
CHIP. Finally, these funds will support more rigorous data analysis and 
an increased focus on civil fraud, such as off-label marketing and 
pharmaceutical fraud.
           improving the efficiency of medicare and medicaid
    The budget includes a package of Medicare legislative proposals 
that will save $407.2 billion over 10 years by more closely aligning 
payments with costs of care, strengthening provider payment incentives 
to promote high-quality efficient care and making structural changes 
that will reduce Federal subsidies to high-income beneficiaries and 
create incentives for beneficiaries to seek high-value services. 
Together, these measures will extend the Hospital Insurance Trust Fund 
solvency by approximately 5 years. The budget seeks to preserve 
stability in the Medicaid program and CHIP during the first full year 
of the Affordable Care Act expansion of coverage while also including 
$7.3 billion in Medicaid savings and $345 million in CHIP investments 
over 10 years to make Medicaid and CHIP more flexible, efficient and 
accountable.
                               conclusion
    The President's fiscal year 2015 budget request reflects the 
administration's commitment to fiscal responsibility, while also 
providing CMS with the resources it needs to support beneficiary growth 
in Medicare, Medicaid, and CHIP, continue administration of the FFM, 
and conduct effective oversight of State-based Marketplaces. Thank you 
for your interest in CMS' efforts to strengthen and modernize the 
Nation's healthcare system to provide access to high-quality care and 
improved health at lower costs, and I look forward to continuing to 
work with the subcommittee on these important issues.

    Senator Harkin. Thank you, Mr. Love.
    Mr. Greenberg, for the Administration for Children and 
Families.
STATEMENT OF MARK H. GREENBERG, ESQ., ACTING ASSISTANT 
            SECRETARY, ADMINISTRATION FOR CHILDREN AND 
            FAMILIES
    Mr. Greenberg. Chairman Harkin, Ranking Member Moran, 
members of the subcommittee, thank you for inviting me to 
discuss the 2015 budget proposals for the Administration for 
Children and Families.
    Mr. Chairman, I want to begin by thanking you for your 
years of leadership and your support of ACF programs over this 
time. In particular, your leadership in education for the 
Nation's youngest children has been critical for Head Start and 
to advancing the Nation's early education agenda. We wish you 
the very best for your retirement.
    Senator Harkin. Thank you very much. I am looking forward 
to it.
    Mr. Greenberg. ACF's budget supports programs serving our 
most vulnerable children and families, including victims of 
domestic violence, of human trafficking, youth and foster care, 
runaway and homeless youth, and others.
    In my opening statement this morning, I will focus on our 
early childhood initiatives, but I would be happy to discuss 
other aspects of our budget in response to your questions.
    Research shows that one of the best investments we can make 
in a child's life is high-quality early education. In 2015, the 
President has renewed his call for investments to create a 
continuum of high-quality early learning services for children 
from birth through age 5. The initiative would expand voluntary 
evidence-based home visiting programs, expand access to high-
quality care for infants and toddlers through Early Head Start-
Child Care Partnerships, and help States provide high-quality 
preschool for 4-year-olds in low- and moderate-income families 
through a partnership with the Department of Education.
    We appreciate this committee's strong support for the Early 
Head Start-Child Care Partnerships in 2014. Our budget requests 
$650 million to support and expand those partnerships. The 
funding will assist communities in increasing access to 
programs that meet Early Head Start standards of quality for 
infants and toddlers.
    Through the partnerships, Early Head Start programs and 
child care providers will work together to provide high-
quality, full-day services, offering comprehensive support to 
meet the needs of working families and to prepare children for 
preschool.
    We are seeking an increase of $270 million for the Head 
Start program in order to maintain current service levels. That 
would bring the total funding for the program to $8.9 billion.
    The 2015 request for the child care and development fund 
involves both mandatory and discretionary funds, a total of 
$6.1 billion between mandatory and discretionary. It would 
support subsidies for 1.4 million children and important 
initiatives to raise the quality of child care.

                           PREPARED STATEMENT

    In discretionary funding, we are seeking an additional $57 
million. We are also proposing that of the discretionary 
funding, that $200 million be targeted to help States develop 
higher health and safety standards, to improve monitoring, to 
increase provider quality through evidence-based professional 
development, and to improve access to information for parents 
choosing a child care provider.
    In concluding, ACF's budget strives to promote the economic 
and social well-being of children, individuals, families, and 
communities. It addresses critical needs in a period of limited 
Federal resources.
    And I would be happy to answer any questions. Thank you.
    [The statement follows:]
                Prepared Statement of Mark H. Greenberg
    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee, thank you for supporting the Administration for Children 
and Families (ACF) in fiscal year 2014 and for inviting me to discuss 
ACF's proposed budget for fiscal year 2015. In addition to an overview 
of ACF's budget, I would like to share with you three areas in which we 
are working to address important needs: (1) early childhood 
development, (2) unaccompanied alien children, and (3) reducing the 
over-prescription of psychotropic drugs for children in foster care.
                        fiscal year 2015 budget
    The fiscal year 2015 budget request for ACF is $51.3 billion. ACF's 
budget supports expanding access to high-quality early education to 
prepare our youngest children for success in life. Funds are also 
included for programs that serve our most vulnerable children and 
families, including victims of domestic violence and human trafficking, 
and runaway and homeless youth. In addition, the budget supports 
important improvements in Head Start, Child Care, and Child Support.
    The budget includes mandatory funding for a new demonstration, in 
partnership with the Centers for Medicare & Medicaid Services, to 
address the over-prescription of psychotropic drugs for children in 
foster care. The budget also proposes to create subsidized job 
opportunities for low-income parents by redirecting $602 million in 
Temporary Assistance for Needy Families (TANF) funding to a Pathways to 
Jobs initiative.
    The fiscal year 2015 discretionary request for ACF is $17 billion, 
a decrease of $637 million below fiscal year 2014, reflecting a fiscal 
climate that forces difficult choices among worthy programs. The budget 
advances high-quality care for infants and toddlers as part of the 
President's plan to help prepare America's children for success in life 
by expanding access to early education. Additional investments are also 
included to continue a groundbreaking study of children at risk of 
abuse or neglect and of children in the child welfare system, and to 
study the prevalence of youth homelessness and the characteristics of 
homeless youth in order to better advance efforts to end youth 
homelessness.
                      early childhood development
    As the President stated in his State of the Union Address, research 
shows that one of the best investments we can make in a child's life is 
high-quality early education. These programs can help level the playing 
field for children from lower income families by improving school 
readiness through increased vocabulary and social and emotional 
development. In fiscal year 2015, the President renews his call for a 
series of investments that will create a continuum of high-quality 
early learning services for children beginning at birth through age 5. 
This initiative would expand current Federal investments in voluntary, 
evidence-based home visiting programs, expand access to high-quality 
care for infants and toddlers through HHS' Early Head Start--Child Care 
Partnerships, and help States provide high-quality preschool for 4 year 
olds in low and moderate income families through a partnership with the 
Department of Education.
    We appreciate the strong support provided by this committee for 
Early Head Start--Child Care Partnerships in fiscal year 2014. The 
budget requests $650 million, an increase of $150 million above fiscal 
year 2014, to support and expand the Partnerships. This funding will 
assist communities in increasing access to early learning programs that 
meet Early Head Start standards of quality for infants and toddlers. 
The funds will be competitively awarded to new and existing Early Head 
Start programs. Applicants may propose to partner with child care 
providers that serve lower income children, especially those receiving 
Federal child care subsidies, or to expand existing services. Through 
these partnerships, Early Head Start programs and child care providers 
will work together to provide high-quality full-day services that offer 
comprehensive supports to meet the needs of working families, and 
prepare children for preschool, in a variety of settings.
    An increase of $270 million is sought for the Head Start program in 
order to maintain current service levels. This will bring total funding 
for the program to $8.9 billion. In addition to the EHS-CC 
Partnerships, this funding level includes over $8.2 billion to provide 
services for an estimated 929,000 slots for Head Start and Early Head 
Start children and their families. The budget continues to include $25 
million in transitional funding for the Designation Renewal System to 
minimize disruption of services to Head Start children and families 
during the transition period to new Head Start providers from low-
performing Head Start programs.
    The fiscal year 2015 request for the Child Care and Development 
Fund is $6.1 billion, which includes $3.7 billion for the Child Care 
Entitlement and $2.4 billion for the Child Care and Development Block 
Grant. The total funding level represents an increase of $807 million 
over fiscal year 2014 in combined discretionary and mandatory funds, 
and will support subsidies for 1.4 million children--approximately 
74,000 more children than would otherwise be served. Of the $2.4 
billion available in discretionary funds for child care, $200 million 
is targeted to help States raise quality by developing higher health 
and safety standards, improving monitoring, increasing provider quality 
through evidence-based professional development, and improving access 
to information for parents choosing a child care provider.
                      unaccompanied alien children
    Unaccompanied alien children (UAC) apprehended trying to enter the 
United States unaccompanied by a parent or guardian are among the most 
vulnerable populations ACF serves. By law, ACF must accept UAC into its 
care and custody upon referral from the Department of Homeland Security 
or other Federal agencies. These children reside in State-licensed 
shelter facilities until ACF can place them with sponsors, usually 
parents or other relatives. The annual number of arriving UAC has 
increased from 6,560 in fiscal year 2011 to an estimated 60,000 in 
fiscal year 2014. Reasons for this increase are complex, but a key 
factor is the high level of violence in Honduras, Guatemala, and El 
Salvador, the countries of origin for most UAC.
    In the last 3 years, ACF has streamlined its placement process, 
reducing the average amount of time unaccompanied alien children spend 
in shelters. ACF has cut the average length of stay for all UAC from 75 
days between fiscal year 2005 and fiscal year 2011 to 35 days in fiscal 
year 2014. ACF has also been able to decrease the per bed costs by 5 
percent. Despite these efforts, total UAC costs have increased 
significantly due to the rising number of UAC.
    As directed by Congress, ACF is working with the Departments of 
Homeland Security, State, and Justice--in an effort to better 
understand the reasons for the increase in the number of UAC arrivals 
and develop strategies for managing rising UAC costs. We appreciate the 
committee's willingness to provide UAC funding based on updated arrival 
estimates in fiscal year 2013 and fiscal year 2014. This action has 
enabled ACF to serve all incoming UAC without reducing services for 
refugees. We are continuing to monitor the flow of UAC in 2014 and will 
keep the committee updated on what impact this will have for the amount 
of funding needed in 2015.
addressing the over-prescription of psychotropic drugs for children in 
                              foster care
    May is National Foster Care Month, which provides us an opportunity 
to reflect on the efforts we've made on behalf of the vulnerable 
children we have taken into our care. Children in foster care receive a 
disproportionate level of prescriptions of psychotropic medication 
compared to other children receiving Medicaid. A 2011 Government 
Accountability Office report using Medicaid claims from five States 
found that 20 percent to 39 percent of children in foster care received 
a prescription for psychotropic medication in 2008, compared with 5 
percent to 10 percent of children not in foster care.
    For fiscal year 2015, ACF's budget includes a request for $250 
million over 5 years in mandatory funding to support State efforts to 
reduce over-prescription of psychotropic medications and improve 
outcomes for young people in foster care by scaling up evidence-based 
psychosocial interventions, in concert with a Medicaid demonstration. 
This initiative will encourage the use of evidence-based screening, 
assessment, and treatment of trauma and mental health disorders among 
children and youth in foster care in order to reduce the over-
prescription of psychotropic medications. This new investment and 
continued collaboration will improve the social and emotional outcomes 
for some of America's most vulnerable children.
                               conclusion
    In conclusion, ACF's budget strives to promote the economic and 
social well-being of children individuals, families, and communities. 
This budget addresses critical needs in a period of limited Federal 
resources. Again, thank you for the opportunity to discuss ACF's 
proposed budget with you. I would be happy to answer any questions you 
may have.

    Senator Harkin. Thank you very much, Mr. Greenberg. And 
thank you for your kind words. I appreciate it. And thank you 
for your long work in this whole area.
    Dr. Frieden, welcome back.
STATEMENT OF HON. THOMAS R. FRIEDEN, M.D., M.P.H., 
            DIRECTOR CENTERS FOR DISEASE CONTROL AND 
            PREVENTION
    Dr. Frieden. Thank you very much, Mr. Chairman, Ranking 
Member Moran, and members of the subcommittee. We appreciate 
this opportunity to share with you our plans for the coming 
year. And we thank you for your support in 2014, and I will be 
able to discuss how some of that support is already being 
brought to bear to protect Americans better.
    CDC works 24/7 to protect Americans from threats, whether 
they come from this country or anywhere in the world, whether 
they are infectious or noncommunicable, whether they are 
intentional manmade or naturally occurring.
    Last week, the U.S. had its first case of MERS coronavirus, 
the Middle East Respiratory Syndrome, which has been highly 
lethal in several countries of the Middle East and has been 
exported to countries in Europe.
    This is the first case we had in the U.S. It was in a 
traveler who went from Saudi Arabia to London to Chicago and 
took a bus to Indiana, where he has been hospitalized.
    And this really emphasizes that we are all connected by the 
air we breathe, by the water we drink, by the food we eat. And 
diseases anywhere are just a plane ride away.
    One of the things we do at CDC is to respond to 
emergencies. And a few years ago, the U.S. Ambassador to Africa 
said to me that CDC is the 911 for the world, and I thought, 
that is wonderful, but really, what we want to do is make sure 
that countries all over the world have their own public health 
911, so that they can find, stop, and prevent health threats at 
the source.
    That will protect us better. That will protect them better. 
And that is what our Global Health Security Initiative is for 
the 2015 budget proposal.
    This will allow us to do better at finding and stopping 
things like Ebola. We currently have a team in West Africa. The 
first time West Africa has had an Ebola virus outbreak. It has 
been large, highly lethal.
    And outbreaks like this destabilize countries. They kill 
people. They also undermine economic development. And they 
affect us in the United States.
    In fact, the SARS (Severe Acute Respiratory Syndrome) 
outbreak 10 years ago cost the world more than $30 billion in 
just 3 months. So we have plenty of good reasons to invest in 
global health security, and the 2015 request is for a $45 
million expansion of what we have done in 2013 and 2014 to 
better protect countries and better protect ourselves by having 
a safer world.
    The second major initiative that we are proposing for 2015 
is addressing a second growing threat to Americans, and that is 
antimicrobial resistance, drug-resistant bacteria.
    We are seeing now at least 23,000 deaths, at least 2 
million illnesses, about $20 billion in healthcare costs in the 
U.S. from drug-resistance. We are losing really our last lines 
of defense. These are miracle drugs.
    I am trained as an infectious disease physician. I 
practiced before there was treatment for HIV (human 
immunodeficiency virus), and then I saw the wonders of HIV 
treatment, and how that transformed the world. I worked in 
tuberculosis control for many years and I, unfortunately, took 
care of patients for whom there were no drugs to treat.
    We are potentially facing a challenge that we will have no 
drugs to treat common infections, if we don't address 
antimicrobial resistance more effectively and urgently. And we 
are confident that we can make real progress.
    Our 2015 request is for $30 million, a 5-year program that 
we are confident will be able to cut two of the most deadly 
threats in terms of microbial threats to the U.S., what is 
called CRE, or carbapenem-resistant enterobacteriaceae, and C. 
difficile. Each of these is a very big problem. We think we can 
cut them in half in 5 years with this support, as well as 
reducing other problems. Just for one of those conditions, that 
would save $2 billion over 5 years.
    The third major new initiative we are proposing is on 
prescription opiate abuse, and this is a huge problem. It is 
one of the very few problems that is getting worse in terms of 
health in this country. We have had a fourfold increase in the 
number of people dying from prescription opiate abuse, and that 
is related to a large increase in prescriptions of these drugs, 
which are very important for drugs for patients with pain 
palliation, such as those with terminal cancer, but are being 
overused to a very great extent.
    We are confident that with this resource, what we will do 
is support States to do a better job helping patients and 
helping doctors use these dangerous medications as effectively 
as possible, and drive down overdoses and overdose deaths.

                           PREPARED STATEMENT

    So I want to thank you again for your support in 2014. We 
are already using the support you gave us through the Advanced 
Molecular Detection Initiative to do rapid sequencing of the 
MERS coronavirus case that is already in the U.S. so we can 
better understand that case. So thank you for that. Public 
health really is the best buy, and I very much look forward to 
answering your questions.
    [The statement follows:]
           Prepared Statement of Thomas Frieden, M.D., M.P.H.
    Good morning, Chairman Harkin, Ranking Member Moran, and other 
distinguished members of the subcommittee. It is a pleasure to appear 
before you as Director of the Centers for Disease Control and 
Prevention (CDC), the Nation's leading health protection agency and an 
operating division of the Department of Health and Human Services, to 
discuss CDC's fiscal year 2015 budget request. Today I would like to 
focus on how CDC works 24 hours a day, 7 days a week to protect 
Americans from health threats, and how we propose to make even more 
progress in fiscal year 2015. We thank this committee for supporting 
CDC through your 2014 appropriations.
    CDC works 24/7 to keep America safe 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 fights disease and supports communities 
and people to do the same. For fiscal year 2015, CDC has requested 
additional funding to accelerate the fight against three growing 
threats--the risk of infectious disease threats from around the world, 
growing resistance to antibiotics, and the increasing epidemic of 
prescription drug overdose.
                working to provide health security 24/7
    CDC helps save lives 24/7 by preventing, detecting, and controlling 
the growing risks of infectious disease outbreaks, emerging infectious 
diseases, drug-resistant bacteria, and natural and manmade hazards and 
disasters. We provide emergency response support, technical expertise, 
and critical rapid development of prevention technologies, including 
vaccines and other medical countermeasures.
    CDC provides boots on the ground presence in the United States and 
throughout the world, supported by our state-of-the-art laboratories, 
which are critical to our Nation's safety and health. With this 
committee's support, CDC is now building our advanced molecular 
detection capacity, unlocking microbial genomes to track and stop 
outbreaks more effectively, and finding new ways to prevent these 
outbreaks in the first place.
    CDC's response to diseases such as influenza, salmonella, 
hantavirus, HIV, and Ebola are highly visible ways CDC protects the 
public from health threats, but it is often what the public does not 
see every day that keeps Americans safe from ever-present health 
threats. CDC plays a pivotal role in our country's ability to respond 
to and mitigate potentially catastrophic events--such as pandemics, 
natural disasters, and acts of bioterrorism--by ensuring that local, 
State and global public health systems are prepared for public health 
emergencies and by working to keep health threats from entering our 
country.
    CDC plays another critically important role protecting Americans 
from the leading causes of death and disability. CDC applies life-
saving solutions that work to drive down the incidence of costly 
diseases and improve the lives of Americans.
    CDC leads prevention and health promotion efforts to improve health 
and reduce chronic diseases such as heart disease, cancer, and 
diabetes, which account for 75 percent of the $2.7 trillion in 
healthcare costs spent in the United States each year. Together with 
State and local partners, CDC deploys proven interventions to build 
healthier communities. For example, CDC worked with Centers for 
Medicare & Medicaid Services (CMS) and private-sector partners to 
launch the Million Hearts initiative, which will prevent one million 
heart attacks and strokes by 2017 through proven strategies such as 
improving blood pressure control and promoting smoking cessation. Our 
efforts to control chronic diseases are expanding in 2014, thanks to 
the support of this committee.
   keeping america and the world safe through global health security
    Diseases and disasters know no borders; we are all connected by the 
air we breathe, the water we drink, and the food we eat. CDC deploys 
scientists and disease detectives globally 24/7, because outbreaks that 
start in remote corners of the world can travel here as quickly as a 
plane can fly. Detection and response time is critical. Diseases 
infecting people around the world in the past 10 years--such as MERS 
Coronavirus, SARS and H1N1 and H7N9 influenza--cost lives and caused 
enormous economic disruption. These and other diseases have far-
reaching health, economic, political, and trade implications. Less than 
a week ago we confirmed our first MERS case in the United States, and 
CDC has a team on the ground helping to prevent the spread of that 
deadly virus.
    Our fiscal year 2015 budget requests $45 million to support 
expanded global health security activities. Over the next 5 years, CDC 
and U.S. Government partners, including the Departments of State and 
Defense, will work with up to 30 countries to protect at least 4 
billion people through global health security efforts. As an important 
step toward this larger goal, CDC's funding request will allow us to 
partner with up to 10 countries in fiscal year 2015 to advance global 
health security, building on successful demonstration projects in 
Uganda and Vietnam, as well as others currently underway. CDC will help 
countries find threats faster, stop them closer to the source, and 
prevent them wherever possible.
                     fighting antibiotic resistance
    Antibiotic resistance--when bacteria do not respond to the drugs 
designed to kill them--threatens to return us to the time when simple 
infections were often fatal. Today, antibiotic resistance causes more 
than 23,000 deaths, more than 2 million illnesses, and up to $20 
billion in healthcare costs in the United States each year. Tomorrow 
could be even worse: A simple cut of the finger could lead to a life-
threatening infection; routine surgical procedures, such as hip and 
knee replacements, would be far riskier; and common complications of 
life-saving treatments such as chemotherapy and organ transplants could 
prove fatal.
    Now is the time to address this threat. CDC's 2015 budget request 
includes $30 million to detect and protect against antibiotic 
resistance. With strategic investment over the next 5 years, CDC can 
turn the tide on the most dangerous of these infections, including 
reducing infections with CRE--the nightmare bacteria--by 50 percent and 
reducing C. difficile infections by 50 percent. Reduction in C. 
difficile alone will save 20,000 lives, prevent 150,000 
hospitalizations, and cut more than $2 billion in healthcare costs. 
Achieving these goals requires investments in laboratory capacity to 
detect resistance across the Nation, implementing best practices for 
infection control in healthcare settings, and improving antibiotic 
prescribing practices.
           reversing the prescription drug overdose epidemic
    We are witnessing a new epidemic rapidly unfold in America: deaths 
from prescription painkiller overdoses. Prescription painkiller 
overdose deaths increased four-fold between 1999 and 2010, killing more 
people than all illicit drugs combined--including cocaine and heroin. 
The prescription drug overdose epidemic is driven in large part by 
fundamental changes in the way healthcare providers prescribe opioid 
pain relievers. We can prevent abuse of prescription drugs while at the 
same time making sure patients receive safe, effective, and appropriate 
pain treatment. CDC's fiscal year 2015 budget requests $16 million to 
work with States and the healthcare system to begin to reverse this 
epidemic.
    As the Nation's health protection agency, CDC has led the way in 
identifying the connection between inappropriate opioid prescribing and 
resulting overdose deaths. CDC's proposed investment would target 
States with the highest burdens of prescription drug overdose to 
implement proven strategies to reverse the trend, including assisting 
insurers and clinicians in improving coordination of care for high-risk 
patients; supporting development and effective use of universal, real-
time, and actively managed prescription drug monitoring programs--
State-run prescription tracking databases; and evaluating State 
programs and policies to build the evidence base for overdose 
prevention.
Public Health Challenges in a 24/7 World
    In the next few years, CDC and our Nation must face both new and 
ongoing challenges to protect our health security in a time of fiscal 
constraint. We must accurately detect and quickly respond to numerous 
and unpredictable disease threats, whether natural or man-made. We must 
also ensure that CDC is able to protect Americans from the leading 
causes of death and disability that weaken our economic productivity 
and global standing. Thank you for your continued support of CDC's 
important work to serve this Nation, and I am happy to answer your 
questions.

    Senator Harkin. Thank you, Dr. Frieden.
    Dr. Wakefield.
STATEMENT OF HON. HONORABLE MARY K. WAKEFIELD, PH.D., 
            R.N., ADMINISTRATOR, HEALTH RESOURCES AND 
            SERVICES ADMINISTRATION
    Dr. Wakefield. Good morning, Mr. Chairman. Before I begin, 
I too want to acknowledge your upcoming retirement and 
personally thank you for the support you have given to the 
programs that are operated through the Health Resources and 
Services Administration across the years. Clearly, you place a 
high priority on the communities and the populations that are 
served by these programs. So thank you for that.
    I should also provide a little bit of a shout-out to your 
staff. Over the years, too, they have just been terrific, both 
in advancing your goals and the goals of this committee.
    With that, Mr. Chairman, Ranking Member Moran, and members 
of the committee, thank you for the opportunity to testify 
today on behalf of the Health Resources and Services 
Administration.
    HRSA is the primary Federal agency charged with improving 
access to healthcare services for people who are medically 
underserved because of their economic circumstances or because 
of geographic isolation or serious chronic diseases, among 
other factors.
    To address these issues, HRSA's programs work through 
partnerships. We engage in partnerships with States, community-
based organizations, academic institutions, healthcare 
providers, and others to strengthen the Nation's primary care 
infrastructure, to bolster the healthcare workforce, and to 
achieve health equity.
    I want to take just a few minutes to provide the committee 
with an overview of HRSA's priorities for fiscal year 2015.
    In terms of strengthening the primary care infrastructure, 
our community health centers program support community-based 
organizations that provide comprehensive primary care services 
in medically underserved communities.
    Health centers provide a really wide range of services, 
medical services, dental, behavioral services. And frequently, 
those services are located in one setting.
    I think it is important to note, too, that when it comes to 
health centers and that infrastructure, nearly half of all of 
them are located in rural communities.
    The HRSA budget includes $4.6 billion for the health 
centers program. This funding will enable us to serve about 31 
million patients, and that is an increase from about 21 million 
patients that were reported in our most recent data.
    That care is provided through 9,500 service delivery sites, 
and those sites stretch across the Nation. They are in every 
State, in the District of Columbia, Puerto Rico, the U.S. 
Virgin Islands, and the Pacific basin.
    In fiscal year 2015, $100 million is allocated to fund 150 
new health center sites that will serve an additional about 
900,000 patients.
    HRSA also has a priority focus on supporting a highly 
skilled healthcare work force through health professions 
training, through curriculum development, and through 
scholarships and loan repayment programs.
    In order to increase the availability of high-quality care, 
HRSA health workforce programs provide targeted support for 
health professions, and for parts of the country where 
shortages of health professionals exist.
    To this end, the HRSA budget includes a new workforce 
proposal to increase the supply of needed healthcare providers 
that are well distributed across the country.
    One of our most important primary care workforce programs 
is the National Health Service Corps. The corps works to build 
healthy communities by supporting qualified health providers 
dedicated to working in rural and urban areas of the country 
where shortages of healthcare providers persist.
    Employed by local primary healthcare sites including rural 
health clinics and community health centers, National Health 
Service Corps technicians work every day to promote health and 
to treat illness and injury. In this case, too, nearly half of 
all our current corps providers work in rural communities.
    To meet the needs of both rural and urban underserved 
populations, the President's budget includes the largest 
increase in funding in the history of the National Health 
Service Corps, and it is projected to support an annual field 
strength of more than 15,000 providers from fiscal year 2015 
through 2020. These are providers who will meet primary 
healthcare needs of more than 16 million patients.
    HRSA's health workforce funding will also support a new 
competitive grant program, the Targeted Support for Graduate 
Medical Education Program. This new program will fund teaching 
hospitals, children's hospitals, and community based consortium 
of teaching hospitals and other healthcare entities in order to 
expand residency training with a focus on ambulatory, primary, 
and preventive care.
    Also integral to ensuring that vulnerable populations have 
access to critical health services is the Ryan White HIV/AIDS 
program. We now know that people living with HIV who are on 
drug treatment and are virally suppressed are much less likely 
to transmit the infection to others.
    By helping people to stay in care and adhere to their 
antiretroviral treatments, the Ryan White HIV/AIDS program 
plays a critical role in preventing the spread of HIV.
    Armed with this knowledge, the Ryan White program supports 
the national HIV/AIDS strategy of reducing transmission by 
serving patients across the care continuum.
    HRSA also administers a number of other critically 
important healthcare programs that collectively touch the lives 
of millions of people across the country, including poison 
control centers, national programs for countermeasures and 
vaccine injury compensation, and Federal organ and blood stem 
cell transplantation.

                           PREPARED STATEMENT

    Across the agency, we take seriously the stewardship of our 
programs and our responsibility for the funds that are awarded 
to grantees and communities. And over the last few years, we 
have developed a number of strategies to ensure the integrity 
of the programs that we operate.
    Thank you again for providing me with the opportunity to 
share our work with you today, and I too will be pleased to 
answer questions.
    [The statement follows:]
           Prepared Statement of Mary K. Wakefield, Ph.D., RN
    Chairman Harkin, Ranking Member Moran, and members of the 
subcommittee, thank you for the opportunity to testify today on the 
Health Resources and Services Administration's (HRSA) budget request 
for fiscal year 2015. HRSA is the primary Federal agency charged with 
improving access to healthcare services for people who are medically 
underserved because of their economic circumstances, geographic 
isolation, or serious chronic disease. Our fiscal year 2015 budget 
addresses these issues by providing critical investments in programs 
that bolster our primary care infrastructure, strengthen the healthcare 
workforce, and improve health equity.
                  bolster primary care infrastructure
    To bolster the Nation's primary care infrastructure, the budget 
includes $4.6 billion for the Health Center program, which supports 
community-based, patient-directed organizations that provide 
comprehensive primary care services in medically underserved 
communities. Health centers provide a wide range of medical, dental, 
and behavioral services, often making all of these services available 
at one location. It is important to note that nearly half of all health 
centers serve rural populations. The fiscal year 2015 investment will 
allow health centers serve approximately 31 million patients, at nearly 
9,500 service delivery sites and provide care in every State, the 
District of Columbia, Puerto Rico, the United States Virgin Islands, 
and the Pacific Basin. The budget also allocates $100 million to fund 
150 new health center sites that will serve an additional 900,000 
patients.
                    strengthen healthcare workforce
    HRSA is also charged with strengthening the healthcare workforce by 
supporting the education and distribution of a highly skilled primary 
care workforce through training, curriculum development, and 
scholarship and loan repayment programs. To this end, the budget 
provides $1.8 billion for health workforce programs and makes new and 
strategic investments to strengthen our supply of healthcare providers 
that are well-distributed throughout the country.
    One of our most important primary care workforce programs is the 
National Health Service Corps. Employed by local rural health clinics, 
community health centers, and other primary care sites, Corps 
clinicians work every day to promote health and treat illness and 
injury in rural and urban areas of the country where access to care is 
limited and where shortages of healthcare professionals persist. Nearly 
half of all current Corps providers work in rural communities. The 
President's budget includes $810 million for the Corps in fiscal year 
2015, which represents the largest level of funding in the history of 
the Corps. This level of funding is projected to support an annual 
field strength of more than 15,000 providers over fiscal years 2015-
2020 and serve the primary healthcare needs of more than 16 million 
patients annually.
    HRSA will also invest in our Nation's health workforce through the 
new Targeted Support for Graduate Medical Education (GME) program, 
which will expand residency training in primary care and other high-
need specialties with the goal of encouraging innovation in training 
models and greater accountability for GME funds. This program will 
support 13,000 residents over 10 years through competitive grants to 
teaching hospitals, children's hospitals, and community-based consortia 
of teaching hospitals and/or other healthcare entities.
    The budget also invests $144 million to develop the Nation's 
nursing workforce through programs that, among other strategies, 
support the enhancement of advanced nursing education and practice, 
increased nursing education opportunities for individuals from 
disadvantaged backgrounds, and an expanded nursing pipeline. The budget 
also provides for two new workforce initiatives, including $10 million 
to support a new Clinical Training in Interprofessional Practice 
program to increase the capacity of community-based primary healthcare 
teams to deliver quality care. In addition, $4 million is provided to 
fund new Rural Physician Training grants to help rural-focused training 
programs recruit and graduate students likely to practice medicine in 
rural communities.
                         achieve health equity
    HRSA considers our work with special populations and eliminating 
health disparities a top priority. The budget includes $2.3 billion for 
the Ryan White HIV/AIDS Program to improve and expand access to care 
for persons living with HIV/AIDS. As a payor of last resort, the Ryan 
White Program funds services not covered by health insurance but which 
are nonetheless critical to ensuring that individuals living with HIV 
are linked into care and started on anti-retroviral drug regimens. Due 
to the Affordable Care Act, many Ryan White clients will continue to 
gain access to health insurance or see improvements in their current 
health insurance coverage in fiscal year 2015. In response to these 
changes, as well as the evolving nature of the epidemic, the Federal 
Government will continue to coordinate closely with State and local 
governments and Ryan White Program grantees to ensure that vulnerable 
populations living with HIV have regular access to quality HIV care and 
life-extending medications.
    The budget also proposes better serve the needs for women, infants, 
children and youth by consolidating funds from Part D of the Ryan White 
program to Part C. The consolidated program will emphasize care across 
all vulnerable populations and will allow resources to be better 
targeted to points along the HIV care continuum and to populations most 
in need throughout the country.
    One of our largest programmatic areas focused on special 
populations is our maternal and child health programs. The HRSA budget 
includes funding through fiscal year 2024 to extend and expand the 
Maternal, Infant, and Early Childhood Home Visiting program, through 
which States are implementing evidence-based home visiting programs 
that enable nurses, social workers, and other professionals to work 
with at-risk families and to connect them to assistance that supports 
the child's health, development, and ability to learn. These programs 
are strictly voluntary and have been shown to improve maternal and 
child health and developmental outcomes, improve parenting skills and 
school readiness.
    In addition to the investments in health centers and the National 
Health Service Corps that will improve access to healthcare in rural 
areas, the budget provides $125 million for targeted programs to assist 
Americans living in rural communities through the HHS Office of Rural 
Health Policy, which is housed within HRSA. The Office serves as the 
Department's primary voice on rural health issues and funds a number of 
State and community-based grant and technical assistance programs to 
help meet the healthcare needs of rural communities.
    HRSA also makes investments in a number of other critically 
important healthcare programs that collectively touch the lives of 
millions of people across the country. These include the 340B Drug 
Pricing Program, which provides discounts on outpatient prescription 
drugs to program that serve a high number of low-income patients, and 
efforts to support Federal organ and transplantation oversight, as well 
as efforts to promote awareness of organ transplantation issues and 
increase organ donation rates.
                               conclusion
    In fiscal year 2015, HRSA will continue its efforts to strengthen 
the safety net by expanding and enhancing primary care services, 
primary care health professionals, services for low-income individuals 
and people with serious health conditions, such as HIV/AIDS or in those 
in need of an organ transplant. We will continue to leverage our work 
on important health services for mothers and children, and targeted 
health professions training. HRSA will also continue to work in 
partnership with other Federal entities, State and local governments, 
private organizations, and Members of Congress to strengthen access to 
care with the aim of improving the health of millions of Americans. 
Thank you again for providing me the opportunity to discuss HRSA's 
fiscal year 2015 budget with you today. I am pleased to respond to your 
questions.

    Senator Harkin. Thank you very much, Dr. Wakefield.
    We will now start a series of 5-minute questions, and I 
will start off.

                EARLY HEAD START-CHILD CARE PARTNERSHIPS

    Mr. Greenberg, I want to start with you, the Administration 
for Children and Families. The budget request includes $150 
million to expand Early Head Start, including the new Early 
Head Start and child care partnerships. This subcommittee had 
provided $500 million for the same purpose last year. I 
understand the grant competition for these fiscal year 2014 
funds will be announced in the next couple weeks. There is a 
lot of excitement and interest in communities across the 
country, because of this.
    So could you talk, just very briefly, about ACF's vision 
for these new Early Head Start-Child Care Partnerships, 
because, as I understand it, what we were trying to do, 
obviously, in promoting more Early Head Start, we recognize 
that there are a lot of different providers of child care out 
there. They are doing good jobs, too, but we want them to be 
coordinated with Early Head Start, not one-size-fits-all, but 
how can we start coordinating it, so these kids are ready to go 
to kindergarten, basically, and first grade? Is that the idea?
    Mr. Greenberg. Thank you, Mr. Chairman. Yes, it is.
    I should say, we are very excited about the Early Head 
Start-Child Care Partnerships, and we have been struck over the 
last number of months, as we have talked and worked with Head 
Start programs and child care programs, and those interested in 
early childhood across the country, how much excitement there 
is.
    Mr. Chairman, as you indicate, the basic concept is that 
there are very high standards that apply in the context of 
Early Head Start, but only a very small number of eligible 
infants and toddlers are able to participate in the Early Head 
Start program. A much larger number are in child care settings 
across the country, and the child care settings vary 
considerably in their quality.
    The vision for the partnerships is that Early Head Start 
providers will actively work with child care providers in their 
communities. In doing so, that will ensure that Early Head 
Start services can be provided to children in child care 
settings, and at the same time, there is a potential to use 
this as a way of raising the overall quality of child care that 
can benefit a much larger group of children.
    So we are excited about it. There is tremendous enthusiasm 
in the field. We are expecting a strong and vigorous 
competition. And we are seeking additional funding, because we 
know that in this first round of competition, we will only be 
able to respond to what is likely to be a fraction of the 
interest that is out there in moving this direction.
    Senator Harkin. Thank you very much, Mr. Greenberg.

                         GLOBAL HEALTH SECURITY

    Dr. Frieden, we included $7.5 million in last year's 
omnibus for CDC to establish national public health institutes 
in developing countries. A lot of this came about because of a 
trip I took with you to Africa one time. And what we saw was a 
lot of fragmentation in these countries, different departments 
doing different things and taking a long time to determine what 
was causing an outbreak, or where it was located, how it was 
being transmitted.
    So the idea was to help set up CDC-like structures in other 
countries. As you know, CDC sort of sets the standard for the 
world. I noticed China has even called its own public health 
institute the China CDC. That speaks volumes.
    So we put that $7.5 million in there. It was, hopefully, to 
start this, to make your agency's job easier when there are 
disease outbreaks. So now the budget for next year zeroed out 
this initiative.
    So tell me what that is all about. And how does your budget 
request for $45 million for global health security fit in with 
this initiative?
    Dr. Frieden. Thank you very much, Senator Harkin. Thank you 
for your leadership on this and so many other issues. I think 
your understanding and commitment to public health have been 
extraordinarily helpful in getting us the progress that we have 
made.
    And as we have seen when we go around the world, the 
leading question I am asked is how can we have our own CDC? 
With these resources, we have put out a call and asked 
countries what they would like to do.
    We have more than 30 countries interested in doing more in 
this area. We anticipate giving five countries cooperative 
agreements to expand an existing public health institute and 
make it more of an effective program, and three countries to 
begin that planning process so they can have something in the 
future.
    The budget always has hard choices, and we wish things 
could be in this that aren't. However, I do think there is a 
synergy between the Global Health Security Initiative and 
national public health institutes. Global health security is 
about helping other countries best find, stop, and prevent 
disease outbreaks within their borders.
    In order to do that, they need a laboratory network. They 
need trained epidemiologists. They need emergency operations 
centers. They need a way of operating. And to do that, they 
have to have effective national public health institutions.
    So I think there is a great deal of synergy between these 
programs. Resources are not what we would all wish they would 
be for the kind of programs that we would like to run, but I do 
think the national public health institutes program is a very 
important one.
    Senator Harkin. My time has run out. I want to follow up on 
that, maybe in the next round, because, one, it seems to me it 
is facilities, bricks and mortar, laboratories. It seems like 
the other one is setting up systems. And I don't know how that 
is working out with both of these.
    Senator Moran.
    Senator Moran. Mr. Chairman, thank you very much. In 
deference to my colleague from Nebraska who has an Ag Committee 
hearing, I will yield my time to Senator Johanns.
    Senator Johanns. I thank the ranking member. Sometimes we 
are called to be in two places at once, and I appreciate it, 
because that is an important hearing also.
    Let me just start out and say, thank you for being here. 
We, certainly, appreciate it.
    I would like to offer a comment, though, about the absence 
of Secretary Sebelius. I have been in the chair of a Cabinet 
Secretary before. I am astonished, absolutely blown away, that 
she is not here today.
    I am a fairly new member to the Appropriations Committee, 
and I can't think of more important work than what we do. We 
guard the taxpayer's dollar.
    We not only look forward in these hearings to what is 
coming in the next year. We look back at how those dollars were 
spent in the past year. So I am very troubled by the fact that 
she is not here.
    It is part of the job of being a Cabinet Secretary. I had 
the honor of being a Cabinet Secretary. And at one point in 
that career, the chairman of this committee was also my 
chairman of my committee of jurisdiction.
    There never would have been a day where, if I was asked to 
appear before a committee he was chairing, that I would not 
have attended. That simply would not have happened.
    Most importantly, what we do here is we try to assure 
Nebraskans and people across this country that tax dollars are 
spent wisely.
    I can tell you, having been in your chair many times, I am 
not sure I would describe it as a pleasant experience, but it 
was important that I defended the priorities in the budget that 
I proposed to Congress.
    And as long as I was Secretary, there was no one else that 
could replace my presence.
    So by not being here, Secretary Sebelius and, I feel, the 
White House, too, because they could direct that she be here--
is sending the message that somehow they are not accountable, 
not accountable to me, not accountable to my colleagues, but 
most importantly, not accountable to the American taxpayer.
    Leadership is not about convenience and being available 
when it works into someone's schedule. It is about accepting 
responsibility for the job you have taken on.
    The fact of the matter is that this budget was compiled 
under the Secretary's watch. No one else's. She was in charge. 
Not only that, she is still running this agency.
    Unfortunately, her absence speaks volumes about lack of 
transparency.
    The Secretary's time at HHS has, certainly, not been a 
picture of success. Last month, a nonpartisan Congressional 
Research Service report revealed that the administration has 
failed to meet more than half--more than half--of the 83 
statutory deadlines required under Obamacare. She is the 
Secretary. I should have the right to ask about that. And the 
Department of HHS was responsible for virtually all of those 
missed deadlines.
    This administration has unilaterally delayed or changed 
parts of the healthcare law more than 20 different times. 
Again, virtually all of these delays are under the jurisdiction 
of HHS. So we have a slew of missed deadlines, changes to the 
law that, quite honestly, we haven't approved in Congress.
    But if anything, that would underscore the importance of 
her being here, to justify that, to tell me why she thinks she 
has the ability to do that.
    Last year during the appropriations process, I actually 
offered an amendment that required HHS to be more transparent 
in spending on Obamacare. I was very pleased that the language 
was included in the final appropriations package.
    It required the Department to submit in this year's budget 
request an outline of the sources of funding used to implement 
the healthcare law's exchanges, and specifically how the 
Department used that money. But she is not here to answer for 
that. Unbelievable.
    I don't believe the HHS budget came close to following 
those requirements, and I have the requirements right here. Why 
should I not be entitled to ask her about that?
    So I want to reiterate my disappointment. I think it was 
important that I use my time to express this. I hope somehow 
the message gets back to the White House that we are serious 
about oversight. We are serious about transparency. And we are 
serious when we ask Cabinet members to attend our hearings.
    Mr. Chairman, thank you very much.
    Senator Harkin. Thank you, Senator Johanns.
    And while we might have some disagreements on certain 
things, we both agree on one thing: It is time to retire.
    Senator Johanns. And we are.
    Senator Harkin. Senator Mikulski.
    Senator Mikulski. Thank you very much, Mr. Chairman. Thank 
you for holding this hearing.
    I wanted to come for several reasons. One, of course, is 
our responsibility to do due diligence on these budgets. But 
also to thank the men and woman at this table and the people 
who work at the agencies that they are the executive leadership 
of. I want to thank them for their service.
    In each and every way and every day, our country is better 
and safer, and our children's lives are brighter, because of 
your leadership, your executive ability, your trying to guide 
us during great times of budgetary turmoil and uncertainty. And 
then facing sequester, facing furloughs, facing uncertainty, 
and facing a rather skimpy cost-of-living increase.
    So I want to thank you. I want to thank people at each and 
every one of these agencies for the job that you do. And I know 
the other day, they gave the so-called Sammies awards for 
thanking people for their service, but we can't do the job we 
want to without that.
    Each and every one of you, we could have had a separate 
hearing on the work that you do, from the CDC, to CMS, to 
Children, and HRSA, et cetera.
    But today, because of a sense of urgency to really hold our 
hearings, do our due diligence, and be able to avoid a lame 
duck, we are working on a bipartisan, bicameral basis to 
restore regular order.
    I want to thank Senator Shelby, for all of his cooperation, 
and then my chairs and my ranking, to be able to accomplish 
this.
    Our goal is to be able to move our committees in an 
expeditious way, and then to be able to complete our work by 
October 1. It is a bodacious, audacious effort, because it has 
not been done since 1996. Since 1996, the Congress of the 
United States has not completed this. So we are going to give 
it a go, and we are going to give it a try.

   ADMINISTRATION FOR CHILDREN AND FAMILIES' FISCAL YEAR 2015 BUDGET 
                                REQUEST

    I am going to focus my time, though, with you, Mr. 
Greenberg. Ordinarily, I go with health and talk to CMS, talk 
to CDC, and talk to HRSA. But I am going to focus on you today 
for two reasons: One, early childhood; and then the other, the 
unaccompanied children.
    I want to thank Senators Alexander, Shelby, Harkin, and 
Burr. We led a bipartisan effort here on children.
    First of all, in last year's appropriation, we put money 
into Head Start, and we did it by working together. And you 
felt that plus-up. So we say Congress did. This is the Congress 
that did it. This is the Congress that did it.
    And then working on a bipartisan basis, we passed the Child 
Care Development Block Grant (CCDBG) that had not been 
reauthorized in, again, over 20 years, by working together.
    So let me get to my question. Is this budgetary request--
first of all, let's go to the CCDBG grant--enough resources to 
implement the new authorizing legislation that was passed on a 
bipartisan basis, particularly on the quality initiatives?
    Mr. Greenberg. Thank you, Senator Mikulski, for your 
comments. I first just want to recognize how much we appreciate 
the bipartisan support in the appropriations process and the--
--
    Senator Mikulski. We appreciate the thanks, but I have 5 
minutes.
    Mr. Greenberg. Okay, so for the requirements of the bill 
that would strengthen health and safety, and strengthen 
consumer education, and strengthen a number of other aspects of 
State performance, States, if their funding is limited, States 
will need to make judgments within their block grant funds 
around prioritizing.
    Senator Mikulski. I am getting lost here. Do you have the 
money or don't you? I mean, is this enough or not?
    Mr. Greenberg. The budget request that the administration 
made was one that was recognizing the importance of additional 
funding for child care, both for access and for quality. It is 
also a budget request that is necessarily constrained by the 
figures that we are operating within.
    Senator Mikulski. Can we go to the Head Start program? You 
say the additional $270 million will maintain current service 
levels.
    Now, we love the President's new initiative. But what we 
feel right now is we have to keep going on that which we have, 
where we don't have new programs, new regs, new compliance 
standards, but keep that which we are doing.
    Now is this Spartan, skimpy, or do you think adequate? 
Because there is a code word here: To maintain current service 
levels. I am concerned about this, that it is not really 
enough. And, again, there is strong bipartisan support for Head 
Start here.
    And I might say, on the other side of the dome, too.
    Mr. Greenberg. Sure. And in the Head Start request, we did 
structure it in order to maintain current services, certainly, 
to go further than that would have required additional funding. 
And we were constrained in what we could request in 
discretionary funding.
    Senator Mikulski. So what I hear you saying is that what we 
are doing here is good, but it is going to be barely enough to 
meet that which we already have on the books.
    I am not trying to put you on the spot.
    Mr. Greenberg. Sure.
    Senator Mikulski. So let me then go to unaccompanied 
children. I am really frustrated about this.
    Colleagues, I would really ask you, knowing your concern, 
both as Senators and fathers, and so on, we have children 
pouring over the border from Central America. These are 
unaccompanied children. We have, like, boat people, but they 
are border children.
    They are pouring over the border. The numbers are 
escalating. When they come over, HHS picks up these children. 
We don't want to warehouse them. We try to put them in foster 
care.
    They are being sent by their families to escape the 
violence in Central America.
    There was a little girl from Ecuador who, when she was 
moved to a shelter, hung herself in the shower. And she had 
been on the road all by herself, and she was 11 years old, and 
she had been on the road for 2 months.
    Now Sebelius called me when I was doing the omnibus, asked 
for more money because they didn't have it. They underestimated 
the numbers.
    So we put in more money. Barbara Mikulski, a social worker, 
working with Richard Shelby, who was not going to leave 
children warehoused in Quonset huts, and, I must say Hal Rogers 
and Nita Lowey, we put the money in.
    Now, I have been saying to the Administration, ``Tell me 
what you need, and don't stick us with the bill at the end.'' 
And I feel that you are not telling me what you need. I really 
don't feel that HHS is telling me what you need.
    So you have gone from--and I say this to my colleagues, 
please go to page 5 of the testimony--in 2011, it was 6,500 
kids. In fiscal 2014, it was 60,000. We have gone from 6,500 to 
60,000, and everybody is saying you can't give me the numbers 
because you can't make the estimates.
    Well, what do you think?
    Really, I have taken this up to Sebelius. I have taken it 
up to Burwell. I am taking it to John Kerry. Senator Harkin has 
done the same. I know I have the support from--we just need to 
know.
    We have to look out for these children while we work on 
root cause. I have been down to root cause before. While we 
were working on root cause, we still have thousands of 
unaccompanied children whose parents paid coyotes and someone 
to bring them over the border to safety.
    Mr. Greenberg. So, as you indicated, Senator, the numbers 
have gone up very dramatically over the period since 2011. And 
the numbers continue to grow.
    The children are principally children from Guatemala and 
Honduras and El Salvador. The best indications are that there 
are a mix of reasons, that the violence that is occurring in 
these countries appears to be a significant contributing 
factor. Additional factors are economic conditions, and in some 
cases, family reunification. So there are a set of reasons. But 
the numbers do continue to grow.
    For HHS, our responsibility is----
    Senator Mikulski. Mr. Greenberg, I so respect you. You have 
such a long history of fighting poverty. But if HHS does not 
receive enough funding for this program where we have 
adequate--not adequate--we need real projections.
    The Department of Homeland Security could end up holding 
these children in cells intended for adults unless we come to 
grips with what are we going to do and how we are going to 
bridge this while we are looking at the root cause.
    So I don't want to take the time of my colleagues. Members 
have been waiting patiently. Senator Harkin did this. I am 
going to stop.
    But this is a humanitarian crisis, and we have to go to the 
edge of our chairs to at least get the estimate for fiscal year 
2015.
    Thank you, Mr. Chairman. I just felt the committee needed 
to be aware of this because this is not only a funding problem, 
it is a humanitarian crisis. But our failure to appropriate 
could exacerbate the humanitarian crisis.
    Mr. Greenberg. Senator Mikulski.
    Senator Mikulski. I need numbers. Thank you very much. My 
time is up.
    Senator Harkin. Senator Moran.
    Senator Mikulski. Thank you. And thank you, colleagues. I 
really think this is a new hot potato here.
    Senator Harkin. A huge issue. And it is a funding issue 
that confronts not only HHS, but also Homeland Security, too.
    Senator Mikulski. And the Department of State.
    Senator Moran. Mr. Chairman, thank you very much.
    I apparently established a precedent. I am going to soon 
yield to the ranking member, the Senator from Alabama.
    But, Madam Chair, while you and your colleagues, 
counterparts in the House, and Senator Shelby, work on trying 
to figure out the gap of $4 billion in the Federal Housing 
Authority that creates huge problems for all of the 
appropriations process, this, in my view, is the issue in this 
subcommittee that is very similar--a $1.1 billion gap, we 
believe, that somehow needs to be addressed, based upon the 
tremendous humanitarian need.
    And while all of us are sympathetic broadly to humanitarian 
needs, particularly when it comes to children, it is 
exacerbated. So it is a high priority.
    But my point would be: We have a similar problem to what we 
have in Federal housing here in this budget as a result of this 
issue.
    Let me yield the balance of my time to the Senator from 
Alabama, the ranking member.
    Senator Shelby. Thank you.
    Thank you, Chairman Harkin.
    First of all, I want to just restate what I have said many 
times--I appreciate what all of you do and what you are trying 
to do. We are short of money, but not short of ideas, not short 
of people that would be great scientific investigators, and so 
forth. We have to make tough decisions. I hope we make some 
wise ones.
    But I support what you do, individually and collectively.
    But now I want to direct my remarks not to you, but to 
Secretary Sebelius.
    On April 2, 2009, then-Governor Sebelius testified before 
the Senate Finance committee at her confirmation hearing to 
serve as Secretary of the Department of Health and Human 
Services. At that hearing, the chairman of the Finance 
Committee asked her the following direct question, and I quote, 
``Do you agree, without reservation, to respond to any 
reasonable summons to appear and testify before any duly 
constituted committee of Congress, if you are confirmed?''
    Governor Sebelius, at that time she was still Governor, 
answered unequivocally, and I quote again, ``I do. And I look 
forward to it.''
    Well, the then-nominee gave us her word that she would 
appear when asked to do so. Apparently, she has changed her 
mind.
    This subcommittee and, of course, the whole committee, has 
two former Secretaries, Senator Alexander who was Secretary of 
Education, and Governor--I call him Governor--Senator Johanns. 
I thought his statement earlier was right on point.
    What has not changed is this subcommittee's responsibility 
to ensure that taxpayer dollars appropriated to HHS are spent 
wisely. That is why we wanted Secretary Sebelius up here.
    And in light of the failures of Obamacare, a lot of us 
believe, it is entirely reasonable to expect the Secretary to 
explain how she spent money previously allocated to her 
Department before we consider her request for $60.8 billion 
more.
    Nevertheless, Secretary Sebelius has reneged on her promise 
to the Senate and refused a reasonable summons to appear and 
testify here today. Why? Because, according to the Obama 
administration, she doesn't want to. That is not sufficient.
    We deserve better than that. We deserve more respect on 
this committee. Thank you.
    Senator Harkin. Senator Reed.
    Senator Reed. Thank you very much, Mr. Chairman.
    And thank you, ladies and gentlemen, for your testimony.

               LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM

    Mr. Greenberg, we understand--it has been highlighted by my 
colleagues--the fiscal pressures the Department is under. One 
area which I have worked on consistently, on a bipartisan basis 
with Senator Collins, is LIHEAP. And once again, the budget is 
very disappointing, honestly.
    We will do our best to try to restore funding. This is 
critical, not just to our region of the country, but it is 
particularly critical in the Northeast, because we are paying 
energy prices that are sometimes three and four times the 
national average. And so, less dollars with higher prices means 
more and more families are literally cold in the winter.
    And I think in the summertime, other parts of the country 
have a similar problem with cooling.
    My question is: I don't know what you can do at this point, 
but I want to stress my disappointment. And can you give us an 
idea of why we couldn't get more money into the LIHEAP budget 
from the administration?
    Mr. Greenberg. Senator Reed, thank you. The LIHEAP decision 
was an extremely difficult one. It does simply reflect the need 
to make decisions and make priority judgments among competing 
priorities with limited discretionary funding.
    For LIHEAP, we are very mindful of the tremendous 
importance of the program. We are very mindful that it only 
reaches a fraction of the eligible households, that for those 
who it does reach, that the benefits that are provided are 
limited in relation to their heating and cooling costs.
    We are mindful of all those limitations. And this was 
simply a judgment about priorities with limited discretionary 
funds.
    We have proposed, as part of the budget, to also move 
forward on energy burden reduction grants, recognizing that a 
part of an overall strategy has to be helping families develop 
ways of lowering their energy costs.
    But, fundamentally, this is about constrained resources.
    Senator Reed. Well, I think, as you can anticipate, we will 
try our best to rebalance.

              HEALTHY HOMES AND LEAD POISONING PREVENTION

    Dr. Frieden, let me move on quickly. CDC, the Healthy Homes 
and Lead Poisoning Prevention Program, is another extremely 
important program. Lead poisoning is a completely avoidable 
childhood disease that can cause irreparable damage to 
children. We have made progress. We were able to restore some 
funding last year to CDC.
    Can you tell us what your plans are to use these resources 
and also to make them stretch further, go further, and help 
more children?
    Dr. Frieden. Thank you, Senator Reed. Thank you for your 
support for this and other public health issues.
    Lead poisoning prevention is critically important, as you 
say. And CDC has a unique role in both surveillance, so we know 
what is happening, and targeting interventions.
    We know that even slight elevations in lead levels can 
result in a lifelong reduction in both intellectual potential 
and in earnings capacity, so it has major economic 
implications.
    What we will do with the funding restored by Congress is to 
support roughly 30 city or State health departments to do a 
better job at surveillance and targeting prevention to better 
protect children and continue to drive down lead poisoning 
rates.
    Senator Reed. Thank you very much.
    In this context, I have to thank Senator Mikulski and our 
former colleague, Kit Bond. When they were leading the Housing 
and Urban Development Subcommittee here, they targeted 
remediation, so that we could literally get the lead out of 
houses. And without Barbara's leadership, thousands and 
thousands of children--and Senator Bond's--would have been not 
only adversely affected----
    Senator Mikulski. And Jack Kemp.
    Senator Reed. And Secretary Kemp, too. So this was a 
bipartisan effort. We like to see it that way.

                    HOME VISITING AND LEAD EXPOSURE

    Final question: If I may, Dr. Wakefield, and that is, you 
have a home visiting program. This relates to the lead 
exposure. You have a home visiting program, and it is an 
opportunity to check on many hazards, including lead exposures, 
and to coordinate with CDC.
    Can you tell us what you intend to do to coordinate between 
these home visits and the Healthy Homes and Lead Poisoning 
Program, so we are getting more bang for the buck? That is what 
we want to do around here.
    Dr. Wakefield. Sure. So the home visiting program is being 
deployed in all 50 States, and it has as a basis, evidence-
based programs that are deploying nurses, social workers, other 
health care providers, to families that choose to participate 
in the program voluntarily.
    But they are families that tend to be at risk, of course, 
and living in at-risk communities.
    So through the home visiting program now, we have over the 
course of about the last year or so, infused in six of those 
evidence-based programs information about lead poisoning 
prevention and healthy housing.
    So I know that is a priority for you and for other Members 
of the Senate, and we have tried to embed that in the program 
in a number--not all yet, Senator--but in a number of the home 
visiting programs.
    Senator Reed. And are you working with CDC?
    Dr. Wakefield. We do very closely. And I have personally 
had conversations with CDC on this topic.
    Senator Reed. Thank you.
    Thank you, Mr. Chairman.
    Senator Harkin. Thank you, Senator Reed.
    Senator Moran.
    Senator Moran. Mr. Chairman, thank you. I thought it was 
finally my time to talk, but Senator Alexander has asked that I 
yield to him, and I am happy to yield.
    Senator Alexander. I am glad we have such a yielding 
ranking member.
    I thank you for your courtesy, Senator Moran.
    Mr. Love, I hope you will express to Marilyn Tavenner our 
sympathy for the loss of her mother, and respect for the way 
she does her job. And we look forward to seeing her soon.
    Dr. Frieden, I wanted to especially thank you for the 
terrific job the CDC did in the meningitis outbreak. You worked 
fast and quickly. And by doing that, and the help that you gave 
the Tennessee Department of Public Health, and Vanderbilt and 
others who worked on that, you saved a lot of lives in that.
    And to all of you, I think we all appreciate and respect 
the work that you do and look forward to more informational 
hearings.
    But this is not an appropriate hearing. I think my 
colleagues know I spend as much time as anybody on the 
Republican side trying to make this Government work in the way 
it is supposed to work.
    I especially appreciate what Chairman Mikulski said about 
the regular order, and I like the fact that she and Senator 
Shelby and Senator Harkin and others and Senator Moran, are 
trying to have us do our job with appropriations, and to do it 
together in the way we are expected. So I am supporting that 
effort, and intend to do everything I can to help her do that.
    But this is not right for the Secretary of the Department 
to not appear to defend the President's budget.
    I was a Secretary. I am pretty sure I answered the same 
question when I was asked, would I show up, when I was asked by 
the committee. And I believe I did, whenever I was asked, at 
least for this specific occasion.
    And I notice that the chairman mentioned a couple times 
that he is retiring this year. But if he is, I haven't noticed 
it. If anybody from Iowa were to ask me if Tom Harkin was 
slowing down in this year of his retirement, I would say, as 
far as I can tell, he is speeding up. I mean, we have a hearing 
every other day, it seems like. And he is busily doing his job, 
and I am glad he is. I enjoy working with him. We have gotten 
more done than any other committee in the Congress, authorizing 
committee.
    I notice that the Senator from Nebraska is also retiring, 
and he not only came to this hearing, he is on his way to 
another hearing.
    So where is the Secretary of Health and Human Services? She 
is still on the job. And if the Secretary of Defense were still 
on the job and waiting for the next Secretary, and we were 
invaded, or Ukraine happened, would the Secretary of Defense 
not show up? That is not appropriate.
    And it is more, I am afraid, than just the Secretary 
playing hooky. I mean, this is getting to be a persistent 
problem with this administration regarding, Article 1 of the 
Constitution and the Congress, the representatives of the 
people as an inconvenience.
    I think Presidents ought to begin their terms by taking the 
Cabinet down to Mount Vernon and reminding themselves that 
while the chief executive is extremely important, the Founders 
didn't want a king. And George Washington, who could have 
stayed forever, as long as he lived, as President, imprinted 
his humility and respect for the people on the Constitution 
that he helped to write. And every President since then, 
almost, has tried to stretch that envelope.
    But this administration has gone further than any I can 
remember, with its recess appointments and its czars and its 
waiver authority for school boards and raising money privately 
to do what Congress did not authorize to do and turning the 
Senate into a place where the majority can do whatever it 
wants, whenever it wants to get a result that the 
administration wants. That is not the way our constitutional 
framework was set up.
    I hope I would say the same thing if we had a Republican 
President whose Secretary didn't show up to testify before a 
Republican committee.
    We have Article 1 for a reason. We represent the people of 
this country for a reason. We are here, ready to do our jobs.
    And I am extremely disappointed that the Secretary of 
Health and Human Services, who helped write this budget over 
the last 6 months, is not here to do her job. What if the next 
Secretary said she couldn't come testify because she didn't 
have anything to do with writing the budget? It is the job of 
the Secretary to be here, to show respect, not for each of us, 
but for the people we are elected to represent under Article 1 
of the Constitution of the United States.
    Thank you, Mr. Chairman.
    Senator Harkin. Thank you, Senator Alexander.
    Senator Shaheen.
    Senator Shaheen. Thank you, Mr. Chairman.

               LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM

    Mr. Greenberg, before I get into the meat of my questions, 
I do want to just echo what Senator Reed had to say about the 
LIHEAP program.
    As you know, in the Northeast, we had a very cold winter, 
and we have a lot of people in New Hampshire who did not get 
the assistance that they really needed through the LIHEAP. So 
while I appreciate we have very challenging resource issues, I, 
certainly, will be arguing on this committee that we should 
increase the amount of funding for LIHEAP.

               IMPLEMENTATION OF THE AFFORDABLE CARE ACT

    Mr. Love, I am really pleased that despite all of the 
challenges with the rollout of healthcare.gov that this past 
week we heard that over 40,000 people in New Hampshire had 
selected a health insurance plan through the exchange. That is 
a significantly greater number than the 19,000 that CMS had 
targeted, so we were pleased about that.
    I am also pleased that there was recently a bipartisan 
compromise in our New Hampshire Legislature that allowed the 
Governor and the Legislature to agree to an expansion of 
Medicaid in the State.
    That will require a waiver, as you know, and I understand 
that there are discussions already underway between the State 
of New Hampshire and CMS, so I would urge those discussions to 
go forward as expeditiously as possible. And I appreciate all 
the work that you are doing to try to make that happen.
    We have 50,000 residents in New Hampshire who will benefit 
from an expansion in Medicaid.
    I wonder if you could talk a little bit about the steps 
that CMS is taking to continue to improve the implementation of 
the healthcare law, specifically with respect to the 
healthcare.gov Web site. What steps are you taking to ensure 
that problems don't exist moving forward? And can you talk 
about the importance of what I believe is the importance of 
having a permanent CEO to head up the effort around the 
technology and the Web site?
    Mr. Love. Thank you, Senator.
    Regarding the rollout of healthcare.gov, as you and other 
members of the committee have mentioned, we have a number of 8 
million that no one I think would have predicted in the early 
fall. And there has been an extremely diligent effort, both on 
the part of the agency as well as our colleagues elsewhere in 
Government, and the private sector, quite frankly, to help us 
get up to speed on that. We have made tremendous progress.
    What we are very much focused on in the next 6 months--the 
end of open enrollment, the first season--is really building on 
that infrastructure, particularly as it regards the consumer 
experience and interacting with the Web site. That is of 
primary importance to us.
    There are other aspects of the Web site that the consumer 
may not see but are also quite important. We are focused on the 
financial management piece of it and various oversight 
functions. And we are working just as hard during the down 
period as we were during the open enrollment. And we hope to 
see a dividend. We hope you will see a dividend to that in the 
next open enrollment in the fall.
    Regarding your question on a chief executive officer for 
our Center for Insurance--CCIIO (Center for Consumer 
Information and Insurance Oversight) is our shorthand--but 
basically, the component that is central within CMS that has 
lead responsibility for that. I know that there are different 
management leadership models under consideration. Right now, we 
do have an acting director, Dr. Mandy Cohen, who is doing a 
great job stepping up since her predecessor left a short while 
ago. And we are looking at different management models to bring 
the type of leadership effort I think you are considering.
    I know the Administrator is consulting both with the 
Department and the White House now on what the most rigorous 
leadership model for the CCIIO front office will be. I am sure 
you will be hearing more about that.
    Senator Shaheen. Thank you. I would urge you to make sure 
that there is a permanent person in charge of that effort in 
the future.

                        PRESCRIPTION DRUG ABUSE

    Dr. Frieden, I am sure you are aware that in northern New 
England, we have had an epidemic of heroin use. In New 
Hampshire, we had more deaths last year from drug overdoses 
than from car accidents, so it is something that we are very 
concerned about.
    I have done several panels with law enforcement, with 
treatment providers, to talk about what might be done to 
address this epidemic. And one of the things I heard recently 
from a former DEA (Drug Enforcement Administration) agent who 
had worked in this field for about two decades was that we 
should be doing more to ensure that there are some protocols 
around how doctors decide on prescriptions, since that, in too 
many cases, has been the avenue through which people got into 
drug use.
    And I wonder if you could talk about what CDC is doing or 
can do to educate providers for appropriate prescription drug 
practices.
    Dr. Frieden. Thank you very much.
    This is, indeed, a huge problem. We have seen a fourfold 
increase in deaths from prescription opiates, currently, more 
deaths than from heroin and cocaine combined.
    And we have also seen devastating impacts on communities, 
where there are some communities where it is so rampant that it 
is difficult to recruit new businesses in because people can't 
pass drug tests.
    We see this as an opiate problem. As you point out, many, 
perhaps even most, people who currently use heroin started off 
with prescription opiates. We have tracked these trends, both 
overall and by State. And the numbers are, frankly, shocking.
    This is, to a significant extent, a doctor-caused, or 
iatrogenic, epidemic. And we do believe it can be reversed by 
things like good guidelines.
    In fact, enough prescription opiates are given each year to 
give every adult in the country 75 opiate pills a year. It is 
just way too much. It is 18 billion pills a year. And we find 
in some States, as many as one in three people get a 
prescription each year.
    So what we have focused on for the 2015 request is to be 
able to support States with several specific things.
    One is strengthening prescription drug monitoring programs. 
These are very important, but there isn't one in the country 
that is yet real-time, universal, and actively managed. So we 
want to get to that key area of tracking prescriptions, and 
intervening with both patients and providers for services as 
needed, or law enforcement if appropriate.
    The second key area is supporting States on a variety of 
measures that they can do with insurers, Medicaid, and others.
    And the third is specifically the issue of guidelines. 
Washington State and some communities have guidelines, but they 
aren't well-followed. They aren't well-established. And by 
establishing guidelines, then insurers, Medicaid programs, 
others can ensure that pain relief, which is very important--
for example, for patients with terminal cancer pain--continues, 
but without the great risk that these drugs provide.
    Senator Shaheen. Well, thank you very much.
    Mr. Chairman, if I can just have one follow-up question. I 
know I am over my time.
    So how much of the requested $15.6 million for prescription 
drug overdose programs is going to be targeted to help 
providers become smarter prescription providers?
    Dr. Frieden. The overwhelming majority of that would go to 
States. And within the States, each State would decide where 
they would move the money, where they would invest it.
    But the three key components are improving prescription 
drug monitoring programs, tracking the system in real-time, and 
strengthening prescriber practices and provider behavior.
    Senator Shaheen. Thank you very much.
    Thank you, Mr. Chairman.
    Senator Harkin. Thank you, Senator Shaheen.
    Senator Moran, please take the time you desire.
    Senator Moran. Mr. Chairman, thank you very much.
    First of all, Dr. Frieden, you have invited me to visit the 
CDC, and I want to express my gratitude and also express my 
sincere interest in accepting the invitation. We will work 
toward accomplishing that. I look forward to that visit.
    The chairwoman of our full committee, the Senator from 
Maryland, talked about the Unaccompanied Alien Children 
program. This is an example of a question that I would ask the 
Secretary if she were here. If she were here, I would ask this 
question: The Unaccompanied Alien Children program is 
underfunded by more than half, $1.1 billion. It is my 
understanding that the administration will not submit a budget 
amendment to address that shortfall. I guess I would ask the 
Secretary if that is true.
    And I would say, Madam Secretary, if we have to live within 
our budget allocations, what HHS programs would you recommend 
that we would use to make up for that $1.1 billion?
    And again, there is no one here who can help us directly 
answer that question.
    Further, on ACA risk corridors, I would ask the Secretary 
that section 1342 of the Affordable Care Act requires the 
Secretary to establish and administer those corridors. Does the 
Secretary have the authority to make payments from the risk 
corridor fund? And if not, how would the administration pay for 
that funding gap?
    Again, perhaps someone here could answer their belief as to 
whether the authority exists, but I don't think there is 
anybody here who could tell us how the administration would 
then pay for that gap.
    We have had a lot of conversation, mostly in the House, 
about the evaluation tap. It was originally implemented 
throughout the Department's budget to use for evaluations of 
those program activities within the Department. Perhaps, 
unfortunately, it is now used--I guess not ``perhaps.'' 
Unfortunately, it is now used to supplant budget authority.
    And I would ask how does the Department of Health and Human 
Services justify taking funding from the National Institutes of 
Health to fund programs that should receive independent budget 
authority.
    There has been a request for an increase in that evaluation 
tap from 2.5 percent to 3 percent, and, Madam Secretary, how 
was it determined that increase in the tap was necessary in 
fiscal year 2015? What deliberations took place within HHS, and 
within the White House, to decide which agencies are sources 
and which are receivers of evaluation tap transfers? And 
specifically, why does the Department use what I would say is a 
budget gimmick to highlight an increase in NIH funding of $200 
million even though NIH is left with only a $58 million 
increase above 2014, after accounting for the tap increase?
    And finally, an example of what I would ask the Secretary 
is regarding the nonrecurring expenses funds. I am trying to 
become more knowledgeable about information technology. We have 
a hearing later today in the Appropriations Subcommittee on 
FSGG.
    The nonrecurring expenses fund dollars went to fund the 
Affordable Care Act-related information technologies, but the 
fund can be used to cover any one-time capital I.T. 
acquisition. And I would be interested in knowing what analysis 
the Department does before moving unobligated funds into the 
nonrecurring expenses fund, and the details of that process for 
the subcommittee.
    How does HHS decide what I.T. projects merit nonrecurring 
expense fund dollars? Does HHS solicit formal or informal 
requests from agencies for nonrecurring expense fund-related 
projects? What programs would have received funding over the 
past 2 years had funding not been siphoned off to fund 
implementation of the health insurance exchange?
    And then finally, an issue that is in my view so important. 
In last year's budget request, there was the $80 million 
increase for Alzheimer's disease research. Congress, in our 
omnibus bill, we were successful in finding $100 million for an 
increase for Alzheimer's disease research.
    And why did the Department not include that increase for 
Alzheimer's disease research in its 2015 budget proposal?
    And perhaps most importantly, will NIH be able to reach the 
goal for finding a cure for Alzheimer's by 2025, the stated 
goal, without an increase in its research funding?
    Mr. Chairman, I thank you for conducting this hearing. I am 
sorry that I don't think these folks can answer my question. We 
will continue the efforts to try to find those answers.
    I was interested in Senator Mikulski's conversation with 
Secretary Sebelius. And perhaps we will have that opportunity, 
either in a hearing sometime or with the new Secretary, to 
explore these issues further.
    Thank you.
    Senator Harkin. Thank you, Senator Moran.
    I just have a couple follow-ups I want to do.

                        COMMUNITY HEALTH CENTERS

    Dr. Wakefield, I want to talk just a little bit about 
community health centers. As you know, we are going to face a 
funding cliff here if we don't extend the mandatory part of 
this budget. So talk to me a little bit about how you envision 
this moving ahead to make sure that we have the necessary 
funds, so that we don't have that budget cliff. I think it is 
2016.
    Dr. Wakefield. Sure. Thank you, Senator.
    The community health centers program is extremely important 
to ensure that individuals across the country have access to 
primary healthcare services and preventive healthcare as well.
    And the importance of that program has really been 
increasing since about 2009 when that infrastructure was seeing 
about 17 million patients. As I mentioned in my opening 
remarks, as of about 2012, we are seeing about 21 million 
patients. And in 2015, we expect we could be seeing as many as 
31 million patients in that infrastructure.
    So your point about sustainability and stability, to ensure 
that individuals and communities across the country have access 
to primary healthcare services, is an important one. And we, of 
course, are concerned about long-term funding as well.
    So in fiscal year 2015, we have $3.6 billion. That is the 
last year of funding through the Affordable Care Act for 
community health centers, in fiscal year 2015.
    Our ask is $1 billion in discretionary for fiscal year 
2015, to provide a total of $4.6 billion to fund community 
health center programs.
    Of that money, Senator, about $1 billion would be applied 
for nonrecurring costs. That is, to invest in construction and 
renovation. And frankly, from the field, from health centers 
across the country, because of this increased demand in numbers 
of people who are seeking healthcare services, a lot of them 
now with insurance coverage, this will allow those community 
health centers to build out and to reconfigure the centers in 
order to be able to accommodate that increased number of 
patients that are being seen.
    So about $1 billion, as I said, in 2015 will be used for 
nonrecurring construction funds.
    Going forward, then, to replace the Affordable Care Act 
funds for fiscal year 2016, 2017, and 2018, we are proposing in 
the budget mandatory funding of $2.7 billion per year.
    In addition, we would assume that there would be 
appropriations made available by the Congress, but that is the 
proposal to ensure stability and access to healthcare services 
in the subsequent years.
    Senator Harkin. Will that $2.7 billion be enough to 
alleviate the funding----
    Dr. Wakefield. So, Senator, if we were to assume that in 
addition to that $2.7 billion, there would be appropriations 
that would also be made available in fiscal years 2016, 2017, 
and 2018, to support the program.
    Senator Harkin. How much?
    Dr. Wakefield. That provides baselines to support 
operations, and so on.
    Senator Harkin. What would that be, about how much a year, 
which you anticipate that would be in terms of discretionary 
budget?
    Dr. Wakefield. Well, I couldn't speak----
    Senator Harkin. We would have to come up with that. I am 
not going to be here, but he is going to be here.
    Dr. Wakefield. So, Senator Moran----
    So, Senator, we are looking closely at the out-years 
additional needs. What we can count on is that need for $2.7 
billion. So we are tracking, for example, the number of 
individuals that are receiving care in health centers that are 
now coming through the doors with insurance coverage, so that 
provides some additional revenue.
    Senator Harkin. So you get some funds coming in through the 
Affordable Care Act?
    Dr. Wakefield. To replace Affordable Care Act, we will have 
our mandatory funding of $2.7 million per year. In addition----
    Senator Harkin. Are you anticipating money that will come 
in because people now have insurance coverage?
    Dr. Wakefield. Yes. So people will be coming in with 
insurance coverage. So we have that phenomenon. People coming 
through the door with insurance coverage, either Medicaid 
insurance coverage where it has been expanded, or private 
insurance coverage.
    But we also know that that is going to be uneven, Senator 
Harkin, because there will be some States where Medicaid has 
not been expanded and individuals have become aware of 
community health centers as a place where they can access 
services. No one is turned away. A sliding fee scale is used 
for people under 200 percent of poverty.
    So we have a little bit of both of those dynamics. And we 
will have to look very closely at that for years 2016 and on.
    Senator Harkin. Do you anticipate any fall off of 
attendance--maybe that is the wrong word--people seeking 
medical care from community health centers because they now do 
have insurance coverage and they might be going to their 
primary care doctor someplace else?
    Dr. Wakefield. We don't. We don't expect a decline in 
demand for services through community health centers based on a 
couple things.
    First of all, we can look to the State of Massachusetts 
that has enacted healthcare reform a number of years ago. And 
even though their rate of uninsured decreased markedly, their 
demand for healthcare services through their community health 
centers increased markedly. So these are health centers that 
are located in underserved communities. They are trusted 
sources of care. They have been embedded in those communities 
for now, in many cases, a number of years. And frankly, they 
provide very high-quality and comprehensive care.
    If you go to a health center, you can access oral 
healthcare services generally onsite. You can access behavior 
of mental health services, generally onsite, in addition to 
traditional medical services. So these are comprehensive 
healthcare delivery settings that have a strong tie to the 
communities that they serve.
    So the answer is no. Sorry.
    Senator Harkin. Thanks.

                       HEALTHCARE FRAUD AND ABUSE

    Mr. Love, let me just quickly go to you. I mentioned the 
healthcare fraud and abuse program. The latest study showed 
that for every $1 spent, we got $8.10 recovered. This is the 
highest 3-year average return on investment in the 17-year 
history of this program.
    Now the Budget Control Act included cap adjustments that 
encouraged Congress to increase this funding by $898 million 
over the past 3 years, an amount that would have saved 
taxpayers more than $6.2 billion.
    But the President's budget did not request utilizing this 
funding. Can you give the subcommittee an idea of what has been 
lost over the last 2 years by not taking advantage of the 
additional funding encouraged in the Budget Control Act?
    Mr. Love. Senator, Mr. Chairman, thanks for the question 
area. I cannot answer that specific question, but I can tell 
you what the budget is projected going forward, and that, as 
you said in your earlier remarks, there was an 8-to-1 return on 
investment, which is an excellent investment, indeed. And we 
remain very supportive of the fraud, abuse, and program 
integrity program.
    What the President's fiscal year 2015 budget does do is 
request $428 million for the Health Care Fraud and Abuse 
Control Fund, HCFAC, which would provide both a dividend for 
Medicaid and Medicare. And the projected dividend on that over 
10 years is $13.5 billion.
    So I think you will see it is, certainly, projected to be 
consistent with the 8-to-1 return on investment that you 
mentioned earlier.
    Senator Harkin. So your budget request increases HCFAC 
funding by $428 million? Is that, which you are saying?
    Mr. Love. Yes, sir.
    Senator Harkin. That is lifting the cap?
    Mr. Love. I believe that is discretionary.
    Senator Harkin. Yes, lifting the cap on the mandatory side 
gives you that $428 million. And with that, you anticipate how 
much of a return?
    Mr. Love. $13.5 billion return over 10 years.
    Senator Harkin. Okay. I got that.

                   GLOBAL HEALTH SECURITY INITIATIVES

    Dr. Frieden, one last thing for you, following up a little 
bit on what I started earlier, and that is setting up CDCs in 
other countries.
    You had a global health initiative, but then the request 
zeroes out the money we put in last year, which was $7.5 
million.
    Again, tell me, how was the $7.5 million utilized? And why 
wouldn't we want to continue that effort rather than just 
putting it all in the global health initiative?
    Dr. Frieden. We certainly do want to continue the effort of 
strengthening national public health institutes around the 
world.
    The current fiscal year, what we are doing is working with 
around eight countries to either strengthen or start the 
process of creating a national public health institute. Some of 
those, it has multiple institutions, binding them together. 
Some of them, it is new.
    We anticipate working in multiple regions in the world. We 
have countries very interested in this area. And it is the kind 
of project that we would hope to be able to continue going 
forward.
    The global health security proposal would also enable us to 
strengthen national public health institutes, but not as 
directly as the funding in the fiscal year 2014 budget. So I 
can't really say more than that, but thank you for that 
support.
    I will comment that, Senator, if I might, after several 
decades, three decades of support for public health, we really 
appreciate your support for public health, not only in this 
country but around the world.
    You, of course, changed our name from the Centers for 
Disease Control to the Centers for Disease Control and 
Prevention, and we embrace that mission, and we thank you for 
your support.
    Senator Harkin. I appreciate that. I will follow-up with 
you further on the continuation of your effort to help other 
countries set up their own CDCs, and basically, to make sure 
that they start having coordinated effort.
    Again, what I picked up in some of my travels, there were 
just so many fragmented parts. And they just don't have a CDC-
like structure to pull it all together.
    They do need labs. They need equipment. They need all that. 
I understand that, too. But they need to change their 
structures.
    So I am going to have my staff further inquire about that. 
And I am a little disappointed that was not in the budget. I 
will get some more information on that as we move ahead in our 
decisions on what we want to do on that.

                         ANTIBIOTIC RESISTANCE

    Two other just quick questions: One, tell us again about 
the looming crisis that I keep reading about in terms of 
antibiotic resistance, what is happening in our country. At 
least here, we are losing the ability to fight off certain bugs 
because of antibiotic resistance. So what is happening? Where 
are we in this?
    Dr. Frieden. What we are seeing, Senator, is a steady 
increase in the proportion of different bacteria, in 
particular, that are resistant to antibiotics.
    And earlier, a few months ago, we released the first-ever 
report on our national status in terms of antimicrobial 
resistance. We found that there are more than 2 million 
resistant infections per year, more than 20,000 deaths per year 
in the U.S. from resistant infections. Another estimate is more 
than $20 billion in expenses.
    We highlighted----
    Senator Harkin. Do you have something in your budget 
request that zeroes in on this?
    Dr. Frieden. Yes, we have a specific initiative to expand 
our efforts to reverse antimicrobial resistance. It is a $30 
million request each year over 5 years. And with that 
investment, we think we can cut some of the deadliest resistant 
infections in half. We are confident we can deliver that value.
    Again, one of them, in particular, that I am very concerned 
about, something called CRE. It is a deadly bacteria. It is 
spreading in hospitals. It started out in one State, and then 
it was in 10, and now it is in virtually every State.
    It can be lethal to half of the hospitalized patients who 
get it. And I called it a ``nightmare bacteria'' because it can 
spread not only from patient to patient, but between different 
species of bacteria. So whole classes of bacteria that can 
cause routine infections, like urinary tract infections, could 
become resistant to virtually all or even all of our available 
antibiotics.
    And we need to respond quickly. So we would do that by 
working intensively with hospitals by setting up regional 
centers of excellence and by moving forward as rapidly as 
possible, to improve both the detection of persistence and 
control of outbreaks, control measures where there are 
outbreaks. We have been able to see big reductions where we 
have been able to control this using a statewide or 
communitywide approach, and prevention measures, which could be 
as simple as hand-washing or vaccination, or as complex as more 
complex interactions that would reduce the number of resistant 
infections.
    We recommended that every single hospital in this country 
have an antibiotic stewardship program so that they can make 
sure that the antibiotics used in the hospitals, where we are 
seeing some of the most resistant infections, can be prescribed 
appropriately.
    Senator Harkin. Thank you.

                      AFFORDABLE CARE ACT FUNDING

    Mr. Love, please take back to CMS for me this: That this is 
my last year here, but I am going to be really vigilant in 
making sure that CMS follows the law and follows what this 
committee prescribes in terms of how the Affordable Care Act 
money is used.
    And let me cut to the quick on this: That there won't be 
any more shifting of money from prevention and wellness 
programs into base programs that CMS already has. Okay? It is 
just not going to happen. So just please take that back. Let 
everybody know.
    Mr. Love. I certainly will, Senator. Thank you.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Harkin. I appreciate that. Thank you.
    Listen, thank you all very, very much. This has been a good 
hearing.
    Again, please take back to Ms. Tavenner the sympathies of 
all of us on the committee. She has been a great administrator, 
and this is a tough time for her, and please take that back to 
her, our deepest sympathies.
    To all of you, thank you again for all of your public 
service. You have been great public servants, carrying out your 
responsibilities well.
    And we will leave the record open for 1 week for other 
Senators.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
                  Questions Submitted to Timothy Love
               Questions Submitted by Senator Tom Harkin
              health care fraud and abuse control program
    Question. The latest HHS report released in March found that for 
every $1 spent on fraud and abuse in fiscal year 2013, $8.10 was 
recovered. This is the highest 3-year average return on investment 
(ROI) in the 17-year history of Health Care Fraud and Abuse Control 
Program (HCFAC). The budget Control Act included cap adjustments to 
encourage Congress to increase this funding by $898 million over the 
past 3 years. I am disappointed that the President's budget did not 
request utilizing this funding. Please describe the savings that have 
been lost over the last 3 years, and the fraud and abuse that has gone 
undetected, by not taking advantage of the additional funding 
encouraged in the Budget Control Act?
    Answer. The fiscal year 2015 budget supports fraud prevention and 
reduction of improper payments, which are top priorities of the 
administration. Despite enactment of multiyear discretionary cap 
adjustments in the Budget Control Act (BCA), annual appropriations 
bills have not provided the full amount of program integrity funding 
authorized in that law. Centers for Medicare & Medicaid Services (CMS) 
actuaries conservatively project that for every new $1 spent by HHS to 
combat healthcare fraud, about $1.50 is saved or avoided. Applying this 
rate of return to the $932 million in HCFAC funding that was not 
provided between fiscal year 2012 and fiscal year 2014 results in an 
estimated $1.4 billion in lost savings. In addition, HCFAC funding has 
also been subject to the cumulative effects of rescissions and 
sequestration, further affecting CMS' ability to detect fraud and 
abuse. Historically, for every $1 spent on healthcare-related fraud and 
abuse investigations through HCFAC and other programs in the last 3 
years, the Government recovered $8.10. This is the highest 3-year 
average return on investment in the 17-year history of the HCFAC 
Program. Therefore, the President's budget proposes to build on recent 
progress on efforts to reduce fraud, waste, and abuse by increasing 
support for the HCFAC program through both mandatory and discretionary 
funding streams.
    The budget includes $697 million in new HCFAC program funding in 
fiscal year 2015: $294 million in base discretionary funding, $25 
million in new discretionary funding, and $378 million in proposed new 
mandatory funding. Starting in fiscal year 2016, the budget requests 
all additional HCFAC funds as mandatory, instead of through the 
discretionary cap adjustment included in the Budget Control Act (BCA). 
All proposed HCFAC program investments, including gradual growth over 
time, are consistent with BCA levels.
    Providing additional resources for HCFAC as a dedicated, dependable 
source of mandatory funding will allow the Departments of HHS and DOJ 
to conduct necessary program integrity activities and make sure that 
only accurate payments are made to legitimate providers for appropriate 
services to eligible beneficiaries. Providing additional mandatory 
funding for HCFAC will also eliminate delays in annual appropriations 
that make it difficult for HHS and DOJ to execute budget plans and 
achieve targeted results each year. The more stable mandatory program 
integrity funding will produce new deficit savings of $2 billion over 
10 years.
               provider non-discrimination (section 2706)
    Question. Section 2706 of the Affordable Care Act, the provider 
``non-discrimination'' provision is intended to prohibit health 
insurance plans from discriminating against entire classes of licensed 
and certified healthcare professionals solely on the basis of the 
provider's licensure or certification. Despite the clear intent of this 
provision, I believe that the HHS, Treasury and Labor erred when it 
released the 2013 FAQ document that subverted the congressional intent 
of the section. The fiscal year 2014 Omnibus directed HHS to work with 
Labor and Treasury to correct the FAQ to reflect the law and 
congressional intent within 30 days of enactment of the bill. Recently 
HHS chose to issue a Federal Register notice requesting additional 
public comment as to the appropriate interpretation of this provision. 
When does HHS plan to correct the FAQ to reflect what congressional 
intent is of the provision?
    Answer. The comment period for that Federal Register Request for 
Information is open until June 10, 2014. After the comment period 
closes, I would expect that HHS, together with the Departments of Labor 
and Treasury would evaluate the comments and use the public input to 
evaluate future rulemaking on that topic.
                                 ______
                                 
            Questions Submitted by Senator Mary L. Landrieu
    Question. CMS recently implemented a final rule that changed 
payments for speech generating devices (SGDs) so that Medicare 
beneficiaries no longer have the option to purchase them, but instead 
must rent them. Constituents with diseases like amyotrophic lateral 
sclerosis (ALS) and cerebral palsy have expressed concern that Medicare 
will not pay the rental fees for the devices if they are admitted to 
hospice, a hospital or nursing home. These devices are highly 
customized and cannot be provided off-the-shelf. My understanding is 
that SGDs are overwhelmingly purchased, upwards of 99 percent of the 
time according to recent claims data. Why did you move SGDs into a 
rental category when the agency indicated that devices that are 
purchased 75 percent of the time should continue to have a purchase 
option? And how do you plan to address concerns about beneficiaries 
losing access?
    Answer. We recognize that patients may use long-term durable 
medical equipment (DME) such as SGDs because of chronic conditions or 
permanent disabilities. However, the statutory DME benefit is for 
equipment used in the home. When the beneficiary is admitted to a 
hospital, skilled nursing facility (SNF), or hospice, it is the 
responsibility of the institution to furnish this device and any other 
DME that a beneficiary needs. CMS is committed to carefully monitoring 
beneficiary access using real-time claims data to ensure that 
beneficiaries are receiving medically necessary items and services.
    Question. As your agency prepares for open enrollment this fall, 
what improvements are you making to help certified health insurance 
agents and brokers seamlessly enroll and assist consumers into the 
health insurance marketplaces? Health Insurance brokers are making sure 
consumers understand the nuances of their plans, and they are the only 
group of certified individuals who handle both enrollment and service 
to policyholders year-round. Specifically, do you plan to establish a 
toll-free helpline for agents and brokers, enable their National 
Producer Number (NPNs) to be added at any point during the enrollment 
process, and list certified agents and brokers on the local help 
section of Healthcare.gov?
    Answer. Agents and brokers will continue to play a vital role in 
enrolling individuals and businesses in coverage, as they do today. 
Agents and brokers act as trusted counselors, providing service at the 
time of plan selection and enrollment and customer service throughout 
the year. CMS provides training for agents and brokers to help them 
better assist consumers at purchasing coverage through the federally 
facilitated Marketplaces. In the first year, over 52,000 agents and 
brokers completed training from CMS.
    Agents and brokers continuing their participation in the individual 
market federally facilitated Marketplace (FFM) for the 2015 plan year 
and future plan years will complete an annual registration renewal 
process that includes re-completion of required training and re-
execution of the applicable FFM Agent Broker Agreements. To continue 
participation in the FF-SHOPs for the 2015 plan year and future plan 
years, agents and brokers will execute the FF-SHOP Agent Broker 
Agreement annually, create an FFM user account, complete identity 
proofing, and are encouraged to re-complete testing and training. 
Agents and brokers who will be participating in the individual market 
FFM and/or the FF-SHOP for the first time for the 2015 plan year must 
register, create an FFM user account, complete market-specific 
training, and execute the applicable FFM Agent Broker Agreements.
    In general, the agent or broker's NPN, name, and FFM user ID should 
be recorded as part of the consumer's application. This will identify 
the agent or broker on the enrollment transaction (called an ``834'') 
so the FFM can appropriately track enrollment and the issuer can 
compensate the agent or broker based upon the enrollment (as may be 
appropriate). However, should an issuer identify a particular 
enrollment that should have had an agent/broker associated with it, the 
issuer should add the agent or broker to the enrollment internally even 
if the agent or broker was not reflected on the 834, in case there is 
any follow-up required as a result of the enrollment.
    If an agent or broker has a legitimate reason to believe he or she 
should be credited for an FFM enrollment, but has not been credited for 
it, the agent or broker should contact the respective QHP issuer 
directly to discuss the specific situation.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
                         meaningful use stage 2
    Question. On May 6, 2014, CMS reported to the Health Information 
Technology Policy Committee that only 4 hospitals and 50 eligible 
professionals had successfully reached Stage 2 of the Medicare and 
Medicaid electronic health record (EHR) incentive program commonly 
referred to as Meaningful Use. We are now 7 months into the program 
year for hospitals and 4 months into the program year for physicians 
and other eligible professionals. Further complicating providers' 
efforts are the lack of certified EHRs in the inpatient hospital 
setting. As of mid-April, only 29 complete EHRs have been certified to 
2014 program requirements. CMS has also said the 370 complete EHRs that 
were certified for the earlier edition of certified technology may not 
be used in 2014, even if providers are still at Stage 1 of the 
Meaningful Use program. These performance statistics for Stage 2 are 
alarming. What steps are you taking to ensure that providers are able 
to safely and effectively transition to Stage 2 of the program?
    In addition, while I understand that there is a hardship exceptions 
process, this process currently provides relief only from the 
significant financial penalties for not attesting in a timely way. 
Could the exemption be broadened to include lost incentive dollars once 
providers attest to Meaningful Use, even if they attest up to one full 
year late?
    Answer. HHS has been listening to providers, healthcare 
associations, EHR vendors, and its partners in the healthcare industry. 
In December 2013, HHS announced that it would engage in rulemaking to 
extend Stage 2 of Meaningful Use for 1 year and allow Stage 3 to begin 
in 2017. In addition, Office of the National Coordinator for Health 
Information Technology (ONC) issued a 2015 Edition EHR Certification 
Criteria Proposed Rule as part of its new regulatory approach to 
provide more frequent updates to the certification criteria.
    By extending Stage 2 until 2017, HHS would have an additional year 
of Stage 2 implementation data to help inform any program changes. An 
extension also allows CMS and ONC to better align quality performance 
measures across Federal programs and to consider effective Stage 3 
approaches to advance interoperability and clinical decision support 
capabilities that will help drive improved health outcomes.
    In response to stakeholder concerns that providers were having 
difficulties meeting the requirements of Stage 2, CMS and ONC announced 
in February 2013 that additional flexibility would be provided for 
payment adjustments and hardship exceptions. For example, eligible 
professionals (EPs) may request a hardship exception because the EP is 
unable to control the availability of Certified EHR Technology at one 
such practice location or a combination of practice locations.
               medicaid institutions for mental diseases
    Question. Given American Chiropractic Associations (ACAs) emphasis 
on patient-centered care and health outcomes, has CMS investigated the 
efficacy and long-term cost-effectiveness of residential substance 
abuse treatment services for Medicaid eligible recipients?
    Answer. The Centers for Medicare & Medicaid Services (CMS) has 
identified existing and, in cooperation with our Federal partners, is 
developing new resources for States seeking to enhance their efforts to 
address the service need of individuals with mental and substance use 
disorders. These resources seek to support States in their efforts to 
improve benefit design, comply with the Mental Health Parity and Equity 
Act, develop community integration strategies and coordinate behavioral 
healthcare with primary care and other services. More information can 
be found in a Center for Medicaid & CHIP Services Information Bulletin 
issued on December 3, 2012 (http://www.medicaid.gov/Federal-Policy-
Guidance/downloads/CIB-12-03-12.pdf). Included as part of the 
Informational Bulletin is information related to the variety of current 
and new coverage options that States may use to cover behavioral health 
services.
                             packaging rule
    Question. In its 2014 Hospital Outpatient Prospective Payment 
System Rule, CMS modified its packaging policy. Under Medicare's 
previous packaging policy, a drug or biologic that is used 100 percent 
of the time, or costs less than $90, may be packaged in a payment to 
hospitals to cover healthcare items and services in a procedure. The 
revised policy allows packaged payments in cases in which the drug or 
biologic is used less than 100 percent of the time or when its cost 
exceeds $90. The decision on which treatment to use is at the clinical 
discretion of the physician and is incorporated into the single payment 
the hospital receives from Medicare.
    How will CMS ensure the accuracy of its cost data in the absence of 
a requirement that hospitals report what drug or biologic is used 
within the package payment? Is CMS planning to conduct audits or 
implement a mechanism to ensure hospitals accurately reporting data?
    Also, is CMS concerned about the effect this rule will have on 
bladder cancer screening and treatment?
    Answer. In general, multiple drugs may or may not be used for a 
given service and the hospital outpatient prospective payment system 
(OPPS) payment for that service reflects the average of all potential 
ancillary items and services used to furnish the primary procedure. The 
OPPS has never had a requirement that a drug is used 100 percent of the 
time with the primary procedure into which the drug payment is 
packaged. In the calendar year 2014 OPPS/ambulatory surgery center 
(ASC) final rule, for the vast majority of drugs and biologicals, we 
continued our traditional methodology for packaging drugs and 
biologicals with a per unit cost under a $1 threshold of $90, which is 
adjusted each year to reflect changes in nominal prices. We also 
finalized packaging all drugs for the following categories of products: 
(1) Drugs, biologicals, and radiopharmaceuticals that function as 
supplies when used in a diagnostic test or procedure; and (2) drugs and 
biologicals that function as supplies when used in a surgical 
procedure. Adopting these packaging policies followed our longstanding 
policy of packaging radiopharmaceuticals and contrast agents into the 
associated imaging test.
    In order to help ensure the accuracy of cost data, CMS expects 
hospitals to correctly report the items and services provided to 
patients according to correct coding principles. CMS provides coding 
guidance every year in our annual OPPS/ASC final rule with comment 
period and in several sections of our online CMS Manuals. For example, 
CMS specifically provides the following coding guidance in the Medicare 
Claims Processing Manual, chapter 4, section 10.4 A: ``[I]t is 
extremely important that hospitals report all HCPCS codes consistent 
with their descriptors; CPT and/or CMS instructions and correct coding 
principles, and all charges for all services they furnish, whether 
payment for the services is made separately paid or is packaged.''
    We are monitoring the effects of our 2014 packaging policies. 
However, because these policies became effective January 1, 2014, not 
enough time has elapsed with these policies in effect for us to 
meaningfully evaluate their effect. We are confident that Medicare 
beneficiaries have access to adequate bladder cancer diagnosis and 
treatment services and we will continue to examine these services as we 
do all other services through our annual rulemaking process.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
    Question. CMS has used public reporting of hospitals' performance 
on certain measures including 30 day outcomes, surgical complications, 
and healthcare associated infections to inform the public about a 
hospital's performance on these and other important metrics. Public 
reporting encourages hospitals to improve their performance and quality 
because they know that they are being compared by their potential 
patients.
    Do you think that public reporting of hospitals' prescription drug 
dispensement can help encourage more thoughtful and appropriate 
prescribing behavior?
    Answer. Under the Hospital Inpatient Quality Reporting (IQR) 
program, hospitals report a variety of quality measures, most of which 
are publicly displayed on Hospital Compare. These measures encompass a 
wide variety of topics, including mortality measures, readmissions 
measures, healthcare-associated infection measures, survey measures of 
patients' experience of care, and measures of timely and effective 
care.
    It is possible that a hospital prescription drug dispensement 
measure could help encourage appropriate prescribing behavior, but the 
details of any such measure would need to be carefully evaluated as 
part of the measure consideration process that CMS has adopted. CMS 
considers additions to measures for the Hospital IQR program every year 
and conducts its measurement activities in a transparent manner, which 
involves the solicitation of input from multiple stakeholders. The 
processes that have been established to solicit such input throughout 
the measure development, selection, and implementation cycle include 
posting calls on the CMS Web site for nominations for technical expert 
panels; posting proposed or candidate measures on the CMS Web site for 
public comment; holding CMS Open Door forums, publicly posting measures 
being considered by December 1 each year as part of the pre-rulemaking 
process; engaging the National Quality Forum through their Measures 
Application Partnership to make recommendations on measures; soliciting 
comments through rulemaking on proposed measures; and soliciting 
suggestions through rulemaking on potential future measures.
    Question. Do you think that providers are prescribing more and 
engaging in more testing because they feel a pressure to satisfy their 
patients?
    Answer. Many different factors can contribute to overprescribing of 
medications. CMS has proposed improvements to the Medicare Part D 
program to address concerns about overprescribing and other abusive 
practices. These improvements include giving CMS the authority to 
revoke a physician or eligible professional's Medicare enrollment if 
CMS determines that he or she has a pattern or practice of prescribing 
that is abusive, represents a threat to the health and safety of 
Medicare beneficiaries, or otherwise fails to meet Medicare 
requirements. CMS will also be able to revoke a physician or eligible 
professional's Medicare enrollment if his or her Drug Enforcement 
Administration (DEA) Certificate of Registration is suspended or 
revoked, or if the applicable licensing or administrative body for any 
State in which he or she practices suspends or revokes his or her 
ability to prescribe drugs.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
                      rate stabilization programs
    Question. Does the Secretary have the authority to make payments 
from the Risk Corridor fund? If not, how will the administration pay 
for a possible funding gap?
    Answer. Risk corridor payments can be made pursuant to section 1342 
of the Affordable Care Act and longstanding CMS user fee authority 
provided in appropriations acts.
    Question. If the Secretary does have the authority to make payments 
from the Risk Corridor fund, how will any surpluses in receipts from 
the program be used? Specifically, could a surplus be used for Program 
Management activities?
    Answer. We intend to implement the risk corridors program in a 
budget neutral manner over the 3 years of the program. HHS issued 
guidance in April clarifying its plan to hold any excess risk corridor 
collections from 1 year to the next to be available to make risk 
corridor payments in subsequent years as set out in law and 
regulations.
    Question. What will happen if the incoming receipts for Risk 
Corridor, Risk Adjustment, and Reinsurance programs are less than the 
Department's projected estimates?
    Answer. If reinsurance collections are not sufficient to fund the 
reinsurance payment pool, all payments will be reduced pro-rata to fall 
within collections received. The proposed rule entitled, Patient 
Protection and Affordable Care Act; Exchange and Insurance Market 
Standards for 2015 and Beyond (79 FR 15808 March 21, 2014) proposed 
that--in the event that collections are less than projected estimates--
CMS would prioritize reinsurance contributions collected to the 
reinsurance payment pool to assure that the pool is sufficient to 
provide the premium stabilization benefits intended by the statute.
    Under the risk adjustment methodology, risk adjustment charges will 
be equal to risk adjustment payments and the program will net to zero.
    We anticipate that risk corridors collections will be sufficient to 
pay for all risk corridors payments over the life of the 3-year 
program. However, in the unlikely event of a shortfall for the 2015 
program year, we recognize that the Affordable Care Act requires us to 
make full payments to issuers. In that event, we would use other 
sources of funding for the risk corridors payments, subject to the 
availability of appropriations. We will provide additional specificity 
in future guidance or rulemaking as necessary.
    Question. When will CMS start making payments under the Risk 
Corridor, Risk Adjustment, and Reinsurance programs?
    Answer. We anticipate payments for these programs will first be 
made in the summer of 2015 for the 2014 plan year.
                          exchange enrollment
    Question. How many previously uninsured Americans have enrolled in 
the Exchanges?
    Answer. In addition to the more than 8 million people who have 
selected plans through the Marketplace during the initial open 
enrollment period, Congressional Budget Office (CBO) recently estimated 
that 5 million people will have purchased coverage outside of the 
Marketplace in Affordable Care Act-compliant plans. Moreover, recent 
national surveys indicate that the number of Americans with health 
insurance coverage is growing, and the number of 18 to 64 year olds who 
are uninsured is declining. For example, Gallup has found an almost 5 
percentage point decrease in the uninsured rate for adults (18 and 
over) from the third quarter of 2014 to April 2014 (18 percent versus 
13 percent, respectively). Similarly, the Urban Institute estimates a 
2.7 percentage point decrease in the uninsured rate for adults (18 to 
64) between September 2013 and 2014 (corresponding to a 5.4 million 
decline in the number of uninsured adults). Meanwhile, the RAND 
Corporation estimates a 4.7 percentage point decrease in the uninsured 
rate (corresponding to a net decrease of 9.3 million uninsured adults, 
ages of 18 to 64) between September 2013 and March 2014.
    Question. Since only 28 percent of the new enrollees represent the 
young, healthy population, how will the Marketplace avoid the so called 
``death spiral'' or significant spikes in premiums in 2015?
    Answer. Consistent with expectations, through the end of 2014 open 
enrollment, the proportion of young adults (ages 18 to 34) who have 
selected a Marketplace plan through the State Based Marketplaces (SBMs) 
and Federally-Facilitated Marketplaces (FFMs) has remained strong. We 
expect that the robust sign-up numbers we are observing in the 
Marketplace's first year--8 million at the close of 2014 open 
enrollment--will encourage insurers to compete on price for consumers 
during next year's open enrollment period. In addition, provisions of 
the Affordable Care Act, including rate review and the medical loss 
ratio rule, will help protect consumers against unfair rate hikes.
    Question. What is the percentage of enrollees that have actually 
paid their premiums to date?
    Answer. CMS and the Department have a longstanding focus on 
transparency and accuracy. When CMS has accurate and reliable data 
regarding premium payments, we will see that this information is 
available. However, we do know that some issuers have made public 
statements indicating that 80 percent to 90 percent of the people who 
have selected a Marketplace plan have made premium payments. It is also 
important to note that issuers have the flexibility to determine when 
premium payments are due.
                             exchange cost
    Question. How did the Centers for Medicare & Medicaid Services 
(CMS) come up with the $1.8 billion estimate necessary to operate the 
Marketplace for fiscal year 2015?
    Answer. As with all of our budget requests, the fiscal year 2015 
Marketplace request represents an assessment of needs based on the 
costs of existing contracts, as well as new functions that will be 
implemented in fiscal year 2015.
    Question. What happens if the Department does not receive the 
projected $1.2 billion in Marketplace user fees?
    Answer. Millions of Americans have already gained quality, 
affordable insurance coverage through the Marketplace, and funding 
continued operations is one of my highest priorities. In line with the 
2015 President's budget, we expect to collect $1.2 billion in user fees 
from issuers participating in the Federal Marketplace in fiscal year 
2015. The Department's fiscal year 2015 request is critical to carry 
out the Department's responsibilities to fund Marketplace operations.
    Question. In fiscal year 2014, the Department estimated $450 
million in Marketplace user fees. Did CMS meet that estimate?
    Answer. User fees for the federally facilitated Marketplace were 
first collected in January 2014 to align with the first month of 
Marketplace coverage. We are still working on updating user fee 
projections for fiscal year 2014, which will be based on recent 
enrollment and premium data gathered from the initial enrollment 
period.
                 state-based exchange replacement costs
    Question. Does the Department plan to provide funds to purchase 
replacement IT systems for the failed State-based Exchanges like 
Oregon? And if so, where will this funding come from?
    Answer. CMS is working with States on addressing the implementation 
challenges with their State-based Marketplace. CMS will be implementing 
contingency plans to smoothly and effectively assume the Marketplace 
functions for any States that are unable to demonstrate readiness to 
continued operation of their Marketplace.
    Question. Will the Department plan to recoup some of these funds 
from contractors who failed to deliver a working system?
    Answer. We need to determine what went wrong and why (and in States 
where things are going right understand that too). In those States 
where Federal Government and taxpayer funds were misused, we need to 
use all available avenues to get those funds back for the taxpayer. 
Finally, we need to make sure that ensure that those who should be 
receiving access to quality, affordable healthcare through those States 
receive that access.
                       critical access hospitals
    Question. When will the Committee receive the list of Critical 
Access Hospitals (CAHs) affected by the 10-mile rule that was requested 
in the fiscal year 2014 Omnibus?
    Answer. CMS is in the process of obtaining a new software package 
that will allow us to produce the list as requested by the committee. 
We will work to provide the list to your staff as quickly as possible.
    Question. How will the proposals regarding CAHs in the fiscal year 
2015 budget request affect access to healthcare for Americans living in 
rural communities?
    Answer. The proposals in the President's budget are aimed at 
preserving beneficiary access while promoting payment efficiency. These 
proposals narrowly targeted and designed to improve efficiency while 
preserving access to care. CMS does not expect either proposal would 
have any significant adverse impact on rural access to care.
    Question. How many hospitals will be at risk of losing their 
designation based on these CAH proposals?
    Answer. Currently, when making a determination of a Critical Access 
Hospital's (CAH) satisfying the statutory location requirements 
concerning proximity to another CAH or a hospital, CMS starts by using 
online driving directions programs (such as Google maps) to calculate 
the number of driving miles to other CAHs or hospitals. CMS also 
considers any evidence to the contrary that the CAH chooses to submit 
before making its determination. Any list would preliminary estimate 
only based on the initial policy proposal. A final determination of the 
effect on the status of any particular CAH would be determined on a 
case-by-case basis and would depend on the legislative language and 
implementing regulations.
                       recovery audit contractors
    Question. What is the current status of the new Recovery Audit 
Contractors (RACs) contracts? Please provide details on the new 
incremental changes that RAC auditors will have to follow under the 
terms of the new contracts.
    Answer. CMS is currently in the procurement process for the next 
round of Recovery Audit Program contracts and plans to award these 
contracts this year. In February 2014, CMS announced a number of 
changes to the Recovery Audit Program that will take effect with the 
new contract awards as a result of stakeholder feedback. CMS believes 
that improvements to the RAC program will result in a more effective 
and efficient program, including improved accuracy, less provider 
burden, and more program transparency.
    Question. When will the Department's Working Group on the RAC 
program propose its recommendations?
    Answer. The Department has formed an intra-agency workgroup with 
representatives from CMS, Office of Medicare Hearings and Appeals 
(OMHA), and the Departmental Appeals Board (DAB) tasked with developing 
recommendations to improve the Medicare appeals process and address the 
significant backlog of appealed claims. We are working diligently to 
identify short- and long-term solutions to address the backlog.
    Question. What is the plan to address the current multiyear backlog 
at the Office of Medicare Hearings and Appeals?
    Answer. The Department has formed an intra-agency workgroup with 
representatives from CMS, OMHA, and the DAB tasked with developing 
recommendations to improve the Medicare appeals process and address the 
significant backlog of appealed claims. We are working diligently to 
identify short- and long-term solutions to address the backlog.
                        community health centers
    Question. This is the last year of mandatory funding for Community 
Health Centers. How has the Department planned for the so-called 
funding cliff for Community Health Centers? How will the Department 
prioritize its current budget in the event that no additional mandatory 
dollars are provided?
    Answer. As you know, the Affordable Care Act appropriated $11 
billion over 5 years in mandatory funding for community health centers, 
with $1.5 billion available to support major construction and 
renovation at health centers, and the remaining $9.5 billion available 
to support ongoing health center operations, establish new health 
center sites in medically underserved areas, and expand primary care 
health services at existing health center sites. While the Department 
has submitted proposals in the past to mitigate the impact of the 
declining mandatory funding, Congress included language in the fiscal 
year 2013 and fiscal year 2014 appropriations bills directing HHS to 
obligate all funding available for each respective fiscal year.
    The fiscal year 2015 President's budget includes a proposal to 
extend mandatory funding for health centers at $2.7 billion annually 
over fiscal years 2016-2018, in addition to a discretionary investment. 
This funding level is projected to support continued operations for 
over 1,300 health centers with nearly 9,500 primary care sites.
    The President has not yet submitted a discretionary budget for 
fiscal year 2016, the year the mandatory Health Center funds will 
expire. If funding for the Health Center Program is significantly lower 
in fiscal year 2016 compared to the previous year a complex procedure 
of grant level reductions, and possibly terminations, could occur. This 
could result in numerous health center sites closing, and a reduction 
in patients served by health centers.
    Question. Why did the fiscal year 2015 budget proposal not attempt 
to offset the funding cliff with discretionary funding?
    Answer. The budget includes a proposal to continue mandatory 
funding for health centers in fiscal years 2016, 2017, and 2018 at $2.7 
billion per year, for a total investment of $8.1 billion. The President 
has not yet submitted a discretionary budget for fiscal year 2016, the 
year the mandatory Health Center funds will expire.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
                     heathcare.gov backend systems
    Question. What is the status of the Affordable Care Act's (ACA) 
appeals system? Has the backlog been resolved? Where are the funds 
coming from to pay for the computer based infrastructure used to review 
these claims?
    Answer. Consumers applying for health coverage in the Marketplace 
receive an eligibility determination that informs them whether or not 
they are qualified to purchase coverage through the Marketplace or 
receive financial assistance. Consumers who disagree with the 
determination may request an appeal.
    CMS first attempts to resolve the appeal directly with the consumer 
through informal resolution, which involves contacting the consumer as 
expeditiously as possible to work through the consumer's concerns. This 
approach has worked particularly well for consumers who filed appeals 
early in the open enrollment period, before system errors were 
corrected. Many of these consumers have since been able to successfully 
enroll in a qualified health plan and have withdrawn their appeals. CMS 
prioritizes medically urgent appeals, and as a result, is working to 
resolve those appeals as quickly as possible. CMS is now holding 
hearings for those cases that are not otherwise resolved through an 
informal process.
    Question. Provide an update on how much of the healthcare.gov 
backend remains incomplete including the automatic payment system. What 
are the current problems with completing this task and the timeline for 
resolving the issues?
    Answer. As CMS has said, the automated payment and reporting system 
between issuers and CMS is not complete or fully tested. CMS has an 
interim process for paying issuers that are owed Marketplace financial 
assistance in the form of Advanced Premium Tax Credits (APTC) or Center 
for Scientific Review (CSR) payments. Under this interim process, 
issuers who are owed payments submit initial, aggregate information on 
a monthly basis in order to receive Marketplace financial assistance 
payments. This data includes preliminary total effectuated enrollments, 
enrollees receiving Marketplace financial assistance, and the estimated 
amount owed to the issuer, all of which are subject to change and 
unconfirmed by CMS. On a monthly basis, CMS compares the effectuated 
enrollment counts submitted by the issuers to the enrollment counts 
generated from the FFM for individual market issuers. These data and 
payments will be further reconciled once the automated payment and 
reporting system is in place. The automatic payment system is a 
priority for CMS.
                               navigators
    Question. How many Navigators have been hired?
    Answer. HHS does not directly hire Navigators. The Affordable Care 
Act requires that each Marketplace, including the federally facilitated 
and State Partnership Marketplaces, establish a program under which it 
awards grants to Navigators. In August 2013, CMS, as operator of the 
federally facilitated and State Partnership Marketplaces, awarded 
Navigator grants to 105 grantees to provide Navigator services to 
consumers in those Marketplaces in 2013-2014. The CMS Navigator 
grantees represent a broad and diverse segment of stakeholders. Each 
Navigator grantee is responsible for determining staffing levels that 
would be appropriate for meeting the terms and conditions of their 
grants. Over the course of Open Enrollment, more than 28,000 in-person 
assisters, including Navigators, were trained, and they reached more 
than 2.4 million consumers through events, outreach activities, and 
storefront locations.
    Question. With the ACA enrollment period closed, have these people 
been laid off (i.e. are they temporary employees)? If not, what will 
the Navigators be doing until the next enrollment period?
    Answer. Staffing levels and deployment are determined by CMS 
Navigator grantees in a manner that best enables the grantee to fulfill 
the terms and conditions of the Navigator grant.
    Question. How much funding from fiscal year 2014 will be allocated 
to the Navigators' program?
    Answer. The Funding Opportunity Announcement for Navigators in the 
federally facilitated and State Partnership Marketplaces for 2014-2015 
has not yet been released.
    Question. How much funding do you expect to allocate to the 
Navigators' program in fiscal year 2015?
    Answer. Funding decisions related to the Navigator program in the 
federally facilitated and State Partnership Marketplaces for fiscal 
year 2015 have not yet been made.
                                 ______
                                 
              Questions Submitted by Senator John Boozman
    Question. According to title XVIII of the Social Security Act, in 
order for a hospital to continue to participate in the Medicare 
program, it must meet all of the statutory provisions of section 
1861(e) of this Act. This section defines a hospital as an institution 
that `` . . . is primarily engaged in providing, by or under the 
supervision of physicians, to inpatients . . . diagnostic services and 
therapeutic services.''
    With no statutory or regulatory definition of ``primarily engaged'' 
in reference to inpatients treated at hospitals, what criteria and/or 
specific recognized quantitative method(s) is CMS using to determine 
whether a hospital meets the statutory provisions of 1861(e) of the 
Social Security Act?
    Answer. CMS has not yet identified any quantitative method, such as 
percentage of services or ratio of inpatient-to-outpatient services, 
which could solely be used to determine whether a facility is primarily 
engaged in furnishing services to inpatients. CMS has heard from 
stakeholders that a fixed standard might exclude certain rural 
hospitals. Therefore, CMS continues to interpret the phrase ``primarily 
engaged'' on a case-by-case basis to consider the facts and 
circumstances of each facility.
    Question. In Arkansas, safety net hospitals have been subject to 
overly aggressive contractors denying an overwhelming number of claims 
based on minor technicalities or the contractor's own inaccuracies. Are 
you aware of this issue? If so, what is being done to address and/or 
correct these situations?
    Answer. CMS uses the Recovery Auditors to perform medical review to 
identify and correct Medicare improper payments primarily on a post 
payment basis. CMS uses the vulnerabilities identified by the Recovery 
Auditors to implement actions that will prevent future improper 
payments nationwide. Since full implementation in fiscal year 2010 
through the first quarter of fiscal year 2014, the Recovery Auditors 
have returned over $7.4 billion to the Medicare Trust Fund.
    To ensure the accuracy of the Recovery Auditor's claim 
determinations, CMS uses an independent validation contractor to review 
a monthly random sample of claims on which the Recovery Auditors has 
made an improper payment determination. The Recovery Audit Validation 
Contractor (RVC) establishes an annual accuracy score for each Recovery 
Auditor. The RVC employs policy experts and clinicians, and presents 
CMS with an independent decision regarding each sample. The accuracy 
score represents how often the Recovery Auditors were accurately 
determining overpayments or underpayments based on the validation 
contractor's review. In fiscal year 2012, all Recovery Auditors had a 
cumulative accuracy score of 92 percent or higher.
    CMS is currently in the procurement process for the next round of 
Recovery Audit Program contracts and plans to award these contracts 
this year. In February 2014, CMS announced a number of changes to the 
Recovery Audit Program that will take effect with the new contract 
awards as a result of stakeholder feedback. CMS believes that 
improvements to the RAC program will result in a more effective and 
efficient program, including improved accuracy, less provider burden, 
and more program transparency.
    Question. What does CMS do when an overly aggressive contractor 
review threatens the financial solvency of a longstanding Medicare 
provider? Specifically, do you assist in the navigation of the appeals 
process, and do you encourage attempts to be creative to achieve an 
alternative resolution?
    Answer. Providers who disagree with a Recovery Auditor improper 
payment determination may utilize the multilevel administrative appeals 
process. Recovery Audit appeals follow the same appeal process as other 
Medicare claim determinations.
    However, CMS is sensitive to the concerns of the provider and 
supplier communities and continues to work with these communities to 
reduce the burden of the review process. The CMS has imposed additional 
documentation request limits on the number of medical records a 
Recovery Auditor may request in a 45-day timeframe. The limits 
establish continuity and help providers prepare for potential audits, 
as well as encourage the Recovery Auditors to select only those claims 
with the highest risk of improper payment. The limits and the 
acceptance of electronic health records help to minimize the time 
necessary to respond to Recovery Auditor requests and offers another 
alternative for providers to safely and quickly transport the 
documentation. The CMS understands that additional staffing is often 
required to address Recovery Auditor correspondence and it is 
constantly working to ensure providers can respond to requests without 
affecting beneficiary care.
    Each Recovery Auditor has a customer service center with 
representatives available to address provider concerns. They are 
required to have a quality assurance program to ensure that all 
customers receive professional and knowledgeable assistance with timely 
follow-up when necessary. Personnel are required to return telephone 
calls within 1 day, respond to electronic inquiries within 2 days, and 
respond to written requests within 30 days. The Medicare Administrative 
Contractors (MACs) are also available to address any Recovery Audit 
Program questions dealing with claims adjustment, recoupment, and 
appeals. If a provider is experiencing financial hardship, the MAC may 
be able to approve an extended repayment plan for the provider.
    CMS works across the agency to minimize provider burden. These 
efforts include ensuring that claims reviewed by one entity are not 
reviewed by another contractor again, unless there is a concern of 
potential fraud. CMS also works to ensure that multiple review entities 
such as Recovery Auditors, Medicare Administrative Contractors, and 
Zone Program Integrity Contractors are not reviewing the same providers 
and the same topics at the same time. CMS is exploring additional 
options to help providers navigate through the audit process. 
Initiatives include enhancing CMS Web sites with consolidated 
contractor information, standardizing documentation request letters, 
and standardizing medical review timeframes. The CMS understands that 
some providers utilize additional staffing to help manage the 
requirements of the Recovery Audit Program and is constantly working to 
streamline program operations as much as possible.
    Question. Are you aware that Recovery Audit Contractor (RAC) 
contractors are denying claims based on minor documentation 
technicalities, which is explicitly prohibited by the RAC Statement of 
Work? If so, how are you striving to correct this problem?
    Answer. CMS regularly evaluates the Recovery Auditors' performance 
and adherence to the requirements in their Statement of Work. Staff 
members go on location to observe medical reviewers, IT systems, and 
customer service areas. When onsite visits are not possible, CMS 
conducts desk audits on claims to confirm that all aspects of the 
review process were completed correctly and accounted for in the Data 
Warehouse. Regular meetings with claims processing contractors, 
provider groups, and other stakeholders are also monitored for 
additional contractor oversight. If there are any findings in these 
evaluations, CMS notifies the Recovery Auditor and requires a 
corrective action plan. The results of these regular evaluations are 
consolidated annually in the Contractor Performance Assessment Rating 
System (CPARS) for an overall performance rating for the year. These 
results are available to all Federal agencies. CMS believes that 
regular contractor oversight is essential to the success of the 
Recovery Audit Program. In addition, CMS uses the Recovery Audit 
Validation Contractor mentioned in the response to the first question 
to ensure Recovery Auditors are identifying accurate improper payments 
based on Medicare policy.
    Question. Does CMS expect its contractors to agree to meet in-
person with providers who have been the subject of an aggressive review 
of claims and a significant number of inappropriate denials?
    Answer. After notification of an improper payment, providers may 
request a discussion with the Recovery Auditors regarding their claim 
determinations. The discussion period offers providers the opportunity 
to discuss concerns about the determination with the Recovery Auditor 
Medical Director and submit additional documentation relevant to the 
determination to substantiate their claims. It also allows the Recovery 
Auditors to review the additional information without the provider 
having to file an appeal. If the Recovery Auditor reverses its claim 
determination, it will stop the claim from being adjusted, or work with 
the MAC to reverse the adjustment if it has already occurred.
    Each Recovery Auditor has a customer service center with 
representatives available to address provider concerns. They are 
required to have a quality assurance program to ensure that all 
customers receive professional and knowledgeable assistance with timely 
follow-up when necessary. Personnel are required to return telephone 
calls within 1 day, respond to electronic inquiries within 2 days, and 
respond to written requests within 30 days. The MACs are also available 
to address any Recovery Audit Program questions dealing with claims 
adjustment, recoupment, and appeals.
    CMS is exploring additional options to help providers navigate 
through the audit process. Initiatives include enhancing CMS Web sites 
with consolidated contractor information, standardizing documentation 
request letters, and standardizing medical review timeframes. The CMS 
understands that some providers utilize additional staffing to help 
manage the requirements of the Recovery Audit Program and is constantly 
working to streamline program operations as much as possible.
    Question. In the recently released fiscal year 2012 Recovery 
Auditor Report, CMS reports data as of the first level of appeal. What 
does CMS do to assess the accuracy of data cited by contractors?
    Answer. The fiscal year 2012 Recovery Auditor Report, in Appendix L 
includes information on the number of appeals at the first 4 levels of 
appeals, including the (1) Medicare Administrative Contractor, (2) 
Qualified Independent Contractors, (3) Administrative Law Judge (within 
the Office of Medicare Hearings and Appeals, an agency independent of 
CMS), and (4) the Departmental Appeals Board. The data reported in the 
Report to Congress is gathered by CMS with assistance from the Office 
of Medicare Hearings and Appeals and the Departmental Appeals Board. 
All collections and appeals data cited in the Report to Congress is CMS 
data and not contingent on Recovery Auditor data.
    To ensure the accuracy of the Recovery Auditor's claim 
determinations, CMS uses an independent validation contractor to review 
a monthly random sample of claims on which the Recovery Auditors has 
made an improper payment determination. The Recovery Audit Validation 
Contractor (RVC) establishes an annual accuracy score for each Recovery 
Auditor. The RVC employs policy experts and clinicians, and presents 
CMS with an independent decision regarding the sample. The accuracy 
score represents how often the Recovery Auditors were accurately 
determining overpayments or underpayments based on the validation 
contractor's review. In fiscal year 2012, all Recovery Auditors had a 
cumulative accuracy score of 92 percent or higher.
    Question. CMS announced in February that it will require RACs to 
adjust the Additional Documentation Requests (ADRs) to levels in line 
with the provider's denial rate, allowing providers with low denial 
rates to have lower ADR limits and providers with high denial rates to 
have higher limits. Although it is yet to be determined whether this 
change will alleviate provider burden as there is disagreement over the 
accuracy of RAC denial rates, I would urge the Agency to continue to 
pursue changes that ensure the RAC program targets improper payments 
while taking into consideration the overall burden on providers. Does 
the Agency have further plans to require such flexibility and 
reasonableness in the RAC program?
    Answer. CMS is currently in the procurement process for the next 
round of Recovery Audit Program contracts and plans to award these 
contracts this year. In February 2014, CMS announced a number of 
changes to the Recovery Audit Program that will take effect with the 
new contract awards as a result of stakeholder feedback. CMS believes 
that improvements to the RAC program will result in a more effective 
and efficient program, including improved accuracy, less provider 
burden, and more program transparency.
                                 ______
                                 
                Questions Submitted to Mark H. Greenberg
            Question Submitted by Senator Richard J. Durbin
                               head start
    Question. In fiscal year 2014, Congress restored the 5.27 percent 
reduction Head Start grantees received in fiscal year 2013 due to 
sequestration with the expectation that grantees would use the funds to 
restore services to pre-sequestration levels. In some cases, especially 
in rural Illinois, restoration of services to exactly match pre-
sequestration enrollment slots or other service levels may be 
impossible or no longer the best use of funds due to reduction in 
population or other changing needs of the community. How is the 
Department working with local grantees to provide flexibility to ensure 
the much needed restored resources are being used to best serve the 
local community?
    Answer. The Office of Head Start (OHS) communicated to grantees the 
expectation that they use the 5.27 percent Congress appropriated to 
restore the number of funded enrollment slots, the number of days or 
weeks in the program year, or the other cuts programs made to absorb 
the reduction. We asked grantees to work with their Regional Office if 
there are circumstances that make full restoration of services or slots 
challenging. As the Senator noted, there are situations where it is no 
longer possible or the best use of funds to restore exactly what was 
cut. For example, some grantees no longer have access to the facility 
where they provided center-based care prior to sequestration or the 
needs of the community have changed, such as declining population or 
expanded pre-school services through other providers. In these cases, 
Regional Offices are working with grantees to explore other service 
enhancements to meet the needs of the community. If the grantee can 
only restore a portion of the slots that were cut, for example, 
Regional Offices engage in discussions on extending the hours or days 
of service as an alternative.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
                               head start
    Question. How will the Administration on Children and Families 
ensure that Early Head Start-Child Care Partnership funding reaches 
rural States like Kansas?
    Answer. We anticipate a robust nationwide competition, including 
rural States and communities. Funding is available within each State 
based on the number of young children in poverty and HHS hopes to fund 
high-quality applications from all 50 States.
                  unaccompanied alien children program
    Question. The budget request did not provide an increase for the 
Unaccompanied Alien Children (UAC) program, knowing that the number of 
children coming into the country illegally would increase this year. 
Therefore, what HHS programs do you suggest we reduce to address this 
shortfall?
    Answer. The fiscal year 2015 budget requested $868 million for the 
UAC program, consistent with the level provided in the fiscal year 2014 
enacted bill, given the high degree of uncertainty around the program's 
future needs. However, the budget also proposed over $2.2 billion in 
discretionary program terminations and reductions at the Department. We 
appreciate the additional funding provided in the fiscal year 2015 bill 
reported out by the subcommittee as well as the enhanced authority to 
draw on other resources in the Department as needed.
    Question. After appropriating a $510 million increase in the fiscal 
year 2014 Omnibus for the UAC program, the subcommittee requested that 
HHS coordinate with the Departments of State, Homeland Security, and 
Justice in an effort to develop strategies for managing the rising cost 
of HHS' program. What proposals have been developed to reduce funding 
increases for this program in the future?
    Answer. HHS has been coordinating with State, DHS, DOJ, and OMB on 
strategies to stem the flow of UAC, reduce the length of stay, and 
otherwise reduce costs. HHS efforts, in coordination with other 
Departments, have already reduced length of stay (from 75 days to 35 
days) and costs, producing a 56 percent reduction in per capita shelter 
costs from 2011 to 2014.
    The Departments have also identified several strategies that are 
currently under consideration for feasibility of implementation. These 
strategies include:
  --Modified approach to children with non-parent relatives--to not 
        treat some children that are apprehended at the border with a 
        non-parent relative as a UAC, and to develop alternate 
        procedures for children apprehended throughout the interior of 
        the U.S., if residing with a relative at the time of 
        apprehension.
  --Modified approach to youth with serious criminal offenses, for whom 
        release to a parent or sponsor is not appropriate.
  --Speeding up voluntary departure.
  --Developing improved transportation services--DHS and HHS are 
        exploring whether an integrated transportation system could 
        reduce costs while maintaining sufficient protections for 
        children.
  --Developing a shared services model.
  --DHS and HHS are exploring a plan for a co-located site, which may 
        yield savings.
                             evaluation tap
    Question. How was it determined that an increase in the Evaluation 
Tap was necessary for fiscal year 2015?
    Answer. The Public Health Service (PHS) Evaluation Set-Aside is 
authorized by section 241 of the PHS Act, which has been amended in 
appropriations bills, to fund activities across HHS like AHRQ and CDC's 
National Center for Health Statistics. These funds are used to support 
critical public health and evaluation activities across HHS. Congress 
sets both the tap percentage and the usage of funds for the purposes 
specified in law. The fiscal year 2015 President's budget proposes an 
increase of the PHS Evaluation Set-Aside from 2.5 percent to 3 percent, 
consistent with the approach taken in the fiscal year 2014 President's 
budget, and transparently reports how this funding would be used, both 
in program level totals and in appropriations language.
    Question. Please explain what deliberations take place within HHS 
and with the White House when deciding which agencies are to be the 
sources and receivers of Evaluation Tap transfers.
    Answer. The PHS Act Set-Aside is authorized by section 241 of the 
PHS Act, which has been amended in appropriations bills and allows HHS 
to assess a percentage of PHS Act authorized program funding to support 
activities across the Department. Historically, activities are excluded 
from the set-aside because they are not PHS Act authorized, they 
support program management, or they have been consciously excluded by 
Congress (e.g., the SAMHSA block grants). The Department examines 
sources and receivers during the annual budget process and Congress 
sets both the tap percentage and the usage of funds for the purposes 
specified in law.
    Question. Why does the Department use a budget gimmick to highlight 
an increase of $200 million for NIH, even though NIH is left with only 
a $58 million increase above fiscal year 2014 after accounting for the 
tap increase?
    Answer. The Public Health Service Evaluation Set-Aside plays a 
critical role supporting key public health programs and Congress sets 
both the tap percentage and the usage of funds for the purposes 
specified in law. As with most of the Department's other public health 
agencies, NIH contributes its mathematical share of resources to the 
PHS Evaluation Fund.
                                 ______
                                 
            Question Submitted by Senator Richard C. Shelby
    children's hospital graduate medical education & new workforce 
                               initiative
    Question. The new Children's Hospital Graduate Medical Education 
(GME) program sets-aside $100 million for children's hospitals. 
Children's hospitals were funded at $265 million in fiscal year 2014. 
Why is the Children's GME program targeted for such a significant 
reduction?
    Currently, the Children's GME is distributed by a formula-based 
payment. Within the new $530 million workforce initiative, only $100 
million will be distributed to children's hospitals using the current 
formula. Children's hospitals along with all teaching hospitals will be 
eligible to compete for the remaining $430 million. How will children's 
hospitals continue to train physicians when they will only receive a 
small percentage of their prior formula-based payments and are not 
successful in the new competition?
    The National Health Service Corps and Targeted Support for GME 
programs are described with a focus on increasing the number of 
physicians in rural and other underserved areas. How will HHS 
accomplish this objective?
    Answer. The Children's Hospital Graduate Medical Education (CHGME) 
Program will be integrated into the new, competitive community-based 
Targeted Support for Graduate Medical Education Program which will 
expand residency slots, with a focus on ambulatory and preventive care 
in order to advance the goal of higher value healthcare that reduces 
long-term costs. To support the transition of CHGME into the new 
program, the budget includes $100 million of mandatory funding per year 
for 2 years to support the Children's Hospital GME Program to be 
allocated using the existing formula. In addition, these hospitals will 
be able to apply for the competitive funding to support pediatric 
residency training through the new Targeted Support for Graduate 
Medical Education Program.
    The Targeted Support for Graduate Medical Education Program will 
continue to support graduate medical education in children's hospitals. 
The program includes a $100 million set-aside for 2 years to be 
distributed to children's hospitals using the current CHGME formula and 
they can compete for additional funding. While HRSA can't estimate the 
number of FTEs supported in Children's Hospitals in the TSGME program 
until a FOA is released and awards are made, HRSA supports efforts to 
train providers who treat children outside of the hospital setting, as 
well as current service delivery to children.
  --NHSC, through both scholarship and loan repayment programs, 
        supported 540 pediatricians, pediatric nurse practitioners, 
        pediatric dentists, and child psychiatrists to serve in HPSAs 
        (as of September 2013).
  --Currently, there are nearly 100 students, residents, and health 
        providers specializing in the health of children and preparing 
        to go into practice and are receiving support from these 
        programs.
  --HRSA also funds the PC Residency Expansion program, which currently 
        supports 14 pediatric residencies to increase the number of 
        resident positions for 5 years, from 2010-2015, adding well 
        over 100 new pediatricians to the workforce.
  --And also relevant to access to care for children, in 2012, health 
        centers treated more than 6.6 million patients under the age of 
        18; in fact, nearly 32 percent of all health center patients 
        are children.
    The Targeted Support for Graduate Medical Education Program will 
focus specifically on key priorities for workforce development and 
transforming the healthcare delivery system. For example, the program 
will focus on increasing training opportunities in community-based 
settings, including in rural and underserved areas. Applicants will 
need to demonstrate that they provide diverse training experiences that 
will help ensure that we are training future physicians in the settings 
where we know patients get the bulk of their care, as well as being 
trained in the models of healthcare delivery that are most effective. 
This will help ensure that HRSA funds residencies that are likely to 
produce primary care practitioners who would work in rural and 
underserved areas, where the need is the greatest.
    In fiscal year 2015, HRSA expects to fund over 10,000 new National 
Health Services Corps loan repayment awards in order to build and 
sustain a field strength of 15,000 primary care providers across the 
country, serving the primary care needs of more than 16 million 
patients in high-need rural, urban, and frontier areas across the 
United States. In fiscal year 2013, 100 percent of all new National 
Health Services Corps loan repayment awards were made to those serving 
in health professional shortage areas (HPSAs) of highest need (scores 
of 14 or higher) and nearly half of National Health Services Corps 
clinicians are serving at rural sites.
    A 2012 retention assessment survey found that 55 percent of 
National Health Service Corps clinicians continue to practice in 
underserved areas 10 years after completing their service commitment. 
Another recent study completed in fiscal year 2013 showed 85 percent of 
those who had fulfilled their service commitment remained in service to 
the underserved in the short-term. Short-term is defined as up to 2 
years after their service completion.
    HRSA continues to provide support to clinicians who practice in 
underserved areas. For example, HRSA has several social media outreach 
efforts to keep clinicians apprised of program updates and events, as 
well as networks to provide additional local resources for clinicians 
serving in underserved communities.
                                 ______
                                 
         Questions Submitted to Thomas R. Frieden, M.D., M.P.H
               Questions Submitted by Senator Tom Harkin
                       prescription drug overdose
    Question. Our country is facing a major public health problem 
regarding the increasing use, and abuse, of prescription painkillers. 
In the past two decades, prescriptions for opioid painkillers in the 
U.S. nearly tripled to over 200 million per year. Just last month, a 
study reported that one in five women on Medicaid used prescription 
opioids during pregnancy. How will the funding you requested in the 
President's budget address the prescribing patterns of doctors 
regarding opioid painkillers?
    Answer. Prescription opioid overdoses quadrupled in the United 
States between 1999 and 2010. During this same time period, the amount 
of prescription opioids prescribed in the United States also 
quadrupled. Centers for Disease Control and Prevention (CDC) identified 
two factors that account for a large percentage of prescription opioid 
overdoses: (1) patients receiving opioids from multiple prescribers 
and/or pharmacies and (2) increased number of prescriptions for high 
daily doses of opioids. As the Nation's public health agency, CDC 
focuses on prevention, and prevention of this epidemic includes 
addressing the prescribing practices that fuel prescription drug abuse, 
addiction, and overdose.
    The President's budget request reflects CDC's focus on prescribing. 
The initiative will deliver the resources and expertise to funded 
States to address prescribing practices that are driving this epidemic. 
The $15.6 million proposed would expand the existing Core Violence and 
Injury Prevention Program (Core VIPP) funds to support State health 
department injury programs to (1) strengthen their ability to track and 
monitor prescribing and overdose trends, (2) build out effective 
insurance strategies to identify and stop inappropriate prescribing, 
and (3) enhance prescription drug monitoring programs (PDMPs) to equip 
doctors and pharmacists with the information they need to protect their 
patients.
    Sixteen of the currently funded 20 States currently use this 
funding to address problem prescribing in important and innovative 
ways. For example, States are improving or evaluating Medicaid patient 
review and restriction programs, protecting patients at the highest 
risk for overdose, integrating PDMP with electronic health record 
systems, or using PDMP data to identify doctors who may be prescribing 
inappropriately.
                      linkages with clinical care
    Question. In the fiscal year 2014 Omnibus, Congress provided CDC 
with funding to make big new investments in heart disease, diabetes, 
and community chronic disease prevention this year. Given all the 
changes in the healthcare system, please describe how these resources 
will help link public health and clinical care to prevent and control 
chronic disease and promote health in our communities.
    Answer. CDC provides scientific leadership and technical expertise 
to State, local, tribes/tribal organizations, and U.S. territories to 
assist them in building capacity to develop and implement chronic 
disease prevention and health promotion programs that have measureable 
impact. CDC is focused on implementing cross-cutting strategies to 
address school health, nutrition and physical activity risk factors, 
obesity, diabetes, heart disease and stroke: (1) conducting 
epidemiology and surveillance, (2) implementing environmental 
approaches, (3) expanding health system interventions, and (4) 
enhancing community-clinical linkages.
    With fiscal year 2014 funds from the Prevention and Public Health 
Fund, CDC will implement Funding Opportunity Announcement (FOA) DP14-
1422, PPHF 2014: State and Local Public Health Actions to Prevent 
Obesity, Diabetes, and Heart Disease and Stroke. CDC is supporting 
implementation of population-wide approaches to prevent obesity, 
diabetes, and heart disease and stroke and reduce health disparities. 
In addition, these new investments target priority population subgroups 
with uncontrolled high blood pressure and those at high risk for type 2 
diabetes that experience racial/ethnic or socioeconomic disparities, 
including inadequate access to care, poor quality of care, or low 
income. This competitive FOA to States and large cities has two 
components, both of which are designed to address heart disease, 
stroke, and diabetes. Through these efforts, CDC builds on and expands 
the work funded in ``FOA 13-1305-State Public Health Actions to Prevent 
and Control Diabetes, Heart Disease, Obesity, and Associated Risk 
Factors and Promote School Health''.
    To specifically address linkages with clinical care, CDC is 
implementing key interventions such as:
  --Implementing systems to facilitate identification of patients with 
        undiagnosed hypertension and people with pre-diabetes.
  --Increasing partnerships to facilitate bi-directional referral 
        between community resources and health systems, including 
        evidence-based lifestyle change programs.
  --Improving the delivery and use of clinical services by increasing 
        implementation of quality improvement processes in health 
        systems (e.g., fully utilizing electronic health records).
  --Working to increase the use of team based care in health systems 
        (e.g., increasing the use of self-measured blood pressure 
        monitoring in conjunction with clinical support).
  --Increasing the use of community health workers (e.g., patient 
        navigators) in the community to promote linkages between health 
        systems and community resources for adults with high blood 
        pressure and adults with pre-diabetes or at high risk for type 
        2 diabetes and to support self-management of chronic diseases 
        and related risk factors.
    Such interventions have been shown to result in measurable impacts 
on heart disease, stroke, and other chronic conditions. The 
interventions build on the lessons learned implementing coordinated 
models intended to maximize CDC's investment in the work of State and 
local departments of health. Using additional non-PPHF funds, CDC will 
work with awardees to operationalize community health needs assessments 
(CHNAs) as a critical tool in improving health and a tangible 
opportunity to link communities and health systems, including nonprofit 
hospitals. Throughout the course of this funding and beyond, CDC will 
continue to monitor and evaluate longer term outcomes associated with 
better connections between the public health and the health sector that 
result from these investments.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
                          biomedical research
    Question. Many Americans think of the Center for Disease Control 
and Prevention (CDC) as a reactive agency that works to contain and 
manage viral epidemics and other public health threats--and it does--
but the agency also conducts important proactive research work.
    What areas of biomedical research are being conducted by CDC? Has 
past research led to any significant health safeguards? How would CDC 
invest a steady increase in funding to expand and supplement this 
research? The fiscal year 2015 budget request cuts CDC funding by more 
than $200 million. What research functions will CDC have to suspend as 
a result of this decrease?
    Answer. CDC has many unique roles that span the research continuum, 
as well as a primary role in applying the knowledge gained through 
research in addressing health threats and making Americans healthier. 
CDC research provides people the information they need to make 
healthier choices; provides clinicians with vaccines to protect 
children against deadly diseases; and gives health systems the tools 
they need to control healthcare-associated infections. CDC's unique 
applied research role is in solving real-world problems, and in taking 
what we learn and know based on research and putting it to work in 
clinics and communities around the world.
    As the Nation's public health protection agency, CDC funds and 
engages in a wide range of research, from laboratory investigations to 
epidemiologic analyses to prevention effectiveness research to clinical 
trials. A few examples of research conducted by CDC include the 
following:
  --Through new fiscal year 2014 funding, CDC is increasing its 
        investment in Advanced Molecular Detection technology to use 
        molecular sequencing tools and better develop bioinformatics 
        capacity. These technologies can more rapidly deliver a greater 
        level of detailed information on infectious pathogens, thereby 
        more quickly identifying and responding to outbreaks, better 
        understanding and controlling antibiotic resistance, and better 
        developing targeted prevention measures.
  --CDC is the source of much of our knowledge about the population's 
        health, from rigorous surveys and scientific studies. For 
        example, CDC's National Health and Nutrition Examination Survey 
        (NHANES) takes measures of nutritional biochemistries, 
        nutrients, toxic chemicals, and other direct biomedical 
        measures to assess the Nation's health. From this and other 
        data from CDC surveys, scientists at CDC and elsewhere analyze 
        the relationship between health risk factors and health 
        outcomes.
  --CDC's laboratories serve as key elements of our Nation's defense 
        against outbreaks, but also generate new knowledge that 
        advances the biomedical sciences. As an example, tobacco 
        laboratories measure addictive and toxic substances in tobacco 
        products and smoke, as well as in the urine and blood of 
        persons who use tobacco or are exposed to secondhand smoke. 
        Similarly, the deadly 1918 influenza virus was safely 
        reconstructed in secure CDC laboratories, using genetic 
        fragments, allowing scientists to better understand influenza 
        genetics and be more prepared to detect new, deadly flu 
        strains.
  --CDC tracks antibiotic resistance, having last year released the 
        first-ever national report on the burden and threats posed by 
        antibiotic-resistant infections. CDC not only tracks these 
        threats, but also assesses and categorizes their hazard level, 
        provides recommendations on preventing the spread of 
        resistance, and addresses gaps in our current knowledge of 
        antibiotic resistance.
  --CDC has developed a portable and effective light trap to kill 
        mosquitoes and other insect vectors of disease. This trap is 
        being used throughout the world.
  --Nutrition and chronic disease laboratories develop new or improved 
        methods for measuring nutritional and dietary bioactive 
        compounds to conduct the most comprehensive assessment of the 
        Nation's nutritional status, improve laboratory measurements to 
        detect micronutrient deficiencies in the United States and 
        developing countries, and operate reference laboratories that 
        ensure the accuracy of clinical measurements for cardiovascular 
        and other selected chronic diseases.
    Question. Has past research led to any significant health 
safeguards?
    Answer. CDC's biomedical and other research has consistently 
supported the protection and improvement of the public's health. New 
scientific discoveries lead to the development and refinement of 
clinical guidelines, health policies, and community programs. CDC 
identifies new pathogens, and develops new diagnostic tests for their 
identification by laboratories across the country and the world. 
Moreover, CDC continually tracks the health of the Nation and the 
emergence of new health threats, providing recommendations for action 
and guiding funding decisions elsewhere.
  --CDC has contributed significantly to the roughly 63 percent 
        decrease in new domestic tuberculosis (TB) cases between 1992 
        and 2012. Since its inception in 1997, CDC's Tuberculosis 
        Trials Consortium has brought together a number of U.S. 
        research institutions and clinical trials sites around the 
        world to develop new TB treatment and prevention strategies. In 
        2009, CDC's TB laboratory developed and implemented the 
        Molecular Detection of Drug Resistance Service, a national 
        clinical referral service providing rapid confirmation of 
        multidrug-resistant and extensively drug resistant TB. CDC also 
        develops TB prevention and treatment guidelines, such as the 
        recent release of guidelines for the use and safety monitoring 
        of Bedaquiline Fumarate, the newest drug for the treatment of 
        multidrug-resistant TB.
  --CDC's influenza laboratories work to develop vaccines and track 
        changes in the circulation of influenza viruses. These 
        laboratories test influenza viruses from around the world to 
        detect antigenic change, which provides information for 
        pandemic preparedness and vaccine composition decisions. 
        Additionally, they produce seed strains for influenza vaccine 
        development, test the immunogenicity (ability to provide an 
        immune response) of influenza vaccines among humans, and test 
        transmissibility of newly emergent influenza viruses in animal 
        models.
  --CDC health data collection drives health funding allocations. For 
        instance, CDC provides HIV surveillance data to the HRSA Ryan 
        White HIV/AIDS Program. Since fiscal year 2007, HRSA has used 
        total counts of living cases of HIV and living cases of AIDS in 
        the Ryan White HIV/AIDS Treatment Program Parts A and B 
        allocation formulae. By providing these data to HRSA, CDC and 
        HRSA are collaborating to ensure that the HIV care and 
        treatment funds are rationally distributed according to the 
        Ryan White program legislation.
  --Chemical threat agents and toxins laboratories support the public 
        health response to emergencies with around-the-clock laboratory 
        capability to identify human exposure to 150 chemical threat 
        agents within 36 hours. This laboratory system provides support 
        to and proficiency testing for State, local, and territorial 
        public health laboratories to maximize national capacity for 
        response to chemical incidents, and develop unique laboratory 
        methods for measuring toxins for diagnosing botulism, anthrax, 
        and ricin poisoning rapidly and accurately.
    Question. How would CDC invest a steady increase in funding to 
expand and supplement this research?
    Answer. CDC research is directed to solving real-world problems. 
Sustained increased funding for research would allow to CDC to steadily 
expand investments in current priorities areas, while also allowing for 
funding to address emerging health threats. The fiscal year 2015 
President's budget includes funding increases for key areas of 
research, such as:
  --Antibiotic Resistance.--CDC is proposing to establish a robust 
        national network to deal with this rapidly growing threat to 
        our Nation and the world. Additional funding will enable better 
        detection of the deadliest antibiotic resistance threats and 
        protect patients and communities, saving lives and healthcare 
        costs.
  --Global Health Security.--All our health security threats are 
        amplified by the globalization of travel and the food supply. 
        MERS is a recent example. CDC will work in partnership with 
        other countries, U.S. Government partners, and global 
        organizations to accelerate progress toward a world safe and 
        secure from infectious disease threats. An important element of 
        this proposal is to establish a global laboratory network 
        capable of detecting all public health emergencies of 
        international concern.
  --Surveillance, Epidemiology, and Public Health Informatics.--The 
        budget request expands CDC's capacity to monitor key health 
        indicators, purchase 12 months of electronic birth records 
        enhanced data, phase in electronic death and birth records, and 
        increase funding for public health systems research.
    Question. The fiscal year 2015 budget request cuts CDC funding by 
more than $200 million. What research functions will CDC have to 
suspend as a result of this decrease?
    Answer. The President's budget request proposes strategic new 
investments and identifies targeted reductions that will allow CDC to 
advance its core public health mission in the most cost-effective 
manner. In a limited resource environment, the request includes 
elimination of CDC funding for Occupational Safety and Health Education 
Research Centers, as well as for the Agricultural, Forestry, and 
Fishing Sector of the National Occupational Research Agenda. CDC 
reductions focused primarily on eliminating duplicative, less 
effective, and lower priority programs in order to fund priorities and 
address urgent public health threats, such as global health security 
and antimicrobial resistance.
                        tobacco and e-cigarettes
    Question. Smoking causes nearly one in every five deaths in the 
United States and costs the country $193 billion each year in 
healthcare expenses and lost productivity. An estimated 43.8 million 
American adults smoke cigarettes, and about 3,800 young people under 
the age of 18 smoke their first cigarette every day. Congress created 
the Prevention and Public Health Fund, a dedicated funding stream for 
crucial investments in prevention for a healthier America, to begin 
addressing these and other public health challenges. The Fund provides 
an opportunity to reverse decades of increasing healthcare costs 
attributable to growing rates of obesity, chronic disease, and other 
preventable illness.
    Please summarize investments made through the Prevention and Public 
Health Fund (PPHF) to promote tobacco prevention and control. What 
measurable economic and health benefits have resulted from those 
investments?
    A portion of the fund went toward the Centers for Disease Control 
and Prevention Tips from Former Smokers campaign. Please summarize the 
status of this initiative and health and economic benefits of this 
campaign. If Prevention and Public Health Funds dollars are reallocated 
toward nonpublic health prevention initiatives, how would that 
reallocation of funds impact tobacco control and prevention efforts and 
the returns on those investments?
    The use and sale of e-cigarettes in the United States has grown 
significantly over the past decade. According to a recent CDC report, 
the number of calls to poison centers involving e-cigarette liquids 
rose from one per month in September 2010 to 215 per month in February 
2014. More than half of the calls to poison centers due to e-cigarettes 
involved young children under age 5, and about 42 percent of the poison 
calls involved people age 20 and older.
    Please summarize CDC's current and planned research on the public 
health effects of e-cigarettes?
    Answer. PPHF-funded tobacco prevention initiatives such as Tips 
from Former Smokers and quitline support are having substantial impact. 
Without these investments we would expect to see substantially fewer 
Americans who have quit smoking.
    Tips From Former Smokers.--The Tips from Former Smokers Campaign is 
currently in its third year, and will return to the airwaves with new 
ads in summer 2014. CDC estimates that so far, Tips has led millions of 
Americans to make a quit attempt, and hundreds of thousands to quit 
permanently. Because of the strong evidence of effectiveness of the 
Tips campaign, the 2014 Surgeon General's Report recommended ``the 
following action should be implemented: Counteracting industry 
marketing by sustaining high impact national media campaigns like the 
CDC's Tips from Former Smokers campaign and FDA's youth prevention 
campaigns at a high frequency level and exposure for 12 months a year 
for a decade or more.''
    On average, annual funding levels have sustained the Tips campaign 
between 3 and 4 months of each year, and represent less than 3 days of 
tobacco industry spending on promotion and marketing. Nevertheless, at 
current levels the funds are having a substantial impact. At a cost of 
less than $200 per life year saved, Tips is also a highly cost-
effective strategy. In contrast, most clinical and preventive 
interventions cost thousands of dollars per year of life saved.
    Quitline Support.--PPHF funds also allowed CDC to dramatically 
expand the reach of State tobacco cessation quitlines through the Tips 
from Former Smokers national tobacco education campaign. PPHF funds 
supported both the campaign and State quitline capacity to handle the 
increased calls generated by the campaign. During the 2012 and 2013 
Tips campaigns, which aired for a combined total of 28 weeks, there 
were a total of 718,042 calls to 1-800-QUIT-NOW, a portal which routes 
callers to their State quitlines. This represents 359,055 additional 
calls beyond baseline levels.
    Community Investments.--In addition, PPHF-funded community 
investments addressing tobacco use (as well as nutrition and physical 
activity) have had substantial impact and reach. For example:
  --As a result of the CDC's chronic disease community investments 
        funded through recovery act funds, an estimated 27.4 million 
        Americans now have increased protections from deadly secondhand 
        smoke exposure in workplaces, restaurants, bars, schools, 
        multi-unit housing complexes, campuses, and recreation areas.
  --As of December 2013, the chronic disease community investments 
        funded through Prevention and Public Health Funds are estimated 
        to have provided 15.6 million new people with access to smoke-
        free or tobacco-free interventions.
    Question.--The use and sale of e-cigarettes in the United States 
has grown significantly over the past decade. According to a recent CDC 
report, the number of calls to poison centers involving e-cigarette 
liquids rose from one per month in September 2010 to 215 per month in 
February 2014. More than half of the calls to poison centers due to e-
cigarettes involved young children under age 5, and about 42 percent of 
the poison calls involved people age 20 and older.
    Please summarize CDC's current and planned research on the public 
health effects of e-cigarettes?
    Answer. Through surveillance analysis and updates, original 
research, and coordination with HHS agencies, CDC is conducting 
cutting-edge research to capture the public health effects of e-
cigarettes.
    Surveillance Analyses and Updates.--CDC's Office on Smoking and 
Health (OSH) is in the process of analyzing available e-cigarette data 
and updating key surveillance systems to incorporate questions about e-
cigarette use, including CDC's National Adult Tobacco Survey, National 
Youth Tobacco Survey, and the Global Adult and Youth Tobacco Surveys.
  --Additionally, CDC is working with partners, other Federal agencies, 
        and States to incorporate e-cigarette questions into existing 
        surveillance systems, including the National Health Interview 
        Survey (NHIS), National Health and Nutrition Examination Survey 
        (NHANES), Behavioral Risk Factor Survey (BRFS), Youth Risk 
        Behavior Survey (YRBS), Pregnancy Risk Assessment Monitoring 
        System (PRAMS), FDA's Population Assessment of Tobacco and 
        Health (PATH), SAMHSA's National Survey on Drug Use and Health 
        (NSDUH), and State Youth (YTS) and Adult (ATS) Tobacco Surveys.
  --Finally, CDC is leveraging opportunities to collect data on e-
        cigarettes from rapid response sources, such as HealthStyles 
        and YouthStyles surveys.
    Research.--CDC is developing a series of research projects to 
address significant knowledge gaps related to e-cigarettes.
  --A request for proposal (RFP) has been announced to support a 
        contract for research to measure the effects of secondhand 
        exposure to e-cigarette aerosol. The CDC study aims to simulate 
        and examine real-life exposure to secondhand aerosol from e-
        cigarettes by conducting an observational pilot research study 
        looking primarily at biomarkers of exposure to nicotine in 
        research participants exposed to secondhand e-cigarette 
        aerosol. CDC anticipates making the award this summer.
  --CDC's Tobacco Laboratory is collaborating with the FDA on studies 
        that address three main categories of e-cigarettes: cigarette 
        look-alikes, pencil size e-cigarettes (these use nicotine 
        liquid) and tank e-cigarettes (large, often with voltage 
        adjustment and use nicotine liquid). These studies will 
        measure: (1) harmful and potentially harmful constituents of e-
        cigarette aerosol and nicotine liquid, (2) addictive compounds 
        in e-cigarette aerosol and liquid, and (3) biomarkers of these 
        harmful and addictive constituents in blood and urine of users 
        and people exposed to e-cigarette aerosol. CDC is also working 
        on standardized smoking machine measurement protocols so 
        measurements of constituents in e-cigarette aerosol can be 
        reliably compared between different laboratories.
  --CDC, in coordination with FDA's Center for Tobacco Products, is 
        conducting a more in-depth analysis to build upon the MMWR 
        published on e-cigarette exposures called to poison centers. 
        The additional analyses will compare the health effects and 
        demographics of reported e-cigarette exposures to other 
        nicotine-delivery methods such as nicotine patches, lozenges, 
        and gums.
  --Formative research is being conducted with adult smokers and former 
        smokers 18-54 years old to understand reasons for use of 
        noncombustible tobacco products (e.g., e-cigarettes, chewing 
        tobacco, snus) in combination with combustible tobacco products 
        (e.g. cigarettes, little cigars).
  --In partnership with FDA, CDC is performing in-depth research with 
        pregnant women and women planning a pregnancy to assess their 
        understanding of risks associated with using electronic 
        cigarettes and other nicotine-containing products during 
        pregnancy.
  --Among youth and adults, CDC is also examining the impact of 
        exposure to e-cigarette advertising on intention to use e-
        cigarettes or other tobacco products.
  --Through a survey administered by the American College of 
        Obstetricians and Gynecologists, CDC is examining screening 
        practices, knowledge and attitudes of obstetricians toward the 
        use of electronic cigarettes and other nicotine containing 
        tobacco products during pregnancy.
    Coordination.--CDC's Office on Smoking and Health works closely 
with HHS agencies to coordinate research priorities, including, for 
example:
  --CDC and the National Cancer Institute (NCI), with the North 
        American Quitline Consortium, are assessing current quitline 
        experiences regarding e-cigarettes to inform future messaging 
        and tracking.
  --CDC and FDA co-authored recent updates on youth use of e-cigarettes 
        (September 2013) and e-cigarette related calls to poison 
        centers (April 2014).
  --CDC and FDA are working together to analyze data from the National 
        Adult Tobacco Survey (NATS) and the National Youth Tobacco 
        Survey (NYTS) on the impact of e-cigarette use on cessation and 
        on youth and young adult intentions to smoke conventional 
        cigarettes.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
    Question. The National Asthma Control Program helps millions of 
Americans control their disease. In the United States today nearly 26 
million people have asthma, including 7 million children. This is 
concerning to me since New Hampshire's asthma prevalence rates are 
higher than the national average.
    The CDC has requested level funding of $27.4 million for the 
National Asthma Control Program, which appears to only fund preventive 
work in 20 States. However, it is my understanding that this program 
was always envisioned to be nationwide. Is CDC committed to ensuring 
that every State has a comprehensive approach to asthma control? How 
much funding would it take to get a quality program in every State?
    Answer. CDC's National Asthma Control program is committed to 
advancing knowledge on asthma interventions with the strongest evidence 
of effectiveness. Comprehensive asthma care entails providing a 
seamless alignment of the full array of services across the public 
health and healthcare sectors so that people with asthma receive all, 
not just some, of the services they need. Providing comprehensive care 
at a population level requires a stepwise approach. The first step is 
to ensure the availability of and access to guidelines-based medical 
management and pharmacotherapy for all people with asthma. Then, for 
the segment of people whose asthma remains poorly controlled, 
additional next steps provide or link them with progressively more 
individualized services (e.g., intensive self-management education, 
environmental trigger reduction services, and other environmental 
management strategies).
    CDC reduced the number of awards in order to increase the average 
award to States ($331,000 in fiscal year 2013 to $650,000 in fiscal 
year 2014). Additionally, CDC restructured the awards using a 
population-based model to ensure that funding was allocated based on 
need. Funding comprehensive care to a subset of States based on need is 
CDC's current approach.
    Question. I am deeply troubled that 1 in 10 kids have asthma 
nationwide and it is a growing contributor to health disparities. What 
can we do to reverse this startling trend?
    Answer. CDC recognizes that asthma prevalence is increasing 
nationwide and is a significant contributor to health disparities. 
Today, African-Americans are 2-3 times more likely to die from asthma 
than any other racial or ethnic group. CDC has a strong network of 
funded State asthma programs and partners and an established 
surveillance role in public health. States use the information we 
collect to target vulnerable populations and implement comprehensive, 
evidence-based asthma interventions.
    Asthma carries with it a significant economic burden. In 2007, 
asthma cost about $56 billion in medical cost, lost school and work 
days, and early deaths. Medicaid spends over $10 billion per year 
treating asthma. While we don't know what causes asthma, we do know 
that attacks are sometimes triggered by allergens, exercise, 
occupational hazards, tobacco smoke, air pollution, and airway 
infections.
    CDC's National Asthma Control program works with States to reduce 
the burden of asthma across the country. While the overall number of 
people with asthma has risen, trends show that more people with asthma 
are living with their disease under control. For example, we have seen 
the hospitalization rate decline by 14 percent in States receiving CDC 
asthma funds (2000-2007).
    Other progress in addressing asthma:
  --1.7 million fewer people had asthma attacks in 2009
  --Over 1,000 fewer people died in 2010
  --Children missed 4.2 million fewer school days because of asthma in 
        2008
    CDC's asthma grantees have also reduced healthcare costs. In 
Connecticut, the ``Putting on AIRS Program,'' a home based program 
focusing on self-management and elimination of asthma triggers, 
reported significant progress:
  --85 percent decline in emergency department visits
  --67 percent decline in asthma-related physician visits
  --62 percent decline in missed days of school and work
  --Net savings of $26,720 per patient after 6 months
    In Michigan, the asthma program worked with the Asthma Network of 
West Michigan and Priority Health, the largest payer in western 
Michigan, to reduce healthcare costs and improve asthma outcomes:
  --44.4 percent decline in emergency department visits among private 
        members
  --24.4 percent decline in emergency department visits among Medicaid 
        members
  --For every $1 invested in home visits, environmental assessments and 
        trigger reduction, it has recouped $2.10 in reduced costs due 
        to uncontrolled asthma.
    These are just a few examples of how CDC is working to reverse 
trends.
    Question. I believe the National Diabetes Prevention Program holds 
great promise to reduce the burden of diabetes and I am anxious to see 
the program implemented in even more communities in New Hampshire and 
across the country. I was pleased to see that the President's budget 
includes a request for $10 for the program.
  --Given the incredible promise of the National Diabetes Prevention 
        Program to reduce the number of individuals with prediabetes 
        that develop type 2 diabetes, can you share with us the 
        agency's plan for expanding the number of program sites and 
        individuals participating in fiscal year 2015?
  --Currently there are 79 million people with prediabetes. Does the 
        agency have an estimate of the resources needed for the 
        National Diabetes Prevention Program to confront the human and 
        economic impact of the disease beyond 2015?
    Answer. New estimates from CDC indicate more than 86 million adults 
in the U.S. have prediabetes, an increase from the previous estimate of 
79 million in 2010. With an fiscal year 2015 appropriation request of 
$10 million (level with the 2014 appropriation), CDC's National 
Diabetes Prevention Program grantees will expand locations, target 
populations, settings, number of sites, number of participants, and 
number of lifestyle coaches, class offerings, and insurance 
reimbursement. Selected grantee activities include:
  --The Black Women's Health Imperative will expand its program sites 
        to New Orleans and Baton Rouge, Louisiana, where they have 
        identified specific prediabetes health disparities.
  --Y of the U.S.A. (Y) plans to increase the number of sites offering 
        the lifestyle change program from 11 to 46.
  --The National Association of Chronic Disease Directors (NACDD) has 
        secured coverage of the lifestyle interventions for the Thomas 
        Jefferson Health System medical school, medical center, and 
        Accountable Care Organization clients.
    In fiscal year 2015, CDC plans to increase the number of 
organizations applying for CDC recognition through promotion of the 
Diabetes Prevention Recognition Program (DPRP). To date, 508 
organizations have applied for recognition, serving approximately 
10,200 participants. CDC is revising its DPRP standards to incorporate 
recognition of virtual lifestyle change programs. Initiating this type 
of program virtually will significantly increase the availability of 
lifestyle interventions in communities where no physical programs exist 
or for those who would prefer to engage at home.
    CDC is partnering with a national medical organization to educate 
their constituency and increase referral and uptake of the intervention 
for their patients with prediabetes. Furthermore, CDC will continue 
educating employers and public/private payers across the U.S. about the 
benefits and cost-savings of offering the evidence-based lifestyle 
change program as a covered health benefit for employees and for 
reimbursing organizations who deliver the intervention.
    Additionally, with fiscal year 2014 funds from the Prevention and 
Public Health Fund, CDC will implement Funding Opportunity Announcement 
(FOA) DP14-1422, PPHF 2014: State and Local Public Health Actions to 
Prevent Obesity, Diabetes, and Heart Disease and Stroke. These new 
investments target priority population subgroups with uncontrolled high 
blood pressure and those at high risk for type 2 diabetes that 
experience disparities, including racial/ethnic or socioeconomic 
disparities, inadequate access to care, poor quality of care, or low 
income. This funding will support environmental and system approaches 
to promote health, support and reinforce healthful behaviors, and build 
support for lifestyle improvements. Diabetes primary prevention 
strategies include:
  --Working with a network of partners and local organizations to build 
        support for evidence-based lifestyle change (e.g., National 
        Diabetes Prevention Program);
  --Implementing evidence-based engagement strategies (e.g. tailored 
        communications) to build support for lifestyle change; and
  --Increasing coverage for evidence-based lifestyle change programs by 
        working with employers and other network partners.
    Question. Currently there are 79 million people with prediabetes. 
Does the agency have an estimate of the resources needed for the 
National Diabetes Prevention Program to confront the human and economic 
impact of the disease beyond 2015?
    Answer. CDC is currently in the early stages of formulating an 
fiscal year 2016 budget request and, therefore, does not have an 
estimate at this time for funding needs in fiscal year 2016 or beyond.
    Question. Studies show that gestational diabetes is a growing 
problem and affects up to 18 percent of all pregnancies in the United 
States. The same studies show that gestational diabetes puts women and 
their children at a higher risk of developing type 2 diabetes later in 
life and is associated with more health problems for both mother and 
child during pregnancy and childbirth.
    Can you talk about steps the CDC is taking to understand, monitor 
and help providers understand and test for gestational diabetes?
    Answer. CDC agrees that gestational diabetes is a prevalent and 
growing public health problem, and considerable work has been conducted 
to demonstrate that the obesity epidemic has contributed to the problem 
of gestational diabetes. However, we do not believe that testing for 
gestational diabetes is an issue; virtually all women who obtain 
prenatal care are tested. Work funded by other HHS agencies (NIH's 
NICHD) has demonstrated that treating even mild gestational diabetes 
has benefits for mothers and their offspring. CDC is mainly concerned 
with the impact of gestational diabetes on the future health of women 
who had a pregnancy affected by gestational diabetes. These women and 
their children are at substantial risk of developing Type 2 diabetes as 
they move through their life course. Short-term follow-up of these 
women may not be adequate; as a result, CDC has:
  --Partnered with national organizations including the National 
        Association of Chronic Disease Directors (NACDD) and the 
        Council for State and Territorial Epidemiologists (CSTE) to 
        facilitate information exchange among members and to provide 
        new information about gestational diabetes. Their reach 
        includes over 500 State and local health departments, 
        healthcare organizations, community health centers, WIC 
        programs, nonprofit agencies, and private providers.
  --Worked with clinical partners to emphasize the need for postpartum 
        testing of women who had a pregnancy affected by gestational 
        diabetes
  --Funded a pilot study (Balance after Baby) to determine how best to 
        structure an intervention for recently pregnant women who had a 
        pregnancy affected by gestational diabetes so that they might 
        optimize their weight, physical activity and nutritional status 
        and prevent or delay the onset of Type 2 diabetes. We are 
        considering expansion of this pilot study.
  --Recommended that all women with a Gestational Diabetes Mellitus 
        (GDM) affected pregnancies be screened for diabetes at their 
        postpartum visit (about 6-8 weeks after delivery); currently 
        postpartum screening rates are very low. As a result, CDC 
        funded a clinical study (Comparison of Glucose Tolerance 
        Testing Immediately Postpartum and at 6 Weeks in Women with 
        Gestational Diabetes Mellitus) to determine if women with GDM 
        could be accurately screened for diabetes during their delivery 
        hospitalization instead of waiting 6-8 weeks for their 
        postpartum visit. If screening at the delivery hospitalization 
        is comparable to the 6-8 week screen, it increases the ability 
        to identify women who are at risk for diabetes and adverse 
        health outcomes.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
                       prescription drug overdose
    Question. The Centers for Disease Control and Prevention's (CDC's) 
budget requests $15.6 million for a new Prescription Drug Overdose 
initiative. Instead of focusing funds specifically to address this 
problem, the budget requests an increase to the Core Violence and 
Injury Prevention Program, which is a much broader injury prevention 
program. Why did CDC not design a program to specifically address this 
problem in the States where the burden is highest?
    Answer. CORE VIPP is an existing system that has shown evidence of 
success in preventing injuries and protecting residents in the States 
in which the program has been implemented. Of the 20 currently funded 
States, 16 have already identified PDO as a priority and have been 
working on this topic with existing resources. Additionally, 10 of the 
highest PDO burden States are already funded through Core VIPP. The 
Core VIPP mechanism allows CDC to target specific activities to address 
this critical public health epidemic while also supporting State health 
departments' overall ability to collect data, use those data to act, 
and collaborate across sectors to address the highest burden injury and 
violence prevention issues. Through the expansion of Core VIPP, CDC can 
direct resources to the States who need it most (i.e., those with the 
highest burden) and those who to demonstrate their readiness to advance 
multiple, complementary approaches--insurance innovations, prevention 
programs, and enhanced State-focused analysis. CDC strives to 
capitalize on existing mechanisms to better coordinate State efforts 
and reduce administrative burden on States.
    The request of $15.6 million in the fiscal year 2015 President's 
budget will support PDO work (via Core VIPP) at the State level, in two 
ways:
  --Provide base injury prevention funding to a number of States that 
        are not currently part of the Core VIPP program, with an 
        emphasis on States with the highest burden of PDO. The goal is 
        to build a State's basic ability for injury prevention in order 
        to have a foundation for PDO-specific activities. Each of these 
        States will be required to include PDO as one of their injury 
        prevention priorities.
  --The majority of the funding will be used for a set of Core VIPP 
        States to expand and intensify their PDO prevention activities. 
        This funding will be competed among existing and new Core VIPP 
        States, with an emphasis on States with the highest burden of 
        PDO and those States most prepared to conduct PDO prevention 
        activities.
                      alzheimer's disease research
    Question. Last year, the budget requested an $80 million increase 
for Alzheimer's disease research. Congress provided $100 million in the 
fiscal year 2014 Omnibus. Why did the Department not include an 
increase for Alzheimer's disease research in the fiscal year 2015 
budget proposal?
    Answer. Unlike the one-time funds provided for Alzheimer's research 
by the NIH Director in fiscal year 2012 and fiscal year 2013, the 
additional $100 million appropriated dollars are added to the base, and 
upcoming budgets for Alzheimer's research will be estimated from this 
increased base. The estimated total NIH-wide support for Alzheimer's 
disease in fiscal year 2014 and again in fiscal year 2015 is $566 
million. This amount is an estimate that could potentially increase, or 
decrease depending on peer review results. Most of the efforts for 
implementation of the National Alzheimer's Project Act and the 
development of the National Plan to Address Alzheimer's Disease (AD) 
are led by the National Institute on Aging (NIA). NIA has awarded 
several major new grants supporting translational and clinical research 
aimed at the disease; they are among the first projects to be developed 
with direction from the 2012 AD Research Summit, and focus on 
identifying, characterizing, and validating novel therapeutic targets 
and identifying possible ways to stop disease progression.
    This brain disease is being aggressively targeted on multiple 
fronts. For example, NIH recently launched the Accelerating Medicines 
Partnership (AMP), an unprecedented partnership with the Food and Drug 
Administration, a number of biopharmaceutical companies, and several 
nonprofit organizations that will use cutting-edge scientific 
approaches to sift through a long list of potential therapeutic targets 
and biomarkers, and choose those most promising for further 
development. This public-private partnership will initially focus on 
three disease areas, including Alzheimer's disease. This truly 
innovative and collaborative approach should speed up the development 
of new treatments and cures for multiple conditions and diseases. 
Another way NIH-funded scientists are accelerating the development and 
application of innovative technologies toward major advances in 
Alzheimer's disease is with the Brain Research through Advancing 
Innovative Neurotechnologies (BRAIN) Initiative. NIH is a major player 
in this pioneering, multi-agency venture that will enable the creation 
of new tools to examine the activity of billions of nerve cells, 
networks, and pathways in real time. By measuring activity at the scale 
of circuits and networks in living organisms, researchers can begin to 
decode sensory experience and, potentially, even memory, emotion, and 
thought. The BRAIN Initiative will provide a foundational platform that 
has the potential to spawn remarkable opportunities in basic and 
applied research for several brain disorders.
    Question. Will NIH reach the goal of finding a cure for Alzheimer's 
by 2025 without an increase in its research funding?
    Answer. While it is still impossible to predict with certainty when 
an effective treatment or preventive intervention will be available, 
the infusion of new Federal funds to Alzheimer's research in the past 
several years has already energized the field, accelerated the pace of 
discovery, and facilitated the support of research projects that may 
not otherwise have been funded.
    In particular, the field is benefiting from the inclusion of an 
additional $100 million in the NIH's fiscal year 2014 budget 
appropriation which will be applied to high-priority research on 
Alzheimer's disease. The National Institute on Aging (NIA), an NIH 
Institute and lead Federal agency for research on Alzheimer's disease, 
will manage the bulk of the projects awarded with these funds. Unlike 
the one-time funds provided for Alzheimer's research by the NIH 
Director in fiscal year 2012 and fiscal year 2013, these additional 
appropriated dollars are added to the NIA's base, and upcoming NIA 
budgets will be estimated from this increased base. NIA is 
strategically distributing these funds among single-year and multiyear 
projects to maintain a stream of new competing dollars to support high-
quality, peer-reviewed research on aging and Alzheimer's disease in 
future years.
    This recent increase in funding comes at an opportune time, and we 
have more reason than ever to be optimistic about the possibility of an 
effective treatment or preventive intervention for Alzheimer's. Recent 
breakthroughs in biomedical imaging are enabling us to identify and 
track the earliest pathological stages of the disease process in the 
living human brain, long before clinical symptoms appear. These 
discoveries, in addition to discovery of other early biomarkers of the 
Alzheimer's disease process, have opened a ``window of opportunity'' 
for us to target and potentially reverse the disease's underlying 
pathology before cognitive, behavioral, and emotional symptoms appear.
    NIH has begun to launch its first such clinical trials in 
presymptomatic individuals. For example, in one study, researchers are 
investigating whether an antibody treatment, crenezumab, which is 
designed to bind to, and possibly clear away, abnormal amounts of 
amyloid protein in the brains of people with Alzheimer's, can prevent 
decline in cognitive function among members of a unique and large 
family population in Colombia sharing a genetic mutation known to 
produce early-onset disease. We anticipate initial results from this 
groundbreaking study by 2017. Another study, the A4 Trial, will test an 
amyloid-clearing drug in the pre-symptomatic stage of the disease, in 
symptom-free older volunteers who have had positron emission tomography 
brain images that show abnormal levels of amyloid accumulation. 
Positive results from these or similar studies would provide important 
``proof of concept'' that targeting preclinical disease is an effective 
strategy, and would represent a major step forward in our efforts 
against Alzheimer's disease.
    NIH also supports more than 35 Alzheimer's disease clinical trials, 
including a number of studies of interventions to slow disease 
progression among individuals who are already showing symptoms. Over 40 
compounds are currently under study to stimulate and advance research 
on the discovery and development of new preventive and therapeutic 
interventions for AD, mild cognitive impairment, and age-related 
cognitive decline.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
                      strategic national stockpile
    Question. The budget proposes, for a second year, to reduce funding 
for the Strategic National Stockpile. This reduction could result in 
fewer people receiving treatment during an influenza pandemic and fewer 
people receiving post-exposure treatment following exposure to anthrax. 
The proposed reduction is more than an efficiency cut; it affects our 
capability to respond in the event of a terrorist attack. If this cut 
is sustained, how does HHS expect the Federal Government to adequately 
respond should there be a bioterrorist attack or disease epidemic?
    Answer. Through collaboration on the Public Health Emergency 
Medical Countermeasures Enterprise (PHEMCE) governance process, CDC and 
other HHS agencies coordinate priorities and activities for future 
fiscal years to utilize all available resources to safeguard the health 
of U.S. populations. CDC will prioritize replacement of expiring items 
that rank the highest on formulary priorities, based on an annual 
review of the SNS and result in efficiencies form improved procurement.
                              duplication
    Question. In the Government Accountability's Office's annual report 
on duplication, it highlighted that it takes 10 different offices at 
the Department of Health and Human Services to run programs addressing 
AIDS in minority communities, that autism research is spread over 11 
different agencies, and that there are 45 early learning and child care 
programs funded by the Federal Government. How is your Department 
addressing this issue?
    Answer. The Department of Health and Human Services (HHS) mission 
is to provide the building blocks that Americans need to live healthy, 
successful lives. HHS programs span from infant home visiting to the 
largest healthcare provider for seniors. In addition to the breadth of 
HHS' mission, several of the programs identified in the report have 
unique aspects to them, which warrant tailored approaches.
    Specifically for AIDS in minority communities, HHS does not support 
consolidating the Minority AIDS Initiative (MAI) into core HIV/AIDS 
funding at this time. MAI is distinct from other HIV/AIDS programs and 
funding as it focuses specifically on the elimination of racial and 
ethnic disparities in HIV/AIDS prevention, care and treatment, and 
outreach and education in the United States. HHS continues to 
deliberate strategies to more efficiently administer MAI and reduce 
duplicative requirements for grantees, while ensuring that the 
Department is being responsive to the needs of racial and ethnic 
minority communities and populations disproportionately impacted by the 
HIV/AIDS epidemic.
    For autism research, the Government Accountability Office (GAO) 
report cites that ``84 percent of the autism research projects funded 
by Federal agencies were potentially duplicative.'' HHS believes that 
this statement is misleading or could be easily misconstrued. It is 
important to recognize the difference between appropriately addressing 
complex problems using multiple strategies and funding redundant or 
duplicative projects. We do not believe that research is necessarily 
duplicative if two agencies fund the same broad objectives in a 
strategic plan. Although GAO's report acknowledges that duplication is 
necessary in science for the sake of replication or corroborating 
results, it does not appreciate the full extent of the necessity of 
replication and the extensive policies in place at HHS and other 
Federal agencies to prevent redundant projects. HHS recognizes that 
scientific endeavors and the path of research discovery are not linear 
undertakings and often require verification and validation efforts.
    HHS is concerned about the GAO report's implication that it is 
wasteful when more than one funding agency addresses an objective or 
aim of the Strategic Plan for Autism Research. It must be recognized 
that the goals and objectives of the Strategic Plan represent complex 
scientific questions that require a multidisciplinary approach, with 
multiple scientific strategies. For example, to develop effective 
interventions for autism spectrum disorder (ASD) that will address the 
full range of symptoms and degrees of disability found in the ASD 
population, research studies on multiple intervention types, such as 
behavioral, pharmacological, educational, and occupational, may need to 
be undertaken simultaneously to facilitate rapid progress that benefits 
individual with varying needs. Based on the urgent need to address 
rapidly the health and services issues that are the most pressing in 
the community, it is not only appropriate, it is critical that multiple 
agencies address the complex questions related to understanding the 
neurobiology of ASD and identifying efficacious strategies for use 
across the lifespan.
    HHS is supportive of and committed to the call for greater 
coordination among Federal research funding agencies and actively 
engages in efforts to minimize risk of research duplication in all 
activities. HHS agrees that there should be continued vigilance and 
coordination to avoid unnecessary duplication across research projects. 
HHS has robust procedures in place for avoiding duplication before 
grant and contract awards are made and to keep the funding 
decisionmaking process fair and equitable. In addition, the internal 
NIH Autism Coordinating Committee (NIH ACC) and the Interagency Autism 
Coordinating Committee (IACC) provide opportunities for monitoring and 
collaboration within NIH and across Federal agencies. These policies 
and coordinating bodies have served HHS well in terms of identifying 
and preventing unwarranted duplication prior to making funding 
decisions. We will continue to monitor the internal NIH ACC procedures, 
as well as participation on the IACC, to make full use of these 
opportunities.
    As part of the HHS Strategic Plan, HHS commits to collaboration 
across State, local, tribal, urban Indian, nongovernmental, and private 
sector partners to support early childhood initiatives. The most recent 
GAO report released in April 2014 (2014 Annual Report: Additional 
Opportunities to Reduce Fragmentation, Overlap, and Duplication and 
Achieve Other Financial Benefits) did not include Early Learning in the 
11 areas that were suggested to take action to address evidence of 
fragmentation, overlap, or duplication.
                                 ______
                                 
             Questions Submitted by Senator Lindsey Graham
    Question. Last month the CDC published the latest prevalence study 
on the rates of autism. The report focused on children born in the year 
2002, and found a 30 percent increase in the rates of autism in just 2 
years--finding that 1 in 68 children born in 2002 is likely on the 
autism spectrum.
    The previous study had included the State of South Carolina and 
found an overall rate of 1 in 90 children born in 2000 on the autism 
spectrum with 1 in 55 boys. This latest report does not include South 
Carolina data. Why not? Can I presume that the rates of autism in South 
Carolina have also increased 30 percent?
    Answer. South Carolina was not able to provide suitable data in 
time to be included in the CDC's 2014 report on autism. CDC is working 
with the South Carolina Autism and Developmental Disabilities 
Monitoring (ADDM) site to finalize their 2010 data; it would not be 
appropriate to speculate or compare SC to the ADDM 2010 published 
findings.
    Question. There is great concern among the autism community that 
the CDC continues to take 4 years to publish the data on 8 year olds. 
The agency should be able to obtain and publish data more quickly. What 
are you doing to improve your turn around time on the data evaluation?
    Answer. CDC's Autism and Developmental Disabilities Monitoring 
(ADDM) Network method for tracking autism has advantages and 
disadvantages. CDC's ADDM Network collects and analyzes in-depth data 
to understand what is happening in communities across the United 
States, rather than simply counting the number of children with autism. 
The ADDM Network does not rely on parents' or providers' reporting of 
autism diagnoses; the network collects detailed information on symptoms 
that are consistent with a diagnosis of autism, as documented in tens 
of thousands of children's health and education records. This method 
allows us to:
  --identify children with diagnosed and undiagnosed autism,
  --cover a very large and diverse population base,
  --track changes over time,
  --examine whether certain groups of children are more likely to be 
        diagnosed with autism than others with similar symptoms,
  --analyze the age when children are being identified, and
  --demonstrate what progress is being made to identify children 
        earlier.
    CDC's ADDM Network is continuously working to maximize our tracking 
system's efficiency. First, we recently rolled out a new Web-based data 
collection system that is helping us collect, manage and review data 
more efficiently. Second, many of the community sources from which we 
collect data have moved to electronic records. This switch might also 
help us collect and review data more quickly. Lastly, we are piloting 
new electronic data mining techniques that hold potential for 
streamlining record review in the future.
    Question. Last month the CDC published the latest prevalence study 
on the rates of autism. The report focused children born in the year 
2002 and found a 30 percent increase in the rates of autism in just 2 
years--finding that 1 in 68 children born in 2002 is likely on the 
autism spectrum.
    There is concern in the autism community that you are not requiring 
each of the State grantees to obtain education data, so that you are 
making apples to apples' comparison from State to State. Two of the 
States included in this year's published study do not have the 
education data, which your report States decreases the prevalence rate. 
If the two States are removed, then the rate of autism goes from 1 in 
68 to 1 in 58. Can you insure that going forward all grantees obtain 
educational data so we are getting the most accurate picture?
    Answer. CDC currently cannot ensure that all grantees will have 
access to educational data going forward. Decisions about whether CDC's 
Autism and Developmental Disabilities Monitoring (ADDM) Network sites 
have access to educational data are made at the local level and are 
subject to change. CDC has and will continue to encourage ADDM Network 
surveillance sites to work closely with their local communities to 
obtain access to as many sources of information on children with autism 
as possible. CDC is assessing ways to maximize information sources in 
the new ADDM Funding Opportunity Announcement in 2014.
                                 ______
                                 
                Questions Submitted by Senator Mark Kirk
    Question. NIH and NCI provide all kinds of grants to researchers to 
provide support for investigator-initiated projects. These grants are 
integral to researcher's ability to pursue academic careers. I have 
heard from several constituents that many young, promising MD/Ph.D. 
investigators are leaving their training programs to go into private 
practice- abandoning their scientific scholarship because there isn't 
funding to support their labs. This is a general problem, but I'm 
particularly concerned about the field of radiation oncology. I 
understand that when the NCI did a review of its grants, it determined 
that about 5 percent of NCI's budget was going to fund radiation 
oncology grants/projects. I'm not sure what the right number would be, 
but 5 percent seems awful small given that radiation oncologists treat 
roughly two-thirds of all cancer patients. Does 5 percent seem small to 
you? And are you willing to review your internal processes to make sure 
that there aren't any problems in the way radiation oncology proposals 
are reviewed that is leading to such a low funding rate?
    Answer. NCI's primary goals are to support and conduct a broad 
spectrum of cancer research. The research NCI oversees uses a wide 
variety of approaches and funding mechanisms, with several goals: 
improving our understanding of the causes and biological mechanisms of 
a large variety of cancers; preventing cancers; detecting and 
diagnosing all types of cancers; and treating cancers, as well as the 
symptoms and sequelae of cancers, more effectively. NCI's research 
projects and programs include studies of the basic aspects of cancer 
biology at the molecular and cellular levels: investigations of how 
cancer cells and processes affect, and are affected by, the cellular 
environment in which they exist, and applications of these discoveries 
toward successful detection, diagnosis, treatment, prevention, and 
control of cancers of all types.
    All research efforts supported by NCI are subjected to rigorous 
review for quality and purpose by expert peer reviewers, program staff, 
and advisory groups. Decisions about individual research projects 
selected for funding are made for a limited period of time, based on a 
series of rigorous evaluations performed by scientific peers, NCI 
divisional program staff, and NCI Scientific Program Leaders, and then 
subjected to final approval by the National Cancer Advisory Board and 
the NCI Director. An emphasis on scientific merit is maintained 
throughout the review process. All of these efforts are monitored 
annually through written progress reports and subjected to competitive 
peer review or terminated on a regular basis, generally between 2 to 5 
years. Similar processes are used to oversee the representation of 
various types and costs of research in our portfolio.
    Radiation therapy plays a critical role in NCI's portfolio of 
cancer clinical trials. It is incorporated as a standard part of the 
treatment plans for patients with stage III squamous and 
adenocarcinomas of the lung, limited stage small cell lung cancer, as 
well as esophageal, breast, brain, and rectal cancers. Investigational 
questions related to new radiation therapy techniques as well as how to 
best combine radiation therapy with systemic therapies and surgery 
comprise a major part of the portfolio of studies carried out by the 
NCI's National Clinical Trials Network (NCTN). The majority of the 
trials conducted by one of the adult clinical trials groups, NRG 
Oncology, focus on studies to improve the use of radiation therapy. In 
addition to NRG, the Alliance, the Children's Oncology Group, the 
Pediatric Brain Tumor Consortium, and the ECOG-ACRIN Cancer Research 
Group also have active studies that incorporate radiation therapy. This 
portfolio of trials is monitored by an NCI oversight committee, the 
Clinical Trials and Translational Research Advisory Committee. The 
overall quality control for radiation therapy clinical studies 
supported by the NCI is also directly supported by a grant to fund a 
core quality control group responsible for overseeing these activities 
across the NCTN. NCI currently supports 50 national trials that 
incorporate radiation therapy as a component of the investigational 
program under examination. In addition to the substantive resources 
provided for radiation therapy-related clinical trials, NCI supports 
basic research into radiation therapy and radiobiology. In fiscal year 
2013, funding for this basic research was approximately $56 million. 
This, of course, is complemented by $107 million per year in funding 
for studies of critical DNA repair mechanisms that are of major 
interest and relevance to understanding the mechanism(s) of action of 
radiation therapy.
    Question. Stroke is the leading cause of disability for adults in 
the United States and the 4th leading cause of death. Recent studies 
show that 1 of 6 veterans returning from war zones and 1 of 4 stroke 
survivors have symptoms of PTSD. Knowing these statistics what cross-
coordinating efforts, if any, are happening within NIH, DOD and the VA?
    Answer. The high rate of PTSD among military servicemembers and 
veterans is of major concern to NIH. The National Institute of Mental 
Health (NIMH) is working with the Department of Defense (DOD), U.S. 
Department of Veterans Affairs (VA), and academic clinicians and 
researchers to focus on the mental health needs of military service 
personnel, as well as veterans and their families. A cross-agency 
priority goal (CAPG) of the DOD, VA, and HHS to improve mental health 
outcomes for Service Members, Veterans, and their families will help 
speed the progress of research efforts related to PTSD, suicide 
prevention, and common co-occurring conditions (e.g., traumatic brain 
injury (TBI) and substance abuse). The CAPG will be supported through 
specific cross-agency priority actions that will be accomplished over 
the next 3 years. Another example of collaborative efforts across 
agencies to address military mental health issues is the Army Study to 
Assess Risk and Resilience in Servicemembers (Army STARRS) project, a 
partnership between NIMH and the Department of the Army to provide the 
Army with actionable data to help them drive down the suicide rate, and 
to address associated problems, such as PTSD, among soldiers. In 
addition, as a result of a 2012 Executive Order, DOD, VA, HHS 
(including NIH), and the Department of Education developed a National 
Research Action Plan, which provides a comprehensive approach to 
accelerating research on traumatic brain injury and PTSD.
    While PTSD most commonly develops after exposure to a terrifying 
event or ordeal, it also occurs in individuals who have suffered an 
acute life-threatening illness, e.g., stroke survivors. An NIH-
supported study estimated that 1 in 4 survivors of a stroke or 
transient ischemic attack (TIA) develop significant PTSD symptoms. More 
than one-third of stroke survivors suffer post-stroke depression. Post-
stroke depression can interfere with daily functioning, inhibit quality 
of life, and if not treated and managed appropriately, can slow 
rehabilitation and lead to further disability. NIH-funded research is 
addressing ways to treat post-stroke depression, including 
psychosocial/behavioral interventions, in addition to novel 
rehabilitation protocols that improve motor function as well as reduce 
depression in stroke survivors. NIH-funded studies are also 
investigating ways to identify patients who will benefit most from 
these therapies, and more generally, trying to understand the 
mechanisms by which behavioral factors contribute to outcome and 
recovery from stroke. The new National Institute of Neurological 
Disorders and Stroke (NINDS) StrokeNet, composed of 25 acute and 
rehabilitation stroke centers, is dedicated to testing new means of 
improving quality of life in stroke survivors which must include 
attention to post-stroke depression and PTSD.
    NIH will continue to look for ways to collaborate with other 
agencies as appropriate to help uncover connections between conditions 
such as PTSD, stroke, and depression.
    Question. Viral hepatitis is the leading cause of liver cancer--one 
of the most lethal, expensive and fastest growing cancers in America. 
More than 5.3 million people in the U.S. are living with hepatitis B 
(HBV) and/or hepatitis C (HCV) and as many as 75 percent of them are 
undiagnosed. With the lack of an adequate, comprehensive surveillance 
system, these estimates are only the tip of the iceberg. Viral 
hepatitis kills 15,000 people each year and is the leading non-AIDS 
cause of death in people living with HIV. These epidemics are 
particularly alarming given the rising rates of new infections and high 
rates of chronic infection among disproportionately impacted racial and 
ethnic populations. Additionally, recent alarming epidemiologic reports 
indicate a rise in HCV infection among young people throughout the 
country. Further, the baby boomer population (those born 1945-1965) 
currently accounts for two out of every three cases of chronic HCV. As 
these Americans continue to age, they are likely to develop 
complications from HCV and require costly medical interventions that 
can be avoided if they are tested earlier and provided with treatment 
options. Can you highlight the problems facing our country with viral 
hepatitis and the urgent need to address these two diseases and what 
could happen if we do not act?
    Answer. Viral hepatitis is an urgent public health problem in the 
United States.
    Hepatitis B (HBV).--There have been dramatic decreases in the 
number of new acute infections among children, resulting from universal 
infant immunization recommendations, and today most new infections are 
among adults. However, an estimated 1.2 million persons in the United 
States have chronic hepatitis B infection, and 25 percent will die of 
HBV-associated complications in the absence of medical interventions. 
Preventing perinatal infections by screening pregnant women and 
vaccinating infants upon birth also remains a priority.
    Hepatitis C (HCV).--Recent data indicate that no more than 50 
percent of HCV-infected persons in the United States have been tested 
for HCV. Of those tested, 32-38 percent are referred for care, 7-11 
percent are treated, and 5-6 percent achieve virologic cure. These low 
proportions reflect gaps in health-care delivery at every stage of the 
HCV continuum of care. Consequently HCV-related disease, healthcare 
costs, and mortality are increasing. Implementation of CDC and USPSTF 
recommendations for birth-year based HCV testing linked to HCV care and 
treatment can avert an estimated 121,000 deaths (Smith BD et al. 
Recommendations for the Identification of Chronic Hepatitis C Virus 
Infection Among Persons Born During 1945-1965. MMWR. 61(RR04);1-18. See 
Table 3 with Source: Rein DB et al. The Cost-Effectiveness of Birth-
Cohort Screening for Hepatitis C Antibody in U.S. Primary Care 
Settings. Ann Intern Med. 2012;156(4):263-270. Modified and reprinted 
in MMWR with permission from Annals of Internal Medicine.). CDC is 
working to improve the continuum of hepatitis C testing, care, and 
treatment; and will leverage the use of newly FDA-licensed safe and 
curative therapies for new prevention opportunities.
    CDC plays a key role in implementing the HHS Action Plan for the 
Prevention, Care and Treatment of Viral Hepatitis. The plan sets out 
ambitious goals and a path forward to confront viral hepatitis. Its 
goals are to increase the proportion of those who are aware of their 
Hepatitis B or Hepatitis C infections; reduce new Hepatitis C 
infections; and, eliminate mother to child transmission of Hepatitis B.
    Question. Given the release of U.S. Preventive Services Task Force 
(USPSTF) grade ``B'' recommendation for HCV screening for baby boomers 
and individuals at risk, do you feel you have the resources to 
implement that recommendation and educate Medicare beneficiaries and 
healthcare providers about hepatitis C and its disproportionate impact 
on baby boomers?
    Answer. Currently, only a small proportion of the baby boomer 
cohort is eligible for Medicare. The cohort will steadily age into 
Medicare eligibility over the next 15 years.
    Recent evidence from CDC demonstration projects indicates that a 
substantial number of people who are either currently Medicare-eligible 
or will become eligible over the upcoming decade can receive 
recommended HCV testing in nonprimary care settings. Therefore, 
Medicare beneficiaries receiving screening and in the near future can 
significantly increase the proportion of people who are aware of their 
infection.
    However, while screening those who are or will soon be Medicare 
beneficiaries is vitally important, it is also important to screen the 
rest of the birth cohort now, so that all who are infected can be 
screened for alcohol use, and receive care and treatment (including 
hepatitis A and B vaccination, as medically appropriate).
    Implementation of new CDC and USPSTF recommendations for HCV 
testing can save over 120,000 lives.
    In fiscal year 2012, CDC received Prevention and Public Health 
Funds to support demonstration sites for hepatitis B and hepatitis C 
testing to identify persons with undiagnosed infection, and for 
linkages to care when appropriate. Nine sites were selected to do 
hepatitis B testing, and 24 sites to do hepatitis C testing. Evaluation 
of these sites is ongoing, but preliminary data indicate that over 
45,000 tests were completed in the first year of the initiative, 
yielding important lessons learned that can be implemented elsewhere. 
CDC was able to provide continuation funding to almost all of the sites 
in fiscal year 2013, and substantial gains in the total number of 
completed tests are expected in the second year.
    In 2014, CDC will support the development and evaluation of new 
viral hepatitis prevention programs in three jurisdictions. These viral 
hepatitis prevention programs aim to establish the platform needed to 
reduce new infections, improve systems of care, and combat hepatitis-
related health disparities; activities will include but not be limited 
to education on hepatitis C.
    Question. Viral hepatitis is the leading cause of liver cancer--one 
of the most lethal, expensive and fastest growing cancers in America. 
More than 5.3 million people in the U.S. are living with hepatitis B 
(HBV) and/or hepatitis C (HCV) and as many as 75 percent of them are 
undiagnosed. With the lack of an adequate, comprehensive surveillance 
system, these estimates are only the tip of the iceberg. Viral 
hepatitis kills 15,000 people each year. These epidemics are 
particularly alarming given the rising rates of new infections and high 
rates of chronic infection among disproportionately impacted racial and 
ethnic populations. Additionally, recent alarming epidemiologic reports 
indicate a rise in HCV infection among young people throughout the 
country. Some jurisdictions have noted that the number of people ages 
15 to 29 being diagnosed with HCV infection now exceeds the number of 
people diagnosed in all other age groups combined. Further, the baby 
boomer population (those born 1945-1965) currently accounts for two out 
of every three cases of chronic HCV. As these Americans continue to 
age, they are likely to develop complications from HCV and require 
costly medical interventions that can be avoided if they are tested 
earlier and provided with treatment options. It is estimated that this 
epidemic will increase costs by billions of dollars--from $30 billion 
in 2009 to over $85 billion in 2024--to private insurers and public 
systems of health such as Medicare and Medicaid, and account for 
additional billions lost due to decreased productivity from the 
millions of workers suffering from chronic HBV and HCV. Over the last 2 
years, CDC and the U.S. Preventive Services Task Force (USPSTF) have 
begun to align their recommendations for hepatitis screening, 
recommending one-time testing of baby boomers and screening vulnerable 
groups for HCV. In April, the Department of Health and Human Services 
(HHS) renewed the Action Plan for the Prevention, Care and Treatment of 
Viral Hepatitis which provides clear and attainable goals to increase 
the number of individuals diagnosed with viral hepatitis and reduce 
transmission of the viruses. The Action Plan identifies discrete 
activities for HHS and other Federal agencies to break the silence of 
this epidemic. Will the agency continue to focus cross agency attention 
on addressing the viral hepatitis epidemic and implementing the Action 
Plan?
    Answer. On April 3, 2014, HHS released the 3-year update of the 
Action Plan for the Prevention, Care and Treatment of Viral Hepatitis, 
which provides a framework around which both Federal and non-Federal 
stakeholders from many sectors can engage to strengthen the Nation's 
response to viral hepatitis and work to improve viral hepatitis 
prevention, screening, and treatment through 2016.
    This update is the culmination of efforts across the Department of 
Health and Human Services as well as at the Departments of Justice, 
Housing and Urban Development, and Veterans Affairs who have worked to 
develop this framework for focused activity by both Federal and non-
Federal stakeholders. Federal colleagues have identified more than 150 
important actions their agencies and offices will undertake between 
2014 and 2016 across six priority areas.
  --Educating Providers and Communities to Reduce Viral Hepatitis-
        related Health Disparities (Confront viral hepatitis by 
        breaking the silence).
  --Improving Testing, Care, and Treatment to Prevent Liver Disease and 
        Cancer (Take full advantage of existing tools).
  --Strengthening Surveillance to Detect Viral Hepatitis Transmission 
        and Disease (Collect accurate and timely information to get the 
        job done).
  --Eliminating Transmission of Vaccine-Preventable Viral Hepatitis 
        (Take full advantage of vaccines that can prevent hepatitis A 
        and B).
  --Reducing Viral Hepatitis Associated with Drug Use (Stop the spread 
        of viral hepatitis associated with drug use).
  --Protecting Patients and Workers From Health Care-Associated Viral 
        Hepatitis (Quality healthcare is safe healthcare).
    In shaping these actions, HHS sought substantial input from non-
Federal partners and stakeholders through public webinars and a formal 
Request for Information (RFI) published in the Federal Register. In 
fact, a notable feature of the updated plan is a more explicit 
recognition that achieving the goals of this national plan will require 
the time, talent, and energy of a broad mix of partners from across all 
sectors of society, both governmental and nongovernmental. As such, the 
updated plan includes a listing of potential opportunities for non-
Federal stakeholders to promote successful implementation.
    Finally, to maximize cross-agency and cross-departmental effort in 
support of the updated Viral Hepatitis Action Plan, the Office of HIV/
AIDS and Infectious Disease Policy, in the Office of the Assistant 
Secretary for Health, actively coordinates a Viral Hepatitis 
Implementation Group (VHIG) composed of senior leaders from HHS, VA, 
DOJ/BOP, HUD and ONDCP. The VHIG meets on a regular basis to share 
progress, discuss challenges and highlight new opportunities.
    Question. There are a number of cancers, and stomach cancer is a 
prominent example, where there is both dismal survival rates and also a 
shortage of ongoing research. The vast majority of stomach cancer is 
diagnosed at metastatic stages, for which there are, at present, no 
cures. Stomach cancer treatments have made little progress in the past 
decade and are quite limited. The investment that the NCI is making in 
a number of cancers through The Cancer Genome Atlas has the potential 
to catalyze research in stomach and other cancers. But for cancers, 
like stomach cancer, with less-developed research infrastructures, how 
can we be confident that research to pursue the findings of the TCGA 
will occur?
    Answer. While NCI has made significant progress in preventing, 
detecting, and treating many cancers, gastric cancer is one of several 
types that are not well understood and remain difficult to treat. For 
such areas, NCI has a variety of tools at its disposal to stimulate 
research in specific areas. Meetings of NCI and extramural experts to 
conduct ``horizon scanning'' for scientific opportunities on a variety 
of cancers occur as part of NCI's standard practices. In fact, NCI 
invited a group of international experts in gastric and esophageal 
cancer to participate in a workshop in May 2011. In addition to 
discussing the basic biology, epidemiology and clinical research, they 
also focused on different patterns of gastric cancer observed in other 
countries. One result of the workshop was the initiation of a pilot 
project for obtaining pre-treatment gastric tumor specimens. (NCI has 
also recently convened workshops for hepatic, lung, and pancreatic 
cancers.)
    Initiatives, such as The Cancer Genome Atlas (TCGA), that provide 
new insights into a wide range of cancer types can greatly accelerate 
progress in many common and rare cancer types, such as gastric cancer, 
and generate prime research opportunities. The genomic sequence data 
from TCGA's gastric cancer samples are already freely available to 
qualified researchers for further study. (NCI has developed websites 
that allow researchers to search for genetic alterations in any cancer 
studied by TCGA and will continue to support these cancer genomics 
portals to promote the widest possible utilization of these data.) The 
first 295 gastric cancer samples have been evaluated, and a report is 
expected to be published early this summer. The report shows that the 
current classification of gastric cancer subtypes by appearance under 
the microscope is imprecise and can be refined by analysis of tumor 
genomes. Some of the genetic abnormalities are characteristic of 
particular gastric cancer subtypes and might be amenable to therapeutic 
intervention. Additionally, several of the mutations found in gastric 
cancer are also present in other cancers studied by TCGA and other 
projects. NCI vigorously supports research into therapeutic strategies 
to target the abnormal molecular pathways that are caused by mutations 
that occur in one or many tumor types.
    The work that is expected to follow up findings from TCGA does not 
require specific research methods or equipment for each type of cancer, 
but it does require certain specific resources: tumor samples, 
appropriate experimental models for each disease, and investigators 
motivated by new opportunities to work on that disease. Suitable 
laboratory models are important for testing candidate drugs or 
immunotherapies for their ability to block abnormal molecular pathways 
and prevent tumor growth. Human cancer cell lines are the mainstay of 
this kind of research, but the currently available cell lines do not 
model all of the diverse subtypes of cancer, including gastric cancers, 
and do not possess all of the recurrent mutations that drive the 
malignant process. NCI is addressing this infrastructural deficiency by 
using biopsies of various kinds of human cancers to create a large 
number of new cancer models with newly available methods (e.g., so-
called ``organoid'' cultures and ``conditionally reprogrammed'' cells). 
When successful, NCI will distribute these new cancer models broadly to 
cancer researchers to help develop diagnostic and treatment strategies 
tailored to specific subtypes of cancer and to specific molecular 
abnormalities. To that end, NCI is soliciting applications to support 
pilot projects at NCI-designated cancer centers for the development and 
characterization of cell lines derived from human cancer specimens. 
These models could also help clarify cellular mechanisms that drive 
tumor progression and generate hypotheses about ways to interrupt those 
processes. Letters of intent have been received from several potential 
applicants, and at least one plans to develop models for gastric 
cancer.
    Question. How can the NCI assist stomach cancer researchers and 
researchers of other cancers with deficiencies in foundational 
knowledge in developing successful RO1 grant applications that can have 
an impact for patients battling stomach cancer?
    Answer. NCI can and does foster opportunities to study gastric 
(stomach) cancer in several ways:
  --by providing new information of the type illustrated by The Cancer 
        Genome Atlas and discussed in response to the previous question 
        (this kind of new information suggests new ideas and 
        opportunities for research, often addressed to diseases that 
        were previously difficult to study);
  --by offering an array of funding opportunities (including team 
        awards), and not only RO1 grants;
  --by supporting the training of talented individuals who might 
        develop an interest in gastric cancer through individual 
        fellowships, institutional training awards, and career 
        development awards; and
  --by highlighting NCI's concerns about the slow progress against this 
        disease through the organization of workshops and public 
        discussion of public health needs and research opportunities.
    In addition, NCI program managers are available to provide guidance 
to investigators who seek help in finding the most appropriate funding 
mechanisms to support proposed work on gastric cancer and other types 
of cancers.
                                 ______
                                 
                Questions Submitted to Mary K. Wakefield
               Questions Submitted by Senator Tom Harkin
                        community health centers
    Question. The Health Centers program received mandatory funding 
under the ACA, a critical investment that the National Association of 
Community Health Centers (CHCs) estimates created over 550 new health 
clinics and expanded capacity at thousands of existing sites. This 
investment needs to be extended, or the mandatory funding will expire 
in fiscal year 2016 and health centers will face a massive funding 
cliff. I have expressed support for fixing this issue by continuing 
mandatory funding, an approach supported in the President's budget. If 
funding was not extended, please provide the administration estimate on 
how that would impact the CHC program in fiscal year 2016. Please 
include how much base funding for existing health centers will be 
reduced, the number of clinics that will close, and the loss in patient 
capacity.
    Answer. The budget includes a proposal to continue mandatory 
funding for health centers in fiscal years 2016, 2017, and 2018 at $2.7 
billion per year, for a total investment of $8.1 billion. This 
investment is part of a total budget that includes more than $400 
billion in specified health savings over 10 years. The President has 
not yet submitted a discretionary budget for fiscal year 2016, the year 
the mandatory Health Center funds will expire. If funding for the 
Health Center Program is significantly lowered in fiscal year 2016 
compared to the previous year a complex procedure of grant level 
reductions, and possibly terminations, could occur. This could result 
in numerous health center sites closing, and a reduction in patients 
served by health centers.
                      ryan white hiv/aids program
    Question. The President's budget proposes to consolidate Part D of 
the Ryan White HIV/AIDS program into Part C of the program. Part D 
provides family-centered primary medical care for women, infants, 
children, and youth with HIV/AIDS. These services include case 
management for HIV-infected pregnant women and HIV-infected children 
and youth.
    Has Health Resources and Services Administration (HRSA) conducted 
an assessment of Part C programs to determine whether Part C programs 
are prepared and have the infrastructure to provide primary and 
specialty care to these populations? How many Part C grantees have 
pediatric providers and are currently equipped to provide primary and 
specialty medical care and support services to infants, children and 
youth?
    Answer. In 2014, 67 percent of Part D programs funded by the Ryan 
White HIV/AIDS Program are dually funded by the Part C program. The 
consolidated program will continue to provide increased access to 
allowable services under Part C that meet the needs of the Part D 
community. All applicants to the fiscal year 2015 Part C Funding 
Opportunity Announcement will be required to demonstrate how they will 
provide care and treatment for the most vulnerable populations, 
including women, infants, children and youth. The assessment of an 
applicant's capacity to provide the services proposed in their grant 
applicant is a key area of focus for the objective grant review 
committee. The consolidation will expand the focus on women, infants, 
children, and youth across all of the funded grantees and will increase 
points of access for the population. In addition, the consolidation 
will result in increased efficiencies, reduced duplication of effort 
and reporting/administrative burden among currently co-funded grantees, 
and allow more funding to be available for direct patient care 
services.
    Question. What are HRSA's plans to ensure a seamless transition of 
services, including case management services, and to ensure that women, 
infants, children and youth are not lost to care, including plans to 
provide technical assistance to current and future grantees?
    Answer. Since 67 percent of Part D grantees are currently also Part 
C grantees, HRSA expects that transition will be manageable. Continuing 
to reduce mother-to-child transmission of HIV remains a priority. The 
President's budget will result in more Part C programs providing women, 
infants, children and youth-focused services, which will result in 
increased access to proven medical care for these populations across 
the country. The Ryan White HIV/AIDS Program provides extensive 
technical assistance opportunities to both current and future Ryan 
White HIV/AIDS Program grantees through our Technical Assistance 
Resources, Guidance, Education & Training (TARGET) Center, AIDS 
Education and Training Centers (AETCs), our national cooperative 
agreements, and during pre-application technical assistance calls when 
the new Funding Opportunity Announcement is released. In addition, one-
on-one technical assistance from the HRSA staff will be available to 
assist grantees receiving new funding under Part C to ensure that the 
Program's most vulnerable populations, which include women, infants, 
children and youth, are not lost to care and treatment.
    Question. What impact will the proposed consolidation have on Part 
C grantees needing to seek a waiver from the 75/25 core medical 
services requirement in order to provide case management services to 
Part D populations?
    Answer. HRSA takes seriously the responsibility to ensure that all 
of the needs of individuals living with HIV/AIDS are met. Under the 
President's budget, all Part D programs that meet the Part C Program 
eligibility for grant funding are encouraged to apply for Part C 
funding. Eligible Part C grantees, and grantees awarded Part C funding 
through the fiscal year 2015 Funding Opportunity Announcement, would 
need to meet the legislative requirements in Part C regarding use of 
funds. This will result in more Part C programs providing women, 
infants, children, youth focused services, which means increased access 
to proven medical care for these populations across the country. HRSA 
will ensure that Part C grantees meet the needs of these populations 
through grant monitoring and technical assistance.
                    the 340 b drug discount program
    Question. The President's budget requests $17 million for the 
Office of Pharmacy Affairs (OPA) to improve program integrity and 
administration of the 340B Federal drug discount program. Congress 
provided $10 million in the fiscal year 2014 Omnibus, an increase of $6 
million over fiscal year 2013, for program integrity consistent with 
existing requirements and recommendations from the Office of the 
Inspector General and the Government Accountability Office. Please 
provide an fiscal year 2014 implementation plan for the program 
integrity effort and describe what has been accomplished to date with 
the increase in funding. How is HRSA prioritizing its program oversight 
activities?
    Answer. The $6 million of additional funding provided in the 
Omnibus Appropriations Act for fiscal year 2014 have enabled HRSA to 
develop a robust strategy to more effectively oversee the covered 
entities and manufacturers that participate in our program. Please find 
a detailed outline of our areas of investment that follows.
Manufacturer Compliance
  --We are devoting resources to implement provisions of the Affordable 
        Care Act (ACA) to prevent overcharges to 340B covered entities.
  --The resources will upgrade our current internal-facing pricing 
        database, providing a secure access mechanism for covered 
        entities and the capacity for HRSA's Office of Pharmacy Affairs 
        to conduct ceiling price verification.
  --The contract will be awarded this summer and upgrades will be 
        complete in 2015.
  --Work has begun to finalize rulemaking on Civil Monetary Penalties 
        for manufacturers and Administrative Dispute Resolution.
Covered Entity and Manufacturer Compliance
  --We are investing in a new compliance management system that will 
        create a sophisticated tracking system for all covered entities 
        and manufacturers participating in the 340B program.
  --We have designed a system overview for proposal, and the contract 
        for building the system will be awarded this summer. Full 
        implementation is expected in fiscal year 2015.
Covered Entity Compliance
  --Five additional auditors, and one audit coordinator, will be hired 
        in order to increase the number of program audits conducted. 
        The resulting increase in audits will be seen in fiscal year 
        2015 when hiring is complete and new staff have been trained.
Overall Program Integrity
  --We are have hired 2 staff and plan to hire 6 additional staff in 
        the Office of Pharmacy Affairs to manage and analyze 
        information from expanded program integrity efforts. This 
        includes Program Integrity Specialists, Data Analysts, and an 
        individual devoted to technical assistance and education. Staff 
        will review audits and other compliance related activities, 
        develop policy, manage and analyze data, and continue work on 
        implementing 340B ACA provisions.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
                             mental health
    Question. According to USDA, 50 million people live in rural 
America. This rural population is disproportionately affected by mental 
health disorders with higher levels of depression, along with domestic 
violence, and child abuse than their urban peers.
    Unfortunately many families in rural American find themselves cut 
off from mental health services, because of geographic and cultural 
barriers. As of January 2013, there are 3,800 Mental Health 
Professional Shortage Areas nationwide, as defined by HRSA. More than 
85 percent of MHPSAs are in rural areas. As a result of the scarcity of 
mental health professionals, primary care providers in rural 
communities typically have a larger role in mental healthcare than 
their urban peers.
    Studies have shown that stigma is a significant concern for many in 
rural America. People suffering from a mental disorder are less likely 
to seek treatment if they fear being recognized.
    In light of this stark data, what steps is the agency taking to 
increase the mental health workforce in rural settings? What steps is 
HRSA taking to better integrate mental health and primary healthcare in 
rural hospitals and FQHCs? What steps does HRSA propose for further 
addressing the scarcity of mental providers in rural settings?
    Answer. The National Health Service Corps (NHSC) is one of the 
Administration's most effective tools for getting healthcare providers 
to the areas where they are needed most, with half of all NHSC 
clinicians serving in community health centers. In fiscal year 2013, 
nearly one in three clinicians (2,854 as of September 2013) in the NHSC 
was a behavioral and mental health professional, which includes 
psychiatrists, health service psychologists, clinical social workers, 
licensed professional counselors, marriage and family therapists, 
psychiatric physician assistants, and psychiatric nurse specialists. 
All NHSC behavioral and mental health practitioners serve in high-need, 
underserved areas that have a mental Health Professional Shortage Area 
(HPSA) designation.
    The fiscal year 2015 President's budget also includes a $3.96 
billion increase in funding for the National Health Service Corps over 
6 years, the largest increase in the program's history. This increase 
will build and sustain an annual field strength of 15,000 and create 
incentives for providers to practice in the areas of the country that 
need them most. Since 2010, based on historical data, over 27 percent 
of the total field strength has been behavioral and mental health 
practitioners.
    In addition, HRSA is implementing programs that help train 
additional behavioral health providers. The Mental and Behavioral 
Health Education and Training (MBHET) Program supports accredited 
graduate schools and programs of social work and accredited doctoral 
psychology schools, programs and pre-degree internship organizations to 
increase the number of behavioral health providers serving the 
medically underserved populations, including rural areas. It is 
estimated that over 2,900 individuals will be trained as a result of 
these activities.
    In fiscal year 2014, HRSA partnered with SAMHSA to expand the 
behavioral health workforce as part of the President's plan to prevent 
gun violence. The initiative will include $35 million to expand 
training for roughly 3,500 behavioral health professionals and 
paraprofessionals, including master's level social workers, 
psychologists and marriage and family therapists, as well as various 
behavioral health paraprofessionals. The program will include an 
emphasis on training to address the needs of children, adolescents, and 
transition-age youth (ages 16-25) and their families. The President's 
fiscal year 2015 budget includes a request to continue to fund this 
effort.
    HRSA's Graduate Psychology Education Program supports clinical 
training programs for doctoral-level psychology students to address the 
behavioral health needs of vulnerable and underserved populations. In 
Academic Year 2012-2013, the most recent data available over a third of 
the individuals supported in this program are from rural or 
disadvantaged backgrounds. In addition, more than half of individuals 
who received a financial award and completed their training reported 
that they were currently employed or pursuing further training in a 
Medically Underserved Community.
    Further, in January, the Vice President announced a $50 million 
Funding Opportunity Announcement to expand access to behavioral health 
services at approximately 200 existing health centers nationwide. 
Health centers will be able to use these new funds, made available 
through the Affordable Care Act, for efforts such as hiring new mental 
health and substance use disorder professionals, adding mental health 
and substance use disorder services, and employing team-based models of 
care. All current health center grantees, nearly half of which serve 
rural areas, were eligible to apply for this funding.
                              oral health
    Question. According to HRSA, 108 million Americans currently lack 
access to dental coverage. In fact, a large number of people with 
dental insurance coverage lack access to dental care. The U.S. has 
141,800 working dentists and 174,100 dental hygienists. However, 
according to HRSA data, there are 4,230 dental health professional 
shortage areas nationwide with 49 million people living in them.
    More than 16 million children in the United States go without 
seeing a dentist each year. Particularly vulnerable are children living 
in rural areas. Although the Children's Health Insurance Program (CHIP) 
provides comprehensive oral health coverage, dental care is the 
greatest unmet health need among children. More concerning, many 
dentists refuse to treat Medicaid beneficiaries, citing low 
reimbursement rates and administrative burdens.
    In 2009, HRSA embarked on an Oral Health Initiative, which included 
a series of Institute of Medicine reports. Based on this work, what has 
the agency done to implement the recommendations from the Initiative to 
close the coverage gap?
    States with the highest Medicaid reimbursement rates still have 
children enrolled in Medicaid who aren't able to access adequate oral 
healthcare. What is the agency's position on expanding the number of 
mid-level professionals to provide care in underserved areas?
    Answer. HRSA has used the IOM reports to advance its work to expand 
access to oral healthcare. In 2012, HRSA/MCHB launched the Perinatal & 
Infant Oral Health National Initiative in tandem with the release of 
the MCHB-funded document: Oral Health Care During Pregnancy: A National 
Consensus Statement. This effort responds to three of the IOM 
committee's Organizing Principles for an HHS Oral Health Initiative: 
reduce oral health disparities (#4), explore new models for . . . 
delivery of care (#5), and promote collaboration among private and 
public stakeholders (#8). Concrete examples of success will include: 
increased utilization of preventive dental care by pregnant women, 
establishment of a dental home for infants by age one, reduced 
prevalence of early childhood caries (ECC), and reduced dental 
expenditures. In 2013, HRSA initiated the first phase of this 
initiative, funding the Perinatal and Infant Oral Health Quality 
Improvement Pilot grant program. The outcome will put into practice and 
continuously assess a statewide approach that responds to the 
comprehensive oral health needs of pregnant women and infants most at 
risk. In 2014, HRSA will award funding to establish the Perinatal and 
Infant Oral Health Quality Improvement National Learning Network. This 
learning network will coordinate the development and testing of an 
evidence-informed strategic framework that can inform statewide 
healthcare systems transformation. Knowledge gained will comprise the 
National Strategic Framework for Improving Perinatal and Infant Oral 
Health through Systems Change.
    HRSA also entered into a cooperative agreement with the National 
Network for Oral Health Access to provide specialized training and 
technical assistance to HRSA awardees around increasing access to 
primary oral healthcare services for underserved and vulnerable 
populations. In February 2014, HRSA issued a report on the Integration 
of Oral Health and Primary Care Practice (http://www.hrsa.gov/
publichealth/clinical/oralhealth/primarycare/
integrationoforalhealth.pdf) as part of an initiative that strives to 
improve access for early detection and preventive interventions by 
expanding oral health clinical competency of primary care clinicians, 
leading to improved oral health. Furthermore, HRSA is supporting a 
pilot project to demonstrate implementation of a core set of clinical 
competencies for primary care clinicians in three Community Health 
Centers. The IOM reports have also informed work on an HHS Oral Health 
Strategic Framework by the HHS Oral Health Coordinating Committee.
    HRSA is also deploying its programs to increase access to oral 
health services. In the National Health Service Corps, the numbers of 
oral health providers (dentists and registered dental hygienists), have 
nearly tripled since 2008, increasing from approximately 480 to 1,300 
in 2013. As of the end of fiscal year 2013, 164 dentists, committed to 
work in underserved areas, are currently in the training pipeline, 
being supported by the NHSC Scholarship Program.
    HRSA's oral health workforce training programs providing financial 
support to over 390 students, residents and fellows participating in 
degree, residency or fellowship programs in dentistry, public health 
and/or dental hygiene. In Academic Year 2012-2013, these programs 
trained over 2,600 oral health students and 517 primary care dental 
residents.
    The State Oral Health Workforce Improvement Program provides grants 
to States to implement innovative programs to address their dental 
workforce needs in a manner that is appropriate to the States' 
individual needs. As part of this program States have used HRSA funds 
for dentist recruitment and retention efforts, expanded training in 
community settings, increased preventive services such as dental 
sealant and fluoride programs, and expansion of clinical services in 
underserved areas.
    HRSA has provided funding to support curriculum development for 
dental therapists and development of community prevention programs 
using expanded practice dental hygienists.
    HRSA grantees have undertaken activities related to the use of 
alternative oral health providers with the goal of expanding the number 
of oral health providers and increasing access to oral health services.
                         postpartum depression
    Question. Maternal depression is often unrecognized and untreated 
because pregnant and postpartum women are not universally screened for 
depression. Estimates of depression during pregnancy range between 14 
and 23 percent. Rates of postpartum depression in the first year range 
from 5 to 25 percent.
    What is the assessment of HHS on the adequacy of current research 
into the causes of postpartum depression? Does HHS have a position on 
the value of universal screening as a meaningful goal and will the 
agency work with the Congress to encourage it? What is HHS doing to 
increase access to mental health services for low-income mothers?
    Answer. HHS supports numerous efforts to address the problem of 
depression among pregnant and postpartum women in the areas of 
research, prevention, screening, and care. In the U.S., we know that 
approximately 12 percent of recent mothers (2009) who had a birth in 
the past 2-9 months reported postpartum depression. We also know that 
postpartum depression disproportionately affects mothers with less 
education and with lower incomes, as well as American Indian/Alaska 
Native mothers.
    Research has shown that risk factors or possible causes of 
postpartum depression include previous depressive episodes, stressful 
life events, and low social support. HHS, through the National 
Institutes of Health, is conducting research examining the 
epidemiologic characteristics of severe postpartum depression, the 
effects of the high levels of stress hormones experienced by pregnant 
women living in poverty, the effects of postpartum depression on 
infants, and effective treatments for this type of depression.
    Regarding universal screening for postpartum depression, the 
Department, has reviewed healthcare research and found the following:
  --perinatal depression is one of the most common complications of the 
        perinatal period;
  --validated screening tools exist that demonstrate high levels of 
        both sensitivity and specificity (at least for major 
        depression); and
  --screening and intervention demonstrate better outcomes for women 
        experiencing perinatal depression.
    However, the agency does not recommend universal screening at this 
time due to an insufficient evidence base for how and when to screen 
and intervene, especially as it relates to non-White women. Further 
study in these areas is needed.
    HHS is also supporting a number of programs to increase access to 
mental health services for low-income and disadvantaged mothers, 
especially in the area of screening and care for pregnant and 
postpartum women. HRSA supports the Maternal, Infant and Early 
Childhood Home Visiting Program, which provides voluntary, evidence 
based home visiting services for low income pregnant and postpartum 
women and their families in all 50 States, DC and territories. All home 
visitors assess maternal depression with valid depression screening 
tools, and they provide referrals to community mental health services 
as available and as needed. The program has established a new 
collaborative this year that focuses on optimizing the management of 
maternal depression. HRSA also supports the Healthy Start program, 
which focuses on reducing infant mortality and improving perinatal 
outcomes in areas of high need throughout the country. All Healthy 
Start grantees screen their clients for perinatal depression before, 
during, and after pregnancy. Screening is repeated throughout the 
pregnancy, with screening frequency dependent upon the woman. If the 
woman is found to need services related to depression, she is referred 
for appropriate care. Healthy Start has also developed perinatal 
screening booklets and materials for materials in English and Spanish, 
which have been widely disseminated.
    Finally, SAMHSA supports Project LAUNCH (Linking Actions for Unmet 
Needs in Children's Health) which seeks to promote the wellness of 
young children from birth to 8 years by addressing the physical, 
social, emotional, cognitive, and behavioral aspects of their 
development. One area in which Project LAUNCH focuses is on the 
strengths and challenges within the family system, including parental 
depression. SAMHSA is also preparing to launch a toolkit on maternal 
depression for family service providers that includes basic information 
about maternal depression, tips, resources and strategies for talking 
with women about depression, screening for depression and referral to 
mental health services.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
    Question. HRSA invests a great deal of resources on doctors in 
training and also for continuing medical education. What can HRSA do to 
help educate providers about appropriate narcotic prescription drug 
dispensement and how to avoid excess prescribing?
    Answer. HRSA supported training is not specifically focused on 
training in prescribing narcotic medications for pain management; 
however, this topic is addressed as part of training curricula for many 
health disciplines. Through the National Health Service Corps (NHSC) 
program, HRSA will seek to increase education about appropriate 
narcotic prescription drug dispensement to NHSC providers through 
various available media, including webinars, newsletters and social 
media.
    Question. As you know, the United States has the lowest ratio of 
primary care providers in the Organization for Economic Cooperation and 
Development countries. American medical students often choose 
specialist training over primary care training.
    How can we incentivize medical students to choose primary care 
specialties?
    Answer. The administration recognizes that primary care is the 
foundation of the healthcare delivery system today, and it will play an 
even greater role in the future.
    HRSA funds several programs that aim to encourage physicians to 
select a primary care specialty. Through the National Health Service 
Corps (NHSC) programs, students and clinicians receive scholarship or 
loan repayment awards in return for a commitment to provide primary 
health services in underserved areas (HPSAs) for at least 2 years. In 
fiscal year 2013, 100 percent of all new NHSC loan repayment awards 
were made to those serving in HPSAs of highest need (scores of 14 or 
higher) and nearly half of NHSC clinicians are serving at rural sites. 
In fiscal year 2015, HRSA expects to fund over 10,000 new NHSC loan 
repayment awards in order to build and sustain a field strength of 
15,000 primary care providers across the country, serving the primary 
care needs of more than 16 million patients in high-need rural, urban, 
and frontier areas across the United States. In fiscal year 2012, the 
NHSC launched the Student to Service Loan Repayment Pilot Program which 
provides loan repayment awards to medical students in their last year 
of school as an incentive to pursue residency training in a primary 
care specialty. To date, 147 medical students have participated in this 
pilot program. In fiscal year 2015, the NHSC expects to award 100 new 
Student to Service Loan Repayment awards.
    In addition to the recruitment of providers, the NHSC also works to 
retain primary care providers in underserved areas after their service 
commitment is completed to further leverage the Federal investment and 
to build more integrated and sustainable systems of care. A 2012 
retention assessment survey found that 55 percent of NHSC clinicians 
continue to practice in underserved areas 10 years after completing 
their service commitment. Another recent study completed in fiscal year 
2013 showed 85 percent of those who had fulfilled their service 
commitment remained in service to the underserved in the short-term. 
Short-term is defined as up to 2 years after their service completion.
    The Primary Care Training Enhancement (PCTE) program strengthens 
primary care by supporting innovation in primary care curriculum 
development, education and practice (i.e. Patient-Centered Medical 
Homes, team-based care, etc.) as well as expanding training 
opportunities by funding primary care residency positions. In Academic 
Year 2012-2013, the PCTE program trained a total of 23,830 physician 
and physician assistant students, medical residents, and fellows. Of 
those individuals trained, approximately 532 received direct financial 
support.
    In addition, in fiscal year 2012, HRSA modified the Scholarships 
for Disadvantaged Students Program to better support the primary care 
workforce by giving priority to applicants who could demonstrate a 15 
percent or better rate of graduates practicing in primary care. The 
program provides funding to eligible health professions schools to 
support scholarships for financially needy students from disadvantaged 
backgrounds.
    The President's fiscal year 2015 budget includes a new Targeted 
Support for Graduate Medical Education program that will train 13,000 
new physicians over 10 years. This new Targeted Support for Graduate 
Medical Education Program will expand residency slots, with a focus on 
ambulatory and preventive care in order to advance the ACA's goals of 
higher value healthcare that reduces long-term costs. Successful 
applicants will need to demonstrate that their training of residents 
addresses key workforce objectives, such as: training and retaining 
residents in primary care and providing comprehensive primary care that 
includes oral health, behavioral health, prevention and population 
health.
    Question. How do you ensure that funding for primary care training 
will not only go to large tertiary care teaching hospitals but also the 
smaller clinics and community hospitals that make up the backbone or 
primary care?
    Answer. HRSA actively seeks to expand primary care training in 
community-based, ambulatory settings. The Affordable Care Act created 
the Teaching Health Center Graduate Medical Education Program to help 
move primary care training into community-based settings. The 5-year 
investment in this program is expected to support the community-based 
training of over 600 new primary care physician and dental residents by 
2015. The program supports community-based training sites in 30 
Federally Qualified Health Centers (FQHCs) and FQHC look-alikes, 2 Area 
Health Education Centers, 2 Native American Health Authorities, 1 
Community Mental Health Clinic and 4 additional community-based 
entities.
    To build on the success of the Teaching Health Center Graduate 
Medical Education program, the President's fiscal year 2015 budget 
proposes a new initiative to expand residency training and build the 
health workforce needed for a changing healthcare system. The Targeted 
Support for Graduate Medical Education Program will focus specifically 
on key priorities for workforce development and transforming the 
healthcare delivery system. The program will fund new residency slots 
using a competitive approach in which applicants demonstrate how their 
training of residents addresses key workforce objectives, such training 
in new models of care that are interprofessional.
    Unlike Medicare GME, which is only paid to hospitals, this funding 
will be available to consortia of teaching hospitals and other 
community-based healthcare entities, as well as to consortia of 
community-based healthcare entities. Consortia partners would partner 
to deliver a broad range of training experiences in different settings 
to strengthen experiential training in ambulatory care settings where 
the vast majority of the public receive care.
    Question. The Office for the Advancement of Telehealth (OAT) 
administers grants to incorporate telehealth in underserved and rural 
communities. What is HRSA doing to help States like New Hampshire with 
a many rural communities benefit from telemedicine access?
    Answer. The Telehealth Network Grant Program (TNGP) helps 
communities build the human, technical, and financial capacity to 
develop sustainable telehealth programs. These networks can be used to 
deliver quality healthcare to medically underserved populations in 
rural and frontier communities and also to provide information and 
training to healthcare providers in remote areas. Currently the Office 
for the Advancement of Telehealth (OAT) funds 20 TNGP grantees, 
including Mary Hitchcock Memorial Hospital located in Lebanon, New 
Hampshire.
    Additionally, OAT funds the Telehealth Resource Center Grant 
Program (TRC), which provides funding to 14 centers of excellence that 
assist healthcare organizations, healthcare networks, and healthcare 
providers in the implementation of cost-effective telehealth programs 
to serve rural and medically underserved areas and populations. The 
Northeast Telehealth Resource Center provides technical assistance to 
rural communities in New England (including New Hampshire), and New 
York.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
                   prevention and public health fund
    Question. What is the overall strategy in determining what HHS 
programs are funded with the Prevention and Public Health Fund (PPHF)?
    What internal departmental discussions take place to determine 
which agencies are recipients from and which agencies are donors to the 
Fund?
    Answer. Funding decisions for the Prevention Fund were made using 
the same formulation process used to develop the annual Federal budget 
and was decided in conjunction with other annual budget decisions. HHS 
works with public health, programmatic, and scientific experts in 
agencies across the department to identify effective and proven 
strategies that will improve health outcomes, promote prevention, and 
aim to reduce the cost of healthcare. Funds allocated to agencies are 
directly appropriated to HHS and are not based on contributions from 
agencies.
                       nonrecurring expenses fund
    Question. What analyses does the Department do before moving 
unobligated funds into the Nonrecurring Expenses Fund? Please detail 
this process.
    Answer. Prior to moving unobligated funds into the Nonrecurring 
Expenses Fund (NEF), the Department of Health and Human Services (HHS) 
works closely with the program offices in determining which funds are 
eligible. HHS is restricted in the types of Federal funds that may be 
transferred to the NEF. Funds must be expired and unobligated, meaning 
the funding is not available for current year obligations and is not 
obligated to a vendor or grantee. However, statutory requirements (31 
U.S.C. 1551-1558) require expired unobligated balances be used for 
routine adjustments to previously recorded obligations, meaning not all 
expired unobligated funds may be transferred to the NEF. As an account 
nears its time of cancellation, HHS is able to identify with more 
accuracy the amounts eligible to transfer. These unobligated balances 
would otherwise cancel or return to the Department of the Treasury if 
not transferred to the NEF. In addition, HHS may only obligate funds 
after notifying the Committees on Appropriations in the House of 
Representatives and the Senate of the planned use.
    Question. How does HHS decide what information technology (IT) 
projects merit Nonrecurring Expenses Fund dollars?
    Answer. HHS has used the NEF to fund critical capital acquisition 
projects necessary for the operation of the Department. NEF funded 
projects have reduced the financial impacts on current year funds, thus 
ensuring appropriations support key programs targeted by Congress. When 
the Department considers funding a project with NEF funds, the HHS 
Office of the Chief Information Officer and subject matter experts 
conduct a thorough review of each project to confirm that each project 
is eligible to receive NEF funding consistent with HHS legal authority, 
regulations, and policies.
    Question. Does HHS solicit formal or informal requests from 
agencies for Non-recurring Expenses Fund-related projects? Please 
provide details on what each HHS agency requested.
    Answer. The Department of Health and Human Services (HHS) does work 
with components to determine investments made through use of the 
Nonrecurring Expenses Fund (NEF). As part of the budget development 
process, HHS examines the needs across the agency seeking to balance 
funds availability, project timing, and optimal use of the fund sources 
available. Determining eligibility on a specific project is a fluid 
process with multiple stages including internal review, subject matter 
expert review, and approval by the Office of Management and Budget. In 
the fiscal year 2015 Congressional Justification to the Committees on 
Appropriations, HHS listed potential project investments, specifically 
financial system modernization and information technology 
infrastructure investments.
    Question. What programs would have received funding over the past 2 
years had funding not been siphoned off to fund the implementation of 
the health insurance Exchanges?
    Answer. The NEF has funded a number of critical capital acquisition 
projects identified by the Department other than the implementation of 
the health insurance Marketplace, including the beginning work on 
financial system modernization, enabling HHS to upgrade its core 
financial platform for both functionality and security reasons, 
critical Cybersecurity infrastructure upgrades, and the initial stages 
for acquisition of an electronic case processing system in the Office 
of Medicare Hearings and Appeals. This system will aide in the 
processing of appeals and secure documents that are currently stored in 
paper files.
                         information technology
    Question. Describe the role of the department's Chief Information 
Officer in the oversight of IT purchases. How is this person involved 
in the decision to make an IT purchase, determine its scope, oversee 
its contract, and oversee the product's continued operation and 
maintenance?
    Answer. HHS is a federated environment where IT purchase decisions 
are made at the Operating Division (OpDiv) level. To improve 
departmentwide visibility, the HHS Office of the Chief Information 
Officer (OCIO) chartered the HHS Domain Governance Office which 
provides oversight for IT acquisitions across the Department of Health 
and Human Services. The Domain Governance Office requires that OpDivs 
within HHS share IT acquisition and project forecasts through the 
Annual Procurement Forecast System. The HHS Chief Information Officer 
is a member of the IT Steering Committee, which reviews planned 
acquisitions and projects to direct strategy and to prioritize 
investments.
    Question. Describe the existing authorities, organizational 
structure, and reporting relationship of your department Chief 
Information Officer. Note and explain any variance from that prescribed 
in the Information Technology Management Reform Act of 1996 (The 
Clinger-Cohen Act) for the above.
    Answer. The Department level Chief Information Officer (CIO) 
provides varying levels of oversight to HHS's OpDivs in regard to the 
Clinger-Cohen Act. Many of the authorities are delegated to the OpDiv 
CIOs, such as governance, program training and management since the 
OpDiv CIOs have a direct line of sight into their investments. Since 
the HHS CIO operates in a decentralized funding structure, the office 
is working towards efforts to increase its ability to strategically 
manage the Department's IT portfolio via the three Domains of the IT 
Steering Committee: Administrative, Health and Human Services, and 
Scientific Research. There is also an HHS CIO Council in order to 
provide transparency and communications throughout HHS.
    Question. What formal or informal mechanisms exist in your 
department to ensure coordination and alignment within the CXO 
community (i.e., the Chief Information Officer, the Chief Acquisition 
Officer, the Chief Finance Officer, the Chief Human Capital Officer, 
and so on)? How does that alignment flow down to department 
subcomponents?
    Answer. The IT Steering Committees (ITSCs) that were recently 
chartered include membership from the Chief Financial Officer (CFO) and 
Chief Acquisition Officer (CAO). Additionally, the Deputy CFO has a 
Financial Governance Board that includes representation from the Chief 
Information Officer (CIO), CAO, Chief of Budget, and the Chief Human 
Capital Officer. The ITSC charter is built upon information from the 
Senior Procurement Executive regarding use and analysis of the Annual 
Procurement Forecast in order to leverage HHS's buying power 
proactively. The CIO has also been proactively engaging with the Chief 
Human Capital Officer in transformative processes used to hire IT 
professionals.
    Question. How much of the department's budget goes to 
Demonstration, Modernization, and Enhancement of IT systems as opposed 
to supporting existing and ongoing programs and infrastructure? How has 
this changed in the last 5 years?
    Answer. In fiscal year 2014, 12.4 percent of HHS's total IT budget 
will go to Development, Modernization, and Enhancement (DME) of IT 
Systems. When Grants to States and Local IT investments are excluded 
(representing 40 percent of the total HHS fiscal year 2014 IT budget), 
the DME portion rises to 20.2 percent. In each case, the trend over the 
past 5 years has been downward from a high of 22 percent in fiscal year 
2010. An off-trend spike to 24.6 percent (30.8 percent without grants) 
in fiscal year 2011 represents DME activity related to implementation 
of the Patient Protection and Affordable Care Act.
    Question. Where and how are you taking advantage of this 
administration's ``shared services'' initiative? How do you identify 
and utilize existing capabilities elsewhere in government or industry 
as opposed to recreating them internally?
    Answer. HHS used the administration's ``shared services'' 
initiative to institutionalize shared services requirements across the 
Department. A dedicated workgroup under the purview of the Enterprise 
Architecture Review Board developed HHS's Shared Services Strategy 
which illustrates the long-term strategy and sets the foundations to 
successfully develop, deploy, and use shared services at HHS. To 
promote the identification and reuse of services, HHS documented and 
published the Shared Services Catalog (available to all HHS employees 
through the intranet). This catalog contains a list of services 
available to use across HHS or within a specific Operating Division 
(OpDiv). Additionally, HHS contributed a list of cross-Agency services 
to Uncle Sam's List so other Agencies can reuse HHS's services. A 
publicly available summary of the Shared Services Strategy can be found 
here: http://www.hhs.gov/ocio/ea/sharedservices.html.
    HHS continues to leverage cloud computing technologies, through 
carefully assessing technical, security, and contractual requirements 
to ensure seamless integration to avoid disruption of current services 
and the mission that we provide for the American public.
    Question. Provide short summaries of three recent IT program 
successes, projects that were delivered on time, within budget, and 
delivered the promised functionality and benefits to the end user. How 
does your department define ``success'' in IT program management?
    Answer. Human Resources IT (HRIT).--The HRIT Shared Service project 
is in progress and has gone through the Enterprise Project Life Cycle 
(EPLC) with the approval to proceed to the final phase of 
implementation. The implemented solution is expected to provide HHS 
with a true end-to-end hire to retire solution that improves data 
integrity by eliminating errors caused by using three separate 
platforms (HR, Time & Labor, Pay). The project is expected to be fully 
implemented on time and within budget.
    HRIT will strengthen internal controls and support the 
administration's PortfolioStat initiative which seeks opportunities to 
shift to commodity IT, leverage technology, procurement, and best 
practices across the whole of government, and build on existing 
investments. By implementing HRIT as a shared service, HHS is poised to 
achieve:
  --reduction of manual data calls;
  --implementation of a single data entry, multiple use model;
  --elimination of manual data reconciliation processes;
  --reduction in the number of handoffs to effect routine HR actions.
    Personal Identity Verification (PIV) Implementation.--HHS 
identified operational improvements to the Department Identity, 
Credential, and Access Management (ICAM) program in order to reduce 
costs and enhance security. The ICAM program reviewed the proposed 
design for the enhancements in the HHS Access Management System (AMS) 
to simplify the efforts by applications to integrate with the 
Department-wide Single Sign-On system. HHS has a mature capability to 
allow user access to the HHS network with a PIV badge issued at Level 
of Assurance (LOA 4). HHS also has the capability to accept PIV or 
Common Access Card (CAC) credentials from other Federal agencies/
departments for access to applications that are integrated with the HHS 
Access Management System for Single Sign-On services. At this time 
there are 18 Enterprise systems and 5 Operational Division specific 
systems integrated with AMS.
    HHS LMS SABA 7.2 Upgrade.--The HHS Learning Portal, also referred 
to as the LMS (Learning Management System), is utilized by the 
Department of Health and Human Services (HHS) to provide a single 
standardized training recording system for all of HHS. The LMS is 
currently used by approximately 80,000 HHS employees and 20,000 
contractors. The LMS software is provided by Saba and is hosted by 
General Strategies (GS). GS also provides technical and consulting 
support to HHS for the LMS and associated technologies. HHS took 
advantage of new technology in SABA version 7.2 with a major upgrade 
that enabled the LMS application to run more efficiently and allow 
employees to have a more enjoyable user experience.
    Defining IT Program Management Success at HHS.--Success at HHS in 
IT Program Management is supported by the HHS Enterprise Performance 
Life Cycle (EPLC) established in 2008. It is an essential part of our 
IT management and governance. The process provides a framework for 
planning, managing and monitoring projects to ensure our projects are 
sufficiently resourced, well managed and achieve their objectives. In 
addition, the EPLC ensures compliance with a variety of IT management 
mandates, including: security, privacy, records management, and 
accessibility. All HHS IT projects are required to follow the EPLC.
    The Department's ongoing commitment to the alignment between IT and 
business processes, organization structure, and strategy has 
strengthened Program Management at HHS. At the highest levels, this 
alignment is achieved through proper integration of enterprise 
architecture, business architecture (business need), process design, 
organization design, and performance metrics to provide value and 
support the mission of HHS.
    Question. What ``best practices'' have emerged and been adopted 
from these recent IT program successes? What have proven to be the most 
significant barriers encountered to more common or frequent IT program 
successes?
    Answer. Best Practices.--The Department will be offering an IT 
Project Management Training contract for all Operating Divisions to 
enhance the technical skill set of our project management community.
    HHS has also taken an active approach to advertise and reuse 
services that are shared between Government agencies, citizens, and 
industry at one or more levels. HHS has developed a catalog of inter-
agency, intra-agency, and intra-OPDIV services that can be shared 
within HHS and with all Federal agencies as seen in our Shared Services 
Catalog. Currently, HHS offers 170 services within specific OPDIVs, 
across HHS, and to other Federal agencies.
    HHS also utilizes CIO Council Meetings as a forum within which best 
practices are collaboratively shared between the participating HHS 
Operational Divisions.
    Significant Barriers.--Some of the most significant barriers to IT 
program success are ensuring that secured and trusted information is 
constantly updated and monitored to align with the rapidly changing 
technology environments. The lengthy acquisition process itself can be 
a barrier to IT success given the rapid pace at which technologies 
continually evolve. Other notable barriers include a risk adverse 
culture, lack of accountability, and shared risk.
    Lastly, one of the Department's most valuable resources is our 
Federal workforce--hiring people with the right skill sets for the job. 
The HHS OCIO has previously relied strongly on contract support to 
supplement our Federal workforce. OCIO is in the process of hiring 
Federal staff to fulfill the needs within areas of Enterprise 
Architecture, capital planning and project management. The hiring of 
these candidates will allow us to build a reliable, talented and 
innovative workforce within the agency that can help accelerate the 
goals of HHS.
    Question. Describe the progress being made in your department on 
the transition to new, cutting-edge technologies and applications such 
as cloud, mobility, social networking, and so on. What progress has 
been made in the CloudFirst and ShareFirst initiatives?
    Answer. HHS continues to make progress in transitioning to new, 
cutting-edge technologies and applications departmentwide. HHS has 
operationalized and integrated a departmentwide Federal Risk and 
Authorization Management Program (FedRAMP) security authorization 
process and is actively using FedRAMP. HHS is developing cloud based 
use cases that will enable other programs to implement and manage cloud 
computing systems in accordance with best practices and Federal 
standards, to improve the transition to a cloud environment.
    Question. How does your department implement acquisition strategies 
that involve each of the following: early collaboration with industry; 
RFP's with performance measures that tie to strategic performance 
objectives; and risk mitigation throughout the life of the contract?
    Answer. Within the OCIO's office, the Vendor Management office 
provides outreach and serves as a conduit to industry and the CIO's 
principal office to connect those vendors who provide products and 
services that meet the needs and requirements for projects that are 
underway or in the planning stage.
    Each departmentwide RFP is developed based on the requirements and 
needs of the Operating Divisions. Service Level Agreements and other 
performance measures are included to ensure these requirements are met 
in the most efficient and effective manner possible.
    Question. According to the Office of Personnel Management, 46 
percent of the more than 80,000 Federal IT workers are 50 years of age 
or older, and more than 10 percent are 60 or older. Just 4 percent of 
the Federal IT workforce is under 30 years of age. Does your department 
have such demographic imbalances? How is it addressing them? Does this 
create specific challenges for attracting and maintaining a workforce 
with skills in cutting edge technologies? What initiatives are underway 
to build your technology workforce's capabilities?
    Answer. OCIO completed an organizational assessment in March 2014 
to update vision, goals, core principles and strategic mapping of OCIO 
goals which included efforts to position the IT workforce to readily 
meet new and complex challenges. OCIO is engaging the workforce through 
a series of communications efforts to include quarterly Town Halls, 
monthly Brown Bag discussions with the CIO and promotion of close 
engagements and frequent communications between managers and employees. 
Communication efforts also include OCIO branding to reflect the one-
team focus in response to OCIO customers. An IT Community Workforce 
Plan is under development which will allow us to:
  --identify IT goals and external workforce trends;
  --identify impact on IT Talent;
  --establish the resulting talent needs;
  --identify gaps in our IT competencies; and
  --describe how IT is to attract high-quality talent and build the 
        best IT team.
    Question. What information does your department collect on its IT 
and program management workforce? Please include, for example, details 
about current staffing versus future needs, development of the talent 
pipeline, special hiring authorities, and known knowledge gaps.
    Answer. HHS has a CIO Workplan that sets goals for each OpDiv. The 
overall goal is to create and administer a comprehensive plan that 
aligns with the Information Resource Management Strategic Plan and day-
to-day work of HHS IT employees that motivates them to achieve their 
best. One of the goals for 2014 is to develop an IT Community Workforce 
Development Plan to:
  --provide challenging projects to work;
  --ensure skills stay current with training;
  --hold employees accountable to deliver; and
  --reward top performers.
    The OCIO is developing an IT workforce plan and establishing an 
OCIO led working group to prioritize goals and implement this activity 
by expanding opportunities for leadership, training, and workforce 
development. We will position the IT workforce to meet new and complex 
challenges by promoting collaboration and enabling free flow of 
information to others who can use it to advance public health and human 
services. Additionally, OCIO is actively sponsoring student interns to 
engage new IT professionals in government services through the Pathways 
program and the Student Volunteer Program.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
                     area health education centers
    Question. The Area Health Education Centers (AHEC) program received 
a $1.8 million increase in fiscal year 2014. Please provide an 
explanation on how these funds were used, including a rationale for the 
allocation between the Infrastructure Development Grants and the Point 
of Service and Maintenance Grants. In the response, please include a 
comparison of the funding allocation to the past 2 fiscal years.
    Answer. HRSA is currently exploring options for fiscal year 2014 to 
support the AHEC program with available resources. The options may 
include increasing funding to current AHEC grantees to the amount 
requested in their fiscal year 2012 grant proposals, or supporting new 
AHEC centers.
    Use of the funds will be consistent with past years, and with the 
requirements of the fiscal year 2012 funding opportunity announcement 
of the program. Recognizing that Infrastructure Development (ID) 
grantees need additional funding support, the fiscal year 2012 AHEC 
Program funding opportunity announcement distinguished between the ID 
and Point of Service Maintenance and Enhancement (POSME) phases of the 
program. These phases were treated as two separate options with 
distinct funding levels in the grant competition. AHEC ID applicants 
were able to request for up to $250,000 for each center, and AHEC POSME 
applicants were able to request up to $102,000 per AHEC center.
    The grant competition and review processes for each of the phases 
also play a factor in how funding is allocated within program. No 
formula or targeted ratio of funding is utilized in making decisions 
for how much funding is allocated to grantees applying for the two 
phases. The proposals and funding requests of the grantees and the 
merit evidenced through their separate objective reviews guide 
decisionmaking for which grantees should receive an award, and at what 
amount. Applications for both phases of the program received an 
objective and independent peer review performed by a committee of 
experts who assessed the technical merit of each grant application. In 
the case of this program, the objective review committee also made a 
specific recommendation for each application as applicable to approve 
or disapprove any new center(s) requested. Last, based on the advice of 
the objective review committee, the HRSA was responsible for final 
selection of grantees and allocating funding as able per the grantee's 
requests, and in making these decisions consideration was given to the 
Sense of the Congress per section 751 of the Public Health Service Act 
``that every State have an area health education center program in 
effect under this section.''
    Question. Why has HRSA held back funding for building approved 
centers when grantees included these in their budget when they were 
awarded multicenter grants?
    Answer. While the fiscal year 2013 enacted budget for the AHEC 
program did include an increase in funding for the AHEC program, 
sequestration significantly reduced available funding, and there was 
not sufficient funding for new activity within the AHEC program to 
support all of the new centers that had been proposed to be added in 
fiscal year 2013. Accordingly, funding for existing AHEC activity was 
prioritized and no new AHEC centers were funded in fiscal year 2013.
    Note that, in anticipation of budgetary constraints, the Notices of 
Award for all fiscal year 2012 grantees informed them of the fact that 
funding for new center(s) would depend on future appropriation levels. 
Specifically, the Notices of Award Stated if the fiscal year 2013 
appropriation level for the AHEC program is the same or less than the 
fiscal year 2012 appropriation level, the additional new center(s) may 
not be funded.

    Senator Harkin. And I would just say publicly, my good 
friend from Kansas, that Ms. Burwell is testifying tomorrow 
before my other committee, the authorizing committee. 
Hopefully, we will get her through and get her in place soon.
    I will, as the chairman, give her some time. Working with 
my ranking member here, I hope that sometime after she gets 
settled and gets fully briefed up, that we will have her up 
here to talk about implementation.

                          SUBCOMMITTEE RECESS

    Senator Moran. Mr. Chairman, thank you very much. I welcome 
that. I have requested an appointment with the nominee and 
expect to have that within the next few days. I look forward to 
getting acquainted with her.
    The point I would make is that this kind of hearing that we 
just had today is valuable, but it ought not be in lieu of a 
Secretary. We ought to do this kind of thing on an ongoing 
basis, and I welcome the opportunity to work with you to 
accomplish that.
    Senator Harkin. Thank you very much, Senator Moran.
    Thank you all very much. And with that, the committee will 
stand adjourned.
    [Whereupon, at 11:40 a.m., Wednesday, May 7, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]