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




                                                        S. Hrg. 113-768

                                                        Senate Hearings

                                 Before the Committee on Appropriations

_______________________________________________________________________


                                                   Department of Labor,

                                             Health and Human Services,

                                             and Education, and Related

                                                Agencies Appropriations




                                                      Fiscal Year 2015


                                        113th CONGRESS, SECOND SESSION
       
       
       
        DEPARTMENT OF EDUCATION
        DEPARTMENT OF HEALTH AND HUMAN SERVICES
        DEPARTMENT OF LABOR
        NONDEPARTMENTAL WITNESSES













                                                        S. Hrg. 113-768

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

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

                                HEARINGS

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________  

                     Department of Education
                Department of Health and Human Services
                          Department of Labor
                       Nondepartmental Witnesses

                               __________

         Printed for the use of the Committee on Appropriations


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



   Available via the World Wide Web: http://www.gpo.gov/fdsys/browse/
        committee.action?chamber=senate&committee=appropriations

                               __________

                         U.S. GOVERNMENT PUBLISHING OFFICE 

87-251 PDF                     WASHINGTON : 2016 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Publishing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001














  
                      COMMITTEE ON APPROPRIATIONS

               BARBARA A. MIKULSKI, Maryland,  Chairwoman
PATRICK J. LEAHY, Vermont            RICHARD C. SHELBY, Alabama, Vice 
TOM HARKIN, Iowa                         Chairman
PATTY MURRAY, Washington             THAD COCHRAN, Mississippi
DIANNE FEINSTEIN, California         MITCH McCONNELL, Kentucky
RICHARD J. DURBIN, Illinois          LAMAR ALEXANDER, Tennessee
TIM JOHNSON, South Dakota            SUSAN M. COLLINS, Maine
MARY L. LANDRIEU, Louisiana          LISA MURKOWSKI, Alaska
JACK REED, Rhode Island              LINDSEY GRAHAM, South Carolina
MARK L. PRYOR, Arkansas              MARK KIRK, Illinois
JON TESTER, Montana                  DANIEL COATS, Indiana
TOM UDALL, New Mexico                ROY BLUNT, Missouri
JEANNE SHAHEEN, New Hampshire        JERRY MORAN, Kansas
JEFF MERKLEY, Oregon                 JOHN HOEVEN, North Dakota
MARK BEGICH, Alaska                  MIKE JOHANNS, Nebraska
CHRISTOPHER A. COONS, Delaware       JOHN BOOZMAN, Arkansas

                   Charles E. Kieffer, Staff Director
             William D. Duhnke III, Minority Staff Director
                                 ------                                

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

                       TOM HARKIN, Iowa, Chairman
PATTY MURRAY, Washington             JERRY MORAN, Kansas, Ranking
MARY L. LANDRIEU, Louisiana          THAD COCHRAN, Mississippi
RICHARD J. DURBIN, Illinois          RICHARD C. SHELBY, Alabama
JACK REED, Rhode Island              LAMAR ALEXANDER, Tennessee
MARK L. PRYOR, Arkansas              LINDSEY GRAHAM, South Carolina
BARBARA A. MIKULSKI, Maryland        MARK KIRK, Illinois
JON TESTER, Montana                  MIKE JOHANNS, Nebraska
JEANNE SHAHEEN, New Hampshire        JOHN BOOZMAN, Arkansas
JEFF MERKLEY, Oregon

                           Professional Staff

                            Adrienne Hallett
                              Mark Laisch
                             Lisa Bernhardt
                            Michael Gentile
                             Robin Juliano
                              Kelly Brown
                      Laura A. Friedel (Minority)
                      Jennifer Castagna (Minority)
                          Chol Pak (Minority)
                         M.V. Young (Minority)

                         Administrative Support

                              Teri Curtin
                              
                              
                              
                              
                              
                              
                              
                              
                              
                              
                              
                              
                              
                              
                              
                              
                            C O N T E N T S

                              ----------                              

                                HEARINGS
                        Wednesday, April 2, 2014

                                                                   Page

Department of Health and Human Services: National Institutes of 
  Health.........................................................     1

                        Wednesday, April 9, 2014

Department of Labor: Office of the Secretary.....................   115

                       Wednesday, April 30, 2014

Department of Education: Office of the Secretary.................   165

                         Wednesday, May 7, 2014

Department of Health and Human Services: Office of the Secretary.   237

                              ----------                              

                              BACK MATTER

Departmental Witnesses...........................................   321
    Corporation for Public Broadcasting..........................   321
    Railroad Retirement Board....................................   326
    Office of Inspector General..................................   328

List of Witnesses, Communications, and Prepared Statements.......   695

Nondepartmental Witnesses........................................   330

Subject Index....................................................   701
    Corporation of Public Broadcasting...........................   701
    Department of Education: Office of the Secretary.............   701
    Department of Health and Human Services......................   704
        National Institutes of Health............................   704
        Office of the Secretary..................................   706
    Department of Labor: Office of the Secretary.................   708
    Railroad Retirement Board....................................   708
        Office of Inspector General..............................   709


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

                              ----------                              


                        WEDNESDAY, APRIL 2, 2014

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Tom Harkin (chairman) presiding.
    Present: Senators Harkin, Durbin, Mikulski, Moran, Cochran, 
Shelby, and Kirk.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                     National Institutes of Health

STATEMENT OF FRANCIS S. COLLINS, M.D., PH.D., DIRECTOR
ACCOMPANIED BY:
        ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY 
            AND INFECTIOUS DISEASES
        HAROLD E. VARMUS, M.D., DIRECTOR, NATIONAL CANCER INSTITUTE
        GARY H. GIBBONS, M.D., DIRECTOR, NATIONAL HEART, LUNG AND BLOOD 
            INSTITUTE
        STORY C. LANDIS, PH.D., DIRECTOR, NATIONAL INSTITUTE OF 
            NEUROLOGICAL DISORDERS AND STROKE
        CHRISTOPHER P. AUSTIN, M.D., DIRECTOR, NATIONAL CENTER FOR 
            ADVANCING TRANSLATIONAL SCIENCES


                opening statement of senator tom harkin


    Senator Harkin. The Appropriations Subcommittee on Labor, 
Health and Human Services, and Education, and Related Agencies 
will come to order. Good morning, everyone, and welcome. Sorry 
we are a little late. We had a vote at 10--that is all.
    Well, today will be my final Appropriations budget hearing 
for the NIH (National Institutes of Health) as the chair of 
this subcommittee. I took over this subcommittee from Senator 
Lawton Chiles in 1989. That is a long time ago it seems, a 
quarter century. I am so proud of all that we have done--all of 
us here--often on a bipartisan basis, to transform the National 
Institutes of Health into truly the jewel and the crown of 
biomedical research not only in the United States, but 
globally.
    On Tuesday, as many of you know, I was on the NIH campus to 
help dedicate the new John Porter Neurosciences building. I was 
struck as I drove around the campus by the growth and 
modernization that has taken place there in the last 25 years. 
But that physical transformation has been more than matched by 
the transformational science and discovery that has sprung from 
that campus.
    If you do not mind, a little bit of reminiscences. My first 
year as chair was the first year that we invested NIH dollars 
in an exciting new project to map the human genome, 1989. I 
will never forget. I had taken over this subcommittee and I was 
visited by Dr. James Watson, whom I had never met before, but 
of course I had read about him--the famous Nobel Prize winner--
Watson and Crick, discoverers of the double helix. And so, I 
was quite full of myself when as a freshman Senator I was 
visited by this great scientist who wanted to talk to me about 
investing in mapping and sequencing the human gene. I had no 
idea what he was even talking about at that time, but he 
brought me along a little bit, and so we were able to put a 
little bit of money into that.
    Thanks again to all that initial work. And thanks to the 
work of Dr. Collins and his colleagues at NIH. We can now 
sequence the human genome at a fraction of the cost that it 
required, and in a shorter timeframe. I might just add, there 
was a study done by the Battelle Institute. It came out last 
year and said that the U.S. Federal Government's $3.8 billion 
funding of the Human Genome Project between 1988--actually it's 
1989, but that is okay--between 1988 and 2003 drove $796 
billion in U.S. economic impact due to the growth of the 
genomics technology industry and the use of genomics in 
healthcare, energy, agriculture, and other sectors--quite a 
rate of return on investment.
    And consider this: In 1989--I remember it well in the 
1980s--HIV (human immunodeficiency virus) was a death sentence. 
Today, thanks in large part to the leadership of Dr. Anthony 
Fauci, HIV is a manageable chronic disease, and we know how to 
prevent it. Since 1989, the proportion of older people with 
chronic disabilities has dropped by nearly one-third. Cancer 
death rates in the U.S. are now falling at a rate of nearly 1 
percent each year. And each 1-percent decline saves our Nation 
nearly $500 billion. There has been near miraculous progress in 
the fight against childhood cancers with the 5-year survival 
rate for the most common type, acute lymphocytic leukemia, now 
rising to a 90-percent cure rate. That is fantastic.
    Two of our witnesses here today direct centers that did not 
exist, that were not part of NIH in 1989. The National 
Institute of Mental Health moved from SAMHSA (Substance Abuse 
and Mental Health Services Administration) to NIH in 1992, and 
this subcommittee created the National Center for Advancing 
Translational Sciences (NCATS) in 2011. And although the 
directors are not here today, I am particularly proud to have 
authored the bill that created the National Institute on 
Deafness and Communication Disorders in 1988. Again, as I said, 
we worked to elevate the Genome Research Office at that time to 
a center in 1989, and we created the National Center for 
Complementary and Alternative Medicine in fiscal year 1992. 
Looking back to 1989, my notes tell me that in 1989 a Yale 
scientist named Francis Collins led a research team to discover 
the gene for cystic fibrosis.
    How far the NIH has come in 25 years. So many Nobel Prizes. 
So many life-saving discoveries. This subcommittee has had no 
higher priority than to support NIH and the scientists all 
across America dedicated to reducing suffering and improving 
public health. So this is a bittersweet moment for me and for 
all of us who revere the work of NIH because these great 
achievements are in the past. The future leadership of NIH is 
threatened by penny wise, pound foolish thinking by too many 
here in the Congress. Most in Congress are obsessed by budget 
deficits. I am more concerned by our deficits of vision and 
ambition and leadership.
    I am proud to say that since 1989, I have either chaired or 
been the ranking member of this subcommittee. Most of that time 
with Senator Arlen Specter. We kept changing back and forth as 
the leadership of the Senate would change, more recently with 
both Senator Shelby and now Senator Moran on this committee. So 
it has been, for me, an enlightening experience, through all 
these years. I do not have a science background, a bit of an 
engineering background, but not much of science. So for me it 
has just been eye opening to see what has happened with NIH 
through all these years.
    As our Government charts a course of stagnation and 
disinvestment in biomedical research, other countries are 
surging ahead. China's government pledged to increase its basic 
research investment by a staggering 26 percent just in the last 
year and will invest more than $300 billion in biotechnology 
over the next 5 years, twice what we are planning on doing.
    So this is the context in which we consider the proposed 
funding levels for fiscal year 2015. The Murray-Ryan budget 
deal partially replaced the sequester for the coming year, and 
while I am pleased that the subcommittee has a solid top line 
figure to work with, these austere budget caps are wreaking 
havoc on NIH and other national priorities.
    With a non-defense cap that increases by $583 million this 
year, it is mathematically impossible to fully replace the 
remaining NIH sequester and provide just an inflationary 
increase to NIH without forcing additional cuts to education, 
and job training, and other priorities.
    By not replacing the sequester this year, we are foregoing 
$56 billion that could be invested in programs to grow our 
economy, programs like NIH. The President proposed a fully 
offset opportunity growth and security initiative that 
represents the $56 billion in lost--that was lost to sequester. 
That initiative would allow for investing an additional $900 
million in NIH, enough to bring NIH back to the pre-sequester 
level and then provide a small increase. That is what we are 
losing by clinging to this devastating policy of sequester. 
Make no mistake: Keeping the sequester in place will mean a 
steady, destructive erosion in our NIH investment. It is no 
longer a question of politics; it is just a question of math.
    So I look forward to the discussion today about the 
exciting work that NIH is doing in the face of these budget 
problems, and in the hopes that we can all work together to 
support this vital institution, and to maintain America's 
leadership in our biomedical sciences. With that, I will yield 
to Senator Moran for his opening statement.


                    statement of senator jerry moran


    Senator Moran. Mr. Chairman, thank you. I look forward to 
continuing to work with you during the remainder of your term 
as chairman of this subcommittee along with Senator Shelby, the 
ranking member, and Chairwoman Mikulski to see that we 
accomplish some of the goals that you outlined in your 
statement.
    And I do appreciate Dr. Collins and his colleagues being 
with us today to discuss the National Institutes of Health. In 
my view, NIH represents hope for millions of patients suffering 
from conditions from Alzheimer's disease to cancer. NIH-funded 
research has raised life expectancy, improved the quality of 
life, and is an economic engine helping to sustain America's 
competitiveness.
    Over the past year, cutting-edge NIH-supported research 
discovered a blood test to predict if a healthy person will 
develop dementia or Alzheimer's disease, uncovered a set of 
rare mutations to a gene that provides protection against type 
2 diabetes, and used targeted immunotherapy to induce remission 
in leukemia. What wonderful developments. A continued 
commitment to NIH is essential to address our Nation's growing 
health concerns, spur medical innovation, sustain American 
competitiveness, and reduce healthcare costs.
    I think NIH is at a critical juncture. We have spent years 
focusing on doubling the NIH budget, and now a decade later the 
NIH budget is falling victim to an Administration's budget that 
does not prioritize biomedical research. The fiscal year 2015 
budget touts an increase of $200 million, or 0.7 percent, 
seven-tenths of a percent. However, with the use of, really, a 
budget gimmick, the increase is all but eliminated with the 
President's proposal to increase the evaluation set-aside. 
Under the President's proposal, $142 million of the $200 
million increase would be transferred to other programs within 
the Department of Health and Human Services, leaving NIH with 
only a $58 million increase.
    Without a consistent commitment to funding our premiere 
medical research agency, the future of biomedical research in 
the United States is in jeopardy. Grant success rates are at an 
all-time low. The average age of a first-time R01 grantee is 42 
years old, up from 38 years old in 1980. I looked out across 
the list of the panel of witnesses and discovered that you all 
remain very young, so perhaps that is defeating the point I am 
trying to make. But our researchers are becoming older as we 
continue this process. In fact, our principal investigators who 
are 65 or older receive more than twice as many R01 grants than 
those 36 and under. Young scientists, which we desperately 
need, will be discouraged by these statistics, and many have 
fled research fields or left for opportunities in other 
countries, putting our Nation at a serious risk for losing our 
global competitiveness in the biomedical research field and 
reducing the chances that we find cures and treatments.
    Dr. Collins has consistently raised this concern about what 
he calls ``deep long-term damage'' to biomedical research, and 
we should all pay attention to his warnings. We cannot let 
these research opportunities slip away. We cannot lose the 
brilliant scientists, the scientific minds that will make 
future ground-breaking discoveries in biomedical research to 
alternative careers or other countries. And we must not 
squander the scientific capacity that we have developed.
    I believe funding decisions represent more than just 
dollars. They reflect our Nation's priorities. And this 
Congress faces unprecedented challenges to reduce Government 
spending. Now is the time to reevaluate our funding priorities 
and invest after evaluating those priorities in biomedical 
research. This is the time of promise in research, and the 
United States should be at the forefront in this area. To do 
so, we must commit to pay for the research. We must accomplish 
this. And I thank you, Mr. Chairman.
    Senator Harkin. Thank you, Senator Moran. Well, again, Dr. 
Collins and colleagues, welcome again to our subcommittee. I 
got your statement. I read it. It will be a part of the record 
in its entirety. And, Dr. Collins, we will recognize you. Just 
proceed as you so desire for 10 minutes or so, or whatever it 
takes you to get it done. Welcome back, Dr. Collins.


              summary statement of dr. francis s. collins


    Dr. Collins. Well, thank you, and good morning, Chairman 
Harkin, Ranking Member Moran, and members of the subcommittee. 
Let me introduce the folks at the table who are here with me: 
Over to your right, my left, Dr. Harold Varmus, the Director of 
the National Cancer Institute (NCI), formerly the director of 
the NIH; next to him, Dr. Gary Gibbons, Director of the 
National Heart, Lung, and Blood Institute; and immediately to 
my left, Dr. Christopher Austin, Director of the new National 
Center for Advancing Translational Sciences, NCATS; to my 
right, Dr. Story Landis, the Director of the National Institute 
of Neurological Disorders and Stroke; and finally as already 
mentioned, Dr. Anthony Fauci, Director of the National 
Institute of Allergy and Infectious Diseases. And they are here 
to answer your questions, as am I.
    Well, it is a great honor for us to be here to appear 
before you and present the Administration's fiscal year 2015 
budget request, and to provide an overview of our Agency's 
critical role in enhancing the Nation's health through 
scientific discovery. But before I begin today, I would be 
remiss if I did not take a moment to thank you, Mr. Chairman, 
for your extraordinary leadership on this subcommittee over 
these 25 years. You have been a remarkable--I would say even 
historic--advocate for biomedical research and for the NIH. We 
are all very grateful for your service, and will truly miss you 
on this subcommittee in the years to come.
    [The graphic follows:]

   [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                 national institutes of health mission


    Dr. Collins. NIH has been advancing our understanding of 
health and disease for more than a century. Scientific and 
technological breakthroughs generated by NIH-supported research 
are behind many of the gains that you can see in this image of 
how our country has enjoyed gains in longevity and in health. 
For example, over the last 60 years, deaths from heart disease 
have fallen by more than 70 percent. Meanwhile, cancer death 
rates, as you have already cited, have been dropping about 1 
percent annually for the last 15 years, life expectancy gains 
that have saved our Nation trillions of dollars. Likewise, HIV/
AIDS treatments have greatly extended lives, and prevention 
strategies are enabling us to envision the first AIDS-free 
generation since this virus emerged more than 30 years ago.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Dr. Collins. But none of these advances could have happened 
without the strong support of the Administration and the U.S. 
Congress, and specifically of this subcommittee. This 
subcommittee came together in a bipartisan way, and I want to 
thank you for that, to make it possible in the fiscal year 2014 
omnibus appropriation to turn a corner.


                           budget challenges


    To be honest, the previous year was quite challenging for 
us. Sequestration applied damaging cuts to ground-breaking 
medical research and affected the morale of the scientific 
community. That impact was further exacerbated by the 
Government shutdown, which forced me to send 12,000 scientists 
home for 16 long days, and required us to turn patients away 
from the NIH Clinical Center.
    With the fiscal year 2014 omnibus, we are optimistic that a 
corner has been turned after a difficult decade during which 
NIH has lost more than 20 percent of its purchasing power for 
medical research, 20 percent down from where we were in 2003. 
The Administration now proposes a fiscal year 2015 budget 
request that is $211 million, or .7 percent, above the fiscal 
year 2014 level. This budget request reflects the President's 
and the Secretary's commitment to improving the health of the 
Nation and to maintaining our leadership in the life sciences 
while remaining within the constraints of the Murray-Ryan 
budget envelope. It allocates resources to areas with the most 
extraordinary promise for medical research, while maintaining 
the flexibility to pursue unexpected scientific opportunities, 
and to address unforeseen public health needs.
    Within the Administration's fiscal year 2015 budget, NIH 
will increase our primary funding mechanism for investigator-
initiated research, the research project grants, or RPGs. And 
this is a critical priority. In fiscal year 2013, our grant 
success rate, as you can see in this graph, reached an all-time 
low of 16.8 percent, a number that desperately needs to rise 
again.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. By careful stewardship of resources, we expect 
to support 9,326 new and competing RPGs next fiscal year, which 
will be an increase of 329 over fiscal year 2014 levels, 
although the total number of grants we support will remain 
approximately the same.
    But now, let me turn to some of the exciting scientific 
opportunities that NIH is pursuing today.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                     future of biomedical research


    Dr. Collins. I can assure you the future of biomedical 
research has never been brighter. Basic science, for which the 
Federal Government serves as the main source of support in the 
U.S., had led the way. Advances in genomics, proteomics, stem 
cells, imagine, the microbiome, and other technologies have led 
to phenomenal advances in our understanding of how life works, 
and also the discovery of more than a thousand new risk factors 
for disease.
    NIH will continue to spend a little more than half of our 
budget on these basic science advances. But as you know, we are 
also deeply committed to catalyzing the translation of these 
discoveries into clinical advances. And this can be quite 
challenging to the dismay of researchers, drug companies, and 
especially patients. We face a situation today where the vast 
majority of drugs entering the development pipeline fall by the 
wayside.
    The most distressing failures, as you see here, occur when 
a drug is found to be ineffective in the later stages of 
development, in phase two or phase three clinical trials, after 
years of work and millions of dollars have already been spent.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                   accelerating medicines partnership


    Dr. Collins. A major reason for such failures is that 
scientists often have not had enough information to choose the 
right biological targets, and if a drug is aimed at the wrong 
target, it will not be effective against the disease it was 
intended to treat, and a failure will occur.
    So to this end, we were particularly thrilled to announce 
the launch of the Accelerating Medicines Partnership, AMP, just 
6 weeks ago.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. This pre-competitive partnership, which will 
share all data openly, will initially focus on three disease 
areas that are ripe for drug discovery: Alzheimer's disease, 
type 2 diabetes, and the autoimmune disorders lupus and 
rheumatoid arthritis.
    Besides NIH, the partners in AMP include the FDA and 10 
biopharmaceutical firms, listed here, and a number of non-
profits, including patient advocacy groups.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                         universal flu vaccine


    Dr. Collins. This unprecedented public/private 
collaboration will use cutting-edge scientific approaches to 
sift through a long list of potential therapeutic targets and 
choose those most likely to lead to success, with the cost 
being shared evenly by NIH and industry.
    But we are not stopping there. Influenza is another area 
where we are poised for rapid progress. In fact, NIH-funded 
scientists are well on their way to developing a universal 
vaccine. The outside of the flu virus, shown here, is coated 
with tiny mushroom-shaped proteins, and each of these proteins 
has a head and a stem.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. Current vaccines target the head of that 
mushroom, but this mutates over time. Here you can see in 
yellow the changes that occurred in three different flu 
viruses.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. These changes, primarily in the head, are 
happening all the time. To keep up, a new vaccine must be 
produced every year.
    On the other hand, you can see here the stem of the viral 
protein remains almost entirely unaltered over time. A 
universal flu vaccine that targets the relatively stable stem 
would not only eliminate the need for an annual flu shot, but 
would also provide protection against outbreaks like the H5N1 
and H7N9 events in Southeast Asia that are causing considerable 
worldwide concern right now.


                            brain initiative


    Another major challenge is exploring what has been called 
the most complex structure in the known universe, the human 
brain. As you know, NIH is leading the new Brain Research 
through Advancing Innovative Neurotechnologies, B-R-A-I-N, 
BRAIN Initiative, and we are grateful for your support.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. This initiative will provide a foundational 
platform for major advances in Alzheimer's disease, autism, 
schizophrenia, traumatic brain injury, epilepsy, and many other 
brain disorders.
    But a final area of scientific opportunity that I want to 
highlight today involves one of our Nation's biggest and most 
feared killers, cancer. Until recently, our weapons for 
attacking cancer have been surgery, radiation, and 
chemotherapy, all of which can be effective, but carry risks. 
Recent advances have given us insights into the intricate 
workings of the cancer cell, and a whole new generation of 
targeted therapeutics is emerging, ushering in an era of 
individualized precision medicine.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                    opportunities in cancer research


    Dr. Collins. This image on the left shows a dramatic 
example of just how effective such targeted therapies can be 
because on the left is a scan of a melanoma patient who carries 
a mutation and a gene that codes a protein called B-Raf. Now, 
B-Raf is implicated when mutated in the development of cancer. 
The hot spots that you see all over this individual's body 
indicate dividing cancer cells that have spread throughout. 
After treatment with a new drug targeted to block the effects 
of mutant RAF, those hot spots almost vanish. The promise of 
targeted therapy is apparent.
    But now, there is a new powerful weapon in the arsenal, 
cancer immunotherapy, a revolutionary new approach that Science 
magazine named its 2013 breakthrough of the year.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. This involves harnessing the body's own immune 
system to fight this dreaded disease. In one of those new 
approaches, certain types of immune cells called T-cells--you 
can see them here--are collected from cancer patients and 
engineered to produce special proteins on their surface. When 
these engineered T-cells are infused back into patients, they 
have the power to seek and destroy cancer cells.
    And in this video, you can see one of those modified T-
cells doing just that, actually obliterating the cancer cell.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. Knowing how to turn T-cells into little Ninja 
warriors required big investments in basic biomedical research 
over more than a decade, but the consequences are starting to 
be amazing.
    I would like to share this story, in closing, of Emily 
Whitehead.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. Nearly 2 years ago, this brave little girl 
became the first pediatric patient to be treated with a new 
kind of cancer immunotherapy. Emily was suffering from acute 
lymphoblastic leukemia, a disease that, as was pointed out by 
Senator Moran, now we cure 90 percent of the time with 
chemotherapy. But distressingly, Emily was in the 10 percent 
where that fails.
    Her parents decided to enroll her in a pioneering cancer 
immunotherapy trial at the Children's Hospital of Philadelphia. 
Emily's T-cells were collected from her blood and re-engineered 
in the lab to recognize a protein found only on the surface of 
her leukemia cells. Those T-cells were then infused back into 
Emily's blood where they circulated throughout her body on a 
mission to seek and destroy leukemia. Just 28 days after 
treatment, she was cancer free, and she remains so to this day.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. Here is Emily today, a happy, healthy third 
grader who is looking forward to celebrating her ninth birthday 
next month. As her mom, Kerry, puts it, ``If you didn't know 
what happened to her and you saw her now, you would have no 
idea what she has been through.'' A wonderful story of success.


                          prepared statements


    And, Senators, I believe there are a great many more Emilys 
on the horizon. Our Nation has never witnessed a time of 
greater promise for advances in medicine. With your support, we 
can realize our vision of accelerating discovery across the 
vast landscape of biomedical research. From basic scientific 
inquiry to human clinical trials, the National Institutes of 
Hope is ready to move forward.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. Thank you, Mr. Chairman, for your support of 
NIH. My colleagues and I welcome your questions.
    [The statements follows:]
         Prepared Statement of Francis S. Collins, M.D., Ph.D.
    Good morning, Mr. Chairman and distinguished members of the 
subcommittee. I am Francis S. Collins, M.D., Ph.D., Director of the 
National Institutes of Health (NIH). It is an honor to appear before 
you today to present the Administration's fiscal year 2015 budget 
request for the NIH and provide an overview of our critical role in 
enhancing our Nation's health through scientific discovery.
    As the Nation's biomedical research agency, NIH's mission is to 
seek fundamental knowledge about the nature and behavior of living 
systems and to apply that knowledge to enhance human health, lengthen 
life, and reduce illness and disability. I can report to you that NIH 
leadership, employees, and grantees continue to believe passionately in 
this mission.
    Before I discuss the tremendous strides we have made and the 
exciting scientific opportunities on the horizon, I want to thank you, 
Mr. Chairman, and Ranking Member Moran, as well as your colleagues, for 
the recent fiscal year 2014 Omnibus Appropriation bill. The 
subcommittee came together in a bipartisan way to increase funding for 
NIH and we are truly grateful for your action. The past year has been 
challenging for us: The sequester reduced funding for groundbreaking 
medical research and affected the morale of the scientific community. 
This impact was further exacerbated by the shutdown.
    There is much good news to report about the science that we 
support. NIH has been advancing our understanding of health and disease 
for more than a century; scientific and technological breakthroughs 
generated by NIH-supported research are behind much of the gains our 
country has enjoyed in health and longevity. For example, deaths from 
heart disease have been reduced by more than 70 percent from 1950 to 
2008. Cancer death rates have been dropping about 1 percent annually 
for the past 15 years--life expectancy gains that save the Nation 
billions of dollars. HIV/AIDS treatment and prevention now enable us to 
envision the first AIDS-free generation since this virus emerged more 
than 30 years ago. NIH research also has given us vaccines to protect 
against an array of life-threatening diseases, including cervical 
cancer, influenza, and meningitis. We can look forward to a future in 
which advanced prevention and treatment strategies such as these allow 
everyone to have a significantly better chance of living a long and 
healthy life.
    These statistics tell you how far we have come--but our aim is to 
go even further, faster. To this end, the Administration's fiscal year 
2015 budget request for the NIH is $30.362 billion, $211 million, or 
0.7 percent, above the fiscal year 2014 level. This budget request 
reflects the President's and the Secretary's commitment to improving 
the health of the Nation and to maintaining our Nation's leadership in 
the life sciences. The request highlights investments in innovative 
research that will advance fundamental knowledge and speed the 
development of new therapies, diagnostics, and preventive measures to 
improve public health.
    The fiscal year 2015 budget request will enhance NIH's ability to 
support cutting-edge research and training of the scientific workforce. 
Within the Administration's fiscal year 2015 budget, we will continue 
to increase Research Project Grants (RPGs), NIH's funding mechanism for 
investigator-initiated research. NIH expects to support 9,326 new and 
competing RPGs in fiscal year 2015, an increase of 329 over fiscal year 
2014 levels. For fiscal year 2015, NIH anticipates funding a total of 
34,197 RPGs. The budget request allocates resources to areas of the 
most extraordinary promise for biomedical research, while maintaining 
the flexibility to pursue unplanned scientific opportunities and 
address unforeseen health needs.
    While we are very grateful for any budget increase, the fully paid 
$56 billion Opportunity, Growth, and Security Initiative (OGSI), a 
program included in the President's budget, would provide an additional 
$970 million investment in NIH programs that would allow NIH to fund or 
expand a host of other cutting-edge initiatives, speeding the 
development of vaccines and cures, and restoring sequestration cuts to 
the number of research project grants.
    Let me describe a few of the many areas in which NIH-supported 
research is opening up extraordinary opportunities to improve the 
health of the American public.
    A major program that began this year is the Brain Research through 
Advancing Innovative Neurotechnologies (BRAIN) Initiative, for which 
thanks are due to this subcommittee for its fiscal year 2014 support. 
NIH is a major player in this pioneering multiagency venture that will 
enable the creation of new tools capable of examining 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, we can begin to decode sensory experience and, potentially, 
even memory, emotion, and thought. Successful pursuit of the BRAIN 
Initiative will revolutionize neuroscience, providing a foundational 
platform for major advances in Alzheimer's disease, autism, 
schizophrenia, epilepsy, traumatic brain injury, and many other brain 
disorders.
    As technology allows us to tackle mind-boggling tasks like 
recording the activity of billions of nerve cells in the brain or 
determining the DNA sequence of tens of thousands of human genomes, 
researchers are generating enormous quantities of data at an 
unprecedented pace. The challenge posed by this revolution is how to 
store, retrieve, integrate, and analyze this mountain of complex data--
and transform it into knowledge that can improve human health. To 
address this challenge that affects virtually all areas of biomedical 
research, we have just launched the Big Data to Knowledge (BD2K) 
initiative. The goals of BD2K are to develop and disseminate new 
analytical methods and software, enhance training of data scientists, 
and facilitate broad use and sharing of complex biomedical datasets. 
With sustained investment and effort, we will overcome the challenges 
associated with Big Data to accelerate real-world applications of basic 
science discoveries.
    We are also excited about another area of intense interest: the 
development of therapeutics. Recent advances in genomics, proteomics, 
imaging, and other technologies have led to the recent discovery of 
more than a thousand risk factors for disease--biological insights that 
ought to hold promise as targets for drugs. But drug development is a 
terribly difficult and failure-prone business. To the dismay of 
researchers, drug companies, and patients, the vast majority of drugs 
entering the development pipeline fall by the wayside. The most 
distressing failures occur when a drug is found to be ineffective in 
the later stages of development--in Phase II or Phase III clinical 
studies--after years of work and millions of dollars have already been 
spent. A major reason for such failures is that scientists often have 
not had enough information to choose the right biological targets. If a 
drug is aimed at the wrong target, it won't work against the disease it 
was intended to treat.
    With that challenge in mind, we were thrilled last month to launch 
the Accelerating Medicines Partnership (AMP). This unprecedented 
public-private effort will use cutting-edge scientific approaches to 
sift through a very long list of potential therapeutic targets, and 
choose those most likely to lead to success. Besides NIH, the AMP 
partners include the FDA, 10 biopharmaceutical firms and a number of 
nonprofits, including patient advocacy groups. This precompetitive 
partnership, which will share all data openly, will initially focus on 
three disease areas that are ripe for discovery: Alzheimer's disease, 
type 2 diabetes, and the autoimmune disorders, lupus and rheumatoid 
arthritis. Through this team effort, we believe we can reach our shared 
goals of treating and curing disease faster.
    Preventing disease is another top priority, and influenza is one 
area of prevention in which we are poised for rapid progress. 
Currently, to provide protection against the rapidly evolving influenza 
virus, a new vaccine must be produced each year and we all need to get 
an annual flu shot. Also, despite best efforts, the vaccine isn't 
always ideal. In an average year, the flu claims up to 49,000 American 
lives and costs the U.S. economy about $87 billion. But it does not 
have to be that way. NIH-funded researchers are now working on a 
universal flu vaccine--designed to protect people against virtually all 
strains of the flu for extended periods of time and, thus, potentially 
reduce the need for annual flu shots. Of critical importance, such a 
vaccine could also protect against a future global flu pandemic.
    While we are several years away from having a universal flu vaccine 
available to the public, our researchers have already demonstrated 
proof of concept and are testing a number of approaches, including two-
stage ``prime boost'' vaccines and ferritin nanoparticles. Clearly, the 
prospect of a universal flu vaccine is not science fiction. Early 
clinical studies are already underway. With sustained investment, the 
United States may be a few years away from realizing its potential to 
benefit our health and our economy.
    As impressive as a universal flu vaccine would be, it is not the 
only trick we are teaching our immune systems. We are also aiming to 
harness the body's own immune system to fight cancer. Until recently, 
our weapons for attacking cancer have been largely limited to surgery, 
radiation, and chemotherapy--treatments that carry risks and cause 
adverse side effects. Now, after years of intense basic and 
translational research, we have an exciting new possibility: Cancer 
immunotherapy.
    Researchers have long been puzzled by the uncanny ability of cancer 
cells to evade the immune response. What stops the body from waging its 
own ``war on cancer?'' As it turns out, our bodies have built-in 
checkpoints to prevent our immune systems from going into overdrive and 
killing healthy cells. Now, NIH-funded researchers have discovered a 
way to genetically modify certain white blood cells called T-cells--the 
soldiers of the immune system--to attack tumor cells. In this new 
approach, T-cells are collected from cancer patients and engineered in 
the lab to produce special proteins on their surface, called chimeric 
antigen receptors (CARs). When the modified cells are infused back into 
patients, they multiply and, with guidance from their newly engineered 
receptors, seek and destroy tumor cells. Promising results in patients 
with leukemia prompted Science magazine to name this its 2013 
Breakthrough of the Year.
    Today, I have provided a very brief overview of NIH's past 
successes and continuing commitment to basic, translational, and 
clinical research. Our Nation has never witnessed a time of greater 
promise for advances in medicine. With your support, we can anticipate 
a future of accelerating discovery across NIH's broad research 
landscape, from fundamental scientific inquiry to human clinical 
trials. The ``National Institutes of Hope'' is ready to move forward.
    This concludes my testimony, Mr. Chairman. I look forward to your 
questions.
                                 ______
                                 
              Prepared Statement of Anthony S. Fauci, M.D.
    Mr. Chairman and Members of the Committee: I am pleased to discuss 
current and future plans for biomedical research at the National 
Institute of Allergy and Infectious Diseases (NIAID) of the National 
Institutes of Health (NIH). The President's fiscal year 2015 NIAID 
budget request of $4,423,357,000 billion is approximately $31 million 
more than the fiscal year 2014 funding level ($4,392,670,000).
    NIAID conducts, supports, and translates basic and clinical 
research into the development of diagnostics, therapeutics, and 
vaccines to detect, treat, and prevent infectious and immune-mediated 
diseases. NIAID has a dual mandate that balances research addressing 
current biomedical challenges with the capacity to rapidly respond to 
new threats from emerging and re-emerging infectious diseases and 
bioterrorism.
                      infectious diseases research
    HIV/AIDS.--NIAID is leading transformational progress in basic and 
clinical research on HIV/AIDS. The decades-long NIAID investment in 
HIV/AIDS research has made the goal of an AIDS-free generation a 
possibility with sustained effort. NIAID continues to improve and 
refine HIV prevention and treatment tools, including antiretroviral 
therapies to effectively manage disease and reduce HIV transmission, 
and pre-exposure prophylaxis to protect against HIV. NIAID also is 
advancing research toward the development of an effective HIV vaccine 
to complement existing prevention strategies. HIV vaccine development 
will be informed by NIAID efforts to identify immunological markers in 
the subset of people protected against HIV infection in the RV144 
trial, the first HIV vaccine trial to show modest efficacy. The NIAID 
Vaccine Research Center together with several NIAID grantees are making 
rapid progress on ways to generate broadly neutralizing antibodies to 
protect against multiple strains of HIV, research that may translate to 
vaccines and therapeutics of global public health significance.
    Years of NIAID-supported research on HIV pathogenesis and the role 
of HIV reservoirs have suggested the feasibility of curing some HIV-
infected individuals. NIAID will investigate promising reports of a 
handful of infants who were born HIV-positive but now test negative for 
the virus following aggressive antiretroviral treatment initiated 
shortly after birth by supporting a clinical trial to determine if this 
strategy is safe and effective for other infants. NIAID also will play 
a major role in implementing the President's $100 million HIV/AIDS cure 
research initiative. As part of this effort, NIAID will support 
additional research on HIV latency and persistence. Understanding these 
processes may reveal new strategies toward a cure.
    NIAID recently restructured its HIV/AIDS Clinical Trials Networks 
to capitalize on the growing body of promising HIV research findings 
and to better address current research questions. The Networks will 
focus on improved ways to prevent and treat HIV, tuberculosis and 
hepatitis C co-infections, and on research toward development of a 
vaccine, microbicides, and a cure.
    Tuberculosis.--Tuberculosis (TB) remains a significant cause of 
illness and death throughout the world, especially among those also 
infected with HIV. NIAID recently launched a genome sequencing project 
that will examine the genetic diversity of TB bacteria and patterns of 
drug resistance to understand TB pathogenesis and to identify new drug 
targets and molecular mechanisms of resistance. This research will be 
particularly important to address the emergence of multi- and 
extensively drug-resistant TB. NIAID-supported scientists also are 
working to modify the existing antibiotic spectinomycin to bypass 
mechanisms of resistance to this drug. These efforts have shown promise 
in TB animal models.
    Malaria.--NIAID continues to progress toward its goal to control, 
eliminate, and ultimately eradicate malaria worldwide. The development 
of vaccines is a critical part of this endeavor. NIAID researchers and 
grantees recently completed an early-stage clinical trial that showed a 
novel vaccine composed of weakened malaria sporozoites was safe and 
protected against malaria. NIAID has developed two new tests to rapidly 
and inexpensively detect resistance to artemisinin, a first-line 
antimalarial drug. NIAID also is exploring innovative methods to 
control the spread of malaria. For example, NIAID-funded researchers 
have established a bacterial infection that passes from female 
mosquitoes to their offspring and kills malaria parasites within the 
mosquitoes before they can infect humans.
    Other Infectious Diseases of Domestic and Global Health 
Importance.--NIAID is committed to research on infectious diseases 
affecting global health. Influenza is among the most important 
infectious diseases of domestic and global concern. NIAID research 
addresses the challenge of seasonal influenza and prepares for the 
threat of an emerging pandemic. NIAID is developing and evaluating 
vaccines against the avian influenza strains H5N1 and H7N9 to deploy if 
needed to prevent further spread among humans. NIAID also is examining 
these vaccines paired with adjuvants--components that enhance the 
immune response--to provide the greatest protection with the smallest 
dose possible. NIAID investigators and grantees are making significant 
progress toward the development of a universal influenza vaccine that 
could generate durable protection over a period of years against a wide 
range of seasonal and pandemic influenza strains. Studies conducted by 
NIAID scientists at the NIAID Special Clinical Studies Unit in the NIH 
Clinical Center are providing important clues into the susceptibility 
and immune response of patients to influenza infection. Future studies 
will examine the effectiveness of new vaccines and therapeutics.
    Respiratory syncytial virus (RSV) is a serious respiratory 
infection primarily of young children that causes significant illness 
and hospitalizations in the U.S. and thousands of deaths worldwide. 
There is no vaccine to protect infants and children against RSV. 
Researchers at the NIAID Vaccine Research Center recently determined 
the structure of a key RSV protein bound to a broadly neutralizing 
human RSV antibody and used it to design an experimental RSV vaccine 
that is effective in animal models. NIAID has advanced this 
groundbreaking RSV vaccine into early-stage clinical trials in humans. 
Science magazine highlighted this discovery among the top 10 scientific 
breakthroughs in 2013.
    Hepatitis C virus (HCV) is a significant cause of chronic liver 
disease and cancer, and often co-infects people with HIV. Traditional 
HCV therapies frequently have severe side effects and may not be 
successful in many patients. NIAID and NIH Clinical Center 
investigators recently led a Phase II trial of a new HCV drug, 
sofosbuvir. The trial demonstrated that sofosbuvir, combined with the 
antiviral drug ribavirin, was highly effective and well tolerated even 
in patients predicted to have poor outcomes with traditional HCV 
treatments. Sofosbuvir and similar therapies for the treatment of HCV 
have recently been approved, potentially revolutionizing treatment 
outcomes.
    Antimicrobial resistance is a significant public health challenge 
and an NIAID priority. NIAID recently reassessed research needs for 
this important issue and established a Leadership Group to design, 
implement, and manage the clinical research agenda for a new 
antibacterial resistance research network. NIAID provides resources to 
lower the investment risk for industry, academia, and non-profit 
organizations to facilitate a robust pipeline of diagnostics, vaccines, 
and therapeutics for resistant microbes.
          research on immunology and immune-mediated disorders
    NIAID's commitment to research on basic and clinical immunology 
continues to foster important insights that ultimately will help to 
better treat and prevent immune-mediated disorders, including food 
allergy. NIAID-funded investigators recently demonstrated that female 
sex hormones affect the gut microbiome and promote development of 
autoimmunity in an animal model, providing clues into why women are 
more likely to be affected by autoimmune diseases. NIAID-supported 
researchers have made progress in understanding how exposure to certain 
microbes in early life, especially those found in homes with dogs, may 
protect against the development of asthma and other allergies. NIAID 
grantees also developed two urine tests to diagnose and predict 
rejection of a transplanted kidney. These simple tests could one day 
replace the invasive procedure currently used to detect organ rejection 
and particularly would benefit African Americans, who are 
disproportionately affected by organ transplant rejection.
                               conclusion
    For more than 60 years, basic and clinical research conducted and 
supported by NIAID on infectious and immune-mediated diseases has 
spurred the development of vaccines, therapeutics, and diagnostics to 
improve the health of millions around the world. NIAID will continue to 
perform the basic, clinical, and translational research critical to 
advancing the health of our Nation and the world.
                                 ______
                                 
              Prepared Statement of Harold E. Varmus, M.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the National Cancer Institute (NCI) 
of the National Institutes of Health (NIH). The fiscal year 2015 NCI 
budget of $4,930,715,000 includes an increase of $7,944,000, or 0.2 
percent, compared to the fiscal year 2014 level of $4,922,771,000.
                  overview of nci research priorities
    This is an era of remarkable opportunity in cancer research. Armed 
with broad knowledge about how various cancers arise and with powerful 
new research tools, the NCI is well equipped to accelerate progress 
towards preventing, diagnosing, and treating cancer more effectively. 
This era of opportunity is due in significant part to the 
subcommittee's consistent support for biomedical research at NCI and 
NIH.
    The resources that you provide allow NCI to address an ambitious 
challenge: reducing the incidence, morbidity, and mortality for all of 
the many types of cancer, with tangible benefits for all Americans. The 
fiscal year 2015 budget will allow the NCI to build on the tremendous 
progress in many areas of cancer research, with the aim of improving 
outcomes for patients with all types of cancer.
    I will summarize some recent accomplishments and highlight new 
opportunities in five areas of NCI-supported research--genomics, cancer 
immunology, targeted therapeutics, bioinformatics, and prevention--to 
illustrate the breadth and pace of NCI's progress.
    The Cancer Genomics research that NCI supports has dramatically 
altered our understanding of how cancer develops, identified the 
molecular signatures that can be used to diagnose and categorize cancer 
more precisely, and provided new targets for therapeutic intervention. 
For example, two major initiatives--TCGA (The Cancer Genome Atlas) and 
TARGET (Therapeutically Applicable Research to Generate Effective 
Treatments)--have addressed nearly twenty common adult cancers and 
several less common cancers that occur in adults and children, 
revealing both tissue-specific patterns of genetic changes and changes 
that are common to several types of cancers. TCGA is a joint initiative 
of the NCI and the Human Genome Research Institute. During the past 
year, TCGA published comprehensive characterizations of acute myeloid 
leukemia, endometrial cancer, and clear cell renal carcinoma, among 
others. While every cancer is distinct genetically, many changes in the 
genome are shared among a wide array of cancer types, and each type of 
cancer has distinct patterns that often reflect exposure to 
carcinogenic agents, such as tobacco smoke and ultraviolet radiation. 
As these massive surveys come to conclusion, the NCI's Center for 
Cancer Genomics is leading efforts to make full use of the TCGA 
results, including the best ways to incorporate genomic findings into 
the design of clinical trials.
    Some of the surprising findings from the TCGA and TARGET projects--
such as the involvement of genes that govern the chemistry of 
chromosomal proteins, that influence cell metabolism, and that guide 
the processing of RNAs and proteins--are influencing the study of 
cancer biology throughout the NCI's programs. TCGA and TARGET will 
certainly enlarge our understanding of carcinogenesis and will likely 
open new frontiers for preventing, diagnosing, and treating cancers.
    Cancer immunology is a rapidly advancing field that, in just the 
past few years, has dramatically altered our understanding of host 
defenses in response to cancers. It has also produced new and well-
validated methods for treating cancer using antibodies that attach to 
proteins on cancer cell surfaces and using methods that modulate the 
complex behavior of the immune system to attack cancer cells.
    For several years, monoclonal antibodies against cancer cell 
proteins have been used to treat blood cancers, such as certain 
lymphomas and leukemias, and subsets of several types of solid tumors, 
such as breast and colorectal cancer. More recently, immunotoxins have 
been created by genetic engineering to fuse antibodies with parts of 
bacterial toxins to selectively kill cancer cells. For example, such 
immunotoxins developed in the NCI intramural program have induced 
remissions in late stage cases of mesothelioma, ovarian cancer, triple-
negative breast cancer, drug-resistant hairy cell leukemia, and 
childhood acute lymphoblastic leukemia.
    There is also great optimism within the science community about 
modulating the immune system by introducing novel antigen receptors 
into cancer-killing T cells and especially by infusing antibodies that 
interfere with a system that impedes the immune response to cancer 
cells. These ``immune-modulating'' antibodies have recently received 
FDA approval, and other antibodies that bond other immune cell 
regulators may soon follow. In 2011, FDA approved a monoclonal 
antibody, called ipilimumab, to treat advanced melanoma. Some patients 
with metastatic melanoma being treated with ipilimumab are still alive 
several years after completing treatment. In 2013, another promising 
antibody to treat melanoma--lambrolizumab--received ``breakthrough'' 
designation by the FDA, helping expedite its development and further 
use in clinical trials, with the possibility of an expedited FDA 
review. In recognition of these and other recent achievements in the 
field of immunology, and the promise of further developments, ``cancer 
immunotherapy'' was named this year's Breakthrough of the Year by 
Science magazine.
    Targeted therapies, based on the use of drugs that inhibit specific 
proteins implicated in the behavior of cancer cells, are now being 
developed and tested for their effects in patients with many types of 
cancer. Over the past decade, FDA has approved several drugs that rely 
on this therapeutic approach to treat cancers of blood cells, lung 
cancer, melanoma, and other cancers, and many more are in development. 
This activity has accelerated because of discoveries in genomics, cell 
signaling pathways, chemistry, and structural biology, and with the 
identification of new ways to inhibit proteins that are required for 
the integrity of cancer cells.
    Mutant RAS proteins are perhaps the most prominent potential 
targets for new therapies that the academic and commercial research 
sectors have thus far failed to target with inhibitory drugs. The 
importance of the RAS gene family in cancer has been clear for over 30 
years; one family member, K-RAS, is mutated in more than 90 percent of 
pancreatic adenocarcinomas, about 40 percent of colorectal cancers, and 
about 25 percent of lung adenocarcinomas. For this reason, the NCI 
recently launched the RAS Project, a large-scale collaboration between 
investigators at the NCI's Frederick National Laboratory for Cancer 
Research and those in NCI's intramural and extramural communities. The 
RAS Project is motivated in part by new developments in the study of 
RAS proteins, including new information about their structural 
properties, binding of mutant RAS proteins to mutant-specific 
inhibitors, interactions with other cellular proteins required for 
function, and new tests for genes required to allow RAS mutants to 
exert their effects.
    Still, while pursuing a path that leads to ``precision medicine,'' 
the NCI must also maintain its capacity to test new ways to deploy the 
currently dominant means of therapy. For instance, a recent study of 
patients with metastatic prostate cancer showed markedly increased 
survival in men who received chemotherapy when starting anti-androgenic 
hormone therapy, a result that is likely to change clinical practice 
for a cancer that continues to kill about 30,000 American men annually.
    Drug resistance commonly emerges in cancers being treated with 
either traditional chemotherapies or novel targeted therapies, allowing 
disease to progress. Over the past decade, NCI-supported studies have 
revealed several mechanisms by which resistance occurs, including 
additional mutations affecting the target molecules, mutations in 
related genes, and changes in gene expression. In some cases, 
especially chronic myeloid leukemias, drugs that overcome resistance 
have been identified, developed and FDA-approved. But in other 
situations, resistance to targeted drugs remains a major impediment to 
success, and the NCI is making major investments to study this problem.
    Bioinformatics, the management of enormous sets of molecular and 
clinical data is a critical component of NCI's toolkit to study cancer 
in all of its manifestations. In work that ranges from cancer genomics, 
to cell signaling, and to clinical trials, the proper collection, 
analysis, storage, retrieval, and distribution of ``big data'' are 
critical elements of the Institute's charge. The NCI's Center for 
Bioinformatics and Information Technology (CBIIT) is addressing these 
responsibilities, in conjunction with NCI divisions. Part of the 
current effort requires the costly development of ``cloud computing'' 
to work with the vast (petabyte) amounts of genomic data generated by 
TCGA, TARGET, and other projects, and to assemble and ultimately 
integrate clinical data with genomic data in manageable forms to 
promote further discovery and improve cancer care.
    Prevention of cancer remains NCI's most desired goal. While 
complete avoidance of cancer may be impossible, since cancers often 
arise through spontaneous mutations, the control of tobacco use, 
vaccination against cancer-causing viruses (human hepatitis B virus and 
human papillomaviruses), sunlight avoidance, and regulation of dietary 
and carcinogenic substances (such as asbestos) have already reduced the 
incidence and the mortality rates of many cancers. For instance, 
between 2001 and 2010, largely due to the earlier reductions in tobacco 
use, there was a 25 percent decrease in male death rates and an 8 
percent decrease in female death rates due to lung cancer, the major 
cause of death from cancer in the United States. Likewise, vaccination 
with current HPV vaccines can drastically reduce the incidence and 
mortality of several types of cancer, including cervical, anal, and 
oropharyngeal cancers that are caused by infection with certain strains 
of HPV.
    Still, NCI recognizes that these successes are incomplete, and 
therefore invests heavily in efforts to address several pertinent 
behavioral and biological questions. For instance, despite dramatic 
declines in the use of tobacco, about 18 percent of Americans continue 
to smoke. New approaches are needed to convince young people not to use 
tobacco and to convince current smokers to quit. Use of HPV vaccines 
remains far from the desired levels among adolescent girls and boys in 
the United States, as the February 2014 report from the President's 
Cancer Panel emphasized. Better methods to promote the use of these 
potentially lifesaving vaccines are needed, at the same time as the 
dosing schedules and the protective breadth of the vaccines are 
improved.
                               conclusion
    An important measure of the overall success of NCI's work is the 
annual ``Report to the Nation,'' which describes trends in the 
incidence and death rates in the United States for many types of 
cancer. As has now been true for over a decade, the most reliable 
indicator--death rates from all cancers combined for men, women, and 
children--continues to decline by about one and a half percent per 
year. This reduction represents the savings of an enormous number of 
years of life and can be ascribed in large measure to the work of the 
NCI to prevent and treat cancers more effectively.
    Still, although mortality rates have been decreasing for most 
cancers, progress has not occurred as rapidly as desired, and for some 
cancers the numbers have not improved--or have worsened. Thus, much 
work remains. But the overall success apparent from both the public 
health data and recent achievements in the laboratory and clinical 
sciences inspires the NCI's conviction that expanded efforts on all 
frontiers of cancer research will produce better health in the United 
States and around the globe.
                                 ______
                                 
              Prepared Statement of Gary H. Gibbons, M.D.
    Mr. Chairman and distinguished members of the subcommittee: I am 
pleased to present the President's budget request for the National 
Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of 
Health (NIH). The fiscal year 2015 budget of $2,987,685,000 includes an 
increase of $4,948,000 over the fiscal year 2014 enacted level of 
$2,982,737,000.
    NHLBI's highest priorities for research investment are conditions 
that contribute substantially to the global burden of disease. Heart 
and lung diseases are the leading causes of death, disability, and 
rising healthcare costs from non-communicable diseases in the United 
States and worldwide. Research supported by the NHLBI has contributed 
to dramatic improvements in longevity, quality of life, and the wealth 
of the Nation. Deaths from cardiovascular disease, for example, have 
dropped by 70 percent in the past 40 years. This success reflects a 
balanced approach to supporting discovery science that spans basic, 
clinical, and population research. As accountable stewards seeking to 
maximize the public's return-on-investment, we are committed to 
continually improving our approach to strategic priority-setting and 
systematic evaluation of our portfolio to ensure the highest possible 
impact on science and health.
    Reflecting upon the NHLBI's legacy of success, many of the previous 
advances involved interventions at the latter stages of chronic 
disease. The fiscal year 2015 budget envisions a research agenda that 
elucidates the underlying mechanisms of disease such that clinicians 
can more accurately predict at-risk individuals and tailor preventive 
interventions for disease long before symptoms and irreversible damage 
occur. Our strategic vision is guided by the breathtaking scientific 
opportunities at hand and public health needs, in consultation with 
domain-experts at the leading edge of discovery science. The fiscal 
year 2015 budget continues a journey toward predictive, preventive 
precision medicine that holds promise for turning research-to-results, 
continuing the dramatic decline in the burden of chronic disease in our 
Nation.
                 unprecedented scientific opportunities
    Sustained investments in fundamental discovery science have led to 
new tools and technologies that stand to revolutionize medical research 
and clinical practice. Biomedical advances in congenital heart disease 
(CHD), the most common structural birth defect, have led to dramatic 
improvements in infant survival over the past 50 years, now with more 
adults living with CHD than children. However, current palliative 
approaches that repair birth defects have limitations that compromise 
the length and quality of life. Recent NHLBI-supported research, 
applying the latest genomic technologies, has identified spontaneous 
genetic mutations that increase the risk of CHD. This breakthrough 
finding is beginning to unlock the mysteries of CHD, helping to define 
what goes awry during the formation of the heart and lay the foundation 
for preventing or fixing defects in the womb. To that end, NHLBI is 
investing in regenerative medicine research to enhance the capacity of 
the heart to repair itself. The 2012 Nobel Laureate, Shinya Yamanaka, 
is part of a large inter-institutional team of NHLBI-funded 
investigators studying how to use a child's own cells to repair a 
congenital defect or create a tissue graft that could grow as a child 
ages.
    NHLBI investments in reparative biology and tissue bioengineering 
may also hold promise for accelerating new drug development platforms 
in partnership with the private sector. For example, NHLBI-funded 
investigators at Stanford University are using stem cells derived from 
adult tissue in a laboratory to create heart cells and model diseases 
such as those that perturb the electrical system of the heart in atrial 
fibrillation. These models are being used to more efficiently screen 
many novel drugs to determine efficacy as well as potential toxicities, 
augmenting the discovery pipeline.
               preempting and preventing chronic disease
    New scientific discoveries hold promise for making public health 
inroads to halt chronic diseases before they become debilitating. In 
sickle cell disease (SCD), for example, we have made great strides in 
reducing complications from the disease, such as penicillin to prevent 
fatal infections in infants, transfusions to reduce stroke risk, and 
hydroxyurea to reduce pain and hospital admissions. While these 
advances have extended lifespans from childhood into the sixth decade 
of life, they target complications not the disease itself--a disease 
that disproportionately affects African Americans (about 1 in 500 
births). We recently funded a new program that we hope will lead to the 
next generation of SCD treatments. Particularly exciting are studies 
that are attempting to raise fetal hemoglobin levels (the most powerful 
known modifier of SCD severity) through modulation of a gene called 
Bcl11A that is involved in the switch from fetal to adult hemoglobin 
during development. These studies open the door to potential treatments 
that can reactivate the fetal hemoglobin gene to inhibit the sickle 
cell shape change of red blood cells, which could preempt disease 
progression.
    Chronic obstructive pulmonary disease (COPD), the third leading 
cause of death, is a prime example of a chronic disease in which 
biomedical research advances have ameliorated symptoms; yet most 
interventions fail to dramatically alter the natural course of the 
disease. There is a critical need to identify at-risk individuals 
earlier in the disease process to prevent disease progression. NHLBI's 
COPDgene study is integrating genetics and imaging studies to 
characterize pre-clinical subtypes of COPD. Such characterization can 
enable clinicians to detect subtle changes in lung function and 
structure long before symptoms develop, conventional clinical tests 
show abnormalities, or progressive lung damage occurs. This leading-
edge research points to a horizon of individualized, precision medicine 
to preempt chronic lung disease.
           translating discoveries into public health impact
    While basic science is the cornerstone of scientific discovery, it 
is the beginning of a long path to public health impact. NHLBI has been 
a leader in traversing this road. Noted research initiatives like the 
Framingham Heart Study first identified the cardiovascular disease risk 
factors now addressed in routine physicals, which led to basic research 
that won Brown and Goldstein the Nobel Prize for their research on 
cholesterol metabolism--setting the stage for the development of statin 
drugs.
    We are currently amidst the unfolding of a similar story. The 
recent discovery of a mutation in the gene PCSK9 among a family with 
very low LDL cholesterol levels and reduced risk of heart attack has 
led to basic science discoveries and the rapid development of PCSK9 
inhibitors. This public-private partnership is moving toward potential 
widespread clinical use as the next generation of cholesterol lowering 
drugs.
    We now know, however, that we must look beyond one-size-fits-all 
treatments. Population science and genetics research have clearly 
demonstrated individual differences not only in predisposition to 
disease but also in treatment response. For example, 26 million 
Americans currently suffer from asthma--the leading cause of missed 
school days for children and a driver of preventable hospitalizations 
and emergency room visits. Asthma disproportionately affects African 
Americans; African American children are twice as likely to have asthma 
as white children and, as adults, are two to three times more likely to 
die of asthma than any other racial or ethnic group. While effective 
treatments exist, they do not reach all of those in need. NHLBI will be 
seeking applications focused on identifying barriers and testing 
strategies to enhance the implementation of evidence-based practices in 
diverse communities across the Nation. Beyond the current treatments, 
next generation therapies should target these differences to achieve 
maximal benefit. NHLBI's multi-center clinical trial network, 
AsthmaNet, is beginning the Best African American Response to Asthma 
Drugs (BARD) study to compare the effectiveness of different treatments 
on the management of asthma in African Americans. BARD will also assess 
how genetics may influence an individual's response to the treatments, 
which could be a paradigm shift in addressing challenges like 
disparities in asthma care.
                               conclusion
    We are in the midst of a very exciting period in science in which 
the capacity to enhance human health has never been greater. New tools 
and technologies are daring us to envision a future that is unburdened 
by chronic heart, lung, and blood diseases--not only ensuring wellness 
but also increasing economic productivity and reducing healthcare 
costs. For example, research shows that treating patients at moderate 
risk for cardiovascular disease with statin drugs to lower cholesterol 
can reduce annual medical spending by up to $430 million. Imagine how 
much can be saved by preventive interventions earlier in the disease 
course before symptoms begin and the costs of treatment rise 
dramatically. By achieving that goal, the return-on-investment of 
biomedical research will strengthen both the health and the wealth of 
the Nation.
                                 ______
                                 
              Prepared Statement of Story C. Landis, Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the National Institute of 
Neurological Disorders and Stroke (NINDS) of the National Institutes of 
Health (NIH). The fiscal year 2015 NINDS budget of $1,608,461,000 
includes an increase of $22,664,000 over the comparable fiscal year 
2014 level of $1,585,797,000. NINDS supports research to reduce the 
burden of neurological disorders, from basic studies of the normal 
brain through clinical trials of prevention and treatment 
interventions. Today, I will make four points: (1) the burden of 
neurological disorders is enormous; (2) past NINDS research has paid 
off; (3) opportunities for future progress are extraordinary; and (4) 
we have well informed plans to exploit these opportunities.
                    burden of neurological disorders
    Nearly 800,000 Americans experience a stroke each year, and 15 to 
30 percent of the 6.8 million stroke survivors alive today suffer 
permanent disability.\1\ Traumatic brain injury (TBI) is the leading 
cause of death and disability in children and young adults, common 
among the elderly, and a major concern for the military and veterans. 
In the United States, 2.5 million people receive emergency care for a 
TBI each year, and millions more suffer mild TBI (concussions). 
Epilepsy affects 2.3 million Americans, including 1 in 26 people at 
some time in their lives. Alzheimer's disease is receiving increasing 
attention, but most people are less aware that frontotemporal dementia 
(FTD) is the most common dementia in people under age 60, and vascular 
dementia, which affects blood vessels in the brain, is the second most 
common dementia overall and is so closely intertwined with Alzheimer's 
disease that most dementia patients have a combination of the two. 
Parkinson's disease, spinal cord injury, cerebral palsy, multiple 
sclerosis, and hundreds of rare diseases that affect children and 
adults add to the immeasurable human and economic burden.
---------------------------------------------------------------------------
    \1\ Statistics for stroke, TBI, and epilepsy from U.S. Centers from 
Disease Control and Prevention www.cdc.gov
---------------------------------------------------------------------------
                   progress for patients and families
    NINDS research drives progress directly, and indirectly catalyzes 
private sector advances. NINDS studies on risk factors and prevention 
contributed to a decline in the age-adjusted stroke death rate by 35.8 
percent from 2000 to 2010; the actual number of stroke deaths fell 22.8 
percent.\2\ NINDS research developed the only approved emergency drug 
therapy that restores blood flow to the brain following stroke, 
increasing likelihood of recovery with little or no disability by 30 
percent. Research has also demonstrated, defying conventional wisdom, a 
wider window of opportunity for stroke rehabilitation--even patients 
who start rehabilitation as late as 6 months after a stroke can 
improve, and patients can continue to improve 1 year after a stroke. 
For people with epilepsy, an implantable device approved this year 
senses impending seizures and delivers electrical pulses to stop them. 
Long-term NINDS research provided the essential foundation for private 
sector development of this device. Similarly, NINDS research directly 
and indirectly contributed to deep brain stimulation (DBS) therapies 
now in use for Parkinson's, essential tremor, and dystonia and under 
clinical testing for many other disorders, as well as to development of 
drugs for multiple sclerosis--10 are now on the market, including the 
first oral drugs. Overall, the private sector has nearly 450 medicines 
in development for neurological disorders, which would not be possible 
without the foundation of NIH research.\3\
---------------------------------------------------------------------------
    \2\ Circulation 2014; 129:e28-e292
    \3\ 2013 Report: Medicines in Development for Neurological 
Disorders, Pharmaceutical Researchers and Manufacturers of America 
http://www.phrma.org/innovation/meds-in-development
---------------------------------------------------------------------------
                      extraordinary opportunities
    Science and technology are opening unprecedented opportunities for 
progress against neurological disorders. Studies on the normal brain 
build the foundation. Notable recent advances, for example, revealed 
how the brain clears out debris during sleep, how molecular structures 
called ion channels control electrical activity, and the first human 
``connectome'' maps, providing astonishing views of the basic wiring 
diagram of living, thinking human brains. Advances in stem cell biology 
now enable researchers to reproduce in cell culture key steps in 
amyotrophic lateral sclerosis (ALS) and other disorders using brain 
cells derived from patients' own skin cells. Basic science has led to 
new insights that explain how chronic pain is wired in the brain, what 
happens in the brain following a concussion, and how cell-to-cell 
propagation of abnormally folded proteins could drive progression of 
Parkinson's, Alzheimer's, and other neurodegenerative disorders. New 
gene sequencing methods and high throughput gene silencing technologies 
have accelerated the discovery of genes that cause epilepsy and 
revealed potential new drug targets for Parkinson's disease. In a few 
dramatic cases, gene discoveries have led directly to treatments that 
help patients with rare disorders, including subtypes of dystonia and 
childhood neurodegenerative disease, but more often painstaking 
translational research is required to advance genetic and other 
discoveries toward therapies. Among the many examples, promising 
reports in laboratory animals this year demonstrated a drug therapy 
that prevented the development of epilepsy, cell transplants that 
controlled seizures, natural growth factor rescue of neonatal brain 
injury, therapies that improved cognition in Down syndrome, and a hand 
neuroprosthesis that restored touch sensation as well as movement.
                        programs and priorities
    NINDS relies heavily upon the wisdom and ingenuity of researchers 
throughout the United States to propose and evaluate the best 
scientific opportunities. Complementing investigator-initiated 
programs, NINDS initiatives target unmet opportunities or public health 
needs. Institute priorities reflect strategic and disease-specific 
planning that engages the scientific community and the public, and 
rigorous evaluation of programs, closing those that have met their 
goals or are no longer appropriate for today's science. Recent plans 
focused on stroke, epilepsy, Parkinson's disease, and Alzheimer's 
Disease-Related Dementias. Among recent initiatives:
  --the Stroke Trials Network will determine more quickly and at less 
        cost what treatment, prevention, and rehabilitation strategies 
        work best.
  --new Epilepsy Centers without Walls will target Sudden Unexplained 
        Death in Epilepsy (SUDEP) and disease modification or 
        prevention.
  --the Parkinson's Disease Biomarkers Program is developing assessment 
        tools that will overcome roadblocks to more effective clinical 
        trials.
  --the International TBI Research Initiative, coordinated with the 
        European Union and the Canadian Institute of Health Research, 
        will answer questions on care and classification of TBI that 
        have confounded development of interventions.
  --two major cooperative studies are investigating the long-term 
        changes in the brain years after a single TBI or multiple 
        concussions, coordinated via the Foundation for NIH's Sports 
        and Health Research Program, which was established with a 
        donation from the National Football League.
  --the NeuroBioBank, NINDS Human Genetics Repository, Federal 
        Interagency TBI Research database, Common Data Elements 
        Program, and an epilepsy clinical genetics data repository are 
        examples of new and continuing resource initiatives that 
        empower individual investigators and promote data sharing.
    Finally, and most ambitiously, the President's Brain Research 
through Advancing Innovative Neurotechnologies (BRAIN) Initiative will 
dramatically improve tools to understand heretofore unapproachable 
questions about how networks, or circuits, of brain cells enable us to 
perceive, think, and act. There are many reasons for confidence that 
this basic research initiative will ultimately advance progress against 
disease. Autism, dystonia, and epilepsy, for example, are fundamentally 
disorders of brain circuitry, and stroke, Parkinson's, and Alzheimer's 
disease disrupt brain circuits as nerve cells die. Even with our 
limited understanding of brain circuits and imprecise technologies for 
altering them, interventions that compensate for malfunctioning brain 
circuits already produce remarkable results. For example, DBS reverses 
symptoms for many people with Parkinson's disease and dystonia, and 
paralyzed people have controlled a robotic arm by signals directly 
monitored from their brains' movement control circuits. It is perhaps 
obvious that better understanding of brain circuits and tools to 
influence their activity would greatly improve these interventions, but 
history teaches that the most important payoffs of the BRAIN 
Initiative, as for basic research generally, may be entirely 
unforeseen.
                                 ______
                                 
           Prepared Statement of Christopher P. Austin, M.D.
    Mr. Chairman, Ranking Member, and Members of the Committee: Thank 
you for the opportunity to present to you the President's budget 
request for the National Center for Advancing Translational Sciences 
(NCATS) for fiscal year 2015. The fiscal year 2015 budget for NCATS is 
$657,471,000, which represents an increase of $25,075,000 over the 
fiscal year 2014 level of $632,396,000. The request includes 
$471,719,000 for the Clinical and Translational Science Awards (CTSA) 
program and $29,810,000 for the Cures Acceleration Network (CAN).
                         translational research
    In recent years, biomedical research has led to significant 
advances in our understanding of human biology. We have sequenced the 
human genome, explored the potential of stem cells, and discovered RNA 
interference. All of these advances have been celebrated as holding 
enormous promise for improving human health, but the road from promise 
to tangible improvements in public health has been long, complex and 
full of obstacles. NCATS aims to turn these game-changing discoveries 
into treatments for patients by addressing the ``translational 
sciences'' needed to close the gap. Translational sciences comprise the 
process of turning observations in the laboratory and clinic into 
effective interventions that improve the health of individuals and the 
public--from diagnostics and therapeutics to medical procedures and 
behavioral changes.
    NCATS takes a system-wide approach to diseases and the 
translational science process. It serves as an ``adaptor'' to connect 
basic, clinical and public health research and as a ``convener'' for 
disparate organizations that play roles in the process of turning 
discoveries into health improvements. Every NCATS initiative is a 
collaboration with partners in the public, private, government or 
nonprofit sector. The Center is committed to developing technologies 
and paradigms that improve the efficiency and effectiveness of one or 
more steps in the translational process, demonstrating that these 
innovations work in specific use cases, and disseminating the 
translational advances widely to catalyze improvements in all 
translational efforts with the ultimate and critically important goal 
of improving health.
                          mission into action
    One NCATS initiative that exemplifies these goals is the 
Discovering New Therapeutic Uses for Existing Molecules program. This 
program matches academic research groups with pharmaceutical companies 
to explore new disease indications for investigational compounds that 
are no longer being pursued by the pharmaceutical companies. The aim is 
to address several challenges in the translation process: the need for 
treatments for the several thousand diseases that have no effective 
therapy, the complicated process of negotiating agreements between 
parties who want to work together, and the largely ad hoc process by 
which academic and pharmaceutical researchers develop collaborative 
projects. In fiscal year 2013, NCATS funded nine projects covering 
eight disease areas, including Alzheimer's disease, Duchenne muscular 
dystrophy and schizophrenia. The program already has resulted in 
positive outcomes. Within 3 months of the grantees receiving funds, 
three compounds were being tested in humans for new uses--two to treat 
schizophrenia and one to treat Alzheimer's disease. In addition, the 
time to establish collaborations between industry and academics has 
been shortened to only 13 weeks from the more typical 9 months to a 
year. NCATS will solicit a second group of projects in fiscal year 
2014.
    The NCATS emphasis on innovation is central to its collaboration 
with the National Eye Institute and Organovo (which makes 3-D tissue 
printers) to develop 3-D, architecturally accurate eye tissue. Such 
tissues have the potential to accelerate the drug discovery process--
enabling treatments to be developed faster and at a lower cost--by 
giving researchers a more accurate view of how drugs will behave in 
human cells before those drugs ever enter clinical trials.
    NCATS serves as a catalyst to increase the efficiency of the 
translational ecosystem, as illustrated by the formation of a research 
team that included scientists from the Johns Hopkins School of Medicine 
and the NCATS Assay Development and Screening Technology Laboratory. 
This team developed new methods to overcome several translational 
roadblocks and was able to demonstrate their effectiveness by 
identifying a promising new compound that prevents the death of cells 
in the eye from glaucoma, a disease that can lead to blindness. Working 
together, the collaborators were able to solve a problem that none of 
them could address alone.
                    translational research spectrum
    Strengthening and supporting the entire spectrum of translational 
research with the ultimate aim of improved public health is a top 
priority for NCATS, and the CTSA program is crucial for these efforts. 
The CTSA program develops new technologies, methods, resources and 
operational paradigms that catalyze clinical research progress, and 
supports the training and career development of translational 
researchers. In June 2013, the Institute of Medicine (IOM) issued a 
report following a review of the CTSA program. The report recommended 
that NCATS take a more active role in the program's governance and 
direction, formalize the evaluation processes of the program, advance 
innovation in education and training programs, and ensure that the 
patient community participates in all phases of research. Since the 
publication of the report, the Center has increased programmatic and 
fiscal management of the grants that support the CTSA program and has 
streamlined the governance of the consortium, consulting closely with 
the CTSA Principal Investigators. A Working Group of the NCATS Advisory 
Council was established in December 2013 to provide input on measurable 
objectives for the program. The Working Group will submit its report to 
the NCATS Advisory Council in May 2014.
                         focus on rare diseases
    NCATS is deeply committed to developing treatments for rare 
diseases, which are defined in the U.S. as affecting fewer than 200,000 
individuals. There are approximately 6,500 rare diseases, but only 250 
have treatments. The NCATS Therapeutics for Rare and Neglected Diseases 
(TRND) program advances potential treatments for rare and neglected 
diseases to first-in-human trials, an approach known as ``de-risking.'' 
This strategy makes new drugs more commercially attractive to 
biopharmaceutical companies, despite the small patient population that 
is characteristic of these diseases. For example, in 2013, a clinical 
trial was started to evaluate a drug candidate called cyclodextrin as a 
possible treatment for Niemann-Pick disease type C1 (NPC1), a rare and 
fatal genetic brain disease affecting children. A TRND-led team of more 
than 20 investigators from NIH, academia, a pharmaceutical company, and 
patient groups developed cyclodextrin as a treatment as well as an NPC 
biomarker to guide its clinical development. An Investigational New 
Drug application for cyclodextrin was approved by the FDA, and a Phase 
I clinical trial currently is ongoing.
                       cures acceleration network
    CAN was authorized to advance the development of high-need cures 
and reduce significant barriers between research discovery and clinical 
trials. At NCATS, CAN is intended to advance initiatives designed to 
address scientific and technical challenges that impede translational 
research.
    Currently, CAN supports the Tissue Chip for Drug Screening Program, 
which is a partnership with the Defense Advanced Research Projects 
Agency (DARPA) and the FDA to develop 3-D human tissue chips that 
accurately model the structure and function of human organs, such as 
the lung, liver and heart. These devices will enable researchers to 
predict harmful health effects of new drugs more accurately, thus 
addressing one of the main reasons that drug studies often fail.
    NCATS has had success moving projects forward with its rare disease 
therapeutics program, but there are significantly fewer groups working 
on developing medical devices, for which there is a great need. NCATS 
could launch a comprehensive collaborative effort to accelerate device 
development as part of the next phase in the CAN program.
                               conclusion
    These projects are just a few examples of the exciting and 
innovative activities underway at NCATS. Though the Center is still 
relatively new, early successes demonstrate how its distinctive 
approaches can help solve some of the most challenging problems in 
translational science. We will build on our accomplishments over the 
past 2 years to accelerate our programs further in fiscal year 2015. I 
look forward to sharing more of our achievements with you as NCATS 
continues to evolve.

    [Clerk's note.--The following Institutes of the National 
Institutes of Health did not appear before the subcommittee 
this year. Chairman Harkin requested these Institutes to submit 
testimony in support of their fiscal year 2015 budget request. 
Those statements follow:]

    Prepared Statement of Linda S. Birnbaum, Ph.D., D.A.B.T., A.T.S.
    Mr. Chairman and Members of the Subcommittee: I am pleased to 
present the President's budget request for the National Institute of 
Environmental Health Sciences (NIEHS) of the National Institutes of 
Health (NIH). The fiscal year 2015 NIEHS budget of $665,080,000 
includes an increase of $556,000 from the comparable fiscal year 2014 
level of $664,524,000. The NIEHS Strategic Plan, Advancing Science, 
Improving Health continues to guide efforts toward fulfilling our 
mission to discover how the environment affects people in order to 
prevent both acute and chronic illness.
                             breast cancer
    NIEHS continues its robust investment into environmental factors 
affecting breast cancer, with the goal of learning how we can prevent 
this widespread disease. NIEHS and the National Cancer Institute (NCI) 
collaborated to support the Interagency Breast Cancer and Environmental 
Research Coordinating Committee, whose report, Prioritizing Prevention, 
recommends strategies to mitigate the environmental causes of breast 
cancer. NIEHS supports several major epidemiological and translational 
breast cancer initiatives. The Breast Cancer and the Environment 
Research Program is a transdisciplinary initiative cosponsored by NCI 
and NIEHS, in which basic scientists, epidemiologists, clinicians, and 
community partners work together to examine the effects of 
environmental exposures that may predispose a woman to breast cancer 
throughout her life, including exposures during puberty, menopause, 
pregnancy, and other ``windows of susceptibility.'' The NIEHS Sister 
Study has recruited a cohort of 50,884 U.S. and Puerto Rican women with 
a sister diagnosed with breast cancer, to prospectively study 
environmental and genetic factors that influence breast cancer risk and 
survival. More than 1,500 incident breast cancers have been diagnosed 
to date. A May 2013 publication from these researchers showed that DNA 
methylation profiling in blood samples may hold promise for breast 
cancer detection and disease risk prediction. The Agricultural Health 
Study, a collaborative effort by NCI, NIEHS, the National Institute for 
Occupational Safety and Health (NIOSH), and the Environmental 
Protection Agency (EPA), includes a comprehensive evaluation of many 
commonly used herbicides and pesticides and their potential impact on 
risk of breast cancer among 32,000 women who are married to pesticide 
applicators (primarily farmers).
                      environment and autoimmunity
    NIEHS supports scientists who are exploring how environmental 
exposures can cause immune system dysfunction. There is evidence that 
autoimmune diseases likely involve an environmental component. 
Therefore, the Environmental Autoimmunity Group in the Clinical 
Research Program at NIEHS is looking at the relationship between 
environmental factors and autoimmune disease. Autoimmune diseases 
result from an immune response directed against the body's own tissues 
and they collectively afflict approximately 24.5 million Americans, 
with women disproportionately affected. The cause(s) of autoimmune 
disorders remain largely unknown and are likely multifactorial 
involving both genetic and environmental influences. In 2013, NIEHS 
released a Funding Opportunity Announcement (FOA) to enable a better 
understanding of the links between exposures and autoimmune disease.
    NIEHS continues to support autoimmune disease research in the 
underserved community of Libby, Montana where the population has been 
exposed to asbestos minerals as a byproduct of vermiculite ore mining. 
Of particular concern is early childhood exposure, since susceptibility 
may be increased during this life stage. Recent efforts to characterize 
children's exposure in Libby estimated up to 15 times higher levels of 
airborne asbestos concentrations during outdoor activities and 73 
percent of the study participants indicated these activities occurred 
in the presence of children.\1\ NIEHS grantees are investigating 
whether childhood asbestos exposures in Libby are associated with 
pulmonary disease later in life.
---------------------------------------------------------------------------
    \1\ Ryan PH et al. Childhood exposure to Libby amphibole during 
outdoor activities. May 22, 2013. J. Expo. Sci. Environ. Epidemiol. 
Published online at: http://www.ncbi.nlm.nih.gov/pubmed/
?term=PMID%3A+23695492
---------------------------------------------------------------------------
                 environment and neurological disorders
    Evidence indicates there is both an environmental and genetic 
component in neurological disorders. NIEHS funds research to advance 
the understanding of environmental factors and gene-environment 
interactions related to neurodegenerative diseases and to help create 
new prevention and treatment approaches. At the NIEHS Centers for 
Neurodegeneration Science (CNS) and in partnerships with the National 
Institute of Neurological Disorders and Stroke (NINDS) and National 
Institute on Aging (NIA), teams of top scientists from different 
disciplines collaborate to examine the root causes of neurodegenerative 
diseases. CNS researchers study how exposure to pesticides, metals 
(e.g. arsenic, lead), and other chemicals affect the development of 
neurodegenerative diseases such as Parkinson's and Alzheimer's disease. 
NIEHS recently published two Funding Opportunity Announcements to 
expand neurological research: one on environmental exposures and 
Alzheimer's disease, and the other on environmental exposures and 
neurodegenerative disease.
    Autism is a highly variable neurodevelopmental disorder, which is 
likely influenced by environmental exposures. NIEHS-funded researchers 
have published work indicating prenatal vitamins might reduce the risk 
of having children with autism.\2\ Exposure to air pollution during 
pregnancy and during the first year of life was also associated with 
autism.\3\ \4\ \5\ NIEHS funds two key autism studies: the Childhood 
Autism Risks from Genetics and the Environment (CHARGE) study, and the 
Markers of Autism Risk in Babies-Learning Early Signs (MARBLES) study. 
In April 2014, NIEHS hosted a community virtual forum on autism and the 
environment that was webcast live and featured a panel of autism 
research experts.
---------------------------------------------------------------------------
    \2\ Int J Epidemiol. 2014 Feb 11. [Epub ahead of print] Maternal 
lifestyle and environmental risk factors for autism spectrum disorders. 
Lyall K1, Schmidt RJ, Hertz-Picciotto I.
    \3\ Epidemiology. 2014 Jan;25(1):44-7. Autism spectrum disorder: 
interaction of air pollution with the MET receptor tyrosine kinase 
gene. Volk HE1, Kerin T, Lurmann F, Hertz-Picciotto I, McConnell R, 
Campbell DB.
    \4\ JAMA Psychiatry. 2013 Jan;70(1):71-7. doi: 10.1001/
jamapsychiatry.2013.266. Traffic-related air pollution, particulate 
matter, and autism. Volk HE1, Lurmann F, Penfold B, Hertz-Picciotto I, 
McConnell R.
    \5\ Autism Res. 2013 Aug;6(4):248-57. doi: 10.1002/aur.1287. Epub 
2013 Mar 11. Prenatal and early-life exposure to high-level diesel 
exhaust particles leads to increased locomotor activity and repetitive 
behaviors in mice. Thirtamara Rajamani K1, Doherty-Lyons S, Bolden C, 
Willis D, Hoffman C, Zelikoff J, Chen LC, Gu H.
---------------------------------------------------------------------------
                research update on endocrine disruptors
    NIEHS is the leading government agency funding research on the 
human health effects of exposure to endocrine disrupting chemicals 
(EDCs). EDCs have the potential to interfere with a host of 
physiological functions, contributing to the development of costly and 
devastating illnesses such as obesity, diabetes, attention deficit 
hyperactivity disorder (ADHD) and behavioral disorders, asthma, 
endometriosis and uterine fibroids, reproductive disorders and 
infertility, and breast, uterine, and prostate cancers. Exposures to 
EDCs have been documented across the population, with fetuses and young 
children at greater risk due to their stages of rapid development. 
NIEHS is currently funding over 100 grants examining effects of EDCs 
including bisphenol A (BPA), arsenic, pesticides, flame retardants, and 
others.
    NIEHS has focused particular efforts on BPA, in part due to its 
ubiquity, that results in daily exposures for most people, mainly 
through diet. The Consortium Linking Academic and Regulatory Insights 
on BPA Toxicity (CLARITY--BPA) research program is a collaborative 
effort of the NIEHS, the National Toxicology Program (NTP), the Food 
and Drug Administration's National Center for Toxicological Research, 
and academic researchers studying a range of health endpoints, while 
also establishing new testing standards and methodologies. A recent 
study of another EDC, phthalates, shows that levels of some 
plasticizers have fallen since a Federal ban on their use in children's 
products and voluntary removal from many consumer goods.\6\ However, 
research at Brown University suggests that replacement chemicals may be 
just as damaging to the reproductive development of boys.\7\
---------------------------------------------------------------------------
    \6\ Zota AR, Calafat AM, Woodruff TJ. 2014. Temporal trends in 
phthalate exposures: findings from the National Health and Nutrition 
Examination Survey, 2001-2010. Environ Health Perspect; http://
www.ncbi.nlm.nih.gov/pubmed/24425099.
    \7\ Saffarini CM, Heger NE, Yamasaki H; Liu T, Hall SJ, Boekelheide 
K. 2012. Induction and persistence of abnormal testicular germ cells 
following gestational exposure to di-(n-butyl) phthalate in p53-null 
mice. J Andrology; 33(3):505-513. http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3607946
---------------------------------------------------------------------------
                   research update on gulf oil spill
    The release of millions of gallons of crude oil following the 2010 
Deepwater Horizon (DWH) disaster posed unpredictable risk to over 
130,000 workers trained and potentially involved in various remediation 
activities and to the people living along the Gulf Coast. To date, 
there have been limited studies on the human health effects of oil 
spills, especially long-term effects. The NIEHS Gulf Long-term Follow-
up Study (GuLF STUDY), funded in part by the NIH Common Fund, is 
investigating potential short- and long-term health effects associated 
with oil spill cleanup activities. The GuLF STUDY has enrolled 32,786 
individuals and has completed home visits for 11,200 participants, 
during which clinical measurements were taken and biospecimens were 
collected for future research.
     NIEHS leads the DWH Research Consortia that funds a network of 
academic and community partners to study health effects in people 
residing in regions affected by the disaster. These studies are 
examining resilience at the individual and community levels, 
perceptions of risk among women and children, and the potential 
contamination of seafood in the Gulf (Strategic Plan Goals 4-6). While 
NTP is conducting research to increase our understanding of the 
toxicology of crude oil, NIEHS grantees have preliminary results that 
suggest increased depression and anxiety among Gulf Coast residents, 
but also suggest strong community networks promote resilience.
                                 ______
                                 
            Prepared Statement of Josephine P. Briggs, M.D.
    Mr. Chairman and Members of the Committee: As the Director of the 
National Center for Complementary and Alternative Medicine (NCCAM) of 
the National Institutes of Health (NIH), I am pleased to present the 
President's fiscal year 2015 budget request for NCCAM. The fiscal year 
2015 budget includes $124,509,000, which is $384,000 more than the 
comparable fiscal year 2014 appropriation of $124,125,000.
    The National Center for Complementary and Alternative Medicine 
(NCCAM) is the Federal Government's lead agency for supporting 
scientific research on complementary practices and integrative health 
interventions. NCCAM's mission is to define, through rigorous 
scientific investigation, the usefulness and safety of such practices 
and their roles in improving health and healthcare.
               complementary and integrative health care
    Complementary and integrative health practices are defined as 
having origins outside of mainstream conventional medicine and include 
both self-care practices like meditation, yoga, and dietary 
supplements, as well as healthcare provider administered care such as 
acupuncture, chiropractic, osteopathic and naturopathic medicine. As 
these modalities are increasingly integrated into mainstream 
healthcare, NCCAM is committed to developing the scientific evidence 
needed by the public, healthcare professionals and health policymakers 
to make informed decisions about the use and integration of these 
various practices.
            use of complementary and integrative health care
    For the past decade, some 30 to 40 percent of Americans have used 
complementary and integrative health practices, according to data from 
the National Health Interview Survey (NHIS) conducted by the Centers 
for Disease Control and Prevention (CDC). The NHIS data shows that 
Americans are willing to pay for these services, spending some $34 
billion in 2007, which represented 1.5 percent of total health 
expenditures and 11 percent of out-of-pocket costs. NCCAM has worked 
with the CDC since 2002, to develop the questions on complementary 
healthcare that are included in the NHIS every 5 years (2002, 2007, and 
2012). Results from the latest survey are currently being analyzed for 
publication later this spring. Analysis will include, for the first 
time, a comparison of regional variations in use of complementary 
health practices by adults in the United States. We also look forward 
to the first detailed look at integration of complementary 
interventions into private medical practice when the results of the 
2012 National Ambulatory Medical Care Survey, which involved interviews 
of 30,000 physicians, are analyzed. NCCAM worked closely with the CDC 
to develop the questions used in this survey, as well.
                        impact on public health
    NCCAM's approach to setting priorities and investment in research 
is guided by the need for rigorous evidence that ultimately may have a 
significant impact on public health. One example of this approach 
involves a major clinical trial supported jointly by NCCAM and the 
National Heart, Lung, and Blood Institute examining the efficacy of 
using EDTA-based chelation therapy to reduce cardiovascular disease and 
prevent heart attacks. The trial, which involved 1,700 patients, showed 
a modest reduction in cardiovascular events for adults aged 50 and 
older who had suffered a prior heart attack. However, the results from 
a secondary analysis of the trial data suggest that the chelation 
treatments produced a marked reduction in cardiovascular events and 
death in patients with diabetes but not in those without diabetes. 
Addressing cardiovascular disease in diabetics is an important public 
health challenge, and better treatment options are required. As this 
study was not designed to discover how or why chelation might benefit 
patients with diabetes, further investigation is needed. Thus, NCCAM is 
exploring the possibility of a follow-up study in collaboration with 
several other NIH Institutes.
             reducing pain and improving symptom management
    According to the Institute of Medicine, pain is a major public 
health problem affecting more than 100 million Americans and costing 
the Nation over $600 billion in medical costs and lost productivity. 
Pain is also the most common reason Americans turn to complementary and 
integrative health practices, as conventional medicine often provides 
incomplete relief. Therefore, pain research is a top priority for 
NCCAM. As such, we continue to invest in research on several promising 
approaches for treating pain, such as spinal manipulation, massage, 
yoga, meditation, and acupuncture. We are particularly interested in 
understanding how these interventions work, for what type of pain 
condition, and for determining the optimal method of practice and 
delivery. Toward this end, NCCAM partners with others in supporting 
research initiatives, participates in the NIH Pain Consortium, and 
leads an NIH Task Force to improve standards for research on chronic 
low back pain (cLBP). The cLBP Task Force has developed common 
standards, measures, and other tools for clinical research on cLBP, and 
a report is expected to be published in The Journal of Pain later this 
year.
    Another important collaborative effort is our partnership with the 
National Institute on Drug Abuse and the Department of Veterans Affairs 
to foster research on complementary and integrative approaches to 
managing pain and other symptoms experienced by military personnel and 
veterans. A number of grant applications were submitted in response to 
our joint solicitation, and we anticipate funding multiple studies 
later this fall.
    One area of particular interest is the means by which complementary 
health practices affect the perception of pain by the brain. 
Specifically, we seek to understand the mechanisms by which emotions, 
attention, and context modulate pain. Using neuroimaging and cutting-
edge technologies, our intramural research program (IRP) is exploring 
the central mechanisms of pain and its modulation, with the long-term 
goal of improving clinical management of chronic pain through the 
integration of pharmacological and non-pharmacological complementary 
health approaches. NCCAM's IRP engages and leverages the exceptional 
basic and clinical neuroscience efforts across NIH.
                 advancing research on natural products
    Another important area of emphasis for NCCAM is research on natural 
products. In addition to exploring the underlying biological effects 
and mechanisms of natural products, such as dietary supplements, herbs, 
botanicals, and probiotics, we are concerned about their safety. While 
there is widespread use of these products by the public, there is 
limited scientific evidence about their effectiveness and safety. In 
addition to gaining greater understanding of whether natural products 
are effective or safe when used alone, there is a need to study how 
they interact with prescription medications. This is very important 
because many patients taking prescription medications also use natural 
products, such as dietary supplements, herbs and probiotics. To 
investigate these issues, NCCAM will launch an initiative to develop 
rigorous methods to evaluate potential interactions between natural 
products and medications. The ultimate goal is to ensure that 
consumers, healthcare providers, and health policymakers are better 
informed of the potential risks and/or benefits associated with the use 
of natural products in combination with medications.
    To propel needed innovations in technology and methodology for 
research on natural products, NCCAM and the NIH Office of Dietary 
Supplements are supporting the establishment of a Center for Advancing 
Natural Products Technology and Innovation. The Center is expected to 
better support the needs of the natural products community while 
reducing resource redundancies.
               providing useful information to the public
    NCCAM provides objective, evidence-based information to scientists, 
healthcare providers, and the general public through a variety of 
approaches, including emerging technology and platforms (i.e., video, 
social media, and mobile applications) and an information-rich Web site 
(www.nccam.nih.gov). Through these approaches, science-based 
information on the safety and efficacy of complementary and integrative 
health practices--already in wide public use--is made available to a 
broad audience.
                               conclusion
    NCCAM continues to support research, collaborate with others, and 
leverage partnerships to build the scientific evidence needed by 
consumers, healthcare professionals, and health policymakers regarding 
the safety and value of complementary and integrative health practices.
                                 ______
                                 
           Prepared Statement of Roger I. Glass, M.D., Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the Fogarty International Center 
(FIC) of the National Institutes of Health (NIH). The fiscal year 2015 
FIC budget of $67.776 million includes an increase of $0.292 million 
more than the fiscal year 2014 enacted level of $67.484 million.
    The United States and the NIH have historically been at the 
forefront of major scientific discoveries that have improved health 
here at home and around the world. Building on these successes, 
ambitious health targets for the future now seem possible--such as a 
decrease in the overall mortality rate of children under the age of 5, 
to 20 deaths per 1,000 over the next two decades and an AIDS-free 
generation. Reductions in morbidity and mortality from non-communicable 
diseases have also begun to affect populations worldwide. At this 
critical juncture, the Fogarty International Center mission and 
investments will continue to accelerate the pace and progress of 
research, engage the best and brightest minds by building capacity at 
research institutions across the globe, and develop the evidence needed 
to confront health challenges wherever they occur. By continuing to 
invest in training outstanding early-career investigators and 
developing future global health research leaders, Fogarty will advance 
the goals and sustain the leadership of the NIH and the U.S. Government 
in biomedical research, while improving the health of Americans and 
populations worldwide.
           today's basic science for tomorrow's breakthroughs
    Non-communicable diseases and disorders (NCDs) are rapidly becoming 
the dominant causes of poor health in all low and middle-income country 
(LMIC) regions \1\ except sub-Saharan Africa, where they are second 
only to HIV/AIDS. For example, World Health Organization data suggest 
that one billion people worldwide suffer from some type of mental, 
neurological or substance abuse disorder.
---------------------------------------------------------------------------
    \1\ LMIC is a World Bank designation for the classification of 
economies, based on Gross National Income (GNI) per capita. Low income 
countries have a GNI per capita of $1,035 or less, and middle income 
countries have a GNI per capita of $1,036-$12,615.
---------------------------------------------------------------------------
    In collaboration with eight NIH Institutes and Centers (ICs), 
Fogarty's Brain Disorders in the Developing World: Research Across the 
Lifespan program supports cutting-edge basic science research in LMICs 
on the nervous system. This research could lead to important new 
diagnostics, prevention and treatment strategies, and interventions of 
direct relevance to both LMIC and U.S. populations. For example, 
Argentinian scientists, in collaboration with Northwestern University, 
are studying neuroprotective gene therapy in a preclinical trial. This 
team demonstrated that a unique vector gene delivery system using two 
powerful neuroprotective molecules could be effectively injected over 
time restoring neuronal function. Future studies will use magnetic 
nanoparticles to perform targeted gene therapy with the goal of 
treating neurodegenerative disease such as Parkinson's, the second-most 
common neurological disease in the United States, affecting 
approximately 1 million Americans (National Parkinson Foundation).
                    nurturing talent and innovation
    Fogarty programs have supported long-term research training for 
more than 4,500 scientists worldwide, in collaboration with more than 
230 U.S. and LMIC research institutions. These investments provide 
unique training opportunities for early-career global health 
researchers, enabling them to effectively collaborate with foreign 
partners in diverse, low-resource international settings to confront 
global health challenges. Fogarty supports these hands-on, clinical 
research training experiences in LMICs in close partnership with a 
number of NIH ICs, providing experiences that encourage U.S. 
investigators to creatively approach problems under constraints that 
may not exist in high-income settings. Scientists trained with Fogarty 
support have conducted research on cardiovascular disease in Kenya, 
surgical capacity in Rwanda, mental health impacts of slum-dwelling in 
India, and the link between breast cancer and osteoporosis in China.
    Solving many of today's complex public health problems requires the 
engagement of investigators from a wide variety of fields. Fogarty's 
Framework Programs for Global Health Innovation awards support efforts 
to bring biomedical scientists together with students from various 
disciplines-- such as engineering, nutrition, business, law, 
environmental science, social sciences, agriculture and public health--
to develop research training initiatives that encourage innovative, 
health-related products, processes and policies. This program supports: 
scientists at Michigan State University studying interactions between 
agriculture, water resource utilization and malaria in Malawi; grantees 
at Northwestern University, Chicago, and the University of Cape Town, 
South Africa training researchers in developing healthcare technologies 
in Nigeria; and scientists at Tufts University School of Medicine, 
Boston, and Christian Medical College, Vellore, India developing a 
training program in translational research related to non-communicable 
and infectious diseases. These international teams are identifying 
critical health needs and conducting the research needed to develop and 
test novel solutions.
the path forward: addressing dual burdens of disease and harnessing the 
 information and communication technology revolution for global health 
                                research
    For over 25 years, Fogarty has contributed to the U.S. Government 
fight against HIV, training and supporting some of the world's foremost 
vaccine and biomedical researchers. As the global burden of disease 
shifts to a greater level of NCDs, Fogarty programs will continue 
critical work in HIV research training while also responding to both 
the NCD epidemic through research and training programs and the nexus 
between the HIV and NCD epidemics, represented by NCD co-morbidities of 
HIV infection and treatment. As scientific priorities evolve to match 
the changing burden of disease, Fogarty research and research training 
programs will train the best and brightest researchers around the world 
and facilitate scientific collaboration that meets new priorities while 
building on existing capacity and infrastructure.
    The information and communication technology (ICT) revolution 
presents exceptional opportunities and new tools for global health 
research and research education. ICT is a broad term that encompasses 
communication devices, applications, and services, such as cell phones, 
computers, radios, videoconferencing and distance learning. Fogarty 
will expand its support of innovation in the use of ICT to generate 
knowledge, scientific exchange, and research education in the hope of 
stimulating the capacity to develop and evaluate different models of 
distance learning and other ICT strategies, as well as adapt various 
ICT platforms for the needs of research and research educational 
communities. This will enable professionals in LMIC institutions to 
determine what works best for their particular settings as they develop 
novel education tools. Students and faculty will access, teach, and 
share information in creative and transformative ways, enabling new 
approaches to collaborative learning and problem solving in partnership 
with colleagues next door and across continents.
    The enormous potential for mobile technology to impact healthcare 
and research has led to the rapid development of new health-related 
phone applications. Rigorous evaluation of health outcomes after 
implementation of these interventions are often lacking. New emphases 
are being pursued to develop mobile technologies tailored to LMIC 
settings, assess their impact on health and determine how they can be 
effectively scaled up in diverse, low-resource settings. Significantly, 
this evidence base is not only critical for LMIC populations, but can 
also be applied to healthcare in the U.S.
    These are indeed exciting times for global health with new 
opportunities for partnership within and outside the NIH, the 
introduction of transformative technologies and mutual scientific 
priorities based on a shared burden of disease across high-income and 
LMIC. Capitalizing on these developments demands a multidisciplinary 
research workforce that can function across cultures and borders to 
solve common health problems. Fogarty will continue to invest in 
training the next generation of leaders in global health research at 
home and abroad to ensure that the U.S. will continue to play a key 
role in confronting the global health challenges of today.
                                 ______
                                 
        Prepared Statement of Patricia A. Grady, Ph.D., RN, FAAN
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's fiscal year 2015 budget request for the National 
Institute of Nursing Research (NINR) of the National Institutes of 
Health (NIH). The fiscal year 2015 NINR budget is $140,452,000 which is 
$128,000 more than the comparable fiscal year 2014 appropriation of 
$140,324,000.
    I appreciate the opportunity to share with you a brief summary of 
some of the exciting areas of research and future scientific directions 
of NINR. The mission of NINR is to promote and improve the health of 
individuals, families, and communities. We fulfill this mission by 
supporting clinical and basic research to build the scientific 
foundation for clinical practice, prevent disease and disability, 
manage and eliminate symptoms caused by illness, enhance end-of-life 
and palliative care, and train the next generation of nurse scientists. 
Today, I offer an overview of NINR's efforts and accomplishments in 
five key scientific areas and provide examples of how the research we 
support improves quality of life, health, and wellness across the 
lifespan.
       symptom science: promoting personalized health strategies
    NINR is committed to finding new and better ways to treat the 
symptoms of chronic and acute illnesses which can cause significant 
suffering for individuals and families. While we still have much to 
learn about the unique ways people experience symptoms and respond to 
treatments, recent advances in genomics are providing new opportunities 
to develop improved, personalized strategies to address adverse 
symptoms of illness, such as pain, fatigue, and disordered sleep. By 
providing a better understanding of the basic underlying biological and 
genetic mechanisms of symptoms, NINR-supported researchers are making 
important contributions to improving health and quality of life. For 
example, one NINR-supported project found that, for pregnant women with 
depression, poor sleep was associated with higher levels of 
inflammatory chemicals in the body known as cytokines, as well as 
adverse pregnancy outcomes such as preterm birth. Other NINR-supported 
scientists identified pro- and anti-inflammatory biomarkers that 
predict how patients experience pain at different stages of breast 
cancer treatment, drawing a new link between pain and inflammation. 
Discoveries such as these pave the way for the development of 
personalized and effective treatments for adverse symptoms of illness.
                   self-management of chronic illness
    According to the Centers for Disease Control (CDC), chronic illness 
accounts for more than 75 percent of healthcare costs in the U.S., and 
often requires long-term management of illness among individuals, 
families, and healthcare providers. Learning how to manage chronic 
illness presents challenges to individuals of any age as well as their 
family members, from children remembering to bring their asthma 
medication with them to school to older adults maintaining daily 
activities as they face multiple chronic conditions, such as arthritis 
and heart disease. To address such challenges, NINR supports research 
that enables individuals with chronic illness and their caregivers to 
take an active role in understanding and managing their condition, and 
improving their quality of life. One current NINR-led initiative aims 
to equip families with effective strategies for improving self-
management of chronic illness in children and adolescents, enabling 
them to follow treatment regimens and make healthy lifestyle choices 
while still allowing ``kids to be kids.'' Another initiative emphasizes 
family-centered self-management that integrates family members as 
partners in care while promoting self-management for individuals of any 
age; this initiative has the potential to strengthen the ability of 
family members to work together to make treatment decisions, manage 
symptoms, and navigate the healthcare system. Through efforts like 
these, NINR's investment in self-management research contributes to 
helping people live active and healthy lives in the face of chronic 
illness.
           wellness: promoting health and preventing illness
    Another area of emphasis at NINR is on wellness research, which 
seeks to understand the physical, social, behavioral, and environmental 
causes of illness, identify healthy lifestyle behaviors, and develop 
interventions to promote health and prevent illness across the lifespan 
and in diverse communities. One study supported by NINR is refining and 
examining the effectiveness of a home-based sensor system for older 
adults, which monitors pulse, breathing, and restlessness while 
sleeping, and alerts healthcare providers to potential illness so that 
they can intervene early. Such warning systems may allow older adults 
to stay active and remain in their homes longer. In another project, 
researchers developed a teacher-delivered healthy lifestyles 
intervention that improved health behaviors and academic outcomes in 
high school adolescents. NINR also maintains its commitment to 
promoting wellness in vulnerable groups who are disproportionately 
affected by chronic illness. We currently lead an initiative to reduce 
health disparities in minority and underserved children through the 
development of culturally-appropriate, multifaceted interventions.
               enhancing end-of-life and palliative care
    Addressing the needs of patients with life-limiting illness through 
high-quality, effective end-of-life and palliative care continues to be 
a critical focus of NINR. As the lead NIH Institute for end-of-life 
research, NINR supports research to ease symptoms and support patients 
and their caregivers in coping with advanced illness, while also 
addressing the challenges of planning for end-of-life decisions. As an 
example, NINR-supported scientists recently found that pain continues 
to be underdiagnosed and undertreated for hospitalized patients at the 
end of life, suggesting that more work is needed to better understand 
the needs of individuals facing life-threatening illnesses. Recognizing 
that palliative care is a critical component of maintaining quality of 
life at any age and at any stage of illness, not just at the end of 
life, NINR supports initiatives to enhance palliative care. Given that 
a diagnosis of serious illness in a child is particularly difficult for 
families, NINR launched the Palliative Care: Conversations 
MatterTM campaign to raise awareness of pediatric palliative 
care and to provide evidence-based materials to help healthcare 
providers initiate often difficult conversations with pediatric 
patients and their families. NINR also continues to support a 
palliative care research cooperative to enhance the evidence base for 
palliative care interventions. A new NINR initiative to promote use of 
and long-term sustainability of the cooperative will encourage 
researchers across the country to capitalize on the existing resources 
and expertise and streamline the research process.
              looking toward the future: nurse scientists
    A primary goal of NINR is to prepare the next generation of nurse 
scientists to address health challenges and to contribute to an 
innovative, multidisciplinary, and diverse scientific workforce. NINR 
funds training and career development grants and programs to prepare 
nurse scientists to conduct research to build the scientific foundation 
for clinical practice. NINR's Summer Genetics Institute is an intensive 
training program on molecular genetics designed to improve research and 
clinical practice among graduate students and faculty. This year, our 
week-long Methodologies Boot Camp focuses on using Big Data in symptom 
research, and provides a research intensive program for participants to 
learn new state-of-the-art methodologies from nationally and 
internationally known scientists. By training nurse scientists to use 
new, innovative scientific methodologies, NINR advances nursing science 
to improve health.
    In closing, thank you for the opportunity to share with the 
Committee some of the ways the science we support impacts the health of 
the Nation. In fiscal year 2015, NINR will continue our mission to 
improve quality of life by advancing nursing science and by supporting 
research to inform high-quality and effective clinical care.
                                 ______
                                 
              Prepared Statement of Eric Green, M.D., Ph.D
    Mr. Chairman and Members of the Committee: I am pleased to present 
the fiscal year 2015 President's budget request for the National Human 
Genome Research Institute (NHGRI). The fiscal year 2015 budget of 
$498,451,000 reflects an increase of $1,323,000 above the enacted 
fiscal year 2014 level of $497,128,000.
    The research funded and conducted by NHGRI in fiscal year 2015 will 
continue to unlock the secrets of life's DNA code. We still have much 
to discover with regard to how the three billion DNA bases of the human 
genome influence our physical and biochemical characteristics--and, in 
turn, our health. While we continue to reveal all the information 
encoded by DNA, we have started pursuing clinical applications of 
genomic knowledge and implementing genomic medicine.
    Understanding how the structure and function of the human genome 
relates to health and disease will be essential for the implementation 
of genomic medicine. Among the knowledge to be gained is how the 
:20,000 genes in the human genome are turned on and off at the 
appropriate times and in the appropriate places; this is largely the 
role of regulatory elements within the genome that act like ``dimmer 
switches'' controlling lights. Through the Institute's Encyclopedia of 
DNA Elements (ENCODE) Project, a more detailed inventory of these 
regulatory elements is emerging. In fiscal year 2015, the Genomics of 
Gene Regulation (GGR) initiative will begin to investigate the 
choreography of these different elements in different cells and 
tissues. Many of the elements that ENCODE has identified and GGR will 
characterize play a role in human diseases and traits, underscoring the 
foundational value of these projects.
    More than 25 million Americans suffer from rare diseases, 
cumulatively more than those afflicted with cancer. While the genomic 
bases for just over 5,000 rare diseases have been established--the 
majority of those established since the end of the Human Genome 
Project--the causal genes for an estimated 2,000-4,000 additional rare 
diseases remain to be identified. To investigate the latter, NHGRI's 
Centers for Mendelian Genomics Program is harnessing powerful DNA-
sequencing technologies to analyze patients' genomes on an 
unprecedented scale en route to establishing the genomic underpinnings 
of these remaining rare disorders. The resulting discoveries offer the 
promise of ending the diagnostic odyssey of afflicted patients as well 
as insights about the diseases that may lead to new therapeutic 
approaches.
    In fiscal year 2015, NHGRI will also focus on more common, but more 
genomically complex, diseases--those diseases that reflect great public 
health burdens. One such disease, cancer, is fundamentally a disease of 
the genome. Hence, NHGRI has been collaborating with the National 
Cancer Institute in developing The Cancer Genome Atlas (TCGA) since 
2006, studying the genomes of different types of tumors and cataloging 
the discovered genomic aberrations. In fiscal year 2015, TCGA will 
reach the milestone of analyzing 10,000 tumor samples, revealing many 
new insights about cancer.
    Similarly, NHGRI has partnered with the National Institute on Aging 
to pursue the largest genomics study of Alzheimer's disease to date. 
The Alzheimer's Disease Sequencing Project (ADSP) is sequencing and 
analyzing the genomes of several hundred Alzheimer's patients to help 
identify the genomic factors contributing to this complex disease, 
which affects as many as 5 million Americans aged 65 and older.
    Investigators throughout the biomedical research enterprise--well 
beyond the study of genetic diseases--are now incorporating genomic 
analyses into their research. A major catalyst for this dissemination 
has been NHGRI's unparalleled Advanced DNA Sequencing Technology 
Program, the successes of which have led to a phenomenal drop in the 
cost of DNA sequencing,\1\ enabling many more investigators to 
incorporate genomic analyses into their research. However, these 
researchers have a widespread and urgent need for improved analytical 
tools for analyzing DNA sequence data. To address this, NHGRI has 
created the Genome Sequencing Informatics Tools (GS-IT) program. Like 
the Institute's development of cutting-edge innovations in DNA 
sequencing, GS-IT is creating pioneering robust data-analysis tools for 
studying genomes.
---------------------------------------------------------------------------
    \1\ Nature 507, 294-295 (20 March 2014) http://www.nature.com/news/
technology-the-1-000-genome-1.14901
---------------------------------------------------------------------------
    To become a reality, genomic medicine needs refined approaches for 
using genomic information to improve health outcomes. For instance, in 
fiscal year 2015, the Implementing Genomics Into Clinical Practice 
(IGNITE) Network will test methods for disseminating genomic medicine 
strategies more widely. IGNITE investigators will be initially studying 
the use of genomic risk information for treating kidney disease, the 
utility of family health history, and the use of genomic information 
for selecting appropriate medications. In another effort, NHGRI is 
partnering with the Eunice Kennedy Shriver National Institute of Child 
Health and Human Development to support the Newborn Sequencing in 
Genomic Medicine and Public Health (NSIGHT) Program, which is examining 
the potential for genome sequencing to improve the care of newborns.
    Pilot programs such as IGNITE and NSIGHT, in addition to other 
large genomics projects, are only valuable if the generated knowledge 
diffuses through the medical establishment. To help healthcare 
professionals become competent with genomic information in delivering 
patient care, NHGRI is working with the National Center for 
Biotechnology Information to develop the Clinical Genome Resource 
(ClinGen), which will provide a curated knowledgebase of clinically 
relevant genomic variants. ClinGen will be freely available to 
clinicians, researchers, and professional organizations developing 
clinical practice guidelines, helping to usher in larger-scale 
implementation of genomic medicine.
    To capitalize on the genomics research funded by NHGRI and other 
NIH institutes for medicine, the next generation of scientists and 
clinicians must be equipped with the skills to lead their fields during 
the 21st century. In fiscal year 2015, new institutional training 
programs and individual career awards in genomics research and in 
genomic medicine will develop leaders in those respective fields, 
including the provision of cross-training in associated disciplines 
such as bioethics and data science.
    Another of NHGRI's educational efforts targets the general public. 
The Institute collaborated with the Smithsonian Institution's National 
Museum of Natural History to create the exhibition Genome: Unlocking 
Life's Code. Privately funded, this widely acclaimed exhibition is 
expected to be visited by more than 3.5 million people before the end 
of fiscal year 2015. In addition, a series of nine public engagement 
programs are being produced; these events will remain accessible via 
the web to complement the exhibition as it travels North America over 
the next 5 years.
    As described above, NHGRI's genome sciences portfolio will continue 
to explain the role of the genome in human traits and disease, while 
its genomic medicine portfolio will apply that knowledge to improve 
human health. The Institute will ensure that information about genomic 
advances is disseminated to scientists and healthcare professionals as 
well as the general public, and that the technologies and generated 
knowledgebase will continue to be a growth engine for our economy.\2\
---------------------------------------------------------------------------
    \2\ http://www.unitedformedicalresearch.com/advocacy_reports/the-
impact-of-genomics-on-the-u-s-economy/
---------------------------------------------------------------------------
                                 ______
                                 
             Prepared Statement of Alan E. Guttmacher, M.D.
    Mr. Chairman and Members of the Committee, I am pleased to present 
the fiscal year 2015 President's budget request for the Eunice Kennedy 
Shriver National Institute of Child Health and Human Development 
(NICHD) of $1,283,487,000. This reflects an increase of $2,657,000 over 
the fiscal year 2014 level of $1,280,830,000.
    Understanding human development, both normative and atypical, 
comprises the core of NICHD's mission. The Institute supports a broad 
range of research, conducted largely at academic institutions across 
the country, ranging from efforts to increase understanding of basic 
biological mechanisms to testing health interventions aimed at 
improving the lives of children, women, families, and those with 
disabilities. NICHD-supported research contributes to knowledge about 
our health, from the earliest stages through maturity.
                      pregnancy and birth outcomes
    Based on NICHD-supported research showing less than optimal health 
outcomes for infants born at 37 and 38 weeks of pregnancy (previously 
considered full-term), leading professional societies announced in the 
past year a new policy that pregnancy would now be considered full-term 
only after 39 weeks. This change should lead to improved standards of 
care and better health outcomes for mothers and infants.
    While previous studies had found that alcohol and illegal drug use 
during pregnancy frequently produce poorer infant health outcomes, a 
NICHD-funded network study has now provided evidence that smoking 
(including secondhand smoke), prescription painkillers, and illegal 
drugs used during pregnancy can double or triple the risk of 
stillbirth. These findings provide women and their clinicians important 
information about healthy behaviors in pregnancy.
    Through our Hunter Kelly Newborn Screening Research Program, NICHD 
has long provided the evidence base for determining whether a health 
condition can be detected in newborns, and whether it can be cured or 
treated. Currently, most states screen newborns for a panel of 29 
conditions, thus preventing extensive disease and disability. Now NICHD 
is partnering with the National Human Genome Research Institute on a 
major study to explore the possibilities for early diagnosis of a much 
larger number of disorders by sequencing newborns' genomes, while also 
exploring technical, clinical, and ethical questions raised by this new 
technology. Researchers also plan to develop a tool to help parents 
understand sequencing results, placing special emphasis on the needs of 
families from diverse cultures and their clinicians.
                  pediatric and adolescent development
    For many conditions, the earlier they are identified and treatment 
begun, the better the outcome. One of the goals of the NICHD-led 
National Children's Study is to amass an unprecedented amount of 
information about children's health, development, and environment to 
understand and improve health. Recently, researchers supported by NICHD 
have developed an updated screening tool, administered to parents, to 
help determine if a child between 18 months and 2 years old has autism, 
much earlier than the current average age of diagnosis of 4 years. 
Previous research has shown that earlier interventions can help improve 
developmental outcomes for children with autism. This tool is now 
widely available online, in 45 different languages.
    Since variations in nutrition and environment so heavily influence 
children's growth and development, NICHD engages in international 
studies to increase knowledge about optimal health in childhood. In 
some nutrient-deficient areas, children receive iron supplements to 
enhance development and prevent anemia; yet, recently, public health 
officials have become concerned that these supplements may increase 
children's risk for malaria. To test this theory, NICHD-supported 
researchers conducted a randomized clinical trial combining iron 
supplementation with prevention efforts (such as sleeping nets) in a 
malaria-prone area of Ghana, finding that the incidence of malaria was 
no higher for children who received the supplements than for those who 
did not, and assuring that beneficial iron supplementation could 
continue.
    Understanding human development in adolescence, with that period's 
substantial physical, mental, and behavioral changes, poses a 
particular challenge for researchers. While there is increased emphasis 
on encouraging young people to be physically active to reduce 
overweight and increase health, engaging in some physical activities 
may pose risks. Concerns have been raised about the potential long-term 
effects of repeated concussions in children, especially young athletes. 
Recently, NICHD partnered with other NIH ICs and the National Football 
League on eight research projects to help understand the effects of 
head injuries and improve the diagnosis of concussions. Although 
awareness is increasing that young people who may have had a concussion 
should not immediately return to play, these studies will help us 
understand the brain's healing process and what is required to prevent 
permanent damage to this vital organ, leading to such advances as more 
precise return to play policies.
    Parents of teenagers will not be surprised that adolescents often 
engage in risk-taking behaviors. They may, however, be surprised that 
informed parental supervision can have an impact on adolescent 
behaviors and even on potential injury or death. An intramural NICHD 
study on teen driving behaviors collected data from a nationally 
representative sample of 10th graders, finding that adolescents who 
reported being exposed to riding with an intoxicated driver in the 10th 
grade were considerably more likely to report driving while intoxicated 
in the 12th grade. The study indicates the importance of parents' not 
only monitoring their own children's driving behaviors, but also that 
of other young drivers with whom their children may be riding.
                             women's health
    One result of NICHD's 2012 ``Scientific Visioning'' process, which 
took a fresh look at what the Institute might accomplish across its 
broad mission over the next decade, was the establishment of the new 
extramural Gynecologic Health and Disease Branch. Researchers supported 
by the branch recently shed light on the relative success and safety of 
two surgical treatments for pelvic organ prolapse (a form of pelvic 
hernia). Previous research supported by NICHD suggested about 3 percent 
of U.S. women experience prolapse in a given year, most commonly older 
women and those who have given birth several times. The study found no 
statistically significant difference between the two types of surgery, 
providing critical information for surgeons and the 300,000 U.S. women 
who have this surgery each year.
                     individuals with special needs
    NICHD has long supported research on the causes and effects of 
intellectual and developmental disabilities, and on identifying 
effective therapies for these conditions. By working closely with 
leading researchers, clinicians, self-advocates, and families, 
Institute scientists identify the scientific resources most critical to 
ongoing progress on these conditions. In September 2013, NICHD, with 
the support of the NIH Down Syndrome Working Group and the Down 
Syndrome Consortium, launched DS-ConnectTM: The Down 
Syndrome Registry. DS-ConnectTM, which already includes over 
1,500 registrants, is a web-based, voluntary, secure health registry 
serving the Down syndrome community, providing anonymized information 
to families and clinicians, and facilitating connections between 
researchers and potential clinical research participants. In addition, 
the Down syndrome community recently provided extensive input on a 
revised NIH Research Plan on Down Syndrome, which will be available 
mid-2014.
    Another pressing need for scientists conducting research on 
cognition and brain disorders is the availability of sufficient brain 
tissue specimens. While NIH historically has funded investigator-
initiated, disease-specific brain banks, it is now taking a new 
approach to providing these scarce research resources by supporting a 
tissue-sharing collaboration among five brain banks. This new 
``NeuroBioBank'' will increase availability of biospecimens and 
establish a standardized resource for the research community.
                    embracing research opportunities
    Increasingly, biomedical and biobehavioral researchers need to work 
in transdisciplinary teams, manage massive amounts of data, and acquire 
new and diverse skill sets. For example, the medical rehabilitation 
needs of those with physical disabilities require a wide range of 
research, from improving our understanding of neurological repair to 
developing new generations of prostheses and assistive devices. In 
2012, a Blue Ribbon Panel made a series of recommendations to NICHD to 
bolster rehabilitation research at NICHD's National Center for Medical 
Rehabilitation Research (NCMRR) and across NIH. NICHD is implementing 
an innovative new operating model for NCMRR that is intended to greatly 
increase coordination of rehabilitation research among the many ICs 
that support it.
    NICHD is excited to launch the Human Placenta Project, a 
coordinated international initiative to understand in real time the 
structure and function of the human placenta, arguably the least 
understood human organ. The placenta is not only critical for both 
maternal and fetal health, but also has substantial implications for 
conditions that arise later in life in both the mother and child, such 
as cardiovascular disease. The Project's goals include understanding 
placental development in normal and abnormal pregnancies, developing 
biomarkers to help predict adverse pregnancy outcomes, and developing 
interventions to prevent abnormal placental and fetal development. The 
currently projected span of the project is a decade, beginning with a 
workshop in May 2014 to develop a research plan.
    Thank you for the opportunity to submit some of NICHD's 
accomplishments over the last year and a few of its many exciting plans 
for the immediate future.
                                 ______
                                 
              Prepared Statement of Richard J. Hodes, M.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's fiscal year 2015 budget request for the National 
Institute on Aging (NIA) of the National Institutes of Health (NIH). 
The fiscal year 2015 budget includes $1,170,880,000, which is 
$1,453,000 more than the comparable fiscal year 2014 level of 
$1,169,427,000.
    More than 40 million people age 65 and older live in the United 
States, and data from the Federal Interagency Forum on Aging-Related 
Statistics indicate that their numbers will double by 2040. In less 
than 50 years, the number of ``oldest old''--people ages 85 and older--
may quadruple. As record numbers of Americans reach retirement age and 
beyond, profound changes will occur in our economic, healthcare, and 
social systems.
    The NIA leads the national effort to understand aging and to 
develop interventions that will help older adults enjoy robust health 
and independence, and continue to make positive contributions to their 
families and communities. We support genetic, biological, clinical, 
behavioral, and social research related to the aging process, healthy 
aging, and diseases and conditions that often increase with age. We 
also support training of the next generation of researchers.
              understanding aging at its most basic level
    NIA-supported studies in the emerging field of geroscience, which 
explores the basic mechanisms underlying age-related changes, including 
those which could lead to increased disease susceptibility, will 
provide needed insight into ways to address aging-related diseases and 
disorders. The NIA-led NIH GeroScience Interest Group (GSIG) involves 
active participation by 20 NIH Institutes and is leading the effort to 
accelerate and coordinate efforts to promote further discoveries on the 
common risks and mechanisms behind age-related diseases and conditions. 
In October 2013, the GSIG and private-sector partners convened a 
national Summit, ``Advances in Geroscience: Impact on Healthspan and 
Chronic Disease,'' which drew more than 500 expert participants from 
around the world. We expect its outcomes to further energize this 
field.
    An increasingly important research area is the identification of 
genes and gene variants related to aging and age-related disease. Such 
research will be accelerated by the addition of data on more than 
78,000 older individuals from one of the Nation's largest and most 
diverse genomics projects, Genetic Epidemiology Research on Aging, to 
the NIH database of Genotypes and Phenotypes (dbGAP). These data will 
be widely available to qualified investigators.
         improving the health and well-being of older americans
    NIH-supported investigators are testing a variety of interventions 
for health conditions common to old age. Ongoing studies include: the 
ASPirin in Reducing Events in the Elderly (ASPREE) trial, designed to 
determine whether the benefits of aspirin outweigh the risks in people 
over 70; testosterone supplementation to delay or prevent frailty in 
older men; exercise for mood, health, and cognition; and an array of 
interventions for menopausal symptoms.
    NIA also supports research aimed at development of interventions 
that will enable older adults to remain independent for as long as 
possible. For example, researchers used data from nine large NIA-funded 
studies to develop diagnostic criteria for low muscle mass and 
weakness. These conditions lead to disability in older people, but are 
rarely recognized as clinical problems by healthcare providers. This 
work is a milestone toward the development of new diagnostic and 
treatment strategies for this common and disabling condition. In 
addition, the recent NIA-supported finding that training to improve 
cognitive abilities in healthy older people lasts to some degree for 10 
years after the training program was completed provides an important 
piece of evidence that cognitive health can be improved and maintained 
into older age.
    Serious injuries from falls, such as broken bones or traumatic 
brain injury, are a major reason for the loss of independence among 
older people. In 2013, NIA and the Patient-Centered Outcomes Research 
Initiative (PCORI) solicited applications for funding to conduct a 
randomized clinical trial of a multifactorial strategy for preventing 
serious fall-related injuries among non-institutionalized older people. 
The trial will begin in 2014.
    NIA is also a leader in the trans-NIH Science of Behavior Change 
initiative. We are hoping that the long-term outcome of this initiative 
will be to enhance the efficacy of interventions to help individuals 
make and maintain positive changes in their health behaviors. As an 
example, one NIA-managed study in this initiative has shed light on how 
stress can reduce or eliminate the ability of individuals to benefit 
from training designed to help them regulate their emotions and better 
control their behavior, suggesting possible changes to our behavioral 
intervention strategies.
    Because investigators often, for a variety of reasons, have 
difficulty recruiting older people into clinical research studies, NIA 
is collaborating with the Administration for Community Living, the 
Centers for Disease Control and Prevention, state and community-based 
health and social service providers, researchers, and private 
organizations on the Recruiting Older Adults into Research (ROAR) 
project.
             building momentum against alzheimer's disease
    NIA is the lead Federal agency supporting research on Alzheimer's 
disease (AD), which despite our best efforts continues to be a serious 
public health issue that directly affects as many as 5 million 
Americans. In fiscal year 2014, NIA received approximately $100 million 
in additional appropriated funds. We plan to use these additional funds 
to support Alzheimer's research in areas of strategic priority, funding 
additional awards to applications received from Funding Opportunity 
Announcements issued in fiscal year 2013-fiscal year 2014. We will 
continue to be guided by the strategic goals outlined in the National 
Action Plan on Alzheimer's Disease and the results from the 2012 
Alzheimer's Disease Summit. A second Summit is planned for February 
2015 to update milestones and stimulate further research.
    Recent findings have expanded our understanding of AD and provided 
insights into prevention and treatment of the disease. For example, 
NIA-funded researchers recently identified a molecule called REST, 
which is lost in the brains of patients with Alzheimer's disease, and 
whose deletion in mice leads to neurodegeneration. REST represents a 
novel potential target for intervention into the disease. Investigators 
have also found that conjugated equine estrogens, the most common type 
of postmenopausal hormone therapy in the United States, has no long-
term risk or benefit to cognitive function in younger postmenopausal 
women, aged 50-55. The earlier Women's Health Initiative Memory Study 
linked the same type of hormone therapy to cognitive decline and 
dementia in older postmenopausal women, but this finding suggests that 
women taking certain estrogen-based hormone therapies in their early 
postmenopausal years may not be at increased risk for eventual 
cognitive decline.
         empowering the next generation of researchers in aging
    As the number of older Americans continues to grow, we must not 
only increase the number of practicing physicians trained in geriatrics 
and relevant subspecialties but also foster the development of the next 
generation of physician-scientists whose clinical research will lead to 
improved care and more effective treatment options for older patients 
with complex medical conditions. Two ongoing programs--Grants for Early 
Medical/Surgical Subspecialists' Transition to Aging Research 
(GEMSSTAR), supporting physicians who seek to become clinician-
scientists in geriatric aspects of their subspecialty, and Medical 
Students Training in Aging Research (MSTAR), targeting first-year 
medical students in order to stimulate early interest in an aging 
research career--remain highly successful. Building on new technologies 
that enable us to reach a wide audience efficiently and inexpensively, 
we have initiated a series of Technical Assistance webinars to provide 
participants, particularly those with an interest in health disparities 
research, with guidance on navigating the NIA grants application 
process. Finally, the Butler-Williams Scholars Program (formerly the 
NIA Summer Institute) remains a vibrant and vital institution at NIA, 
drawing a record number of applications for the 2014 session.
                                 ______
                                 
           Prepared Statement of Stephen I. Katz, M.D., Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the National Institute of Arthritis 
and Musculoskeletal and Skin Diseases (NIAMS) of the National 
Institutes of Health (NIH). The fiscal year 2015 NIAMS budget of 
$520.189 million includes an increase of $0.851 million over the 
comparable fiscal year 2014 level of $519.338 million.
    The NIAMS supports a broad range of research, training, and 
information dissemination activities. Many of the conditions within the 
NIAMS mission are very common while some are rare, affecting only a few 
thousand people world-wide. All have a major impact on the quality of 
people's lives. Diseases addressed by NIAMS affect individuals of all 
ages and of all racial and ethnic backgrounds; many disproportionately 
affect women and minorities. Over the years, NIAMS-funded research 
teams have made significant progress in uncovering the causes of and 
improving the treatments for many disorders of the bones, muscles, 
joints, and skin.
    While many treatments for arthritis and musculoskeletal and skin 
conditions have their origins in NIH-supported basic research, the 
timeframes for translating fundamental knowledge into therapies remain 
unacceptably long, and too many potential therapies fail late in 
development. To improve the drug development process, NIAMS has 
partnered with industry, non-profit groups, and other government 
agencies for the NIH Accelerating Medicines Partnership program in 
lupus and rheumatoid arthritis (RA). Through the program, a network of 
investigators will use advanced tools and techniques to analyze blood 
and tissue samples from patients. The overall goals are to gain 
insights into lupus and RA biology, improve the selection of biological 
targets for drug development, and ultimately produce new therapies.
    The advent of technologies for collecting and analyzing large 
amounts of data corresponds with an increasing appreciation of the 
interactions that occur among different tissues and organ systems, and 
with the microorganisms inside our body or on our skin. When 
researchers compared the gut microbes of people who had newly 
diagnosed, untreated RA with those found in the digestive tracts of 
healthy people, patients with RA who were receiving treatment, and 
psoriatic arthritis patients, they found that the bacterium Prevotella 
copri (P. copri) was more abundant in patients with new-onset RA than 
in the other groups. If additional studies determine that altered 
levels of P. copri contribute to RA, therapies that target the 
bacterium could help to prevent the disease or delay its onset. 
Similarly, another group of researchers recently demonstrated that 
Staphylococcus aureus colonies on the skin of people who have atopic 
dermatitis, or eczema, release a toxin that causes skin inflammation. 
This finding provides an impetus for further studies into whether 
blocking the toxin could help people who are susceptible to atopic 
dermatitis.
    Other research is uncovering complex connections between the immune 
system and skeletal health, and the role of hormones produced by bone 
on the development and function of the nervous system. Recent findings 
have linked the misfolding of a protein that helps immune cells 
recognize and destroy invading bacteria or viruses to the bone erosion 
that characterizes spondyloarthritis of the spine. Other research has 
revealed that the bone-derived hormone osteocalcin is capable of 
interacting with neurons in the brain and influencing brain structure 
and behavior, at least in mice.
    Many people think of broken bones as a normal part of an active, 
healthy childhood. Although any bone will break if enough force is 
applied to it, researchers are learning that the bones of some children 
and teens have structural deficits that can be readily identified based 
on what the patient was doing when the bone was broken. Children who 
broke an arm because of moderate impact, as would occur when falling 
off a bicycle, had bones that resembled their uninjured peers; but, 
those whose forearm bones broke upon mild impact (e.g., a fall during a 
minor playground scuffle) showed signs of compromised bone strength and 
bone quality. While we do not know the extent to which bone weakness 
during childhood predisposes people to osteoporosis and fragility 
fractures later in life, this study is the first to suggest that a 
simple screening question could identify the young people who might 
benefit most from dietary changes and activities to improve bone 
health.
    NIAMS also is involved in efforts to identify laboratory-based or 
imaging biomarkers that will guide treatment development or will 
improve patient care. Activities include the Foundation for the NIH 
(FNIH) Biomarkers Consortium project to evaluate biochemical and 
imaging biomarkers for more precise ways of measuring osteoarthritis 
progression during clinical trials; this project builds on resources 
created by the Osteoarthritis Initiative (OAI), a public-private 
partnership spearheaded by NIAMS and the National Institute on Aging 
with support from other NIH components, the U.S. Food and Drug 
Administration, the FNIH, and private sponsors. A separate research 
team, focused on molecular changes associated with scleroderma, 
recently reported that blood levels of a protein appeared to 
distinguish between patients who were likely to develop life-
threatening lung complications that require aggressive treatments and 
those whose disease would not warrant risky therapies. Investigators 
are confirming their observations as a next step before the findings 
are applied clinically.
    Additional research into disease-associated genetic defects and 
molecular pathways is pointing to new uses for drugs that have been 
approved for other conditions. Work by investigators studying a group 
of muscle diseases called the disferlinopathies--which includes limb-
girdle muscular dystrophy type 2B--suggests that calcium channel 
blocking drugs might reduce some of the tissue damage that accumulates 
as the diseases progress. Another example comes from a team that 
identified 42 areas in the human genome that are associated with RA; 
many of the gene products are already targeted by existing drugs. These 
potential drug repurposing opportunities will be explored more 
thoroughly before clinical trials can begin in patients.
    Once results from clinical studies are available, many healthcare 
providers insist that findings be validated before changing how they 
practice medicine. The ability to verify conclusions is equally 
important at the basic and preclinical levels of research, particularly 
when results become the basis for clinical trials. In fiscal year 2015, 
NIAMS plans to refocus the Pilot and Feasibility Clinical Research 
Grants in Arthritis and Musculoskeletal and Skin Diseases program--a 
grant mechanism to foster early-stage clinical trials on which larger, 
more robust studies will be based--to emphasize the need for a strong 
scientific premise on which a proposed project is based.
    NIAMS is committed to ensuring that well-trained basic scientists 
and clinical researchers are prepared to conduct cutting-edge studies 
related to rheumatic, musculoskeletal, and skin diseases. The Institute 
awards a combination of institutional training grants and individual 
fellowships for this purpose. NIAMS has expanded its participation in 
NIH training programs for fiscal year 2015 to include the Ruth L. 
Kirschstein National Research Service Awards for Individual Predoctoral 
MD/PhD and Other Dual Doctoral Degree Fellows (F30) program. The 
Institute also has begun meeting with clinical or patient-oriented 
research career development awardees--both early in their award and as 
they are about to transition to independent careers--to identify 
challenges that they face and ways to better support them and future 
awardees.
    As part of a commitment to communicating about NIAMS programs and 
research results, NIAMS has enhanced its outreach to patients, 
healthcare and research professionals, and the general public via 
social media and other activities. Building on a successful 2013 effort 
to ensure that the results of NIH research investments and health 
messages reach all Americans, NIAMS again partnered with other 
components of the Department of Health and Human Services and with 
patient advocacy groups to create a new set of health planners, titled 
A Year of Health, A Guide to a Healthy 2014 for You and Your Family. In 
the past 2 years, NIAMS received requests for these health planners 
from all 50 states and five U.S. territories, demonstrating a robust 
need for credible, research-based health information in African 
American, American Indian/Alaska Native/Native Hawaiian, Asian 
American/Pacific Islander, and Hispanic/Latino communities.
    Looking to the future, we are updating the Institute's Long-Range 
Plan. As with the fiscal year 2010-2014 plan, the new document will 
inform the Institute's priority setting process while enabling the 
NIAMS to adapt to the rapidly changing biomedical and behavioral 
science landscapes. When complete, the plan will outline the 
Institute's perspective on research needs and opportunities within the 
NIAMS mission, and will serve as a resource for all who are interested 
in our activities.
                                 ______
                                 
                Prepared Statement of George Koob, Ph.D.
    Mr. Chairman and Members of the Committee: As the new Director of 
the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the 
National Institutes of Health (NIH), I am pleased to present the 
President's budget request for the Institute. The fiscal year 2015 
NIAAA budget request of $446,017,000 reflects an increase of $606,000 
over the comparable fiscal year 2014 enacted level of $445,411,000.
                          scope of the problem
    Excessive alcohol use has profound effects on individuals, families 
and communities; and the Centers for Disease Control and Prevention 
(CDC) estimates that excessive alcohol consumption cost the U.S. $224 
billion in 2006. In 2012, nearly one quarter of the U.S. population 
aged 21 and older and over 15 percent of young people ages 12-20 
reported binge drinking (i.e. consuming five or more drinks on a single 
occasion) at least once in the past month, according to the Substance 
Abuse and Mental Health Services Administration (SAMHSA). Binge 
drinking has serious acute and long term consequences--both for youth 
and adults. NIAAA estimates that 18 million Americans have an alcohol 
use disorder (AUD) and NIAAA research has established an important 
connection between early alcohol use and the development and severity 
of AUD. Of those who meet the criteria for an AUD, only about 15 
percent ever seek treatment.
                             niaaa research
    To reduce the considerable burden of illness and the societal costs 
associated with alcohol misuse, NIAAA is working to advance evidence-
based prevention and treatment for alcohol problems for individuals at 
all stages of life, including those with co-occurring disorders. 
NIAAA's research portfolio is broad, ranging from studies on the 
underlying biological mechanisms that drive excessive drinking and the 
development of medications for AUD targeting these mechanisms, to 
studies on policies and interventions designed to reduce harm both to 
drinkers and those around them. NIAAA's portfolio also includes both 
research on the health benefits associated with moderate drinking and 
on the consequences of alcohol misuse, including fetal alcohol spectrum 
disorders (FASD), alcohol effects on the developing adolescent brain, 
and alcohol effects on tissue and organ damage.
    NIAAA's cutting edge work in the neuroscience of alcohol effects on 
the brain provides not only a firm foundation for development of novel 
treatments for AUD but also a framework for prevention. The NIAAA 
portfolio focuses on the neurocircuitry changes that promote the 
development of AUD as well as those that convey resilience. 
Particularly critical are the studies of the adolescent brain and how 
excessive alcohol intake can delay, or permanently compromise normal 
development of the brain's executive and self-regulatory functions.
    A key goal of NIAAA is to work with other NIH Institutes and 
Centers and Federal agencies to enhance integration of research on the 
abuse of alcohol and other substances. Notably, NIAAA co-leads the 
Collaborative Research on Addictions at NIH (CRAN) with the National 
Institute on Drug Abuse (NIDA) and the National Cancer Institute (NCI); 
co-chairs the Alcohol Policy and Underage Drinking Subcommittee of the 
HHS Behavioral Health Coordinating Council with the CDC; and 
collaborates with the National Institute of Mental Health (NIMH), NIDA, 
Department of Defense (DOD) and the Veterans Administration (VA) on the 
implementation of the National Research Action Plan for Improving 
Access to Mental Health Services for Veterans, Service Members, and 
Military Families.
    Recognizing that medications currently available to treat AUD can 
be highly effective but do not work for everyone, NIAAA continues to 
make significant progress towards developing additional evidence based 
pharmacotherapies. NIAAA's Clinical Investigations Group (NCIG), 
established to rapidly test candidate compounds (within 12-18 months), 
is streamlining the medications development process for AUD. NCIG 
recently completed a multisite clinical trial that showed the anti-
smoking medication varenicline (Chantix) significantly reduced alcohol 
consumption and craving in both smokers and non-smokers with AUD. Going 
forward, NCIG will test both repurposed and novel compounds often 
working in collaboration with extramural scientists and the 
pharmaceutical industry. NIAAA also supports promising pharmacotherapy 
research outside of NCIG. In an independent study, the widely 
prescribed anti-seizure medication gabapentin, used to treat pain and 
used off-label for migraines, reduced heavy drinking and other related 
symptoms in alcohol dependent patients. A study to replicate the 
gabapentin finding within NCIG is anticipated. It is important to note 
that currently available medications are very effective for many, and 
that NIAAA is working to make clinicians and the public aware of the 
range of available treatment options for AUD, as well as promoting 
research into more effective implementation of treatment.
    Given that AUD often co-occurs with other substance use and/or 
mental health disorders, major priorities of the Institute are to 
understand the complex relationships between and develop effective 
treatments for alcohol misuse and co-occurring disorders. For example, 
AUD frequently co-occurs with post-traumatic stress disorder (PTSD), 
thereby complicating treatment for both conditions. PTSD is prevalent 
among military personnel and veterans, and also among individuals who 
have experienced sexual assault--a far too common occurrence on college 
campuses, and one often associated with excessive drinking by both 
perpetrators and victims. PTSD increases risk for AUD; conversely, 
chronic alcohol use may increase the risk for PTSD by altering the 
brain's ability to recover from a traumatic experience. Using an animal 
model of PTSD, NIAAA intramural researchers discovered that chronic 
alcohol exposure altered neurons in the medial prefrontal cortex region 
of the brain, making the animals slower to suppress a conditioned fear 
response. Differences in the ability to handle fear responses could 
help explain differences in vulnerability to PTSD among humans, and 
lead to new therapeutic approaches and diagnostic risk biomarkers. 
NIAAA also supports other promising studies on co-occurring PTSD and 
AUD.
    The consequences of binge drinking for all ages range from acute, 
e.g. injuries and blackouts, to long term, e.g. severe AUD and organ 
damage. Recent results of NIAAA-supported research have revealed that 
binge drinking may be harmful in more ways than previously thought. For 
example, in results published this year, a single episode of binge 
drinking (which in the study raised the blood alcohol concentration to 
0.08 g/dL, the legal limit for driving while intoxicated, within 60 
minutes) increased leakage of bacterial endotoxins from the gut into 
the bloodstream and elicited an immune response, demonstrating that 
binge drinking produces acute damage in the body, even in healthy 
people. Notably, women had higher blood alcohol levels and circulating 
endotoxin levels than men. Often viewed as a rite of passage, binge 
drinking is pervasive among our Nations' youth with 1.7 million young 
people ages 12-20 engaging in this behavior five or more times per 
month according to SAMHSA. NIAAA's current studies on the effects of 
alcohol on the developing brain will inform a more extensive study 
under CRAN to assess the effects of drugs and alcohol, alone and in 
combination, on the adolescent brain. College and University Presidents 
are especially concerned about the rampant heavy use of alcohol among 
their students resulting in an estimated 1,825 deaths, 696,000 
assaults, and 97,000 sexual assaults annually. NIAAA will soon release 
a decision tool to help college administrators select effective 
evidence-based interventions appropriate for their campuses. NIAAA also 
promotes screening and brief intervention (SBI) for youth, and launched 
an online course with Medscape to provide continuing medical education 
for healthcare professionals to help them conduct fast, evidence-based 
alcohol SBI with youth. To date, over 14,000 healthcare providers have 
been Medscape certified.
    Preventing, diagnosing, and treating alcoholic liver disease (ALD) 
is also a major priority. NIAAA funds four research consortia to pursue 
new clinical approaches to treat alcoholic hepatitis, a severe form of 
ALD. NIAAA will also continue to pursue biomarkers of liver injury to 
facilitate earlier diagnosis.
    NIAAA has significantly advanced our understanding of the health 
and social impacts of alcohol use and misuse. NIAAA will continue to 
pursue opportunities leading to better outcomes for alcohol-related 
problems, and support a diverse biomedical research workforce that is 
equipped to tackle these public health challenges.
                                 ______
                                 
            Prepared Statement of Donald A.B. Lindberg, M.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the National Library of Medicine 
(NLM) of the National Institutes of Health (NIH). The fiscal year 2015 
budget of $372,851,000 includes an increase of $5,628,000 over the 
comparable fiscal year 2014 level of $367,223,000.
    The National Library of Medicine, the world's largest biomedical 
library, builds and provides electronic information resources used 
billions of times each year by millions of scientists, health 
professionals and members of the public. Many health information 
searches that are initiated on the Internet actually retrieve 
information from an NLM Web site. NLM is crucial in the dissemination 
of biomedical research results--DNA sequences, clinical trials data, 
toxicology and environmental health data, research publications, and 
consumer health information to scientists, health professionals, and 
the public. A leader in biomedical informatics and information 
technology, NLM also supports and conducts research, development, and 
training in biomedical informatics, data science, and health 
information technology; and coordinates the 6,100-member National 
Network of Libraries of Medicine that promotes and provides access to 
health information in communities across the United States.
    NLM's programs and services directly support NIH's key initiatives 
in basic research, precision medicine, research training, as well as in 
data science and Big Data. NLM's National Center for Biotechnology 
Information (NCBI) is a focal point for ``Big Data'' in biomedicine and 
a leader in organizing and providing rapid access to massive amounts of 
genetic sequence data generated from evolving high-throughput 
sequencing technologies. NCBI serves more than 30 terabytes of 
biomedical data to more than 3.3 million users daily. Some of the 
largest datasets, such as those from NIH's 1000 Genomes Project, are 
also available in the Amazon cloud. This allows faster access and 
analysis by researchers who may be otherwise hampered by insufficient 
bandwidth or computing power. Additionally, the Library organizes and 
provides access to the published medical literature; assembles data 
about small molecules to support research and therapeutic discovery; 
provides the world's largest clinical trials registry and results 
database; and is the definitive source of published evidence for 
healthcare decisions. NLM's PubMed Central (PMC) provides essential 
infrastructure for the NIH Public Access Policy, making published NIH-
funded research freely and permanently available to the public. NLM/
NCBI databases are cited in laws and Congressional legislation (e.g., 
Public Law 110-161,Consolidated Appropriations Act and HR 4186, the 
Frontiers in Innovation, Research, Science, and Technology) as a model 
for facilitating public access to federally funded data and 
publications.
    Research supported or conducted by NLM underpins today's electronic 
health record systems. The Library has been the principal funder of 
university-based informatics research training for 40 years, supporting 
the development of today's leaders in informatics research and health 
information technology. NLM's databases and its partnership with the 
Nation's health sciences libraries deliver research results wherever 
they can fuel discovery and support health decisionmaking.
               biomedical and health information services
    NLM's PubMed/MEDLINE database is the world's gateway to research 
results published in the biomedical literature. It links to full-text 
articles in PubMed Central, including those deposited under the NIH 
Public Access Policy, and on publishers' Web sites, as well as 
connecting to vast collections of scientific data. PubMed contains more 
than 23 million references to articles in the biomedical and life 
sciences journals providing high quality information to about 2.3 
million users per day. NLM is a primary source for results of patient-
centered outcomes research, providing access to evidence on best 
practices to improve patient safety and healthcare quality. NLM is also 
a hub for the international exchange and use of data utilized in 
molecular biology, genomics, and clinical and translational research. 
Many NCBI databases, including dbGaP, the Genetic Testing Registry 
(GTR), and ClinVar are fundamental to the identification of important 
associations between genes and disease, and to the translation of new 
knowledge into better diagnoses and treatments.
    NLM's Lister Hill National Center for Biomedical Communications 
operates ClinicalTrials.gov, the world's most comprehensive clinical 
trials database. It contains registration data for more than 160,000 
clinical studies with sites in 185 countries and summary results for 
more than 11,000 trials, including many results that are not available 
elsewhere.
                standards for electronic health records
    For 40 years, NLM has supported seminal research on electronic 
patient records, clinical decision support, and health information 
exchange, including concepts and methods now reflected in electronic 
health record (EHR) products and personal health record tools. EHRs 
with advanced decision-support capabilities and connections to relevant 
health information are essential to improving healthcare and helping 
Americans manage their own health. As the Department of Health and 
Human Services (HHS) coordinating body for clinical terminology 
standards, NLM works closely with the Office of the National 
Coordinator for Health Information Technology and the Centers for 
Medicare and Medicaid Services to facilitate adoption and ``meaningful 
use'' of EHRs. NLM supports, develops, and distributes key terminology 
standards now required for U.S. health information exchange. To help 
EHR developers implement standard terminologies, NLM produces related 
software tools, frequently used subsets, and mappings to administrative 
code sets, and provides the authoritative versions of terminology value 
sets for required clinical quality measures. NLM's MedlinePlus Connect 
also supports meaningful use by providing a way for EHR products to 
link patients to high quality health information relevant to a specific 
health conditions, medications, and tests, directly from their EHRs.
                   health information for the public
    The NLM has a wide range of outreach programs to enhance awareness 
of NLM's diverse information services among biomedical researchers, 
health professionals, librarians, patients, and the public. To improve 
access to high quality health information, NLM works with the 6,100 
institutions of the National Network of Libraries of Medicine, a 
network of academic health sciences libraries, hospital libraries, 
public libraries, and community-based organizations and has formal 
partnerships with tribal colleges and other minority serving 
institutions. In fiscal year 2013, dozens of community-based projects 
were funded across the country to enhance awareness and access to 
health information, including in disaster and emergency situations, and 
to address health literacy issues.
    The Library's MedlinePlus Web site provides integrated access to 
high quality consumer health information produced by all NIH components 
and HHS agencies, other Federal departments, and authoritative private 
organizations. It serves as a gateway to specialized NLM information 
sources for consumers, such as the Genetic Home Reference and the 
Household Products Database. Available in English and Spanish, with 
selected information in 40 other languages, MedlinePlus averages well 
over 750,000 visits per day. Mobile MedlinePlus, also in both English 
and Spanish, reaches the large and rapidly growing mobile Internet 
audience.
    The NIH MedlinePlus print and online magazine, in English and 
Spanish, is an outreach effort made possible with support from many 
parts of NIH and the Friends of the NLM. Distributed free to the public 
via physician offices, community health centers, libraries and other 
locations, the print magazine reaches a readership of up to 5 million 
nationwide and the online version reaches millions more. Each issue 
focuses on the latest research results, clinical trials and guidelines 
from the 27 NIH Institutes and Centers.
    The Library diversifies access to all its information resources, 
through mobile devices and ``apps.'' NLM continues to be a leading 
player in social media amongst HHS agencies with active Facebook, 
Twitter, and You Tube accounts, including the very popular @medlineplus 
Twitter feed and a Spanish-language counterpart, several online 
newsletters, and its National Network of Libraries of Medicine, which 
covers the United States and hosts eight Facebook pages, 10 Twitter 
feeds and 12 blogs. NLM is consistently ranked among the most liked, 
most followed, and most mentioned organizations amongst small 
government agencies with social media accounts.
    In conclusion, the Library is a trustworthy source of health 
information for the public and vital to the practice of 21st century 
medicine and the progress of science. NLM's information services and 
research programs serve the Nation and the world by supporting 
scientific discovery, clinical research, education, healthcare 
delivery, public health response, and the empowerment of people to 
improve personal health. The Library is committed to the innovative use 
of computing and communications to enhance public access to the results 
of biomedical research.
                                 ______
                                 
               Prepared Statement of Jon R. Lorsch, PH.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget for the National Institute of General Medical 
Sciences (NIGMS) of the National Institutes of Health (NIH). The fiscal 
year 2015 budget of $2,368,877,000 includes an increase of $6,983,000 
above the comparable fiscal year 2014 level of $2,361,894,000. NIGMS 
considers its public funds a precious resource and focuses on 
efficiency and effectiveness in making investments in research and 
training. The Institute spends 97 percent of its budget outside of the 
NIH, funding biomedical research and training at universities and other 
institutions across the country--where creative minds are at work every 
day producing new knowledge about health and disease.
    Scientific discovery is the engine for advances in medicine, as 
research results lead to new treatments and refine current standards of 
care. Biomedical research relies on attracting and retaining a creative 
and well-trained workforce. NIGMS remains committed to enabling 
researchers throughout the United States to answer important scientific 
questions in fields such as cell biology, biophysics, genetics, 
developmental biology, pharmacology, physiology, biological chemistry, 
biomedical technology, bioinformatics, computational biology, selected 
aspects of the behavioral sciences and specific cross-cutting clinical 
areas that affect multiple organ systems. To assure the vitality and 
continued productivity of the research enterprise, NIGMS also provides 
leadership in training the next generation of scientists as well as in 
developing and increasing the diversity of the scientific workforce.
                             back to basics
    The high value of investigator-initiated research has stood the 
test of time. This approach, in which scientists decide what questions 
are important to study, ultimately leads to major advances in medicine 
and technology. Examples include:
  --Studies of virus-resistant bacteria led to the discovery of 
        restriction enzymes, which act like highly specific scissors 
        for cutting DNA. This discovery launched the multi-billion-
        dollar biotechnology industry, starting with the laboratory-
        based production of life-saving medicines like insulin and now 
        extending even beyond biomedicine into agriculture and 
        biofuels.
  --Seemingly esoteric studies of how electric fields affect DNA 
        replication in bacteria lead directly to the discovery of the 
        anti-cancer drug cisplatin, which has saved thousands of human 
        lives.
  --Studies of enzymes that copy DNA and RNA and that cut proteins 
        enabled the development of drugs to treat HIV infection.
    To ensure a continued pipeline of fundamental scientific advances 
that will lead to future medical and technological breakthroughs, NIGMS 
is rebalancing its portfolio to renew and reinvigorate its support for 
question-driven, investigator-initiated research. This rebalancing has 
received strong support from stakeholder organizations, including the 
Federation of American Societies for Experimental Biology, an umbrella 
group representing 26 scientific societies and over 115, 000 
researchers.
                   planning carefully for the future
    NIGMS has begun a new strategic planning process that is focusing 
on enhancing the efficacy, efficiency, and adaptability of the 
Institute's internal processes and the mechanisms through which we 
support biomedical research. In particular, we are exploring the 
development of new grant mechanisms that would increase stability and 
flexibility for researchers and maximize the scientific return on 
taxpayers' investment. These mechanisms will focus on the efficient use 
of funds, encouraging scientists to undertake ambitious and creative 
projects that may be the breakthroughs of tomorrow.
    NIGMS is also developing new strategies to strengthen and maintain 
the pipeline of talented, creative, diverse and highly skilled young 
investigators. This segment of the biomedical workforce is essential 
for the future of scientific research in the United States, which is in 
turn essential for the future health and economic competitiveness of 
our Nation. Specific strategies we are considering to address the 
challenges facing young investigators include outcomes-based 
enhancements of our training programs and efforts to improve the 
competitiveness of young investigators in obtaining and keeping 
research grants.
                    supporting a diversity of ideas
    NIGMS is proud to be the home of the IDeA program, which ensures 
that cutting-edge research is conducted in every region of the country. 
This strategy is critical to the strength of our biomedical research 
enterprise, as it meets the need to involve the most diverse set of 
minds, experiences and approaches for solving difficult health-related 
problems. Last year, NIGMS funded or co-funded 58 competing grants to 
IDeA researchers, this included 25 competing Centers of Biomedical 
Research Excellence awards. Particularly exciting research developments 
funded by the IDeA program include the demonstration by Kentucky 
researchers that electrical stimulation of the spinal cord can restore 
some motor function in individuals with paraplegia; a study by 
scientists in South Carolina showing that nanoparticles coated with 
antioxidant proteins can protect against stroke-related damage; and a 
neonatal telemedicine center in Arkansas that has contributed to a 
significant decrease in statewide infant mortality.
    As requested by both the House and Senate and required by the 
Consolidated Appropriations Act of 2014, NIH has submitted a response 
to the National Academies' Report on EPSCoR and related programs. As 
part of the NIGMS strategic planning process, we are developing plans 
for enhancing access to resources for moving discoveries and innovative 
ideas from laboratories in IDeA states into commercial products. In 
particular, we are exploring support for regional biotechnology 
incubators that would give faculty in IDeA states access to laboratory 
space, equipment, expertise, and advice required to make their work 
competitive for SBIR/STTR and venture capital funding.
                   advancing health through discovery
    This past year, NIGMS-funded scientists broke new ground in a range 
of areas relevant to health, including chemistry, microbe-host 
interactions, computer modeling, and metabolism. Selected examples 
include:
  --A Tennessee researcher developed a chemical method to shave the 
        cost of manufacturing expensive drugs, including those used to 
        treat HIV/AIDS. The method is also environmentally friendly in 
        that it employs natural molecules called enzymes instead of 
        synthetic chemicals that are often hazardous.
  --A scientist from Vermont created the first-ever interaction map of 
        human proteins that attach to proteins from arenavirus and 
        hantavirus, providing potential new targets for therapies to 
        treat the often deadly illnesses caused by these classes of 
        viruses.
  --A Pennsylvania researcher found compounds that block a recently 
        discovered pathway for preventing production of damaged 
        proteins. These chemicals have antibiotic activity, suggesting 
        they might eventually be developed into a new class of 
        antibacterial drugs.
  --A scientist from California learned from mouse studies that a high-
        fat diet influences the internal body clock controlling liver 
        metabolism. The team also discovered that the effect was 
        reversible by returning to a balanced, low-fat diet.
    These discoveries are a small subset of the productivity of the 
nearly 4,000 scientists NIGMS supports throughout the United States. 
Our public investment to fuel their curiosity-driven exploration of 
biomedicine is growing knowledge, and local economies, as well as 
improving the health of all Americans.
    Thank you, Mr. Chairman. I would be pleased to answer any questions 
that the Committee may have.
                                 ______
                                 
             Prepared Statement of Yvonne T. Maddox, Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget for the National Institute on Minority Health 
and Health Disparities (NIMHD) of the National Institutes of Health 
(NIH). The fiscal year 2015 budget of $267,953,000 is the same as the 
fiscal year 2014 enacted level of $267,953,000.
                              introduction
    As the primary Federal agency for leading, coordinating and 
facilitating research to improve minority health and eliminate health 
disparities, NIMHD impacts the lives of millions of Americans burdened 
by disparities in health status and healthcare delivery, including 
racial and ethnic minority groups as well as rural and low-income 
populations. A population is a health disparity population if it is 
determined that there is a significant disparity in the overall rate of 
disease incidence, prevalence, morbidity, mortality, or survival rates 
in the population as compared to the health status of the general 
population. The elimination of health disparities requires a 
multidisciplinary approach, with collaboration, coordination, and 
integration across NIH Institutes and Centers (ICs), other Federal 
agencies and private-sector organizations to fully understand and solve 
the underlying biological and non-biological causes of health 
disparities.
                   fundamentals of health disparities
    In order to understand the social, behavioral, biological, and 
environmental factors influencing health disparities, NIMHD is studying 
the fundamental causes of diseases and conditions that 
disproportionately affect individuals from health disparity 
backgrounds. For example, one project studies the higher incidence and 
mortality of breast cancer in African American women through research 
that examines the role genetic differences in the tumor suppressor 
protein, p53, plays in the disparity. Researchers hypothesize that some 
racial/ethnic groups have disproportionate p53 variants that may 
contribute to breast cancer health disparities in the age of onset, 
incidence, and lack of pregnancy protection in African American women. 
Another study takes knowledge about causal pathways learned at the 
bench and extends the findings to social, behavioral, health services 
and/or policy approaches to test ways to improve minority health and 
eliminate health disparities. This project examined unconscious 
stereotyping of Hispanic patients among medical and nursing students. 
The study found that students endorsed stereotypes that Hispanic 
patients would be non-compliant or likely to engage in high-risk health 
behaviors, even if the students reported trying consciously to avoid 
biased thinking. This unconscious bias of medical providers can be one 
factor in the disparity in healthcare delivery faced by minority 
patients.
                    collaborative research framework
    Comprehensively addressing health disparities requires a 
transdisciplinary framework that fosters an integrated approach 
involving biology, behavioral and social sciences, environmental 
science, public health, healthcare delivery, economics, public policy, 
and many other disciplines. It also requires strong collaborations 
between researchers and community organizations, service providers and 
systems, government agencies, and other stakeholders to ensure that 
contextually appropriate and relevant research is conducted, and that 
findings can translate into sustainable individual, community, and 
systems level changes that improve the health of the U.S. population. 
The NIMHD supports two programs that focus on transdisciplinary and 
translational research: the Centers of Excellence (COE) and the 
Transdisciplinary Collaborative Centers for Health Disparities Research 
(TCC). The COEs, which were established as partnerships between 
academic institutions and community organizations, have been in place 
for over a decade and have reached more than 102 sites, across 31 
States, the District of Columbia, Puerto Rico, and the U.S. Virgin 
Islands. The COEs are addressing health disparities research along the 
translational spectrum from basic science to clinical research, with 
information dissemination a required component.
    The TCC Program, established in fiscal year 2012, supports 
research, implementation, and dissemination of activities that 
transcend customary discipline-specific approaches conducted at the 
local level. Transdisciplinary research collaboration at the regional 
level provides opportunities for academic institutions, community-based 
organizations, and other partners to conduct targeted research to 
respond to specific population-based, environmental, sociocultural, and 
political factors that influence health within a particular region.
    The Collaborative Research Center for American Indian Health is 
bringing together tribal communities and health researchers from a 
variety of disciplines to work together to address the significant 
health disparities experienced by American Indians in South Dakota, 
North Dakota and Minnesota, particularly the social determinants of 
health and its application to programming public health interventions. 
The National Transdisciplinary Collaborative Center for African 
American Men's Health is addressing unintentional and violence-related 
injuries as well as chronic diseases that affect African American men 
across the life course, as part of a national initiative.
                          community engagement
    Active community involvement in biomedical and behavioral research 
is essential to improving the health of the public. The NIMHD 
Community-Based Participatory Research (CBPR) Initiative supports the 
development, implementation, and evaluation of intervention research 
that utilizes the principles of community engagement as partners in the 
full spectrum of research. A number of CBPR planning phase and 
dissemination phase projects are under way. The Partnerships to Improve 
Lifestyle Interventions and Partners in Care programs tested the 
effectiveness of a culturally adapted diabetes self-management 
intervention among Native Hawaiians and Pacific Islanders. The study 
found improvements in weight loss, physical capacity, and diabetes 
self-management.
    Another CBPR project focused on a culturally appropriate, church-
based Hepatitis B screening and vaccination intervention program for 
Korean Americans which found increased screening and immunization rates 
in the intervention group compared with the control group. Academic-
community partnerships were essential in balancing science and 
community needs in the design and conduct of the needs assessment, 
pilot and full-scale clinical trial.
                  research training and infrastructure
    In order to advance the science and speed translation of 
discoveries into better health outcomes for all Americans, it is 
critical to expand and diversify the Nation's workforce of well-trained 
scientists who are dedicated to improving minority health and 
eliminating health disparities. A diverse biomedical workforce will 
improve the quality of the educational and training environment, 
balance and broaden the perspective in setting research priorities, 
improve the ability to recruit subjects from diverse backgrounds into 
clinical research protocols, and improve the Nation's capacity to 
address and eliminate health disparities. NIMHD-supported programs to 
train researchers to conduct minority health and health disparities 
research are focusing on providing educational, mentoring, and/or 
career development programs for individuals from health disparity 
populations that are underrepresented in the biomedical, clinical, 
behavioral, and social sciences. NIMHD continues to support research 
training and infrastructure through its Research Endowment Program, 
Building Research Infrastructure and Capacity Program, and Research 
Centers in Minority Institutions Program.
                               conclusion
    NIMHD has a unique and critical role at the NIH as the focal point 
for conducting and coordinating research on minority health and health 
disparities, raising national awareness about the prevalence and impact 
of health disparities, and the dissemination of effective individual, 
community, and population-level interventions to reduce and ultimately 
eliminate health disparities. NIMHD is looking forward to identifying 
new opportunities to accelerate the pace of research and to advance its 
mission through strengthening partnerships and enhancing its role in 
the community.
                                 ______
                                 
        Prepared Statement of Roderic I. Pettigrew, Ph.D., M.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the National Institute of Biomedical 
Imaging and Bioengineering (NIBIB) of the National Institutes of Health 
(NIH). The fiscal year 2015 NIBIB budget request of $328,532,000 is 
$2,173,000 more than the fiscal year 2014 enacted level of 
$326,359,000.
    NIBIB is dedicated to improving human health through the 
integration of the physical and biological sciences. NIBIB's mission 
spans the entire health spectrum and is not limited to a single 
disease, group of illnesses, or population. Working with doctors from 
every field of medicine and bringing together teams of scientists and 
engineers from many different backgrounds, NIBIB aims to develop 
innovative approaches to healthcare. Our research focus is to improve 
the understanding, detection, treatment and ultimately, the prevention 
of disease.
  innovation in treating spinal cord injury: new hope for those with 
                               paralysis
    Building on a long history of research on restoring function in 
spinal cord injury, researchers have discovered a fundamentally new 
intervention that led to voluntary movement in individuals with 
complete paralysis. This outcome, initially seen in a single 
individual, has now been reported in three successive patients, all of 
whom had been paralyzed for more than 2 years. This achievement is a 
significant milestone in spinal cord injury research. In the approach, 
electrical stimulation is applied to the surface of the spinal cord 
through a surgically implanted device that is normally used for the 
suppression of back pain. After just a week of stimulation, on average, 
the patients were able to voluntarily move their legs and flex their 
feet and toes when the stimulator was turned on. With continued daily 
stimulation and extensive physical training, the patients saw 
improvements in their movements and could initiate them with decreased 
stimulation. With their stimulators turned on, the patients are now 
able to stand for about an hour. Restored function was accompanied by 
increased muscle mass. In addition, these individuals have regained 
bladder and bowel function and experienced improvements in autonomic 
responses such as sweating and return of sexual function in some cases.
      immunoengineering to modifiscal year immune system responses
    The immune system is the body's defense against an array of 
infectious agents. However, the immune system can also trigger many 
diseases such as diabetes, rheumatoid arthritis, lupus or multiple 
sclerosis; this occurs when immune cells are directed against an 
individual's own cells and is referred to as autoimmunity. As our 
understanding of the immune system increases, we are approaching a 
point where the immune response can be engineered to enhance or reduce 
specific responses. Two recent examples highlight this 
``immunoengineering'' approach. In the first case, the problem being 
addressed is improving targeted delivery of chemotherapeutic drugs to 
tumors. Nanoparticles can be used to ferry chemotherapy directly to 
tumors, minimizing exposure of these toxic medications to healthy 
tissues in the body. Researchers have found a way to ferry 
nanoparticles carrying chemotherapy drugs past cells of the immune 
system, which would normally engulf the particles, preventing them from 
reaching their target. The technique takes advantage of the fact that 
all cells in the human body display a protein on their membranes that 
functions as a specific ``passport'' in instructing immune cells not to 
attack them. By attaching a small piece of this protein to 
nanoparticles, scientists were able to get immune cells in mice to 
recognize the particles as ``self'' rather than foreign particles, and 
thereby not attack them. The nanoparticles also have other labels that 
can concentrate the drugs in the tumors, so higher doses of 
chemotherapy are delivered to the tumor.
    In a second example, researchers have developed a strategy to 
modulate the immune system to halt the progress of a disease model of 
multiple sclerosis in mice. In multiple sclerosis, the immune system 
attacks the myelin sheaths that surround nerve cells. To stop this 
attack, engineered nanoparticles are coated with myelin antigens, and 
these nanoparticles are presented to another set of cells in the immune 
system that re-identifies myelin as `self' rather than `foreign'. The 
result is that the immune system stops attacking myelin as a foreign 
body, and the disease progression is halted. This approach begins to 
take advantage of the complex control of immune response which contains 
multiple positive and negative feedback loops in order to selectively 
turn off one specific inflammatory response. It holds promise for 
treating multiple sclerosis and other autoimmune diseases that 
previously have escaped effective therapies.
              cancer detection from a routine blood sample
    Most cancers spread by way of the circulatory system. As a result, 
there are cancer cells present in blood samples. The number of cells, 
however, is so low that they have been difficult or impossible to find. 
The problem is to find and isolate the few cancer cells from the 
billions of other cells that are present in the blood. Researchers over 
the past several years have developed new techniques to find these 
cells, but those techniques have generally been destructive to the 
cancer cells. Now, with a new sorting technology, researchers have 
demonstrated the ability to sort the cancer cells and, of equal 
importance, to collect them for further analysis. After collection, the 
circulating tumor cells can be subjected to the full array of analysis 
techniques available to normal tissue biopsies of a tumor. This 
technology also permits sorting, using a variety of markers that allow, 
for example, the identification of triple negative breast cancer cells. 
Successful isolation has been demonstrated in several other cancers 
including lung, prostate, pancreas, breast, and melanoma. This new tool 
has the potential to improve both the early diagnosis and effective 
treatment of cancer.
an implantable artificial kidney holds promise for patients on dialysis
    Expenditures in the United States for end stage renal disease 
exceed $40 billion annually. Treatment of end stage renal disease 
includes renal transplant and thrice-weekly, in-center hemodialysis. 
Renal transplant is limited to a small fraction of potential recipients 
by a shortage of donor organs. As a result, more than 400,000 Americans 
are on dialysis, which is expensive, inconvenient, and over time 
associated with significant morbidity and mortality. Researchers are 
developing an implantable bioartificial kidney called the Implantable 
Renal Assist Device (iRAD), in which a patient's blood will be filtered 
through an artificial kidney consisting of silicon nanopore membranes 
and a bioreactor of cells to mimic the functions of a healthy kidney. 
Such a device could offer numerous advantages for patients including: 
freedom of mobility, decreased infection risk due to a permanent 
vascular connection, and continuous treatment, which avoids the build-
up of toxins that occurs between in-center hemodialysis visits. In 
addition, incorporation of the patient's own cells could provide normal 
renal metabolic function that would be more physiologic than dialysis 
and not require anti-rejection drugs used for transplant. This combined 
filtration and metabolic treatment has been shown to work using a room-
sized external model. Multi-day animal model testing to demonstrate 
hemofilter biocompatiblity has been conducted. Although human studies 
have not been initiated with the iRAD, these researchers are working 
with the Food and Drug Administration (FDA) on an initiative that 
facilitates new ways for FDA staff and innovators to jointly bring 
breakthrough medical device technologies to patients faster and more 
efficiently.
         smart homes for healthy independent living at all ages
    The population is aging and, increasingly, medical treatment 
involves the management of chronic and/or degenerative diseases. 
Management of such conditions requires monitoring and early 
intervention to prevent more severe complications. The rapid 
development and ever expanding capabilities of smart phones, advanced 
sensors, point-of-care diagnostics, and integrated Internet 
connectivity provides a framework on which new healthcare models can be 
developed to provide this monitoring and intervention. Investigators 
are testing real-time home observation of high-risk patients for early 
signs of illness, using a built-in camera, computer tablet and a smart 
phone for simultaneous monitoring of daily activities by family members 
and health professionals. This includes analysis of daily habits, 
mobility patterns, and gait rate and rhythm as indicators of change in 
health status. Developing automated technologies to help identify early 
indicators of changes in health status will extend the amount of time 
individuals can live independently in their own homes.
                                 ______
                                 
        Prepared Statement of Griffin P. Rodgers, M.D., M.A.C.P.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's fiscal year 2015 budget request for the National 
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the 
National Institutes of Health (NIH). The fiscal year 2015 budget 
includes $1,743,336,000, which is $1,462,000 above the comparable 
fiscal year 2014 appropriation of $1,741,874,000. Complementing these 
funds is an additional $150,000,000 authorized in fiscal year 2015 from 
the Special Statutory Funding Program for Type 1 Diabetes Research. 
NIDDK supports research on a wide range of common, chronic, costly, and 
consequential diseases and health problems that affect millions of 
Americans. These include diabetes and other endocrine and metabolic 
diseases; digestive and liver diseases; kidney and urologic diseases; 
blood diseases; obesity; and nutrition disorders.
           today's basic science for tomorrow's breakthroughs
    NIDDK-supported basic research is achieving remarkable progress and 
building the foundation for previously unimaginable strategies to 
improve health and quality of life. For example, recent research has 
better defined human brown adipose (fat) tissue in the neck, and has 
further elucidated the role of a family of proteins as molecular 
signals regulating brown fat physiology--findings that could help 
inform new approaches for altering metabolism to clinical advantage. 
The microorganisms that inhabit the gastrointestinal tract are 
important factors in maintaining or tipping the balance between health 
and disease. A recent study of young twin pairs in Malawi revealed that 
gut microbes may play an important role in causing severe malnutrition 
in children that persists in spite of nutritional interventions. 
Gaining new insight into gastric bypass surgery, scientists studying a 
mouse model found that restructuring of the digestive tract leads to 
weight loss and metabolic benefits in part by altering the communities 
of bacteria that normally live in the intestines. Another study has 
shown that deletion of the protein olfactomedin-4 in white blood cells 
improves their ability to eradicate infections with the harmful 
bacteria Staphylococcus aureus in an animal model of the immune 
disorder chronic granulomatous disease. Scientists supported by our 
Institute have used a series of genetically engineered mice to identify 
the contribution of different kidney cell subtypes to the process of 
fibrosis that follows kidney injury, confirming myofibroblasts' 
contribution to fibrosis and tracking their developmental origins--
results that could inform future treatment strategies. Scientists have 
discovered a link between two proteins known to contribute to the most 
common form of polycystic kidney disease and a cell-surface structure 
in a subset of kidney cells in mice. NIDDK-supported researchers 
conducted a study in mice showing that chemotherapy damages nerves that 
regulate bone marrow niches responsible for making new blood cells; 
future research in humans could explore ways to reduce nerve damage and 
improve blood cell regeneration after chemotherapy. A new study has 
shown that it may one day be possible to treat people with cystic 
fibrosis (CF) using a combination of medicines that work cooperatively 
to stabilize an aberrant form of CFTR, the protein that is defective in 
CF.
    NIDDK will continue support for basic research across the 
Institute's mission, to gain further insights into health and disease 
and propel new ideas for interventions. Areas of emerging opportunity 
include research on generating or repairing nephrons that can function 
within the kidney; diet-host microbiome interactions in autoimmune and 
metabolic diseases; and a collaborative research network on disease 
modeling and tissue repair and regeneration.
                clinical science and precision medicine
    Through innovative design and rigorous testing of interventions--
whether in the operating room, doctor's office, or home or community 
settings--NIDDK-supported researchers are improving lives with new 
approaches to prevent, treat, and reverse diseases and disorders. For 
example, researchers studying type 1 diabetes have used smartphone 
technology to move a step closer toward developing an artificial, 
bionic, pancreas. Scientists reported data on insulin resistance and 
secretion that suggest early and rapid deterioration of pancreatic beta 
cell function in youth with type 2 diabetes, underscoring the need to 
intervene early and aggressively. Researchers have found that patients 
with irritable bowel syndrome show an improvement in symptoms following 
a short course of group therapy involving psychological and educational 
approaches. Recent research has shown that in dialysis patients with 
diabetes, measuring another set of modified blood proteins may better 
predict the risk of death and cardiovascular disease than the current 
standard test to assess blood glucose control.
    The NIDDK supports research aimed at tailoring treatments for 
disease to the individual characteristics of each patient. For example, 
a detailed genetic study has now identified rare mutations of the 
SLC30A8 gene that sharply reduce risk for type 2 diabetes in several 
different racial/ethnic populations, suggesting that inhibitors of the 
Slc30A8 protein may one day be therapeutically valuable. New research 
has greatly expanded knowledge of the specific genetic mutations 
capable of causing CF, leading to much more comprehensive CF genetic 
testing. A recently discovered set of mutations in the DGKE gene may be 
behind some cases of the serious blood disorder hemolytic uremic 
syndrome. Scientists participating in NIDDK's Childhood Liver Disease 
Research and Education Network have utilized patient samples and an 
animal model to identify a genetic deletion in the GPC1 gene that may 
play a role in the development of biliary atresia. NIDDK researchers 
have created and confirmed the accuracy of a mathematical model that 
predicts how weight and body fat in children respond to adjustment in 
diet and physical activity.
                    nurturing talent and innovation
    NIDDK will continue programs to train and support researchers at 
all stages of their careers, and to ensure that we benefit from the 
best scientific minds. One major objective of the Network of Minority 
Health Research Investigators is to encourage and facilitate 
participation of members of underrepresented population groups and 
others interested in minority health in the conduct of biomedical 
research. In addition, several NIDDK-sponsored programs provide 
opportunities for minority students to obtain research experience. The 
NIDDK's Short-Term Education Program for Underrepresented Persons, or 
STEP-UP, provides research education grants to seven institutions to 
coordinate high school and undergraduate STEP-UP programs that enable 
students to gain summer research experience and training.
          integrating science-based information into practice
    NIDDK also will continue to support education, outreach, and 
awareness programs. Research clearly shows that communications alone 
about the seriousness of diabetes will not reverse the diabetes 
epidemic. The NIDDK is committed to focusing more efforts to promote 
the theme of moving from awareness to action, by providing behavior 
change tools and other resources to help people with diabetes and those 
at risk make and sustain lifestyle changes. For example, the NIDDK-CDC 
National Diabetes Education Program has developed the Diabetes 
HealthSense Web site, an online library of tools and resources 
developed by partners from around the country to address a wide array 
of psychosocial and lifestyle challenges. The NIDDK's National Kidney 
Disease Education Program (NKDEP) works to identify people with chronic 
kidney disease (CKD) and promote the implementation of evidence-based 
interventions, focusing on populations at highest risk for CKD and the 
providers who serve them. In addition, through collaborative community 
partnerships with organizations such as the Chi Eta Phi Nursing 
Sorority and the American Diabetes Association, NKDEP brings NIH 
science-based information to the grassroots.
    In closing, NIDDK's future research investments will be guided by 
five principles: maintain a vigorous investigator-initiated research 
portfolio; support pivotal clinical studies and trials; preserve a 
stable pool of new investigators; foster research training and 
mentoring; and disseminate science-based knowledge through education 
and outreach programs.
                                 ______
                                 
           Prepared Statement of Paul A. Sieving, M.D., Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the National Eye Institute (NEI) of 
the National Institutes of Health (NIH). The fiscal year 2015 budget 
proposal is $675,168,000, which is $0.9 million more than the fiscal 
year 2014 enacted level of $674,249,000. As the director of the NEI, it 
is my privilege to report on the many research opportunities that exist 
to reduce the burden of eye disease.
                     nei audacious goal initiative
    Vision research is often on the cutting edge of biomedical 
research, from the first successful gene therapy clinical trials that 
restored some visual function in patients with an inherited form of 
blindness, to clinical trials for macular degeneration using tissue 
derived from embryonic stem cells, to a retinal electrical prosthesis, 
approved this past year by the FDA, after years of development by 
Second Site, a small business that received research support from both 
NEI and the Department of Energy. NEI is now starting a new chapter in 
its ambitious research agenda. I have launched a new initiative--The 
NEI Audacious Goal Initiative in Vision Research and Blindness 
Rehabilitation--to identify a groundbreaking long-term research goal 
that will markedly improve prevention and treatment of common eye 
diseases.
    We started this effort over a year ago by soliciting audacious 
ideas from scientists, stakeholders, patients, clinicians, and the 
public through a Challenge Competition. After a thorough scientific 
review of more than 500 submissions, we chose 10 winning entries, which 
were presented and intensively discussed at the NEI Audacious Goals 
Development Meeting last year. In May, I announced that the NEI 
Audacious Goal will be to Regenerate Neurons and Neural Connections in 
the Eye and Visual System. To kick start this initiative, we will soon 
release funding opportunities focusing on different components of this 
goal. Implementation of work toward the goal will include oversight, 
guidance, and direction from non-governmental consultant experts.
    This goal will focus on two types of retinal neuronal cells that 
underpin many of the leading causes of visual impairment. One such 
target is photoreceptor cells, the specialized neurons in the retina 
that detect light and initiate the neural response. Blindness in some 
diseases, such as retinitis pigmentosa, is a direct result of 
photoreceptor cell death, whereas in other diseases such as diabetic 
retinopathy or macular degeneration, damage elsewhere in the retina 
indirectly causes photoreceptor cells to die.
    Retinal ganglion cells (RGCs) are the second cell type targeted in 
this program. These neurons reside in the retina but send long 
projections (axons in the optic nerve) that connect to the brain. When 
RGCs degenerate and die in diseases such as glaucoma and multiple 
sclerosis, vision signals from the eye can't get to the brain. Two of 
the primary scientific challenges of this initiative include protecting 
newly regenerated cells from dying, and inducing them to form 
appropriate neural connections in the brain. Success in achieving this 
goal will not just revolutionize how we approach diseases in vision, 
but all of neuroscience.
    NEI is also a key contributor and participant in the President's 
BRAIN initiative, which seeks to decode the brain, just as the Human 
Genome Initiative decoded DNA. While NEI's Audacious Goal is 
independent from the BRAIN initiative, the eye is the gateway to the 
brain--it is the most accessible part of the central nervous system. 
There is good opportunity for synergy between these exciting 
initiatives.
                         new areas of emphasis
    In the process of identifying our Audacious Goal, we also 
identified two high-priority, complementary areas of emphasis, for 
which we have released two funding opportunities and are currently 
reviewing grant applications: Molecular Therapy for Eye Disease; and 
the Intersection of Aging and Biological Mechanisms of Eye Disease. 
With recent advances in genomics, we now have a good understanding of 
genes and molecules that are altered in many diseases. The National 
Ophthalmic Disease Genotyping and Phenotyping Network (eyeGENE), is a 
critical resource created by NEI for identifying the mutated genes in 
patients with inherited eye disorders and giving researchers access to 
DNA samples (over 4,000 collected since 2006), clinical information, 
and patients looking to participate in research studies. But the 
current tools at our disposal to treat genetic diseases are limited. 
Building on our recent successes in gene therapy, the exciting 
potential of designing personalized therapies to correct mutant genes 
lies in the research ahead of us over the next decade.
    Many eye diseases are associated with aging: from cataracts and 
presbyopia, which are common in all adults as they age, to some of the 
leading vision impairment diseases, age-related macular degeneration 
(AMD) and glaucoma. Understanding what aspects of the aging process 
contribute to eye disease has the potential to delay the onset of 
vision loss or even avert the disease.
                   nei regenerative medicine program
    Also contributing to the Audacious Goal Initiative are researchers 
at NEI, working with the NIH Center for Regenerative Medicine to create 
retinal tissues from induced pluripotent stem (iPS) cells for several 
basic and translational research applications. iPS cells can be 
generated from any adult cell, and then converted into virtually any 
other type of cells. A major thrust of this program is to derive iPS 
cells from patients with retinal diseases. Then, the iPS cells are 
differentiated to form retinal pigment epithelial (RPE) cells or 
photoreceptors and studied to identify disease-causing molecular 
pathways. Diseases of interest currently include AMD, Best disease, 
late-onset retinal degeneration, Stargardt's disease, and retinitis 
pigmentosa. This program is exploiting these techniques to develop 
high-throughput drug screens to identify potential therapeutic 
compounds for treating retinal degenerative diseases.
    Another potentially powerful application of iPS cell technology is 
to generate iPS cells from normal tissue and then differentiate those 
cells into monolayer sheets of RPE for tissue transplants. NEI 
intramural investigators are engineering a bio-degradable scaffold in 
order to grow the RPE tissue and transfer it to patients with RPE-
associated retinal degenerative diseases. In fiscal year 2015, the stem 
cell program will also use stem cell technologies to evaluate synaptic 
connections in 3-D retinas derived from iPS cells.
    As I reflect on the remarkable progress the vision community has 
made in these past few years, I can hardly anticipate the exciting 
opportunities that lay ahead.
                                 ______
                                 
          Prepared Statement of Martha Somerman D.D.S., Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the National Institute of Dental and 
Craniofacial Research (NIDCR) of the National Institutes of Health 
(NIH). The fiscal year 2015 NIDCR budget of $397,131,000 includes an 
increase of $29,000 over the enacted fiscal year 2014 level of 
$397,102,000.
    In keeping with its mission to improve the Nation's oral health, 
the breadth of NIDCR's research touches the lives of nearly all 
Americans. Our research spans multiple disciplines, scientific 
approaches, and research directions, all focused on the goal of 
improving people's lives. Today, I will highlight selected areas of 
particular promise in our efforts to understand the development of 
tissues of the face and head, conquer oral infectious diseases through 
better understanding of the body's own defenses, help people facing 
chronic orofacial pain conditions, and develop new approaches to 
improve oral cancer survival.
                      development and regeneration
    The human face is among the body's most distinctive structures. 
NIDCR is the leading supporter of research on the development of the 
human face and skull, collectively known as the craniofacial region. By 
defining the complex web of environmental and genetic instructions that 
drive craniofacial development, the hope is that scientists one day 
will learn to repair damaged or malformed facial structures such as 
cleft lip and palate by harnessing the body's ability to heal itself.
    Five years ago, NIDCR began assembling information on the genetic 
code that instructs facial development with the launch of its FaceBase 
Consortium. Through this endeavor, scientists have assembled nearly 500 
publicly available datasets involving the biological instructions for 
the middle region of the human face, which includes the nose, upper 
lip, and palate, or roof of the mouth. FaceBase begins a second phase 
this year, as it expands its focus to include studies on additional 
regions of the face. This new phase will add to our knowledge about the 
genetics that underlie craniosynostosis, a birth skull defect that may 
result in severe and permanent problems if not corrected.
    NIDCR is also translating knowledge about craniofacial development 
into tools to re-grow bone and cartilage damaged by disease or injury. 
Ongoing studies are using the power of stem cells to regenerate 
tissues, improve wound healing, and help control inflammatory-
associated diseases of the mouth. Related research uses specially 
designed stable small molecules modified from naturally occurring 
molecules called resolvins that control inflammation in a wide range of 
conditions to target oral inflammatory diseases such as periodontitis. 
We envision a future where natural tool kits are used to regenerate and 
repair damaged teeth, diseased gums, and broken or defective bones by 
utilizing stem cells and adapting natural molecules and processes.
              oral infections, immunity and the microbiome
    The NIH's human microbiome project has reinforced that no man is an 
island. Although human beings coexist with a plethora of 
microorganisms, microbial cells outnumber human cells by 10 to 1, 
living on surfaces of our body in sticky layers of polymicrobial 
communities called biofilms. Under normal circumstances, these 
microbial guests coexist with us and even contribute to sustaining 
human health. But, if conditions in some part of the body are altered, 
the balance is disrupted, and the disease-causing organisms that live 
on our gums and teeth can overwhelm our natural immune defense systems 
causing oral infectious diseases such as tooth decay and periodontal 
diseases. NIDCR-supported scientists are beginning to assemble the 
precise molecular details of how select oral pathogens destabilize the 
immune system to cause oral diseases. For example, individuals with 
leukocyte adhesion deficiency (a rare genetic disorder affecting the 
body's immune system) suffer from frequent bacterial infections, 
including severe periodontitis. New research has demonstrated that 
blocking certain molecules that are part of the individual's own immune 
system can reverse this inflammation and resulting bone loss.
    In combination with these discoveries, we have made great strides 
in understanding how an individual's own microbiome affects his or her 
health and disease. NIDCR continues to invest in microbiome research, 
supporting a database of information on oral microbes that will one day 
allow dentists to visualize the microbes within a patient's oral 
biofilm in real time--offering new tools to diagnose and treat oral 
disease. For example, a dentist might observe an overgrowth of a 
particular type of bacteria that uniquely predisposes a patient to 
tooth decay, and could treat that bacterial imbalance to prevent the 
individual from developing cavities. These emerging leads will not only 
guide future personalized dental treatment for millions of Americans; 
they will help scientists throughout biomedical research to inform 
better treatment approaches for other microbe-host diseases such as 
colitis.
                   temporomandibular joint disorders
    Thousands of Americans this year will be diagnosed with a painful 
and debilitating disorder of the jaw called temporomandibular joint and 
muscle disorder (TMD). Some of these individuals will recover after a 
single bout of TMD, while others will go on to develop chronic 
disease--and their healthcare providers, currently, are unable to 
predict the likely outcome for any individual patient. NIDCR-supported 
research is providing key insights that could identify people at risk 
for developing TMD, and predict the likelihood of progression to 
chronic disease. In 2006, NIDCR launched the Orofacial Pain: 
Prospective Evaluation and Risk Assessment (OPPERA) study. The study's 
latest findings present the most in-depth picture to date of the 
factors that may contribute to a person's developing an initial bout of 
painful TMD. Among the many interesting findings is that there is 
almost no difference in the rate at which men and women develop TMD for 
the first time. And yet, females are far more likely to progress to 
chronic TMD than males. Researchers will continue to examine potential 
causes of this difference, such as hormonal regulatory factors, leading 
to more targeted strategies for detecting and managing TMD in the 
future.
    Although TMD specifically afflicts the jaw, OPPERA researchers 
found only about 15 percent of OPPERA participants diagnosed with 
chronic TMD have orofacial pain only. The other 85 percent have 
additional ailments, many of which are painful in nature, including 
chronic fatigue syndrome, fibromyalgia headache, and low back pain. 
This finding demonstrates that first-onset and chronic TMD are complex 
disorders that must be understood within a biological, psychological, 
and social model of illness. NIDCR will continue to help lead the way 
for all those battling these chronic conditions to find relief through 
a more accurate diagnosis and more personalized care.
               oral cancer and human papillomavirus (hpv)
    When many people hear the acronym HPV, they think of its 
association with cervical cancer. But over the last decade, various 
types of this virus also have been shown to contribute to head and neck 
cancers. In fact, the incidence of HPV-related head and neck cancer has 
risen steadily over the last decade and if the pace continues, it will 
soon surpass the incidence of cervical cancer. This trend is 
particularly alarming because no effective diagnostic test currently 
exists to detect early HPV-related head and neck cancer. Tools are 
needed to screen those at increased risk of the condition and to test 
for possible persistence of the condition following therapy.
    NIDCR will help to fill this public health need by launching an 
initiative to develop a viable diagnostic test. The initiative will 
identify DNA markers associated with HPV-related head and neck cancer, 
develop and validate saliva and plasma-based diagnostic tests, and 
evaluate and test the biomarkers in humans. Clinical studies are also 
ongoing to establish the safety and feasibility of administration of a 
DNA vaccine in certain HPV-associated head and neck cancer patients. 
NIDCR scientists recognize the urgency of developing innovative 
approaches to detect oral cancer early, when personalized treatment can 
be more successful, leading to better patient outcomes.
    There has never been a better time to take advantage of the 
remarkable opportunities in science and technology waiting at our 
doorstep. Seizing this moment brings us closer to preventing and 
treating dental, oral, and craniofacial conditions as well as other 
diseases that share risk factors and therapeutic strategies.
                                 ______
                                 
         Prepared Statement of Lawrence A. Tabak, D.D.S., Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for the Office of the Director (OD) of 
the National Institutes of Health (NIH). The fiscal year 2015 OD budget 
of $1,451,786,000 includes an increase of $51,033,000 above the 
comparable fiscal year 2014 level of $1,399,753,000.
    The OD promotes and fosters NIH research and research training 
efforts in the prevention and treatment of disease through the policy 
oversight of both the extramural grant and contract award functions and 
the Intramural Research program. The OD stimulates specific areas of 
research to complement the ongoing efforts of the Institutes and 
Centers through the activities of several cross-cutting program 
offices. The OD also develops policies in response to emerging 
scientific opportunities employing ethical and legal considerations; 
provides oversight and management of peer review policies; coordinates 
information technology across the Agency; and, coordinates the 
communication of health information to the public and scientific 
communities. Moreover, the OD provides the core management and 
administrative services, such as budget and financial management, 
personnel, property, and procurement services, ethics oversight, and 
the administration of equal employment policies and practices.
    The fiscal year 2015 request will also support activities managed 
by the OD's operational offices. OD Operations is comprised of several 
OD Offices that provide advice to the NIH Director, policy direction 
and oversight to the NIH research community and administer centralized 
support services essential to the NIH mission.
    The functions and initiatives of the OD's research offices are 
described in detail as follows:
 division of program coordination, planning, and strategic initiatives 
                                (dpcpsi)
    DPCPSI provides leadership for identifying, reporting, and funding 
trans-NIH research that represents important areas of emerging 
scientific opportunities, rising public health challenges, or knowledge 
gaps that merit further research and would benefit from collaboration 
between two or more Institutes or Centers (ICs), or from strategic 
coordination and planning.
    The Division includes major programmatic offices that coordinate 
and support research and activities related to HIV/AIDS, women's 
health, behavioral and social sciences, disease prevention, dietary 
supplements, research infrastructure, and science education. DPCPSI 
serves as a resource for the ICs and the NIH Office of the Director for 
portfolio analysis by developing, using, and disseminating data-driven 
approaches and computational tools.
    The fiscal year 2015 budget for DPCPSI, including the immediate 
Office of the DPCPSI Director, the Offices of Portfolio Analysis and 
Program Evaluation and Performance, and the Office of Strategic 
Coordination is $11,138,000.
           office of research infrastructure programs (orip)
    ORIP provides support for a variety of research infrastructure 
needs, including animal models and facilities; research models, human 
biospecimens, and biological materials; training and career development 
for veterinarians engaged in research; the acquisition of state-of-the-
art and shared and high-end instrumentation; and research resources 
grants to expand, re-model, renovate, or alter existing research 
facilities. The ORIP budget for fiscal year 2015 is $275,654,000.
              science education partnership awards (sepa)
    The goal of the Science Education Partnership Awards (SEPA) program 
is to invest in educational activities that enhance the training of a 
workforce to meet the Nation's biomedical, behavioral and clinical 
research needs. The SEPA program encourages the development of 
innovative educational activities for pre-kindergarten to grade 12 (P-
12), teachers and students from underserved communities with a focus on 
Courses for Skills Development, Research Experiences, Mentoring 
Activities, Curriculum or Methods Development or Informal Science 
Education (ISE) exhibits, and Outreach activities. In fiscal year 2015, 
the SEPA Program will be coordinated with the Department of Education 
to ensure that program activities are aligned with ongoing P-12 reform 
efforts included in the President's budget request. In fiscal year 
2015, the budget for SEPAs is $18,541,000.
                   the office of aids research (oar)
    OAR plays a unique role at NIH by serving as a model of trans-NIH 
planning and management, vested with primary responsibility for 
overseeing all NIH AIDS-related research. OAR coordinates the 
scientific, budgetary, legislative, and policy elements of the NIH AIDS 
research program. OAR's response to the AIDS epidemic requires a unique 
and complex multi-institute, multi-disciplinary, global research 
program. This diverse research portfolio demands an unprecedented level 
of scientific coordination and management of research funds to identify 
the highest priority areas of scientific opportunity, enhance 
collaboration, minimize duplication, and ensure that precious research 
dollars are invested effectively and efficiently, allowing NIH to 
pursue a united research front against the global AIDS epidemic. The 
fiscal year 2015 budget for OAR is $61,923,000.
     the office of behavioral and social sciences research (obssr)
    OBSSR furthers the mission of the NIH by emphasizing the critical 
role that behavioral and social factors play in health, healthcare and 
well-being. OBSSR serves as a liaison between NIH and the extramural 
research communities, other Federal agencies, academic and scientific 
societies, national voluntary health agencies, the media, and the 
general public on matters pertaining to behavioral and social sciences 
research. OBSSR's vision is to bring together the biomedical, 
behavioral, and social science communities to work more collaboratively 
to solve the pressing health challenges facing our Nation. OBSSR also 
coordinates and helps support the NIH Basic Behavioral and Social 
Science Opportunity Network, a trans-NIH initiative to expand the 
agency's funding of basic behavioral and social sciences research. The 
fiscal year 2015 budget for OBSSR is $26,094,000.
            the office of research on women's health (orwh)
    Since its creation in 1990, ORWH has worked to ensure the inclusion 
of women in NIH clinical research, to advance and expand women's health 
research, and to promote advancement of women in biomedical careers. 
ORWH is the focal point for NIH women's health research and works in 
partnership with the NIH ICs to incorporate a women's health and sex 
differences research perspective into the NIH scientific framework. 
ORWH activities are guided by the 2010 NIH Strategic Plan for Women's 
Health Research. This strategic plan outlines six goals to maximize 
impact of NIH research effort. The NIH strategic plan for women's 
health and sex differences research serves as a framework for 
interdisciplinary scientific approaches. The fiscal year 2015 budget 
for ORWH is $40,903,000.
                 the office of disease prevention (odp)
    The ODP is responsible for assessing, facilitating, and stimulating 
research in disease prevention and health promotion, and disseminating 
the results of this research to improve public health. Research on 
disease prevention is an important part of the NIH mission because the 
knowledge gained from this research leads to stronger clinical 
practice, health policy, and community health programs. In early fiscal 
year 2014, ODP released its first strategic plan. This plan outlines 
the priorities that the Office will focus on over the next 5 years and 
highlights the ODP's role in advancing prevention research at the NIH. 
The fiscal year 2013 budget for ODP is $5,861,000. The Office of 
Dietary Supplements (ODS) is within the ODP organizational structure. 
The mission of the ODS is to strengthen knowledge and understanding of 
dietary supplements by evaluating scientific information, stimulating 
and supporting research, disseminating research results, and educating 
the public to foster an enhanced quality of life and health for the 
U.S. population. The fiscal year 2015 budget for ODS is $26,786,000.
     the office of strategic coordination (osc) and the common fund
    OSC oversees the management of the Common Fund (CF), working with 
trans-NIH teams for each of the more than 30 Common Fund programs. 
These teams ensure that each program meets the criteria of Common Fund 
programs to synergize with IC funded research. The NIH CF was created 
by the 2006 NIH Reform Act which codified the approach of the NIH 
Roadmap for Medical Research to support cross-cutting, trans-NIH 
programs that require participation by at least two NIH ICs or would 
otherwise benefit from strategic planning and coordination. CF programs 
tackle major challenges in biomedical research that affect many 
diseases or conditions or that broadly relate to human health. The CF 
provides limited-term funding for goal-driven, coordinated research 
networks to generate data, solve technological problems, and/or pilot 
resources and tools that will stimulate the broader research community. 
The fiscal year 2015 budget for the Common Fund is $583,039,000.
                loan repayment and scholarship programs
    The mission of the NIH Intramural Loan Repayment Programs is to 
seek to recruit and retain highly qualified physicians, dentists, and 
other health professionals with doctoral-level degrees. These programs 
offer financial incentives and other benefits to attract highly 
qualified physicians, nurses, and scientists into careers in 
biomedical, behavioral, and clinical research as employees of the NIH. 
The Undergraduate Scholarship Programs (UGSP) offers competitive 
scholarships to exceptional college students from disadvantaged 
backgrounds that are committed to biomedical, behavioral, and social 
science health-related research careers at the NIH. The fiscal year 
2015 budget for ILRSP is $7,145,000.
    I am happy to answer any questions you may have about the OD's 
programs and activities as well as our plans for the upcoming year.
                                 ______
                                 
               Prepared Statement of Nora D. Volkow, M.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the fiscal year 2015 President's budget request for the National 
Institute on Drug Abuse (NIDA). The fiscal year 2015 budget request for 
NIDA is $1,023,268,000, which reflects an increase of $7,514,000 over 
the fiscal year 2014 level of $1,015,754,000.
    The impact of substance abuse in this country is daunting; the 
economic toll alone exceeds $700 billion \1\ a year in healthcare, 
crime-related, and productivity losses. NIDA strives to translate the 
returns of its investments in genetics, neuroscience, pharmacotherapy, 
and behavioral and health services research into new strategies for 
preventing and treating substance abuse and addiction. This scientific 
investment is crucial if we are to tackle rapidly evolving public 
health threats such as the increase in marijuana use among young people 
and the growing prevalence of opioid addiction and overdose deaths.
---------------------------------------------------------------------------
    \1\ U.S.DHHS. The Health Consequences of Smoking--50 Years of 
Progress: A Report of the Surgeon General. Atlanta, GA, CDCP, National 
Center for Chronic Disease Prevention and Health Promotion, Office on 
Smoking and Health, 2014; Rehm J, Mathers C, Popova S, 
Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of 
disease and injury and economic cost attributable to alcohol use and 
alcohol-use disorders. Lancet. 2009 Jun 27;373(9682):2223-33; National 
Drug Intelligence Center (2010). National Threat Assessment: The 
Economic Impact of Illicit Drug Use on American Society. Washington, 
DC: United States Department of Justice.
---------------------------------------------------------------------------
           today's basic science for tomorrow's breakthroughs
    There is a fundamental need to understand the complex steps of how 
body chemistry influences behavior and how their disruption can lead to 
addiction. A more detailed and personalized account of these steps will 
lead to a more effective and precise medicine to prevent and treat this 
complex brain disorder.
    In this context, and thanks to recent technological developments, 
we've made important advances in linking genes with behavior. As a 
result, we now have an unprecedented capacity to screen for thousands 
of genetic variations and catalogue how they modulate abuse/addiction 
risk by influencing brain maturation, its neural architecture, and 
behavioral patterns. NIDA researchers are also pursuing genome and 
whole individual sequence analysis to identify genes that modulate 
addiction risk (e.g., genes that regulate drug metabolism), advancing 
their understanding of how environmental factors (e.g., parental style, 
drug exposure) can affect the expression of those genes to either 
strengthen or weaken behavioral patterns through epigenetic changes. 
The systematic identification of genetic, environmental, and 
neurocircuitry variations that modulate abuse/addiction risk will 
revolutionize our prevention and treatment capacities.
                     big opportunities in big data
    Big data sets are essential platforms for the analysis of complex 
systems in genetics and epigenetics, proteomics, brain imaging and 
clinical science. Vast amounts of data are being produced by the 
overlaying of structural and functional brain imaging information that 
links the molecular and cellular data with the expression of higher 
level brain function. A prime example is the new fMRI-based approach to 
generating images of the functional connectivity (FC) among brain 
regions in the absence of any specific task, so called resting state 
(rs) FC. This technique offers a powerful window into circuit-level 
functions that may generate behavioral responses underlying 
vulnerability or a diseased state. Open access to such massive 
databases could lead to the identification of biomarkers of psychiatric 
illness risk including addiction, their trajectories, and treatment 
responses that could be translated for clinical use and the optimal 
management of patients.
    Similarly, NIDA is funding the development of an open source, open 
framework, free National Pain Registry that collects patient 
demographic and treatment information from around the Nation. This 
information can be used to identify which pain management interventions 
are most effective for specific chronic pain patients and predict which 
patients might be at higher risk for opioid addiction. Combined with 
concerted efforts in the pharmacogenomics of prescription opioids, pain 
registries are poised to help us maximize the effectiveness of pain 
treatments while minimizing the likelihood of prescription opioid abuse 
and addiction.
                    nurturing talent and innovation
    NIDA currently supports a great deal of innovative research on drug 
addiction and related health problems such as pain and HIV/AIDS and 
will continue to be at the forefront of training the next generation of 
innovative researchers. The 6-year old Avant-Garde award is a good 
example of a program that stimulates high--impact research that could 
lead to groundbreaking opportunities for the prevention and treatment 
of HIV/AIDS in substance users. NIDA is now crafting a new kind of 
award, which blends NIH's Pioneer and New Innovator award mechanisms. 
This new opportunity, called the ``AVENIR'' award, is designed to 
attract creative young investigators to genetic research on substance 
use disorders and HIV/drug abuse research. Another example is NIDA's 
Cutting-Edge Basic Research Awards (CEBRA), designed to foster highly 
innovative or conceptually creative research that advances our 
understanding of drug abuse and addiction. The latest results of this 
effort include three independent studies exploring the potential 
benefits of neurofeedback training, transcranial magnetic stimulation, 
and meditation on facilitating smoking cessation.
       better pain management: a major goal of addiction research
    Pain management is an important component of high-quality, 
compassionate medical care. Opioid analgesics are among the most 
effective medications for the management of severe pain and frequently 
used for pain treatment. Unfortunately, the benefits of long term 
opioid analgesic treatment are accompanied by significant risk of 
developing drug tolerance (and the need for escalating doses) and 
hyperalgesia (increased pain sensitivity). Exposure to potentially 
rewarding substances, like opioid analgesics, may reinforce drug taking 
behavior for persons with risk factors for addiction and trigger 
relapse in those that are in recovery. These are intrinsic liabilities 
of opioid analgesics that clearly increase the risk for diversion, 
abuse, addiction and overdose.
    NIDA recognizes it has a critical role in ensuring the availability 
of safe and efficacious chronic pain management options while 
minimizing risk of abuse. This is why we are committed to supporting 
research to better predict who is at risk of addiction and to develop 
new classes of effective, non-addicting pain medications. Parallel to 
these efforts, NIDA is proactively pursuing methods to minimize the 
risk of overdose with existing medications. For example, NIDA and 
Lightlake Therapeutics Inc. have partnered to develop an intranasal 
delivery system of naloxone (an opioid receptor blocker that can 
rapidly reverse the overdose of prescription and illicit opioids), 
which could greatly expand its availability and use in preventing 
opioid-related deaths, a public health problem of epidemic proportion 
in the U.S.
                  health consequences of marijuana use
    There is a dangerous and growing misperception that marijuana use 
is harmless, resulting in its status as the most commonly used illicit 
drug in the United States with about 12 percent of people aged 12 and 
over reporting use in the past year.\2\ Marijuana use has been 
associated with significant adverse effects, including addiction, 
cognitive impairment and car accidents. The key to minimizing negative 
outcomes lies with the intensification of our efforts to educate the 
public about the dangers of marijuana use and, with the deployment of 
multipronged, evidence-based strategies to prevent and treat the abuse 
of and addiction to marijuana and other drugs. To meet this challenge, 
NIDA has released several funding announcements to encourage research 
on the impact of changing marijuana policies; and, in partnership with 
other NIH institutes, is planning a large-scale, prospective study that 
follows children prior to drug use into early adulthood to determine 
whether and how marijuana and other commonly used substances (e.g., 
alcohol, tobacco) affect the developing brain.
---------------------------------------------------------------------------
    \2\ Substance Abuse and Mental Health Services Administration, 
Results from the 2012 National Survey on Drug Use and Health: Summary 
of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-
4795. Rockville, MD: Substance Abuse and Mental Health Services 
Administration, 2013.
---------------------------------------------------------------------------
                        medications development
    Our current approaches to develop next-generation pharmaceuticals 
take advantage of new technologies using immunotherapeutic or biologic 
(e.g., bioengineered enzymes) approaches for treating addiction. The 
goal is to develop safe and effective vaccines or antibodies that 
target specific drugs, like nicotine, cocaine, and heroin, or drug 
combinations. If successful, immunotherapies--alone or in combination 
with other medications, behavioral treatments, or enzymatic 
approaches--stand to revolutionize how we treat, and maybe even someday 
prevent addiction.
                               conclusion
    The field of addiction research continues to benefit from the 
explosion in genetic knowledge, the advent of precise technologies to 
probe neuronal circuits, and the emergence of openly accessible big 
data platforms. NIDA's research is strategically poised to take full 
advantage of these and other emerging opportunities to develop the 
knowledge base that can be used to reduce drug use in this country.
                                 ______
                                 
             Prepared Statement of Jack Whitescarver, Ph.D.
    Mr. Chairman and Members of the Committee: I am pleased to present 
the President's budget request for fiscal year 2015 for the trans-NIH 
AIDS research program, which is $3,004,973,000. This amount is 
$19,882,000 above the fiscal year 2014 enacted level of $2,985,091,000.
    The authorizing law requires that the Office of AIDS Research (OAR) 
function as ``an institute without walls'' and allocate all dollars 
associated with this area of research across the NIH. Therefore, the 
total for AIDS research includes both extramural and intramural 
research (including research management support, management fund, and 
service and supply fund), buildings and facilities, training, and 
evaluation, as well as research on the many HIV-associated co-
infections and co-morbidities, including TB, hepatitis C, and HIV-
associated cancers. It also includes all of the basic science 
underlying this research. Other disease areas are not reported this 
way. Therefore the total for AIDS-related research is not comparable to 
spending reported for other individual diseases.
                   nih aids research accomplishments
    In the three decades since AIDS was first reported, NIH continues 
to be the global leader in research on HIV and its many related 
conditions. New avenues for discovery have been identified, providing 
possibilities for the development of new strategies to prevent, treat, 
and potentially cure HIV. Recent accomplishments include:
  --Development of new treatments for many HIV-associated co-
        infections, co-morbidities, malignancies, and clinical 
        manifestations;
  --Development of new strategies for the prevention of mother-to-child 
        transmission;
  --Demonstration of the first proof of concept that a vaccine can 
        prevent HIV infection and identification of potential immune 
        markers for protection;
  --Discovery of more than 20 potent human antibodies that can stop up 
        to 95 percent of known global HIV strains from infecting human 
        cells in the laboratory;
  --Demonstration that the use of antiretroviral therapy by infected 
        individuals can dramatically reduce HIV transmission to an 
        uninfected partner; and that the use of antiretroviral drugs by 
        uninfected individuals can reduce their risk of HIV 
        acquisition;
  --Discovery that genetic variants may play a role in enabling some 
        individuals, known as ``elite controllers,'' to control HIV 
        infection without therapy; and
  --Advances in basic and treatment research aimed at eliminating viral 
        reservoirs in the body that for the first time are leading 
        scientists to design and conduct research aimed at a cure for 
        HIV/AIDS.
    In just the past several months, NIH intramural and extramural 
researchers have produced a number of exciting new advances. NIH 
researchers published the results of studies utilizing potent human 
neutralizing antibodies that successfully suppressed a form of HIV in 
primates. This important research could potentially result in a new 
form of treatment for HIV that could be used as an adjunct to 
antiretroviral therapy and could lead to opportunities for novel 
research to treat and potentially cure HIV. NIH-sponsored researchers 
also have made tremendous strides in producing and analyzing proteins 
that may provide an important new pathway in AIDS vaccine design.
    A team of NIH-funded investigators recently reported the first case 
of a newborn in Mississippi who was ``functionally cured'' of HIV 
infection. The infant received antiretroviral therapy immediately after 
being diagnosed at birth but was then lost to follow-up and treatment. 
The now nearly three year-old child has re-entered care with no 
indication of HIV disease and no detectable virus in the absence of 
therapy. Additional studies are under way to better understand this 
case and may lead to clinical trials to see whether a similar approach 
could be used to achieve a ``functional cure'' for other HIV-infected 
newborns. NIH is leading global research efforts to capitalize on all 
of these advances, move science forward, and begin to turn the tide 
against this pandemic.
                           the aids pandemic
    Despite this progress, the HIV/AIDS pandemic will remain the most 
serious global public health crisis of our time until better, more 
effective, and affordable prevention and treatment regimens--and 
eventually a cure--are developed and available around the world. UNAIDS 
reports that in 2012, more than 35 million people were estimated to be 
living with HIV/AIDS; 2.3 million were newly infected (half of them 
women); and 1.6 million people died of AIDS-related illnesses.
    In the United States, HIV/AIDS continues to be an unrelenting 
public health crisis, disproportionately affecting racial and ethnic 
populations, women of color, young adults, and men who have sex with 
men. The Centers for Disease Control and Prevention estimates that 
approximately 1.1 million people are HIV-infected; approximately 50,300 
new infections occur each year; and one in four people living with HIV 
infection in the U.S. is female.
              coordinated trans-nih aids research program
    The NIH AIDS research program is coordinated and managed by the 
OAR, and carried out by nearly every NIH Institute and Center (IC). 
Through its unique trans-NIH planning, budget, and portfolio review 
processes, OAR identifies the highest priority areas of scientific 
opportunity and ensures that precious research dollars are invested 
effectively. Scientific priorities for AIDS research are constantly 
reassessed and reflected in the budget. The annual trans-NIH AIDS 
strategic plan, developed by OAR in collaboration with both government 
and non-government experts, guides the development of the trans-NIH 
AIDS research budget. Each year, the state of the science is reviewed, 
newly emerged and critical public health needs are assessed, and 
scientific opportunities are identified. This annual process culminates 
with the identification of the highest strategic priorities and 
critical research needs. OAR develops each IC's AIDS research 
allocation based on the Plan, scientific opportunities, and the IC's 
capacity to absorb and expend resources for the most meritorious 
science----not on a formula. This process reduces redundancy and 
ensures cross-Institute collaboration. The fiscal year 2015 budget 
request reflects the priorities of the fiscal year 2015 strategic 
planning process.
               aids research priorities and opportunities
    The advances made by NIH investigators have opened doors for new 
and exciting research opportunities to answer key scientific questions 
that remain in the search for strategies to prevent and treat HIV 
infection both in the United States and around the world. The fiscal 
year 2015 budget priorities are:
  --Basic research that will underpin further development of critically 
        needed prevention methodologies, including vaccines;
  --Innovative multi-disciplinary research and international 
        collaborations to develop novel approaches and strategies to 
        eliminate viral reservoirs that could lead toward a cure for 
        HIV;
  --Research to develop better, less toxic treatments and to 
        investigate how genetic determinants, sex, gender, race, age, 
        nutritional status, treatment during pregnancy, and other 
        factors interact to affect treatment success or failure and/or 
        disease progression; and
  --Studies to address the increased incidence of co-morbidities, 
        including AIDS-associated malignancies; cardiovascular, 
        neurological and metabolic complications; and premature aging 
        associated with long-term HIV disease and antiretroviral 
        treatment.
                                summary
    The NIH investment in AIDS research has produced groundbreaking 
scientific advances that have benefited not only patients with HIV, but 
those with other diseases as well. For example, the development of 
protease inhibitors to treat HIV has led to development of a new drug 
combination that can cure hepatitis C, which affects about 150 million 
people globally. That advance in hepatitis C research may, in turn, 
provide important knowledge toward an HIV cure. Drugs developed to 
treat HIV-associated opportunistic infections are benefiting the more 
than 28,000 Americans who receive an organ transplant each year. 
Research on HIV-associated neurologic and cognitive manifestations 
ultimately will benefit millions of patients with Alzheimer's disease 
and other aging and dementia issues.
    Despite these advances, however, AIDS is not over, and it is far 
too soon to declare victory. Serious challenges lie ahead. The HIV/AIDS 
pandemic will remain the most critical public health crisis of our time 
until improved and affordable prevention and treatment regimens are 
developed and universally available. NIH will continue to search for 
critical solutions to prevent, treat, and eventually cure AIDS.
    Thank you for your continued support for these efforts.

    Senator Harkin. Thank you very much, Dr. Collins. We will 
start a round now of 5-minute questions. As I said at the NIH, 
I have never come away from a conversation or listening to you, 
Dr. Collins, without being more enlightened and more hopeful 
about the future. I like that ``National Institutes of Hope.''
    Let me just ask you a question about the BRAIN Initiative, 
if I can start with that. I have got two or three questions on 
the BRAIN Initiative. Paint for me a picture of how you see the 
research going ahead in the BRAIN Initiative. And we have some 
partners, four outside partners, right now that are also 
putting money into this, and you have an advisory group from 
DARPA (Defense Advanced Research Projects Agency) and NSF 
(National Science Foundation). Paint for me the picture of how 
you see this developing in the next 2, 3, 4, 5 years. And sort 
of what do we hope to get from this?

                            BRAIN INITIATIVE

    Dr. Collins. Well, we are enormously excited about this, 
and I am going to ask my colleague, Story Landis, who is a 
major leader at NIH in the BRAIN Initiative, to say a word. But 
just very briefly from my perspective, this is one of those 
moments that comes along once in a long time where the 
technology to be able to tackle a truly important problem, 
understanding how the circuits in the human brain work, has 
arrived at the point where we have this kind of push, bringing 
disciplines together that have not necessarily found each 
other, and making this a priority. We believe we can transform 
our understanding of this incredible organ with its 86 billion 
neurons, each of which has maybe a thousand connections. But, 
Story, say where we are and where we are going.
    Dr. Landis. So we are very excited about the opportunity to 
really understand how neural circuits in the human brain work--
86 billion neurons, each of which are connected in complicated 
circuits and pathways that process information, that allow us 
to see an image and interpret it, to hear words and understand 
what they mean, to remember, to reason.
    We have some understanding now of how those 86 billion 
neurons are organized into circuits, but we do not nearly have 
enough detail, and we do not know enough about how information 
is processed. And the goal of the BRAIN Initiative in the first 
five or so years is to really develop the tools that will allow 
us to probe those questions. There will be early on potential 
opportunities to translate to disease, and I could give you 
some examples if you would like.
    Senator Harkin. Let me ask you this, Dr. Landis. Are you 
working with the National Institute on Aging? Is there any 
connectivity between the BRAIN Initiative and Alzheimer's 
research?
    Dr. Landis. Absolutely, although the understanding that we 
will gain from the BRAIN Initiative will then be applied to 
understanding how circuits are perturbed in Alzheimer's. 
Alzheimer's disease nerve cells die. We would like to prevent 
that death, but in the absence of tools yet to do that, the 
circuits reorganize when cells are lost. And the BRAIN 
Initiative will give us a better understanding of why that 
reorganization occurs and how we can potentially use the 
neurons that remain to have much more function.
    Senator Harkin. Well, I asked that because, you know, we 
have a lot of things confronting us in the future. I will get 
to Dr. Varmus and cancer. But if we do not do something about 
Alzheimer's, that is a tsunami that is going to hit us big 
time. And so I just really wanted to get that on the record 
that the money that we are putting into the BRAIN program, 
BRAIN research program, also has a connectivity to Alzheimer's 
research.
    Dr. Landis. Absolutely.
    Senator Harkin. Okay.
    Dr. Collins. Think of the BRAIN Project as a foundation for 
all neurological diseases, just like the Genome Project was a 
foundation for all genetic diseases. It lifts all of those 
boats of research to go higher and faster.
    Senator Harkin. Sure.
    Dr. Landis. And psychiatric diseases and drug abuse, all 
the brain disorders.

                       FUTURE OF CANCER RESEARCH

    Senator Harkin. Exactly. Dr. Varmus, again, I would be 
remiss if I did not thank you for a lifetime of devotion and 
dedication to biomedical research, stewardship of the NIH for a 
lot of the time I was either chairman or ranking member. And it 
is good to have you back as the head of the National Cancer 
Institute.
    Here is my question: What excites you the most right now? 
In all of cancer research and stuff, what is it that gets you 
up in the morning right now that you are looking ahead to do?
    Dr. Varmus. Thank you. And before I give you a brief answer 
to that question, let me first of all compliment you on your 
service. You and I have been facing each other across the dais 
like this for 20 years off and on, and I have always admired 
your passion, your commitment to the NIH, your honesty. And 
even on those rare occasions when we disagreed on a few issues, 
we have had a collegial and constructive relationship. And your 
departure from this Congress is a heavy blow to the NIH and to 
its supporters.
    Senator Harkin. I appreciate that.
    Dr. Varmus. What most excites me at the moment is the deep 
intellectual understanding we have about how cancer arises and 
how the body tries to respond to it. And the connection between 
basic science and its very near apposition to what we can do 
practically is thrilling.
    Over 40 years ago, I have to confess when I began doing 
cancer research, the application of what we were trying to 
learn with chicken viruses and mouse viruses was very far away. 
Today we use tools of genomics and immunology and biochemistry 
in a way that is very closely connected to what we are doing in 
the clinic. So when we discover a new gene that is involved in 
cancer, it is not long before we find some drug, perhaps an 
existing drug, that can be applied to patients whose tumors are 
being analyzed with the instruments of genomics to identify 
exactly what is wrong with that cancer, and to carry out in a 
precise fashion a clinical trial that is designed in entirely 
new ways.
    Similarly, we have learned from basic immunology the kind 
of thing that Dr. Collins just illustrated is also being 
applied in immediate ways to try to interfere with the breaks 
on the immune system that have kept the immune system from 
attacking cancer cells.
    Senator Harkin. My time has run out, but I will have a 
follow-up on that on immunotherapy and Dr. Rosenberg and what 
he is doing out there. Okay.
    Senator Moran.

                          ALZHEIMER'S DISEASE

    Senator Moran. Mr. Chairman, thank you very much. Dr. 
Collins, Dr. Landis, and others, thank you very much for 
attending the recent hearing we had in regard to Alzheimer's in 
particular. Several members asked that day if we would reach 
the goal of a cure for Alzheimer's by 2025 and how much money 
it would take to do so.
    I understand how difficult it must be to quantify such an 
answer, but I think it is important for us to know if our 
Alzheimer's research funding is on track. Therefore, I am 
looking for your professional opinion or opinions as to how 
much money does NIH need in fiscal year 2015 to keep pace with 
the goal of a cure for Alzheimer's by 2025.
    Dr. Collins. Well, thanks for the question, Senator, and 
that was an excellent hearing that was held by this 
subcommittee. And we had a great opportunity there to look at 
the challenge and also the scientific opportunities, which are 
really coming forward in very exciting ways, recognizing that 
the challenge here in terms of both the economic and human cost 
of this disease can hardly be overstated.
    As you have pointed out, we have an action plan for 
Alzheimer's disease, part of the legislation that put in place 
this project--plan. And the National Institute on Aging, 
directed by Dr. Hodes, has been deeply engaged in that, running 
a research summit at NIH, and polling the entire community 
about where the research opportunities would be. It is 
wonderful that in fiscal year 2014, largely due to this 
subcommittee's efforts, $100 million has been appropriated for 
the National Institute on Aging, the bulk of which will be put 
into promising Alzheimer's research.
    I have looked carefully at the way in which the Alzheimer's 
plan maps across the various years. As you know, science tends 
not to operate in 1 year intervals. Many of the components of 
the plan are more in a 3-year kind of timetable. I could show 
you a Gantt chart that goes on for many pages about how each of 
these components might start and hopefully reach a milestone.
    It is very difficult, though, with all the multiyear aspect 
of this to say, well, what do we need exactly in fiscal year 
2015? And I have sort of tried with Dr. Hodes to come up with 
that kind of estimate, and I am afraid it would not be a 
reliable one. Part of that is, of course, we do not have the 
ability in science to know exactly what is going to happen next 
month or the month after that. And a lot of the research in 
Alzheimer's is being developed by investigators out there in 
our wonderful brain trust, the universities that are doing this 
research. And we might wake up tomorrow and find that something 
has happened that completely changes the direction we want to 
go. So while this plan is a good one to work with, it will 
undoubtedly evolve over time.
    So I know I am sounding like I am not giving you an answer, 
and I guess I am trying to say I think to put a dollar figure 
right now on fiscal year 2015 would be to overstate what I 
really can predict to be necessary for this purpose. Again, we 
are thrilled with $100 million in 2014. We were delighted to 
see in the President's Opportunity, Growth, and Security 
Initiative another $100 million would come to Alzheimer's 
disease should that become possible.
    Senator Moran. You have the capability, Dr. Collins, I 
assume, of telling us or telling me that the $100 million in 
fiscal year 2014 was not too much.
    Dr. Collins. It was not too much. You are quite right about 
that. And, you know, you are asking about Alzheimer's. You 
could be asking about many other areas of NIH research as well, 
and I would tell you we do not have too much money to work on 
anything that we are working on. We are not limited by ideas. 
We are limited by resources, whether it is cancer, infectious 
disease, heart disease, whatever. That is our current state.
    Senator Moran. Doctor, let me take this question in a 
broader step. But first let me say that my expectation would be 
as those scientific developments occur, a reason that we should 
have the kind of hearings that we have on an ongoing basis is 
so that you can then come to us and say this development has 
happened in some university in the country or here at NIH. And, 
therefore, if you would invest additional dollars in this area, 
we believe we can advance the outcomes more quickly.
    And so, my continued effort, I think, will be to try to get 
you to help us prioritize spending based upon science, based 
upon success in research where we ought to put the dollars that 
we have to allocate within the 27 Institutes and Centers that 
you and NIH engage in.
    Dr. Collins. Senator, I would welcome those kinds of 
conversations at any time, and appreciate your leadership in 
that kind of planning process.

                        DISEASE SPECIFIC FUNDING

    Senator Moran. I have 28 seconds left for a follow-up 
question, which is this: You have--you, NIH--has historically 
opposed disease-specific funding. You want the allocations to 
occur based upon science, not on politics, and I certainly 
share that goal. If we are underfunding in an area of 
research--if we start with low funding in a particular area of 
research, it is harder to have the developments that then allow 
you to come to us and say we have had a breakthrough, we need 
more. We need to accelerate the funding of that research.
    How are you--I mean, can you give me examples--I do not 
have the history that Senator Harkin has, but does it happen 
from time to time in which you come to Congress and say we need 
to prioritize the research in this area, and are you willing 
then to tell us that we reduced the priority someplace else? 
How do we ever get into the circumstance in which any of us are 
willing to say our money should go into this basket, knowing 
that it is not infinite? The money has to come out of some 
other basket.
    Dr. Collins. Well, again, I appreciate the question. And 
this is the kind of conversation we have around the table at 
NIH all the time with the 27 Institute and Center directors, 
each of whom has a strategic plan that they are constantly 
refreshing and revising.
    The good news is that the boundaries between those 
institutes are very porous. And if we collectively identify an 
opportunity that demands additional investments in a particular 
direction, we often can figure out how to do that without 
having to go through a long lead time to try to adjust a future 
year's budget. And we are quite capable of doing so.
    And increasingly, that is a good thing because the next 
breakthrough in cancer might come from the Diabetes Institute, 
and the next breakthrough in infectious disease might come from 
the Center that is looking at translational sciences. So we are 
really, more than we ever have been, a unit, a whole here that 
thinks about biomedical research collectively, not in a series 
of buckets.
    Senator Moran. Thank you very much.
    Senator Harkin. Thank you, Senator Moran. And our 
distinguished Chair of the entire Appropriations Committee, who 
happens to have a real interest in NIH, I can tell you that.
    Senator Mikulski.
    Senator Mikulski. Thank you very much, Senator Harkin, and 
we are so glad that you are holding this hearing. And I think 
it shows the significance of the way we think about the 
National Institutes of Health, which we all affectionately and 
with great admiration do call the National Institutes of Hope. 
The fact that Senator Shelby is here, the vice chairman of the 
Appropriations, and myself shows our commitment to really 
trying to make sure that NIH has the resources it needs to 
continue to be the premiere global agency for biomedical 
research, and to do it on a bipartisan basis.
    I know you spoke earlier, if I could. You were kind of 
emotional about this hearing, and I am emotional about this 
hearing for you. I recall coming to the United States Senate. I 
was sworn in 1987, working with then the beloved Nancy 
Kassebaum, you, and Ted Kennedy, when women were not even 
included in the protocols, many of the research things, at NIH. 
There were many reasons. Many were just flawed sociology rather 
than good biology.
    Imagine in those years when we were not even included, and 
then we advocated for the Office of Women's Health. The funding 
then for breast cancer was quite spartan and skimpy. Again, we 
turned to you. And then as we made steady advances, George 
Herbert Walker Bush appointed Bernadine Healy to be the head of 
NIH. Dr. Healy also reached out again to us to ask us to look 
for a famous longitudinal study on hormone therapy. That 
hormone therapy study resulted in the change in the way 
hormones are treated in terms of hormone therapy for women, and 
it resulted in breast cancer coming down by 15 percent.
    I recall with great emotion my last call with Bernadine 
Healy, and this is what she said. I called her, and there was 
an article in the New York Times, Dr. Varmus, that said breast 
cancer rates have come down 15 percent. And I said, ``My god, 
Bernadine, can you believe that?'' She said, ``Yes, Barbara. 
Can you believe because we worked together we are saving lives 
a million at a time?''
    That is what we are trying to do here with this hearing. We 
are trying to look at these issues. And I am going to say to 
you, Senator Harkin, the Catholic nuns had a phrase when they 
taught people like me. They had a phrase in Latin called 
``exegi monumentum aere perennius aedificabo.'' It means we 
will build a monument more lasting than bronze. I feel our 
monument to you, to both you, to Senator Specter, to Bill 
Frist, Ted Kennedy, is the way we walked across the aisle is to 
build a monument more lasting than bronze, and that is to make 
a significant public investment this year in the National 
Institutes of Health to get it right back on track to where it 
was, and to have a steady growth plan of action so that at the 
end of the day, at the end of the year, at the end of our 
terms, we know that we have been working together to save lives 
a million at a time. So I want to just shake your hand and 
thank you. And, Moran, you are from Kansas.
    Senator Moran. Yes.
    Senator Mikulski. You know what Nancy did shoulder to 
shoulder here. Senator Shelby has been a great advocate.
    I have many questions that I am going to ask. We could hold 
a hearing on each and every one of those people--distinguished 
people here. We are lucky to have them. Their combined years of 
service are stunning. Many of them at this table could be in 
such lucrative careers in the private sector.
    I remember working with Dr. Fauci when there was this 
unknown disease in which men were dying all over the country. 
It was called AIDS. A little boy named Ryan White came here 
with his mother when he had been targeted by his classmates for 
taunts and isolation. Now look at where we are. We could take 
item after item, issue after issue, and it really shows what we 
need to do.
    So we need to not only fund the research, we need to 
support the people who do the research. And to those young 
people out there right now thinking about careers that there is 
hope in trying to find cures to give people hope. And so, this 
is where we really need to work on a bipartisan basis, hands 
across the aisle, hands across the dome. And I think we can 
make a significant difference. So we want to help build a 
monument more lasting than bronze.
    I yield back my time.
    Senator Harkin. Thank you very much. That was a very 
poignant statement, and I thank you for that. The only thing I 
would add is we have to come to grips with the funding, and I 
am open for any and all suggestions.
    Senator Mikulski. I know we are all going to get into this.
    Senator Harkin. I just met yesterday with a couple of 
people who had an interesting idea on funding for translational 
science. Gordon Gund and Karen Petrou from the Foundation for 
Fighting Blindness have come up with--I do not need to go into 
that now, but there are ideas being spawned out there on how we 
might raise more money for NIH. So anybody that has got 
suggestions, we need to keep looking.

                      PREFERRED METHOD OF FUNDING

    Senator Mikulski. And, Mr. Chairman, if I could, if Dr. 
Collins could comment. We had a great hearing on Alzheimer's, 
and also that is an epidemic in our country, as is autism, 
quite frankly. And again, many here could comment on it. And 
then there are those things that seem benign and not too scary, 
but then along comes flu. But when we look at the ``A'' words--
autism--there was talk of, like, do we need, like, a Manhattan 
Project.
    And I wonder to Dr. Collins and the esteemed panel, what is 
it that is the best thing for NIH, sustained, steady growth 
with kind of an agreement across the aisle and across the dome 
of steady increases to the way we had the concept of--I 
understand if we added--kept pace with inflation at 3 percent, 
and then another 5 percent, we could get to almost doubling 
NIH--we do not want to use that phrase anymore--to $40 billion. 
Is that better rather than a concentrated big buck expenditure 
on one particular area for----
    Dr. Collins. I really appreciate the question. And I wanted 
to show you a graph----
    [The graph follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Senator Mikulski. In other words, does the idea of a 
Manhattan like project really have efficacy, or does it sound 
good, but----
    Dr. Collins. What you see on the screen here is the 
projection over the past years since 1990 of the NIH support 
corrected for inflation because we have to deal with that. That 
is the yellow line. You see the blue bar is there for the 
Recovery Act, those 2 years of an increment which helped with 
sort of pent-up need.
    But notice the doubling, which happened there between 1998 
and 2003, then encountered essentially flat budgets, which 
inflation has eroded ever since. And you can see interestingly, 
the dotted line is the trajectory we were on before the 
doubling, which if you go back to 1970, we were on a period of 
about 3.7-percent annual growth. If we had stayed on that 
steady trajectory, we would now be $10 billion almost higher 
than we are. Very interesting to sort of contemplate this.
    Now, the doubling was wonderful. The doubling did huge 
things for biomedical research. But what came after has been 
really quite painful. And to answer Senator Mikulski's 
question, the worst thing you can do, I think, to biomedical 
research is to create an area of uncertainty, of ups and down, 
of a roller coaster. Science operates not as a spring, but a 
marathon. You need confidence that there is going to be support 
there so that young scientists can tackle really innovative 
risky projects. And this up and down circumstance now hitting 
historic lows in terms of opportunities to get support is 
really quite damaging.
    And what would be vastly better, Senator, would be for us 
to be able to count on a more or less stable trajectory of 
inflation plus some percentage that you could be fairly 
confident was going to be maintained. I understand how hard 
that is in the current fiscal situation, but if you are asking 
my judgment about what NIH needs in order to flourish and in 
order to contribute to this Nation what we think we can 
contribute and to the world, that would be it, that kind of 
steady trajectory that you could be confident in.
    Senator Harkin. Thank you, Dr. Collins. Senator Shelby, our 
ranking member of the entire committee. Used to be the ranking 
member of this subcommittee.
    Senator Shelby. Thank you. Thank you, Chairman Harkin, and 
thank you for all your service here and advocacy for NIH. I 
believe as a veteran member of the Appropriations Committee 
looking at all the aspects of the various requests for money 
that the NIH, I think, by far is the best investment we have 
made. And we should make sure that it is properly funded and 
not let it be eaten up with inflation.

                 ECONOMIC IMPACT OF BIOMEDICAL RESEARCH

    Dr. Collins, tell us the economic impact of biomedical 
research, including pharmaceutical research--NIH is the leader, 
but going on elsewhere, too, in the private sector--in this 
country, and how important is it not to just our health, but to 
our economy and our leadership in the world. You have some 
numbers there?
    Dr. Collins. I have some numbers. I could go on all day 
with numbers because----
    Senator Shelby. How about taking a few minutes?
    Because the chairman will gavel----
    Dr. Collins. I will try to rein it in here.
    Senator Shelby. Thank you.
    Dr. Collins. I will tell you when I came to this job to be 
Director of NIH, I did not realize how important it was going 
to be to have this kind of case in front of the public and in 
front of the Congress in order to justify what we are doing 
because the main reason I am excited about being at NIH is the 
advances in research that are going to help people. But there 
is another great story here, which is that every $1 that we 
give out in grants to all 50 States, by most estimates, returns 
more than two-fold in terms of economic----
    Senator Shelby. It is a huge multiplier, is it not?
    Dr. Collins. It is about $2.21 per $1 according to one----
    Senator Shelby. In GDP (gross domestic product) and jobs, 
right?
    Dr. Collins. And in jobs. We directly support about 432,000 
jobs through our grants. But if you figure out how NIH is sort 
of part of the ecosystem that creates jobs in biotech and in 
pharma, the estimate is something like 7 million jobs are 
dependent upon the progress that NIH makes, and are somewhat 
jeopardized by our current circumstance.
    And when you look at the competition issue, which is 
another one that people raise, certainly America has led the 
world in biomedical research for the last 20 or 30 years, but 
that is gradually eroding, and, in fact, eroding more quickly 
these days, especially after sequester. And if we are 
interested in seeing those kinds of returns like were talked 
about with the Genome Project, a 141 to 1 return on those 
dollars, do we really want those returns to go somewhere else, 
or do we want them to happen right here?

                          AUTOIMMUNE DISEASES

    Senator Shelby. Absolutely not. We want to keep it here. 
Let me ask you a question. I am limited in time. We have a 
chairman with a good gavel here. In the autoimmune area that I 
have worked with you before, rheumatoid arthritis and lupus, 
are you cutting back on the money there? It seems like you are. 
And if so, why?
    Dr. Collins. We are only cutting back because we have to 
cut back everywhere.
    Senator Shelby. Because of lack of money.
    Dr. Collins. Even with the wonderful things you all did 
with the fiscal year 2014 omnibus, we did not recover 
everything we lost in the sequester. I will say one bit of good 
news about lupus is the development of this partnership with 
industry called the Accelerating Medicines Partnership, AMP, 
because lupus is one of the targets that we are going after.
    Senator Shelby. They are kind of matching you on money, 
right?
    Dr. Collins. They are, $230 million over 5 years, half of 
it from us, half from them, and bringing scientists around the 
same table who would not normally be talking to each other, and 
having this all done in an open access fashion. This is an 
interesting experiment, but it may very well get us that next 
generation of drug targets for lupus.
    Senator Shelby. Doctor, how important is not just for 
lupus, but all the autoimmune diseases--the whole spectrum 
affects so many of the areas of research that you are working 
on, does it not?
    Dr. Collins. Absolutely, and maybe Dr. Fauci would want to 
say a word about this since he is the most distinguished 
immunologist in the room.
    Senator Shelby. We know.
    Dr. Fauci. Thank you for the question, Senator. Indeed, I 
think the issue with autoimmunity is really an example of how 
fundamental basic research and understanding how the immune 
system is regulated over the last several years have provided 
extraordinary insight into how we can better manage, diagnose, 
and ultimately treat, and in some cases even prevent, 
autoimmune diseases.
    Whenever you think about autoimmunity, the terminology 
itself is descriptive, namely an immune response against 
oneself that is inappropriate, and that is what is studied at 
the very basic level. At the NIH, we now are developing 
consortia where, as you hinted, multiple institutes are 
involved in immunology--the Cancer Institute, the Heart, Lung, 
and Blood Institute, our institute, the Arthritis 
Musculoskeletal and Skin Diseases Institute, et cetera. They 
all are, and we have a consortium now----
    Senator Shelby. Immunology kind of transcends it all, does 
it not?
    Dr. Fauci. It is one of those disciplines that essentially 
touches to a greater or lesser degree virtually everything we 
do.

                            CYSTIC FIBROSIS

    Senator Shelby. Dr. Collins, in another area--my time is 
limited, just a few seconds--but cystic fibrosis. We have come 
a long way there. We are a long way from a cure, but we have 
extended a lot of the children's lives, you know, beyond, gosh, 
what we thought. Where are we today, and what are some of the 
hopes there?
    Dr. Collins. Well, cystic fibrosis is a wonderful example 
of how knowing the molecular basis of a disease can get you to 
a point with a great deal of hard work to a targeted 
therapeutic that is not just hoping something will work, but 
designing it to work.
    So cystic fibrosis, where my lab had the privilege of being 
involved in that and found the gene in 1989. Just a year ago, 
the first really effective therapeutic for about 5 percent of 
cystic fibrosis patients that have a particular mutation in 
that gene was approved by the FDA, infact. And it is truly 
dramatic the stories you hear from those individuals. I have 
heard stories of kids who were on the lung transplant list who 
are now not on it anymore.
    The main challenge now is to find an equivalent therapy for 
the majority of cystic fibrosis patients that have a different 
mutation, the so-called Delta F508, and there is a clinical 
trial very actively underway by Vertex. The drug is called VX-
809. We are all holding our breath to see what the results of 
that will look like. The initial glimpse with a smaller phase 
two study looked pretty promising.
    So you have gone--it took a long time. And one of the 
things that NCATS, and my colleague here, Dr. Austin, is 
charged to do is to try to shorten what would be a 20-year 
timetable into something much faster. But the pathway here that 
was charted by cystic fibrosis in a collaboration with the CF 
Foundation that was a major partner here is truly exciting. It 
is a paradigm. We could do this again.
    Senator Shelby. Thank you very much for the work you do. 
Thank you, Mr. Chairman.
    Senator Harkin. Thank you, Senator Shelby.
    Senator Kirk.

                        REHABILITATION STANDARDS

    Senator Kirk. I want to ask Story a question as a stroke 
survivor. We have two members--senators on this committee who 
are stroke survivors. I would like to take you into the world 
of our rehab standards, which Senator Johnson and I have both 
introduced legislation, S. 1027, to speak on behalf of the 
900,000 Americans who will survive stroke we expect this year. 
We know that roughly one-third of them will never return to 
work. And Tim Johnson and I have a belief that we could set a 
national standard of returning those stroke survivors to work. 
That would unlock a hell of a lot of Americans to pay taxes and 
be productive.
    Let me just burrow in for rehabilitation standards. My 
understanding is out of the $3 billion NIH, about $66 million 
is spent. I think the country would do well to have NIH 
establish a rehabilitation standard.
    Dr. Landis. So, NINDS (National Institute of Neurological 
Disorders and Stroke) recently established a stroke network of 
clinical centers that will undertake stroke trials. And one of 
the major reasons we did this was to have a balance in our 
investment in prevention, acute treatment, and stroke 
rehabilitation. We have recently finished one trial, which has 
shown that it is not--never too late to start rehabilitation 
for stroke, that significant gains can be made even after 6 
months. We have another trial underway. But this has clearly 
been an area where there has not been sufficient investment, 
and this clinical trials network will enable us to do more 
trials better and faster, which will create the kind of 
standards that you are asking for.
    Dr. Collins. Could I add one thing, that the number you 
mentioned is the funding for the National Center for Medical 
Rehabilitation Research, NCMRR, which is actually within the 
National Institute of Child Health and Human Development. But 
that is not the sum total of all that we spend on 
rehabilitation research. Much of what Dr. Landis was just 
talking about is in a different part of the budget. So the 
total expenditures on rehabilitation research are several times 
that number, just to clarify.

                          JOHN PORTER MEMORIAL

    Senator Kirk. Thank you, Mr. Chairman. I just wanted to--
could I follow up and thank you for honoring my political 
mentor, Congressman John Porter, the other day, the man who on 
a bipartisan level led to the doubling of funding for this 
institution. You guys honored a great man who really put 
together an awesome team with Speaker Gingrich on that.
    Dr. Collins. And, Senator, let me thank you for sending a 
wonderful video that the 400-some people who were there for 
that dedication watched and were touched by. And I appreciate 
very much your contributing to our event. This was a grand 
moment for NIH.
    Let me say one other thing about rehabilitation research. 
We are very much in the process now of seeking a new director 
for this National Center for Medical Rehabilitation Research, 
someone who will be particularly forward looking in identifying 
opportunities, how to work with the institutes, how to build 
the case here for rehabilitation research to be even more 
vigorous than it has been. And we are looking for the very best 
person on the planet to do that.
    Senator Harkin. Thank you very much. We will start another 
round.

                   FUNDING HISTORY AND SUCCESS RATES

    Dr. Collins, do you still have that chart that showed where 
that doubling was? You showed that line for the constant 
inflationary increase of, I think it was $3.7 or something. 
That one right there.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Senator Harkin. Again, just for the record--there may be 
people who were not here at that time. Here is how we came 
about that doubling. In the 1990s, we saw the rate of approval 
of grants percentage going down and down and down from what it 
had been in the 1980s.
    And so, meeting with people at the Institute then--it was 
Dr. Varmus at that time, if I remember right, others. We were 
talking about what would it take to sort of get back up to that 
level where we were in the 1980s for the percentage of--what is 
the phrase I am looking for--grant approvals, right?
    Dr. Collins. Success rate. Success rate.
    Senator Harkin. Yes, success rate. And so, we got that. And 
what that would take would be--what it meant was to double the 
funding over a period of 5 years. Our thought was that once we 
did that and got up there, that blue would then start up there 
where the top was, and we would go on----
    Dr. Collins. That is what we were hoping for, too, believe 
me.
    Voice. The soft landing.
    Senator Harkin. This was never meant as some transitory 
type of a funding bump. Now, maybe the Recovery Act was. That 
was sort of a transitory bump, but the doubling was to get us 
back up to that level and then continue on.
    Dr. Collins. Yes.
    Senator Harkin. And so, we sat here through the 2000s and 
saw what happened. Again, I do not mean to speak politically, 
but just factually. We had two wars going on. 9/11 had 
happened. More and more money was being siphoned off for that. 
I am not making a judgment call on that. That is just what 
happened. And we were in a situation where we were not raising 
revenues, but more and more money was going for the War on 
Terrorism, and that is what happened. We just did not have the 
resources, and we came back down, and that is where we are 
today.
    It pains me, and it pains a lot of people to think that 
that happened. We deliberately did that to get that line back 
up there and to keep it going. And, well, other things 
happened, and so we are back in this situation now, and we are 
scrambling to find the resources that we need to do this. We 
need more revenues. That is just my own thing. We need revenue. 
I think the taxpayers of this country would not mind paying a 
little bit more in their taxes or the wealthy or the 
corporations, everybody, to know that this was going to help 
NIH and that is where the money was going.
    And so, somehow we have just got to get the revenues in for 
this, and like I said, I am open for any other thoughts and 
suggestions on how to do it. Senator Hatfield at one time had 
an ingenious idea of doing that. I joined him in that. That did 
not get very far, but it was a proposal that we would take, I 
think it was 1 cent out of every $1 that went for healthcare 
premiums. See, a lot of people do not know that when you go to 
a drugstore and you buy a prescription, and when you get a 
prescription drug or something like that, some of that money 
goes for research. But we do not do that in our healthcare 
policies. When you buy a healthcare policy, none of that goes 
for research.
    So the idea that Hatfield came up with was that 1 cent out 
of every $1 that would be--go into a fund that would come to 
this committee. That would go to NIH as long as we funded NIH 
at last year--at the previous----
    Senator Mikulski. Maintenance of effort.
    Senator Harkin. Maintenance of effort, thank you. That 
phrase, ``maintenance of effort,'' then that money would be 
available to NIH. That would have been a great deal to have, 
but we did not get it. And I am still thinking that there is 
something out there in that realm of healthcare policies where 
people who are buying healthcare policies would say, ``Yes, I 
would like to have a half a penny or something go to biomedical 
research and come into a fund.'' I think people would support 
that if they knew that is where it was going. It was going to 
NIH. They would support that. So I have not quite totally given 
up on that idea, but there may be others.

                       RETIREMENT OF CHIMPANZEES

    Dr. Collins, I have one other question I want to ask sort 
of off of what we have been talking about here, but it is one 
that I hear a lot of about, people keep asking me about. There 
is a great interest in this country about what is happening to 
our chimpanzees. As you know, we have had a great partnership 
with you, with the Humane Society, on retiring these 
chimpanzees from research.
    I know Senator Landrieu has been kind of in the forefront 
of this, and I know she wants me to also ask this question. I 
was one of three Senators who requested the IOM (Institute of 
Medicine) report that revealed that chimpanzee research could 
not be justified except for a very few conditions. Again, Dr. 
Collins, you are to be commended for adopting the IOM 
recommendations so promptly, the very day the report was 
released. Your decision to retire approximately 310 of the 360 
Government-owned chimpanzees currently in laboratories was a 
bold maneuver, and I thank you for that.
    As a long-time appropriator, however, I know that the work 
takes far longer than the issuing of a policy or the signing of 
a bill. I am keenly aware of the complexity of creating 
sanctuary space, grouping, transporting chimpanzees, arranging 
for their care. Many of these chimpanzees suffer from illnesses 
and conditions we gave them for the sake of research. So could 
you please update the subcommittee on the plan for retiring 
these chimpanzees? Can you highlight the challenges and 
considerations involved, including any funding challenges that 
we need to be cognizant of?
    Dr. Collins. Well, thank you, Mr. Chairman, and thank you 
for your leadership on this issue in many steps along the way, 
including asking the IOM to conduct that study, which concluded 
that the need for chimpanzees in research had now been greatly 
reduced and that we could, in fact, get by just fine by keeping 
a small group of 50 available for emergency needs or special 
things where only chimpanzees could be used for research.
    And you also helped us with a fix on what had been a 
legislative problem about a cap on the amount of funds that NIH 
was allowed to spend on chimps in sanctuaries, and that made it 
possible for the retirements that we very much wanted to go 
forward. But you are quite right, we have a long way to go here 
in terms of the number of chimps that need to be moved into 
sanctuaries. And at the present time, that space does not 
exist.
    We have moved many already into Chimp Haven, which is 
already now pretty close to capacity. We are looking vigorously 
at other----
    Senator Harkin. Is that the one in Louisiana?
    Dr. Collins. Yes, and we are vigorously looking at other 
alternatives because there are other chimp sanctuaries to make 
sure that they meet the standards that you would want to see so 
these chimps are well cared for. And there is much interest in 
philanthropy in helping out with this, and the Humane Society 
has been a wonderful partner as well. My dear friend, Jane 
Goodall, who will turn 80 years tomorrow, has been very helpful 
in raising the consciousness of everyone about what an 
important issue this is.
    I would not tell you that we have this solved. I think it 
is going to be several years before the space can be 
identified, the funds can be found, and the completion of the 
retirements can be achieved so that we are left with just those 
50 chimps for research. And we will be re-evaluating that 
regularly as well to see whether those are even needed at that 
level. But I appreciate your interest and this committee's 
interest in this, and we are going to keep you regularly 
briefed on what the needs might be.
    Senator Harkin. This started back in the late 1990s, and 
that is when Jane Goodall came to see us. And Senator Bingaman 
I know was involved. The Senator on the Senate side that 
introduced the bill on saving the chimps was Senator Bob Smith 
from New Hampshire. I remember that. I forget who the other one 
was, but there was a strong bipartisan effort. And so, it has 
taken a long time. I know we got that cap removed. It was a $30 
million cap if I am not mistaken. We got that removed.
    Dr. Collins. Yes. Yes.
    Senator Harkin. But there is a great deal of interest in 
moving ahead on this. And maybe if you cannot today, could you 
get to the committee sort of the timelines you see and what 
more do we need to do to kind of expedite this?
    Dr. Collins. I am glad to do that.

    [Clerk's Note: The information requested can be found in the 
``Additional Committee Questions'' for Senator Harkin.]

    Dr. Collins. And, Mr. Chairman, again, when I came to this 
job as NIH Director, I did not imagine that this issue would 
become so prominent. And yet it has turned out to be, I think, 
one of the more gratifying opportunities to work across many 
different constituencies and do the right thing for these 
special animals, who are our closest relatives.
    Senator Harkin. Our closest cousins.
    Dr. Collins. Absolutely.
    Senator Harkin. Thank you very much.
    Senator Moran.

                     DISEASE FUNDING PRIORITIZATION

    Senator Moran. Chairman, again, thank you. Dr. Collins, I 
am going to ask one more question about prioritization, and 
then a couple of questions for a couple of your directors.
    What are the criteria--when you say this is an ongoing 
conversation about how to prioritize funding within NIH among 
the various diseases--that you look at? Is it the likelihood of 
success, the next opportunity for a breakthrough? What role 
does it play about the cost of the disease? How many people are 
afflicted, what the cost of care and treatment are? Is it a 
more scientific exercise in trying to prioritize how to spend 
money correctly, or is it a broader concept that you pursue?
    Dr. Collins. That is a great question, and it is something 
that we work on every day. It is a mix of all those things. 
Certainly the public health impact has to be a concern for us, 
the number of people affected, and the severity of the illness, 
and what it does in terms of quality of life or premature 
death. Those are all factored in. But if we only thought about 
those things, then rare diseases would get neglected, and we 
have learned so much from studying rare diseases. And if it is 
your family, it does not matter so much to you that it is a 
rare disease than if it is your child who is suffering from it.
    We also think about scientific opportunity because that has 
got to be a major reason to decide to make a push in a 
particular direction, that something is emerging that is 
possible and maybe it was not a year or two previously, and you 
do not want to lose the opportunity to push forward on that.
    On top of that, of course, a lot of our portfolio is not 
top down managed, and it should not be. It comes from the 
insights, the ingenuity, the creativity, the bold vision of 
those investigators out there and the universities across this 
country who are remarkable in their abilities to think of 
things that we could not have thought of. And, we, therefore, 
have a very substantial fraction of our portfolio that is not 
targeted or directed based on anybody's idea about public 
health need or about scientific opportunities other than the 
fact that they are proposing something scientific. Those then 
go through a peer review process. If the idea does not measure 
up, it does not make it into the next tier.
    I would tell you, though, that peer review, while it is 
critical, it is not the only part of what we do. And all of the 
Institute directors you see here, once we have had the peer 
review, look across that, and the things that are somewhere 
near the pay line, decide what is the highest program priority 
based upon the issues that I just talked about--public health 
need, scientific opportunity--and also is our portfolio well 
balanced, or do we have a big pile up of things in one area and 
neglect in other areas. All of that calculus folds into this 
every day that these institute directors and I are struggling 
with. And I think we do a reasonable job of it, but we are 
always trying to do better.

              NATIONAL CANCER INSTITUTE COMMUNITY PROGRAMS

    Senator Moran. Thank you for your answer. Dr. Varmus, NCI's 
budget request includes information on expanding access to 
clinical trials for patients treated in community settings and 
expanding access to trials by minority and underserved 
populations. One of those underserved populations is rural 
Americans, and I was interested in knowing if you could talk 
about the goals of that program and how many new NCI community 
oncology research programs, projects you might expect to find.
    Dr. Varmus. Well, Senator, I cannot give you an exact 
number for that, but as you were rattling off the names 
suggested, you are aware that we have just amalgamated two of 
our community-based programs into one called NCORP for 
Community Oncology Research Program, in which we are paying 
special attention to minority populations and rural populations 
and trying to bring hospitals that are not in our NCI 
designated cancer centers into the network of organizations 
that organize our clinical trials and provide more patients. 
And indeed, many of these centers that compete particularly 
effectively for money to support clinical trials have been in 
these areas--have been producing large numbers of patients to 
accrue them into our trials over the last several years. That 
is an important factor in making a decision about who will get 
support.
    As you know, we have constraints across the board because 
our fiscal levels are not what they used to be, so I cannot 
promise you any specific number until we have fully competed 
and awarded those grants. But our intention is to recruit as 
many patients as we need to carry out a new style of clinical 
trial that we are encouraging; that is, trials that are based 
as much on the genetic damage that has driven the cancer as in 
the organ on which the cancer has arisen. So, there is a new 
style of doing trials that is more costly because it requires 
more preliminary testing.
    And we are also under the direction from a report from the 
Institute of Medicine to pay our investigators a higher fee for 
each patient accrued to those trials, so our trials have become 
more costly. So our interest in expanding our trials, 
especially with all the new therapeutics, not just drugs, but 
also antibodies and immune strategies, and radiotherapy that 
have come our way, is difficult to meet under current 
conditions because we cannot simply do trials. We also have to 
be investing, and this is part of the prioritization question 
in the basic research that fuels new therapeutic approaches.
    And indeed, I would just make a footnote to your question 
about making priority judgments about what we spend our money 
on by pointing to a new initiative at the NCI, despite our 
declining budget, that targets one particular mutant gene 
called RAS that is mutated in over a quarter of all cancers. So 
here is a major target against which, despite knowing about 
this target for 30 years, we have made very little progress.
    So we have started what is called a hub and spoke project 
centered in Senator Mikulski's favorite location, Frederick, 
Maryland, where we have a contract program called the Frederick 
National Laboratory for Cancer Research. We have recruited 
somebody from the University of California at San Francisco to 
come and lead this effort, which involves grantees around the 
country working shoulder to shoulder with a hub of people at 
Frederick who are leading the charge on six specific new 
opportunities for advancing our understanding of cancers that 
are driven by RAS mutations. And this is a way to lead to new 
kinds of compounds that can then be tested nationwide in trials 
that are specifically directed to cancers that have mutations 
in that specific gene.

               CLINICAL AND TRANSLATIONAL SCIENCE AWARDS

    Senator Moran. Doctor, thank you. My time has expired. Dr. 
Austin, I will submit a question in writing to you. I am 
interested in the recommendations by the Institute of Medicine 
in June of 2013 on the Clinical and Translational Science 
Awards, and I am interested in hearing how things are going to 
develop. So I look forward to having a conversation with you. 
Thank you.
    Senator Harkin. Thank you.
    Senator Mikulski.

                  IMPACT OF FUNDING ON U.S. INNOVATION

    Senator Mikulski. Thank you very much, Mr. Chairman. And I 
just want to say to you and to all the Institute directors and 
everyone who works at NIH, we are fortunate to have you. But 
again, I want to come back to your longevity, which shows 
really your dedication, and we view it as a blessing.
    I also want to just comment that we--many of us here are 
worried about the innovation deficit both at NIH and in others. 
There is an effort that is being led by Senator Durbin in this 
area, and to that end, we on the Appropriations Committee are 
going to hold a full committee hearing on innovation to make 
sure that budget cuts and possibilities of future sequester 
does not dampen our standing as a world innovation leader. Yes, 
we worry about the deficit, but we also worry about the 
innovation deficit. So, we are going to be holding that hearing 
on April 29. Dr. Collins will be testifying, the science 
advisor. We are going to be listening to NSF, DARPA, and also 
the Energy Secretary. So we will be doing that.

                             WOMEN'S HEALTH

    In the short time I have because others are now here, I 
want to raise the issue of the Office of Women's Health, that 
which I referenced earlier. It has been flat funded for 3 years 
at $40 million. Now, what I would like to get a picture of is: 
What do you need to have the Office of Women's Health, number 
two, kind of the way we are thinking about running it because 
each and every one of those institutes does important work with 
women. So when we embarked upon our initial endeavor that I 
referenced with Dr. Healy, breast cancer was our preoccupation. 
Those rates are coming down, but lung cancer in women is high.
    Dr. Gibbons could tell me that women with heart disease are 
now escalating, and our symptoms are different, but are early 
diagnoses there? We could go to Dr. Landis and we think about 
something like atrial fib that is there, but if you do not take 
your blood thinner, you could end up with a stroke and 
wondering where are you, et cetera. And then, of course, 
autoimmune is several things, one of which is lupus for which 
only recently the first drug--therapeutic drug in 50 years, of 
course, came out of Human Genome in a Maryland company. So it 
is across all the institutes, which was the idea why we never 
wanted an institute on women; we wanted an office that would 
work. So could you tell us really with the $40 million, how is 
it going, do you need more, and then how do you see this 
working across the institutes?
    Dr. Collins. Thanks for the question. I very much resonate 
with what you are saying, and we have made a lot of progress, 
Senator, thanks to you and others for raising this issue to the 
attention of NIH 20 years ago. We have been fortunate in the 
Office of Research on Women's Health (ORWH) to have remarkable 
leaders in Vivian Pinn, who recently retired, and now Janine 
Clayton, who is a terrific leader for that effort who I just 
met with day before yesterday to go over the status of her 
portfolio. And she has been, as Vivian was, very effective in 
building partnerships across NIH to support special efforts 
that focus on women's health.
    There are particular programs in ORWH, particularly the 
Specialized Centers of Research on Sex Differences, the SCORE 
Programs, as well as training programs that have done a good 
job, I think, in increasing both research on women's health and 
also increasing the proportion of researchers who are women. 
And I would say if you look at the statistics, it looks 
reasonably good, but there are obviously things that we need to 
do better.
    In fiscal year 2013, 57 percent of those enrolled in NIH 
clinical research trials were women--57 percent. And you know 
what that was 20 years ago, in phase III trials, 73 percent. 
So, we have really come a long way. Many of those trials are, 
of course, disease specific and may, therefore, be sex 
specific, for instance in breast cancer. But many of them as in 
heart disease are balanced.
    What we are currently particularly concerned about is 
actually that this same idea has not trickled down in animal 
models, and there is clearly a problem in that many of the 
investigators who are studying models of disease are studying 
only males--male rats, male mice--for reasons that are not 
defensible. And Dr. Clayton and I are about to publish an 
exhortation to the community about this, and we are going to 
start looking very closely at grants to see whether this can be 
corrected because if you did not learn about those sex 
differences in your complete clinical, you are going to miss 
out on an inference that might be really important.
    How much money do we need? Well, we need more money as you 
have heard from all of us in every area of what we are doing. I 
would say Dr. Clayton has been quite effective in brokering the 
dollars that her office has to build relationships and get a 
lot done, but there is a lot more we could be doing.
    Senator Mikulski. Well, as you know, the health data on 
women are changing, and the recent IOM report over the last 2 
years shows that mortality and morbidity among women is on the 
rise. Anyway, a longer topic.
    Dr. Collins. I would love to converse further with you 
about this at any time. It is a passion of mine as well.
    Senator Mikulski. Thank you.
    Senator Harkin. I just want to publicly again thank Senator 
Mikulski. When she first came to the Senate opened our eyes and 
got the NIH to do internal studies to show that women were not 
being included in clinical trials. So it was Senator Mikulski 
who really moved the ball forward on that. That has been over 
20 years ago.
    Senator Mikulski. It has been a long time.
    Senator Harkin. A long time ago. And so, we thank you for 
moving in the right direction.
    Senator Shelby.

                            ANIMAL RESEARCH

    Senator Shelby. Just for the record, I want to touch on 
something Senator Harkin brought up, and that is the research 
on chimpanzees, animals, and so forth. As a kid growing up in 
the Birmingham area in Alabama, I tried to rescue every dog in 
the neighborhood. I still love dogs. I still rescue them. But 
my parents could only feed so many.
    And I was brought to reality, but that did not change my 
caring about animals as all of us do. On the other hand, we are 
all used in research, you know. I have been used by permission 
in research because you gather information that helps 
everything. But is there a real substitute--none of us want to 
be cruel and inhumane to animals. You have used animals in 
biomedical research as you have used us, you know, in different 
aspects. But is there a real substitute for that? Dr. Collins, 
do you want to pick up on that?
    Dr. Collins. I will, and I appreciate your making the point 
that research----
    Senator Shelby. Because we all love--I love dogs still.
    Dr. Collins. So do I.
    Senator Shelby. But I do not collect them anymore, you 
know.
    Dr. Collins. And we have learned enormous amounts from the 
study of animals in research, and we will continue to depend 
heavily on those insights for advances in human medicine, no 
doubt about it. With the chimpanzees, the IOM basically felt 
that there was nothing unique that would justify the continued 
maintenance of hundreds of chimpanzees.
    Senator Shelby. Oh, I totally agree.
    Dr. Collins. We could shrink this back to a small group. 
But your question about a substitution, I am going to ask Dr. 
Austin to say something about an approach to studying toxicity 
of drugs, which traditionally has used animals, and maybe now 
we have got a better way to do this.
    Dr. Austin. Yes, thank you for the question. So this is 
common saw in the translational world that the best animal 
model is the human. And so, what we are trying to do is move 
more of this work to human models, and one of them I actually 
have sitting right in front of me. This is a kidney, but it is 
a kidney on a chip, and it is populated by human kidney cells, 
which is a wonderful model and a much better model of testing 
drugs than in a rat or a chimpanzee and predicting which 
drugs----
    Senator Shelby. Because it is a human being which you are 
working on ultimately to help save, right?
    Dr. Austin. Right. And so, this is part of a tissue chip 
program, that you have probably heard about, that is developing 
so-called organoids. They are three-dimensional micro organs on 
a little micro fluidic platform, a human on a chip. To be able 
to represent human organs in this sort of format that will 
dramatically change, but we believe, both the accuracy and the 
speed with which this testing is done and will make animal 
models irrelevant, obsolete. We are not there yet. We have got 
a lot of work to do. And actually----
    Senator Shelby. But you are going down the right road, are 
you not, Dr. Austin?
    Dr. Austin. Yes.
    Senator Shelby. You are going down the road.
    Dr. Austin. Yes, absolutely.
    Senator Shelby. Well, a lot of my lawyer friends are 
probably glad to hear this because, you know, people have said 
tongue-in-cheek, ``Gosh, if we run out of basic research, we 
could use lawyers as a surplus.'' I said, ``Do not do that.''
    Thank you.
    Dr. Collins. Well, fortunately induced pluripotent stem 
cells came along to save the lawyers because we have this 
amazing new technology, which this committee has heard about, 
but I just got to say it gets better every day. A skin biopsy 
or a blood sample from any one of you could be used to make 
those kidney cells on that chip by doing all of this clever 
manipulation that has only come to light in the last 5 years of 
turning genes on or off. And that means that we could generate 
not just any old kidney chip, but your kidney chip, and find 
out whether that drug that you are going to get is going to be 
good for you or it is going to make your kidneys not so good.

                         BIG DATA TO KNOWLEDGE

    Senator Shelby. Dr. Austin referred to something that I 
just want to pick up on with you, Dr. Collins. The data that is 
collected from all of us in biomedical research willfully and 
knowingly will help to cure diseases and so forth. How 
important is that in the research field, whatever it might be, 
immunization, or neurological, cancer, you name it.
    Dr. Collins. It is critical, and of course we have this 
challenge to both keep track of increasingly enormous 
databases, but also to be sure we are protecting the privacy of 
the individuals' data so that it is not exposed in a way that 
they would not have given consent for.
    I am glad you raised this because NIH has just this year 
initiated a new program we are calling BD2K, Big Data to 
Knowledge. We have enormous opportunities from genomics, from 
imaging, from electronic health records, from everything you 
can think of to make insights about health and disease. Unless 
we focus on the problem of data itself, the sort of new science 
called data science, we are going to get all drowning in the 
data that we have produced instead of making inferences from 
it.
    So we are putting an unprecedented amount of effort into 
it, and this omnibus for fiscal year 2014 has given us a nice 
push in that regard. We aim to ramp that up to $100 million on 
the big data initiatives over the next couple of years, and I 
hired a remarkable scientist from San Diego to lead that 
effort, Dr. Philip Bourne.
    Senator Shelby. Mr. Chairman, one last observation and 
question to Dr. Collins. You mentioned earlier about how 
important it was for scientific investigators to go down the 
right road. Sometimes you do not know you are on the right 
road, and sometimes you are on the wrong road and discover 
something else, though, do you not--that is worthwhile to 
mankind.
    Is that a question of supervision of more investigators, or 
is it a question of better education correlation with what 
people are doing? There may be no answer to it because a lot of 
scientific breakthroughs have come from finding something or 
they did something backwards. Hey, you all know it better than 
I do. Do you want to comment on that?
    Dr. Collins. Absolutely. I think you are quite right that 
many of the most dramatic observations that have led us to 
insights about life and life sciences have come in directions 
that nobody would have predicted were going to be the case, you 
know, from Pasteur on. And serendipity does sort of favor the 
prepared mind. But I worry that at the present time with our 
young scientists feeling so constrained by anxieties about 
support that they may be less inclined when faced with an 
unexpected result to think of that as an opportunity to go down 
a new path because of the necessary kind of need to keep 
pursuing something that they think is in the mainstream and 
more likely to get supported.
    This is one of those secondary effects of a difficult 
budget situation that worries all of us, that creativity, that 
innovation, that risk taking, that sort of seeking a different 
pathway than you had planned to is more difficult. We are 
funding a certain set of grants that aim to try to make that 
possible. The Pioneer Awards are perhaps the best known where 
investigators basically get 5 years of support. And if they 
encounter something they did not expect, they can go after it. 
But many of the other grant systems are not quite so favorable 
for that.
    Senator Shelby. Thank you, Mr. Chairman.
    Senator Harkin. Senator Durbin.

                 NATIONAL INSTITUTES OF HEALTH FUNDING

    Senator Durbin. Thank you very much. Thank you for 
dedicating a major part of your professional life to medical 
research at the premiere biomedical research agency in the 
world. And we are proud of it, and thank you for that. I also 
want to acknowledge--he will have plenty of tributes paid, but 
when the history is written of the NIH, there will be a chapter 
that is entitled ``The Porter-Harkin-Specter'' chapter when 
they made a decision to move forward in a dramatic way and 
double the appropriation for the National Institutes of Health 
over a 10-year period. Tom, of all of your accomplishments, you 
probably created more good for the world with that undertaking, 
although there are lot more that would compete. So I thank you 
for your leadership.
    Dr. Collins, when I met with many of you just a few months 
ago, I sat down and said where do we go next. I am not sure I 
can come with a straight face to Congress and say double it 
again. I am not sure they will do it. And we had a conversation 
about what it takes each year to increase an investment in 
research in NIH and CDC, Department of Defense, healthcare, VA 
health research.
    And you first noted that when we fall behind the cost of 
living, it really ties your hands in the long term to award 
grants. The failure to provide a regular cost of living 
adjustment (COLA) to NIH, as I understand it, has cost you 22 
percent in terms of your ability to award grants for research 
over the last 10 years.
    The President's budget proposed for your agency for the 
next fiscal year gives you, I believe, 0.7 percent COLA. We 
know that the actual cost of living increase will be 1.7 
percent. So built into the President's budget is a further 
decline, falling behind more when it comes to the actual cost 
of living.
    And at that time, I said, ``Give me an idea of what it 
would take in real growth to build this agency forward.'' And 
you said--for the record I am going to ask you to comment on 
this--``Give us 5 percent real growth per year for 10 years 
over the cost of living and we will show you the kind of growth 
in research that America and the world needs.''
    So here you are on the record, and I am going to remind you 
of that conversation since I took it to heart and introduced a 
bill. So please tell me if you still believe that.
    Dr. Collins. Senator, thank you for the question and for 
introducing that bill, and it was a wonderful opportunity to 
talk with you when you came to NIH. And your taking on this 
leadership is deeply appreciated.
    I am showing you here this graph that I think we talked 
about when you came to visit, and, yes, it is exactly as you 
have said.
    [The graphic follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Dr. Collins. The blue bars there are the appropriations for 
NIH, but the yellow reflects the effect of the biomedical 
research and development price index (BRDPI). It is sort of 
like a cost of living, but it is our cost of living for doing 
research, the ``BRDPI'' as we call it. And you can see what has 
happened since 2003. At the end of the doubling, those yellow 
bars have been dipping down steadily ever since.
    Earlier when you were at another hearing, I showed another 
version of this graph that basically says if we had stayed on 
the same pathway we were back in sort of 1970 to 1995, which 
was sort of steady growth of inflation plus about 4 percent, we 
would now be at about $40 billion as far as the total NIH 
budget, $10 billion more than what we currently have.
    To get back on that pathway, which would be a wonderful way 
to encourage research to really move forward at the pace that 
it could because we are not limited by talent or by ideas. 
Putting this NIH trajectory on a steady path where you could 
count from year to year on inflation plus a percentage--and 
five would be wonderful--would get us back to where perhaps we 
really need to be in a few years, and would give such a jolt of 
confidence and excitement to frankly a fairly demoralized 
biomedical research community.
    Senator Durbin. And you have told me about it, and we know 
the young investigators are disappearing. Three percent are 
under the age of 36 today. Back 30 years ago it was 19 percent. 
And the other thing that struck me when we talked about AMP was 
you were asking for--asked for and received a commitment of 
$150 million, if I remember correctly, from the top 10 
pharmaceutical companies to be matched by NIH to pursue cures 
and whatever in the areas of Alzheimer's, type 1 diabetes, if I 
am not mistaken, and rheumatoid arthritis.
    To put that in perspective, what I have called for in the 
American Cures Act is $140 billion over a 10-year period of 
time for the four agencies to get real 5-percent growth--$140 
billion. Last year alone we spent over $200 billion in Medicare 
and Medicaid on Alzheimer's--$200 billion. If we could delay 
the onset of that disease, it would more than pay for all of 
the increased investment in research.
    We have got to step back and take stock of what we are 
doing here. As we short change you, we add to the cost of our 
healthcare programs instead of reducing that cost. And just to 
put it in a global perspective, other countries are not 
waiting. Europe is moving forward. The United Kingdom is moving 
forward. In 8 years China will pass us in real dollars spent on 
research. And that ought to be sobering, and I hope it will 
awaken us.
    I know the chairman has a meeting to go in a few minutes as 
I do, too, so I will not dwell on this other than to say I am 
going to keep pursuing this. I really believe that what you are 
doing is really a great credit to this country and will 
alleviate suffering and pain around the world. Thank you, Mr. 
Chairman.
    Dr. Collins. Thank you, Senator.
    Senator Harkin. Thank you, Senator Durbin. Thanks for your 
kind words. I appreciate that.
    Senator Cochran.
    Senator Cochran. Mr. Chairman, I am pleased to join you and 
other members of the committee at this hearing. We appreciate 
your attention to the appropriations request for NIH, and we 
congratulate Dr. Collins and his team for the excellent work 
they continue to do in biomedical research, and the benefits 
that flow from that to our great country.

                        POTENTIAL CARE FOR AIDS

    Last year it came to my attention that at the University of 
Mississippi Medical Center, a pediatrician, Dr. Hannah Gay, 
reported that a patient of hers who is now more than 3 years 
old remained HIV-free after receiving anti-retroviral therapy 
within hours of her birth. We have recently heard about a 
similar case in California. I am impressed with the research 
being done in my State and am hopeful that this could be good 
news for continued research efforts, not only in Jackson, 
Mississippi, but throughout the country.
    What do we know or what do you know about these cases that 
you can share with us in terms of their impact? And what does 
this mean for research and treatment as far as a potential cure 
is concerned?
    Dr. Collins. Well, we have the world's expert in the room, 
Dr. Fauci.
    Dr. Fauci. Thank you, Francis. Thank you for the question, 
Senator Cochran. This is truly a very important case because, 
as you described accurately, this was a mother who came into a 
clinic in Mississippi who was HIV-infected, who had no prenatal 
treatment for her HIV, which put the child at very high risk. 
The astute physicians, pediatricians in Mississippi, instead of 
treating the baby in a prophylactic way to prevent infection, 
they immediately aggressively treated the baby as if the baby 
were infected. After that very rapid application of full-blown 
aggressive therapy as opposed to waiting for a few weeks for 
the diagnosis, the baby turned out actually to be infected.
    By a series of circumstances after several months on 
therapy, there was a discontinuance in care. The mother dropped 
out of the healthcare system, came back several months later, 
and the baby had not been on therapy for several months. The 
physicians watched because they could not find any virus in the 
baby, and now 3 years out the baby is well, growing well, and 
has no evidence of infection, which is likely the first real 
cure of HIV infection.
    That has now triggered an NIH-funded study in which a large 
number of babies who are born of high-risk mothers, namely 
mothers who have not been treated, will be put on aggressive 
therapy to see if, in fact, you can cure babies. Now, the 
reason that is important is that the risk to benefit ratio of 
treating babies aggressively very early on has weighed on the 
side of waiting because you are not sure if you are ever going 
to have the opportunity of curing someone, so you say let us 
not expose the baby to aggressive therapy because you might 
actually hurt the baby if the baby is not infected. And all you 
are doing is going to be saving a few weeks of treatment.
    Now that you know you can actually cure a baby if you are 
aggressive, then the risk benefit ratio switches all the way 
over to the possible benefits. So it was a very important case, 
and it has triggered a study which will begin in the middle or 
end of May, a multicenter study to see if we can verify that 
and apply it to a larger number of babies.
    Senator Cochran. Thank you. That is very exciting, Mr. 
Chairman. And I hope we learn from that that we need to listen 
to these witnesses when they come before our committee. We are 
all going to learn something, and it may be reflected in direct 
appropriations that really do improve not only the lives of 
American citizens, but actually saves their lives. Thank you 
very much.

                               CONCLUSION

    Senator Harkin. Thank you, Senator Cochran. Well, listen, 
thank you all very much again. It is always enlightening. 
Always a pleasure to hear about the National Institutes of Hope 
and what you are doing. I hope that our subcommittee can meet 
the obligations of funding that you have talked about here that 
is in the President's budget, maybe even go beyond that in some 
cases I hope in terms of funding for NIH. We just have to 
recommit ourselves to breaking this logjam of the funding for 
NIH. We have got to get back to the success rate that is less 
than 20 percent across the board. We have got to get down to 
that 15 percent level some time. I think that is what we did 
after we doubled it. It was down around that area, if I am not 
mistaken.
    And so, as I said before, I think the American people 
support that. I do support it. And we just have to meet our 
obligations to do all we can to fund it and, as I said earlier, 
to find any ideas on ways of funding and getting more money for 
NIH. We just cannot give up on this. We just cannot. Too much 
is at stake.
    I often think there are so many young people out there with 
keen minds, want to get into science, biotechnology. We need to 
give them the hope that if they want to pursue that as a life 
career like so many of you have had, that they are going to 
have the opportunity to succeed. They are going to have the 
opportunity to put those keen minds to work and investigating 
and asking those questions of how and why and what happens.
    Basic research to me has always been the most stimulating. 
I often put it in the past in terms of if you have--let us say 
you have 10 doors to a potential cure. Well, if you open one 
door, the odds are, what, 10 to 1, 9 to 1--I am not too good at 
math--that you are not going to find the right door. If you 
open five doors, the odds become even better, or eight or nine. 
That is what basic research is, is opening those doors. A lot 
of times it may not lead to where you think it is going to 
lead, but sometimes that basic research leads to something 
else. I always remember John--Dr. Enders and the kidney cells, 
and the Salk polio vaccine. That is not where he was headed, 
but that is what happened later on.
    And so, to me basic research needs to be--we just have to 
fund it. It always pains me when people say, ``Oh, we put all 
that money into basic research, but, you know, when are we 
going to have an end date? When are we going to find this cure 
and stuff?'' I say, ``Well, that is not a legitimate question 
to ask of basic research. The legitimate question to ask of 
basic research is do you have a question. Does something 
stimulate your curiosity that you are willing to spend some 
time to investigate it and take it as far as you can without 
knowing exactly what the end result is going to be?'' That is 
what basic research is.
    And we need to stimulate that kind of thinking in America, 
that kind of excitement about basic research. And if we do not 
fund NIH, we are telling young people and these keen minds do 
something else maybe. Maybe there is something else for you to 
do. So to me, the funding for NIH is not only the here and the 
now, but it is the next generation, the generation after that 
we encourage to take this up and to devote their lives to 
science and to basic research. We will do whatever we can to 
make sure that that happens.

                     ADDITIONAL COMMITTEE QUESTIONS

    And I thank you all for all of your dedication--your 
lifetime dedication to exploring the frontiers of science and 
health, finding so many cures and therapies. It has been 
amazing, amazing thing to see what has happened in the last 25, 
30 years that I have been here. There next 30 years can be even 
better. Let us make it so. Thank you very much.
    I am supposed to--we will keep the record open--the record 
will remain open until April 9 for Senators to submit other 
questions and for responses to questions.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
               Questions Submitted by Senator Tom Harkin
                         chimpanzee retirement
    Question. Dr. Collins, I want to thank you for the partnership you 
have had with this subcommittee and the Humane Society on the process 
of retiring chimpanzees from research. As you know, I was one of three 
Senators who requested the Institute of Medicine (IOM) report that 
revealed that chimpanzee research could not be justified except for a 
very few conditions. You are to be commended for adopting the IOM 
recommendations so promptly--the very day the report was released. Your 
decision to retire approximately 310 of the 360 government-owned 
chimpanzees currently in laboratories was suitably bold.
    As a long-time appropriator, however, I know that the work takes 
far longer than the issuing of a policy or the signing of a bill. I am 
keenly aware of the complexity of creating sanctuary space, grouping 
and transporting chimpanzees, and arranging for their care. Many of 
these chimpanzees suffer from illnesses and conditions we gave them for 
the sake of research goals.
    Can you update the subcommittee on the plan for retiring these 
chimpanzees? Can you highlight the challenges and considerations 
involved, including any funding challenges?
    Answer. Thank you for your leadership in working with the National 
Institutes of Health (NIH) and the Institute of Medicine (IOM) to 
resolve issues related to NIH-owned or supported chimpanzees in 
research. An update on the NIH plan for chimpanzee retirement follows. 
Many factors must be considered to ensure a successful chimpanzee 
retirement process: Availability and complexity of creating the 
physical sanctuary space, grouping of animals based on individual and 
group behavioral characteristics, transporting chimpanzees (which 
requires healthy animals and temperate weather), and arranging for the 
care of an aging population. NIH has retired approximately 270 
chimpanzees. At the present time, there is insufficient space in the 
Federal chimpanzee sanctuary system to accommodate all of the 
chimpanzees that will eventually be transferred. Sufficient and 
appropriate sanctuary space is one of the major hurdles to retiring 
more animals. Another is the need to select carefully the 50 most 
suitable research animals prior to retiring the remainder.
    Since 2005, NIH has moved nearly 270 chimpanzees into the Federal 
Sanctuary System. Our plan to transfer all remaining NIH-owned 
chimpanzees from the New Iberia Research Center has been completed. The 
last group of nine chimpanzees was moved to the Federal Sanctuary 
System on June 12th. Currently, Chimp Haven, Inc. is the only facility 
in the Federal Sanctuary System, and it is nearing capacity. As a 
result of natural attrition and careful planning of group composition, 
we anticipate retiring approximately 30 more chimpanzees by the end of 
2014. We are actively looking for alternate sites that meet, or can be 
modified to meet, the high standards required to ensure that these 
chimpanzees are well cared for. These requirements include adherence to 
PHS Policy on Humane Care and Use of Laboratory Animals, the CHIMP Act 
of 2000 (Public Law 106-551); Chimp Haven is Home Act (Public Law 110-
170); the CHIMP Act Amendments of 2013 (Public Law 113-55); and the 
sanctuary specific regulations at 42 CFR Part 9. Chimp Haven, Inc. 
meets these requirements.
    A Request for Information NOT-OD-14-067 (April 7, 2014) was issued 
to solicit information from facilities potentially qualified to join 
the Federal Chimpanzee Sanctuary System. Responses identified three 
potential options for additional sanctuary space, but all would require 
additional and potentially costly construction. NIH is looking at all 
options to develop sufficient sanctuary space but cannot yet estimate 
the time required.
    Second, a major hurdle is the determination of the 50 chimpanzees 
most suitable for critical research. This selection must occur prior to 
retirement because the Chimp Act, as modified by the Chimp Haven is 
Home Act, mandates that retired chimpanzees cannot be returned to 
invasive research. These research chimpanzees will be chosen after an 
extensive NIH review of experimental protocols to ensure that all IOM 
criteria are met. These protocols, and the final selection of research 
animals, may require a period of several years. No chimpanzees will be 
used for NIH-supported invasive biomedical research unless chosen as 
part of the group of 50. Chimpanzees will stay at their current 
facilities, receiving high-quality medical and dental care, in their 
social groups, and under the care of familiar staff. Once the 50 have 
been chosen, remaining animals will be transferred to the Federal 
Sanctuary System as space permits. NIH will regularly reevaluate 
research needs and reduce the number of research animals as warranted.
    Some chimpanzees at the research or reserve facilities will be 
available to move to the Federal Sanctuary System almost immediately 
because they will not be suitable for research protocols. The 
professional staff at each facility is currently identifying these 
animals based on many criteria. We are making progress, but it is not 
yet possible to specify a timeline for the disposition of all 
chimpanzees. It is likely to be several years before the completion of 
all chimpanzee retirements.
                           disease prevention
    Question. I don't have to tell anyone here about my passion for 
disease prevention. NIH has an important role to play in conducting 
research on disease prevention--after all, it is the National 
Institutes of Health, not the National Institutes of Treatment.
    I was very pleased to see that NIH recently released its first 5-
year strategic plan for the Office of Disease Prevention, within the 
Office of the Director. How will this new plan help advance disease 
prevention research? I'm particularly interested in how the plan will 
address gaps in research that are identified by the U.S. Preventive 
Services Task Force.
    As you know, the ACA included a provision that requires insurance 
companies to cover any preventive service recommended by the US 
Preventive Services Task Force (USPSTF) with no deductible, no co-pay. 
When the USPSTF review interventions, they often find that there is not 
enough research to make a recommendation. In those cases, they publish 
a number of questions that need to be answered before a recommendation 
could be made. NIH does not currently use these questions in their 
research agenda planning process.
    The Office of Disease Prevention (ODP) was created in 1986 in 
response to the Health Research Extension Act of 1985 which required 
the creation of an Associate Director for Prevention. ODP includes the 
Office of Dietary Supplements, the Tobacco Regulatory Science Program, 
and supports NIH's Prevention Research Coordinating Committee.
    On January 3, 2014, NIH adopted its first-ever strategic plan for 
disease prevention research, which had the following priorities:
  --Systematically monitor NIH investments in prevention research and 
        assess the progress and results of that research.
  --Identify prevention research areas for investment or expanded 
        effort by the NIH.
  --Promote the use of the best available methods in prevention 
        research and support the development of better methods.
  --Promote collaborative prevention research projects and facilitate 
        coordination of such projects across the NIH and with other 
        public and private entities.
  --Identify and promote the use of evidence-based interventions and 
        promote the conduct of implementation and dissemination 
        research in prevention.
  --Increase the visibility of prevention research at the NIH and 
        across the country.
    Some examples of grants funded by ODP in 2013 are:
  --Transforming Cancer Health Messaging: Engaging Alaska Native People 
        Through Digital Storytelling
  --Cyber Partners: Harnessing Group Dynamics to Boost Motivation to 
        Exercise
  --Uganda Working Group on Non-communicable Disease Risk Factors
  --Psoriasis and the Risk of Diabetes
  --Financial Incentives for Smoking Cessation Among Disadvantaged 
        Pregnant Women
  --Mood and Insulin Resistance in Adolescents at Risk for Diabetes
  --Natural Disaster Effects on Aggressive Children and Their 
        Caregivers
  --Biomarkers in HPA Axis and Inflammatory Pathways for Suicidal 
        Behavior in Youth
  --Collaborating to Measure the Effects of Stroke Preventive 
        Interventions
    Answer. In February 2014, the NIH Office of Disease Prevention 
(ODP) released its first Strategic Plan which outlines the priorities 
that the Office will focus on over the next 5 years. The goal of this 
effort is to increase the scope, quality, dissemination, and impact of 
prevention research supported by NIH. The ODP will achieve this goal by 
providing leadership for the development, coordination, and 
implementation of prevention research in collaboration with NIH 
Institutes and Centers and with other partners. While the priorities 
and objectives outlined in the plan are designed to benefit the broader 
NIH prevention research community, the plan itself was developed as a 
tool for the ODP and does not represent a trans-NIH plan for prevention 
research.
    The ODP strategic plan includes six strategic priorities that will 
allow the Office to expand its influence by, for example, providing 
training in prevention methodology and developing new strategies for 
identifying research needs--activities that may not otherwise be 
addressed by a single NIH Institute or Center but are important for 
advancing disease prevention research more broadly. Interest in disease 
prevention has grown, and NIH has a responsibility to ensure that the 
best prevention science is supported to inform clinical and public 
health initiatives at the individual, organizational, community, and 
policy levels. The strategic priorities included in the plan will allow 
the ODP to play an important role in that process while giving NIH 
Institutes and Centers the flexibility to support prevention research 
within its extramural and intramural programs that best reflects its 
mission and state of the science of their programs.
    Strategic Priority II supports the identification of prevention 
research areas that may benefit from investment or expanded effort by 
NIH. In addition to utilizing results of new portfolio analysis tools 
that are under development (Strategic Priority I), the ODP will achieve 
this goal by working closely with the NIH Institutes and Centers, as 
well as other Federal and non-Federal partners such as the U.S. 
Preventive Services Task Force (USPSTF) to identify and prioritize gaps 
in prevention science and promote research in these areas to broaden 
the knowledge base. The USPSTF conducts scientific evidence reviews of 
a broad range of clinical preventive healthcare services (such as 
screening, counseling, and preventive medications) and develops 
recommendations for primary care clinicians and health systems. As part 
of its clinical recommendation process, the USPSTF identifies 
significant gaps in key areas of knowledge that may limit the full 
realization of the benefits of evidence-based preventive services 
recommendations. Of particular concern to the research community are 
areas that receive an Insufficient or ``I'' recommendation by the 
USPSTF, which indicates that current evidence is insufficient to assess 
the balance of benefits and harms of the service under consideration. 
As the NIH liaison to the USPSTF, the ODP refers Insufficient or ``I'' 
recommendations made by the USPSTF to NIH scientific program staff. The 
NIH Institutes and Centers can use this information to help them make 
decisions during the post peer-review process to further expand 
knowledge within a given research area.
    To further advance Strategic Priority II, the ODP is also 
developing a systematic process that can be used by NIH Institutes and 
Centers to report recent advances or on ongoing research that addresses 
the research gaps identified by the USPSTF and other partners. This 
information, along with identified gaps, will help to highlight 
research areas that are in need of additional support. In addition to 
disseminating this information to our colleagues, the ODP will 
incorporate this information into its own efforts to promote 
collaborative prevention research projects and facilitate coordination 
of such projects across NIH and with other public and private entities 
(Strategic Priority IV).
                        rehabilitation research
    Question. I was pleased to hear that NIH is implementing many of 
the recommendations of the 2012 Blue Ribbon panel on rehabilitation 
research. This is a critical area of research to improve the functions 
and abilities of people with severe injuries, illnesses or conditions 
so that they can live independently.
    This research is done across many Institutes and Centers, but there 
is no consistent definition of rehabilitation research. Without a 
common definition, it is difficult to ensure that core priorities are 
being addressed and to accurately track the science across all of the 
Institutes and Centers. In the fiscal year 2012 Labor-HHS bill, this 
subcommittee asked that NIH adopt an NIH-wide definition. A year later, 
the Blue Ribbon panel went a step further to recommend that NIH adopt 
the WHO definition. What steps is NIH taking to address this issue?
    Rehabilitation research is cross-cutting and focuses on improving 
the ability of people with severe injuries, illnesses, disabilities and 
chronic conditions to improve skills and functions and live as 
independently as possible.
    Medical rehabilitation research is conducted at NIH through 
numerous Institutes and Centers. The research is intended to be 
coordinated by the National Center for Medical Rehabilitation Research 
(NCMRR) within the National Institute for Child Health and Human 
Development (NICHD). One of the main difficulties in coordinating the 
work being done at the various Centers and Institutes is that NIH does 
not have a consistent definition of ``rehabilitation research''.
    The fiscal year 2012 Senate LHHS report language:
      Rehabilitation Research.--The Committee commends NIH for 
        appointing a blue-ribbon panel to evaluate rehabilitation 
        research at the National Center for Medical Rehabilitation 
        Research [NCMRR] and across all of NIH. The Committee requests 
        a copy of the panel's report when it is available. The panel is 
        urged to identify gaps in the field of rehabilitation research 
        and recommend which ICs or other Federal agencies should be 
        responsible for addressing them. In addition, the Committee 
        recognizes the improvements that have been made in delineating 
        rehabilitation research as part of NIH reporting mechanisms 
        established since the passage of the NIH Reform Act. However, 
        the Committee encourages NIH, through the leadership of NCMRR, 
        to further clarify a consistent definition of rehabilitation 
        across all institutes and centers and to seek ways to delineate 
        between physical, cognitive, mental and substance abuse 
        rehabilitation when characterizing NIH-supported research. 
        Finally, the Committee encourages NCMRR to explore the broader 
        social, emotional and behavioral context of rehabilitation, 
        including effective interventions to increase social 
        participation and reintegrate individuals with disabilities 
        into their communities.
    The December 2012 report from the Blue Ribbon Panel on Medicare 
Rehabilitation Research further emphasized the importance of taking 
action to clarify the definition of ``rehabilitation research'' by 
recommending the following:

    ``The study of mechanisms and interventions that prevent, improve, 
restore or replace lost, underdeveloped or deteriorating function, 
where function is defined at the level of impairment, activity and 
participation according to the WHO-ICF model (World Health 
Organization's International Classification of Function, Disability and 
Health).''

    Answer. Since enactment of the 1990 law authorizing the 
establishment of the National Center for Medical Rehabilitation 
Research (NCMRR) under the auspices of the National Institutes of 
Health (NIH), NIH has been using the definition of medical 
rehabilitation research included in the statement of purpose for the 
Center (Sec. 452 of the Public Health Service Act, 42 U.S.C. 285g-4), 
which states that the purpose of the Center is to support research, 
training, and health information dissemination ``with respect to the 
rehabilitation of individuals with physical disabilities resulting from 
diseases or disorders of the neurological, musculoskeletal, 
cardiovascular, pulmonary, or any other physiological system (hereafter 
in this section referred to as ``medical rehabilitation''). This 
definition, which is used consistently across NIH, has allowed medical 
rehabilitation research to be distinguished from other rehabilitation 
research efforts, such as those that involve mental health or addictive 
disorders. The World Health Organization (WHO) definition was adopted 
since that time; while NIH has no objections to using the WHO 
definition, the law would need to be amended to replace current 
language.
    If the definition were changed, it would need to be translated into 
an operational definition to allow appropriate characterization of the 
more than 11,000 competing grants that NIH currently funds each year. 
NIH uses its ``Research, Condition, and Disease Categorization (RCDC)'' 
system--a sophisticated text-data mining software--to categorize and 
cluster words and phrases that reflect agreed-upon definitions. See 
http://report.nih.gov/rcdc/. NIH has already started to develop an RCDC 
``fingerprint'' for medical rehabilitation research, which will allow 
NIH to track the research portfolio as it changes over time, and to 
understand the breadth and depth of the portfolio as part of the 
upcoming effort to develop a strategic research plan.
                        medication in pregnancy
    Question. Each year more than four million women give birth in the 
United States and more than 3 million breastfeed their infants. Nearly 
all of these women will take a medication regularly or receive a 
vaccine, but little is known about the effect of most drugs on the 
woman or her child. For most drugs, we don't know the impact on child 
development and we don't know the impact on the effect of the 
medication. A study in the American Journal of Medicine illustrated 
that fewer than 10 percent of medications approved by the FDA since 
1980 have enough information to determine their risk for birth defects. 
Women and doctors are forced to guess whether to continue their 
treatment.
    This gap in understanding has become increasingly problematic as 
more women delay childbearing and rates of chronic disease rise. More 
expectant mothers than ever before are requiring medications to manage 
conditions such as diabetes, hypertension, depression, and asthma.
    What types of research activities is NIH engaged in to fill these 
research gaps? What is the state of our understanding of the effect of 
drugs during pregnancy and breastfeeding?
    Answer. Primarily through its Obstetric and Pediatric Pharmacology 
and Therapeutics Branch (OPPTB), the Eunice Kennedy Shriver National 
Institute of Child Health and Human Development takes a range of 
approaches to support research activities on medication use in 
pregnancy and during breastfeeding, collaborating with other NIH 
Institutes and Centers as appropriate for their areas of expertise.
    The Obstetric-fetal Pharmacology Research Units (OPRU) Network was 
established in 2004 with four academic research institutions to improve 
the safety and effectiveness of the medications commonly used (but 
often never having been tested) in women during pregnancy and 
postpartum. The OPRU Network has provided critical research 
infrastructure for a multidisciplinary collaboration of researchers to 
perform basic/translational studies and phase I/II clinical trials 
aimed at characterizing and evaluating the impact of medications on 
metabolism and physiological, cellular, and molecular changes during 
pregnancy. The OPRU Network also conducted opportunistic studies of 
medications in women who were already taking these medications during 
pregnancy. More than 100 research articles from these studies have been 
published in peer-reviewed scientific journals.
    Some study results have directly informed clinical practice. For 
example, a study of the anti-diabetes drug glyburide use during 
pregnancy showed that glyburide can cross the placenta and that the 
drug's concentrations are about 50 percent lower in pregnant women with 
type 2 diabetes than in non-pregnant women with type 2 diabetes, 
suggesting that a higher dose may be needed to achieve optimal 
therapeutic effects. A study of oseltamivir, a medication for treating 
and preventing influenza, indicated that the drug plasma concentrations 
are much lower and apparent clearance significantly higher in pregnant 
women compared with non-pregnant women, suggesting an increased dose 
may be necessary to achieve comparable effects.
    The OPRU Network currently supports a randomized clinical trial to 
determine the pharmacologic effects of anti-diabetic drugs (glyburide 
and metformin) separately, and in combination for management of 
gestational diabetes, a phase I clinical trial to evaluate the effect 
of early treatment with pravastatin for prevention of preeclampsia, and 
an exploratory study to identify vaginal biomarkers of response to 
progestin treatment of preterm birth. The Network also is funding 
several investigator-initiated grants on nicotine replacement therapy 
for smoking cessation during pregnancy and safety and effectiveness 
studies on anti-hypertensive medications in pregnancy. In addition, to 
encourage young investigators working in this area of research, the 
OPPTB supports several postdoctoral training programs.
                          cancer and distress
    Question. I know first-hand that a cancer diagnosis can be 
devastating for patients and families. Studies show that half of all 
cancer patients experience psychological and social distress as a 
result of their cancer diagnosis. But there is good news: a study 
conducted by Dr. Barbara Andersen and published in the Journal of 
Oncology showed that patients with breast cancer who receive distress 
screening and social and emotional follow-up care have a 45 percent 
reduced risk of cancer recurrence, a 56 percent reduced risk of death; 
and a 59 percent reduction in breast cancer death even WITH recurrence.
    These are remarkable outcomes. Yet the Institute of Medicine has 
consistently concluded that cancer care provides state of the art 
biomedical treatment but does little address the psychological and 
social needs of cancer patients.
    What requirements, if any, does NCI have on its intramural and 
extramural research programs to screen patients for distress and ensure 
follow up care? What kind of research is being done, either at NCI or 
at the Mental Health Institute, to further this promising area of 
research?
    Answer. As the Federal agency that supports the Nation's cancer 
research enterprise, the National Cancer Institute (NCI) conducts and 
facilitates research and the development of valid tools that can inform 
standard clinical practice and medical decisionmaking. However, NCI 
does not establish standards of care or place requirements on care-
givers. Other Federal agencies and private-sector organizations (such 
as specialty societies and cancer-specific groups) develop medical 
recommendations for cancer, building upon NCI's research and the work 
of these other agencies in the Department of Health and Human Services 
(HHS) to develop guidelines or recommendations about all aspects of 
medical practice related to cancer care.
    Still, it is important to emphasize that both NCI and the National 
Institute of Mental Health (NIMH) support research related to screening 
for emotional distress experienced by patients who receive a cancer 
diagnosis and subsequent treatment. In this area, NCI's role is to fund 
and support research that shows the efficacy and impact of systematic 
screening for emotional distress on cancer survivors' subsequent health 
and function. Historically, we have funded--and we continue to 
support--randomized controlled trials that test the ability of 
psychosocial and behavioral interventions to reduce psychological 
distress and promote adaptation to illness. This research has shown 
that a wide variety of interventions (both at the individual and group 
levels and varying in content) are effective in improving understanding 
of illness and adherence to treatment, reducing depression, fatigue, 
and stress, and adopting healthy behaviors.
    A key response by NCI to the Institute of Medicine (IOM) report, 
Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, 
was to include attention to survivorship and palliative care in the 
funding of NCI's Community Cancer Centers pilot program (NCCCP). One of 
the deliverables for funded NCCCP sites was to develop the capacity to 
screen for distress and refer individuals to appropriate psychosocial 
care as needed. NCCCP sites also had to expand their psychosocial 
programs, as well as training of staff to identify and manage these 
issues in patients being treated at each institution. In addition, NCI 
solicited information from the clinical-investigator community about 
the tools they are using to screen for distress, as part of the Grid 
Enabled Measures (or GEM) initiative. The GEM database collects 
questions that measure unmet needs, depression, and anxiety. These are 
available for clinicians and researchers to access, evaluate, and (with 
the exception of copyrighted instruments) be used to care for patients 
under active treatment and other cancer survivors. NCI is initiating 
collaborations with the American Society of Clinical Oncology (ASCO) 
and the Commission on Cancer. In 2012, the Commission gave member sites 
until 2015 to implement psychosocial distress screening in their 
centers.
    NIMH has funded several studies in recent years investigating 
psychological distress and depression associated with cancer diagnosis 
and treatment. For example, NIMH has supported the development of the 
Mental Health Assessment and Dynamic Referral for Oncology software, 
which enables oncology treatment providers to screen for and monitor 
several patient care domains, including: (1) mental health functioning; 
(2) cancer-related symptoms and side effects; (3) the patient-provider 
partnership; (4) barriers to treatment; and (5) adherence with medical 
regimen and lifestyle change recommendations. Another team of NIMH-
funded researchers has studied whether depression can be prevented in 
patients with head and neck cancer during treatment (with relevance to 
other cancers), as well as whether initiating prophylactic 
antidepressant treatment can improve timely completion of the cancer 
therapy and preserve quality of life. Other NIMH-funded researchers 
have studied the impact of cancer treatment, as opposed to diagnosis, 
on mental health--for example, whether antidepressants can prevent the 
impact of melanoma treatment on the brain, endocrine, and immune 
systems.
    In addition to these extramural efforts, the NIMH Division of 
Intramural Research Programs conducted a multiyear study investigating 
biological, psychological, and social factors that affect living with a 
chronic life-threatening illness such as cancer, HIV, or other rare 
diseases, as well as suicide risk and palliative care decisionmaking 
procedures for treating children and adolescents with life-threatening 
conditions.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
                           american cures act
    Question. In 1965, the U.S. spent more than 25 percent of our non-
defense discretionary budget on research and development--last year 
that number was 10 percent. Between 2003 and 2012, the NIH budget has 
not even kept up with inflation, resulting instead in a 22 percent 
decline in real purchasing power. The number of research grants at NIH 
has declined every year for the past 10 years.
    Dr. Collins, you have warned that continuing this trend of funding 
will cause some of America's best young researchers to take their 
talents to other industries--or other countries.
    What promising breakthroughs or developments do you think are at 
risk of delay due to the U.S. Federal Government failing to keep pace 
with inflation in funding the NIH?
    Answer. NIH-supported researchers make scientific discoveries every 
day, advancing research related to countless health and disease issues. 
While it is impossible to predict exactly when breakthroughs will occur 
in a particular scientific field, the pace of discovery will be delayed 
if funding fails to keep pace with inflation. For example, this could 
cause delays in the significant progress that researchers are making in 
developing a universal flu vaccine that could offer protection against 
any flu virus strain, including those that may cause pandemics. 
Similarly, NIH efforts to develop a vaccine for HIV or even a cure for 
AIDS may be hampered.
    In cancer research, recent results indicate that immunotherapy may 
be a new and effective form of treatment. However, opportunities to 
expand this research to include additional patients and other types of 
cancer may not be possible if NIH funding remains stagnant. NIH also is 
engaged in extensive efforts to respond to the emerging public health 
threat from antimicrobial resistance (AMR), including support for basic 
research, development of new and faster diagnostics, and creating a 
national database of genomic sequence data. These efforts could be 
hampered if NIH funding does not keep pace with inflation. NIH efforts 
to leverage its resources in partnerships with the private sector also 
could be disrupted, such as the new Accelerating Medicines Partnership 
(AMP) that brings biopharmaceutical companies and several nonprofit 
organizations together with NIH to identify and validate biological 
targets of disease for future drug development.
    Please describe the biomedical discoveries, training of junior 
scientists, and economic benefits that could result if NIH was provided 
with a steady source of funding that increased year after year to keep 
up with inflation?
    Answer. A steady source of funding helps support biomedical 
scientists. Having a budget that keeps pace with inflation would help 
to reassure scientists that they will have the necessary support for 
the duration of their projects. Steady investment in the National 
Institutes of Health (NIH) helps enable our researchers to achieve 
their full scientific potential in all research areas, fueling 
biomedical discoveries from autism to Alzheimer's disease to cancer to 
diabetes. Inflation-adjusted budgets also may enable NIH to award more 
grants to fund investigator-initiated research, thereby allowing the 
country's most innovative scientific thinkers to chart the best path 
forward in their research areas.
    Promising young scientists who have chosen career paths outside of 
biomedical research in recent years due to uncertain funding also would 
be encouraged by a stable funding model and may reconsider pursuing 
research careers. Coupled with NIH's commitment to fund new 
investigators at success rates equal to those of established 
investigators, this scenario would enable NIH to attract and sustain a 
talented biomedical research workforce.
    NIH investments reap substantial economic benefits; the agency 
directly supports about 300,000 researchers at more than 2,500 
institutions in every state, and these investments spur additional job 
creation in those communities as well. In 2012, United for Medical 
Research estimated that NIH investments supported more than 402,000 
jobs and resulted in $57.8 billion in economic output nationwide. A 
report from the Milken Institute indicates that a $1 increase in NIH 
funding can increase the bioscience industry output by $1.70 in a given 
year, and the long-term effects could be even greater. Given these 
short-term economic effects, an inflation-adjusted budget for NIH could 
spur job growth across the country, increase economic output, and 
reduce health spending by producing better, more cost-effective 
treatments and prevention strategies. Over the long term, increased 
support for NIH will lead to reductions in disease, longer lifespans, 
and improved quality of life for all Americans.
                 sequestration and government shutdown
    Question. The National Institutes of Health is the Nation's medical 
research agency and the leading supporter of biomedical research in the 
world. More than 80 percent of the NIH's budget goes to over 300,000 
research personnel at more than 2,500 universities and research 
institutions through the United States. Last year, sequestration cut 
the NIH's $30.7 billion budget by almost $1.6 billion. The deleterious 
effects of sequestration were compounded by the government shutdown 
which took place October 1 to October 16 of 2013 and temporarily 
curtailed most of NIH's operations.
    Please summarize the impact that sequestration and the government 
shutdown had on NIH's ability to award grants and support the training 
and education of scientists. Please describe the impact that 
sequestration and the government shutdown had on biomedical innovation 
and how the cuts in funding impacted patients currently enrolled in 
clinical trials.
Impact of Sequestration
    Answer. Sequestration dampened NIH's ability to support biomedical 
research. The overall award rate for NIH research project grant 
applications in fiscal year 2013 fell to approximately 15 percent, a 
historic low.\1\ \2\ Compared to fiscal year 2012, in fiscal year 2013, 
NIH funded approximately 750 fewer competitive research project grants 
(e.g., new or renewal applications) that were determined to be highly 
meritorious in grant review, including over 200 fewer competing renewal 
applications. Competing renewal applications represent promising 
follow-on research stemming from previously funded grants. Lack of 
continued funding diminishes the NIH's ability to leverage previous 
investments and capitalize on recent scientific progress.
---------------------------------------------------------------------------
    \1\ http://nexus.od.nih.gov/all/2014/03/05/comparing-success-award-
funding-rates/#sthash.aM0tN2GL.dpuf
    \2\ NIH's definition of ``award rate'' is the number of awards made 
in a fiscal year divided by the absolute number of applications.
---------------------------------------------------------------------------
    NIH Institutes and Centers (ICs) were also forced to reduce funding 
for noncompeting, ongoing research grants. Reductions varied by IC, but 
the NIH-wide average was -4.7 percent. Further, at least ten new 
funding initiatives (``request for applications'' or ``request for 
proposals'' concepts) were planned but not published, including cancer 
studies that could have improved our ability to distinguish accurately 
non-lethal tumors from life-threatening ones, and autism studies to 
investigate genetic and environmental factors that affect the risk of 
autism in preterm infants.
    Many of the NIH ICs also reduced their funding for training grants 
and fellowships. For example NIGMS, which sponsors the majority of NIH-
supported pre-doctoral trainees, funded 186 fewer trainees than it 
would have without sequestration. Trainees who were already funded also 
were affected, as there was no increase in stipend levels for National 
Research Service Award recipients in fiscal year 2013.
    Sequestration also diminished NIH's ability to conduct research at 
the Clinical Center. Approximately 750 fewer new patients were admitted 
to the NIH Clinical Center, a decrease from 10,695 new patients in 2012 
to approximately 9,945 new patients in 2013. This reduced the number of 
patients who could have benefitted from enrollment in clinical 
protocols, as well as slowed the pace of important clinical research. 
Note that while much of the decrease in enrollment numbers is due to 
funding, patient recruitment is dependent on multiple factors.
    Funding cuts driven by sequestration have had ripple effects 
throughout the biomedical research community. One recent survey 
examined sequestration's impact on research conducted by universities 
across the country.\3\ The most commonly cited impacts of the sequester 
among survey respondents were a reduction in the number of new Federal 
research grants (70 percent of responding universities), delayed 
research projects (also 70 percent), personnel reductions (58 percent), 
reduced research activity (81 percent), admission of fewer graduate 
students (23 percent), as well as tuition reductions and reduced 
stipend levels for students (14 percent).
---------------------------------------------------------------------------
    \3\ Association of American Universities, Association of Public and 
Land-grant Universities, and The Science Coalition. Survey on 
Sequestration Effects: Selected Results from Private and Public 
Research Universities. November 2013.
---------------------------------------------------------------------------
Impact of Government Shutdown
    The Government shutdown impacted NIH and the biomedical research 
community. Approximately 75 percent of the NIH workforce was furloughed 
during shutdown. For the community of NIH's extramural investigators, 
shutdown caused delays in grant review and funding processes. 
Typically, NIH receives the largest number of grant applications in 
October. Because of the prolonged shutdown, all of the October receipt 
dates were rescheduled for November, including those for NIH's largest 
grant activities, such as the investigator initiated R01 applications, 
Small Grants (R03), Exploratory Development Grants (R21), AREA awards 
(R15), and Career Development (K) activities. Reviews of more than 
11,000 grant applications were delayed by the shutdown.
    October is also one of the 3 months with the largest volume of NIH 
Scientific Review Group meetings, the first step of peer review. Over 
200 Scientific Review Group meetings had to be rescheduled due to the 
shutdown; most of the October meetings involved reviewers travelling to 
meetings scheduled to be convened ``in-person''. These ``in-person'' 
meetings had to be rescheduled, and travel arrangements had to be 
cancelled and re-arranged.
    The NIH Intramural Research Program (IRP) was also profoundly 
affected and lost progress during the shutdown. The Clinical Center did 
not enroll any new patients in clinical trials or to start new trials. 
Therefore, approximately 200 new patients were not admitted to the 
Clinical Center. Of those denied access, 30 were children, including 10 
with cancer. Only 15 to 20 percent of IRP staff were ``excepted'' from 
furlough, so that they could protect life (mostly in the Clinical 
Center, where 75 percent of the staff were required to work), guarantee 
safety (infrastructure support including security and the power plant), 
and protect large investments in materials and property (animals, cell 
cultures, and expensive equipment).
    The shutdown took a toll on NIH intramural training programs and 
trainees, too. In addition to being a biomedical research enterprise, 
NIH is the largest training facility in the world for biomedical 
researchers. During the shutdown, there were approximately 4,000 
postdoctoral fellows, 800 post baccalaureate students, 500 graduate 
students, and 45 medical students who were unable to conduct their 
research. For many of these trainees, time is of the essence. Their 
appointments are time-limited (less than 1 year for the medical 
students, up to 2 years for the post baccalaureate students, and 
usually three to 4 years for the postdoctoral fellows and graduate 
students). Loss of a few weeks of research and mentoring as well as the 
additional work time needed to regain momentum--while cell lines are 
started up again, animals are bred, and experiments that may have 
suffered in the shutdown are repeated--represent a significant 
proportion of their NIH training experience that could affect their 
future careers.
                        congenital heart disease
    Question. Congenital Heart Disease (CHD) is one of the most 
prevalent birth defects in the United States and a leading cause of 
birth defect-associated infant mortality. Due to medical advancements, 
more people with congenital heart defects are living into adulthood.
    The healthcare reform law includes a provision that authorizes the 
Centers for Disease Control and Prevention (CDC) to expand surveillance 
and track the epidemiology of CHD across the life-course, with an 
emphasis on adults. The Consolidated Appropriations Act of 2014 
provided the CDC with $2.9 million in new funding for enhanced CHD 
surveillance. Recent data suggest that the number of infant deaths 
related to CHD is decreasing. Successful interventions in infancy and 
childhood are resulting in an aging population of congenital heart 
disease survivors.
    How is the NIH systematically responding to this new population of 
survivors reaching adolescence, adulthood, and advanced age?
    How is NIH utilizing adult congenital heart disease research 
experts in these efforts?
    How is NIH supporting adult CHD professionals so the field can 
grow? Is the NIH offering training grants to grow the field? Is the 
Pediatric Heart Network inclusive to adult CHD experts? Is your agency 
formally engaging adult populations in CHD research?
    Answer. Advances in diagnosis and care have led to significant 
improvement in survival rates for Congenital Heart Disease (CHD) such 
that more adults than children are now living with CHD. The National 
Heart, Lung and Blood Institute (NHLBI) supports research on the causes 
of CHD and the evolving natural history and co-morbidities in adults 
with CHD across the lifespan. For example, the Bench to Bassinet 
Program (B2B) is identifying genetic and epigenetic causes of CHD to 
help risk-stratify and personalize treatment for children and adults 
with CHD. The Pediatric Heart Network (PHN) was launched in 2001 to 
conduct studies to improve outcomes and quality of life in children 
with heart disease and includes experts in adult congenital heart 
disease (ACHD). The PHN is following the largest assembled cohort of 
individuals with single ventricle physiology into adulthood to 
determine barriers to transitioning to adult care and to evaluate their 
health status and co-morbid conditions at specific intervals. The PHN 
is also in the process of launching a trial in adolescents and young 
adults with single ventricle physiology to assess whether use of a 
phosphodiesterase-5-inhibitor medication will prevent functional 
deterioration and delay the onset of heart failure.
    NHLBI also partners with ACHD-themed organizations to advance the 
field of ACHD research, such as The Health, Education and Access 
Research Trial (HEART-ACHD) and The Research Empowerment for Adult 
Congenital Hearts (REACH) project, both funded by NHLBI and conducted 
in partnership with the Adult Congenital Heart Association (ACHA) and 
the Alliance of Adult Research in Congenital Cardiology (AARCC). In 
June 2014, NHLBI and the ACHA will host a working group, ``Adult 
Congenital Heart Disease: Emerging Research Questions,'' to identify 
critical research gaps in the care of adults with CHD. This group will 
build partnerships between ACHD experts and experts in the 
complementary fields of adult cardiovascular care and pediatric 
cardiology. Participants will develop methodological approaches that 
leverage recent progress in multicenter ACHD research and existing 
congenital heart disease data infrastructure, and will develop 
strategies to engage patients in the development and execution of 
research studies.
    To ensure a robust community of ACHD investigators spanning basic 
and clinical research, NHLBI supports institutional training grants for 
CHD, the PHN Scholars award, to fund small pilot studies, and 
individual career development awards for ACHD investigators For 
example, an NHLBI-supported career development awardee is developing, 
testing, and validating a Quality Assessment Tool for Adults with 
Congenital Heart Disease (QAT-ACHD) for the outpatient management of 
selected ACHD conditions to help standardize high-quality ACHD care. 
Another NHLBI career development awardee is studying the role of 
myocardial fibrosis in three ACHD conditions. The same investigator has 
also secured funding from the Eunice Kennedy Shriver National Institute 
of Child Health and Human Development (NICHD) for a pilot study on 
enlarged thoracic aortas in patients with bicuspid aortic valve. 
Mechanisms such as these are designed to ensure growing expertise in 
the field of ACHD research, with a strong focus on the long-term 
implications of CHD and its treatment for the increasing number of 
persons who survive for many decades after diagnosis.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
                                 oppnet
    Question. Can you provide an update about OppNet, the 5-year 
initiative to support basic behavioral and social sciences research 
that began in 2010? What can you tell us about the findings of that 
initiative? When will a report be available?
    Answer. Between October 2010 and May 2014, the Basic Behavioral and 
Social Science Opportunity Network (OppNet) provided $64.2 million to 
fund 152 extramural research projects. OppNet lists all its grants by 
original year of funding at http://oppnet.nih.gov/resources-
initiatives.asp. Among the OppNet grants is early investigator Dr. 
Santosh Kumar's Predicting Smoking Abstinence via Mobile Monitoring of 
Stress and Social Context. This study demonstrates that modern sensor 
technology can obtain a much more detailed and accurate representation 
of personal and environmental influences on smoking than previously 
possible. Based partially on this work, Popular Science magazine named 
Dr. Kumar one of the 10 most brilliant young scientists. Another 
project, Neural Mechanisms of Habit Formation and Maintenance, analyzes 
cellular, molecular, and circuit mechanisms to understand how behaviors 
become ``automatic'' regardless of outside influences. Dr. Henry Yin 
found that stimulating mouse neurons to generate dopamine can foster 
the adoption of healthy behaviors and reduce unhealthy behaviors--all 
without providing incentives (e.g., food rewards). These findings, 
already appearing in at least five peer-reviewed publications, suggest 
exciting possibilities for future studies with important clinical 
implications.
    OppNet has expanded both the perspective of researchers and NIH 
program directors. Nineteen of OppNet's 28 new investigators (68 
percent) received non-Federal funding prior to applying, compared with 
21 percent of basic behavioral and social sciences research (basic-
BSSR) and 39 percent of applied behavioral and social sciences research 
(applied-BSSR)--an example of the initiative's success at expanding 
NIH's scope of basic-BSSR. NIH program directors report that OppNet has 
increased their knowledge of other NIH Institutes and Centers (ICs)' 
missions and research interests and that OppNet has allowed them to 
solicit and fund projects that likely could not have occurred without 
OppNet's infrastructure. Perhaps the best examples to date are the 
grants funded through the funding opportunity, Basic Behavioral 
Research on Multisensory Processing http://oppnet.nih.gov/resources-
2013fundedapp.asp. These projects explain how a combination of visual, 
auditory, olfactory, gustatory, non-pain somatosensory, and/or 
vestibular input influences basic perceptual and behavioral processes. 
This initiative stimulated new collaborations between ICs that were 
supporting research on sensory processing, but from the perspective of 
single sensory systems, such as vision or audition.
    ICs are organized somatically or by disease. OppNet's 
infrastructure facilitates the trans-sensory and transdisciplinary 
research projects that likely would lack a clear ``home.'' Moreover, 
OppNet has been so successful at coordinating basic and applied BSSR 
across the NIH that some ICs decided to fund all or part of 23 
additional projects beyond what was planned for in the OppNet budget. 
As the grants funded under OppNet have not gone through a full five-
year funding cycle, a formal and comprehensive program evaluation would 
be premature at this time. However, OppNet makes its activities and 
accomplishments available to the public through its Web site at http://
oppnet.nih.gov/.
                                diabetes
    Question. I understand that, as a result of previous studies, there 
is evidence of a link between poor blood glucose control and 
development of diabetes complications, and the tremendous long-term 
benefits of early, effective blood glucose control, particularly in 
recent onset diabetes. Can you tell me what the agency is doing to 
better understand the underpinnings of complications like kidney 
disease?
    Answer. Controlling and preventing diabetes are the best approaches 
to preventing or minimizing its many health complications, including 
kidney disease. Diabetes--both type 1 and type 2--is the major cause of 
end-stage kidney failure. The landmark NIH-supported Diabetes Control 
and Complications Trial (DCCT) and its follow-up study, the 
Epidemiology of Diabetes Interventions and Complications (EDIC), 
demonstrated how critically important it is to control blood glucose 
levels early in the course of type 1 diabetes in order to reduce the 
likelihood of subsequent complications. DCCT participants who 
intensively controlled their blood glucose levels had significantly 
lower rates of eye, nerve, kidney, and cardiovascular complications 
than those who received standard care. This effect extended for many 
years after the study ended.
    A second landmark NIH-supported clinical trial, the Diabetes 
Prevention Program (DPP), showed that an intensive lifestyle 
intervention designed to achieve modest weight loss through a 
combination of diet and exercise lowered type 2 diabetes rates by 58 
percent, and that the generic diabetes medication metformin reduced 
diabetes rates by 31 percent, relative to placebo. A follow-up study to 
the DPP, the DPP Outcomes Study (DPPOS), is assessing the long-term 
effects of interventions used in the DPP on the development of type 2 
diabetes and its complications. After 10 years of follow-up, DPPOS 
found that the lifestyle intervention continued to dramatically reduce 
the development of type 2 diabetes--and consequently its 
complications--and also reduced cardiovascular risk factors.
    Diabetes is the leading cause of kidney disease, followed by high 
blood pressure. Abnormally high blood glucose levels damage the 
kidney's filtering units, which progressively and irreversibly impairs 
kidney function. Thanks to NIH-supported research, scientists have made 
great progress in developing methods, in addition to controlling blood 
glucose levels, which slow the onset and progression of kidney disease 
in people with diabetes. Two types of drugs used to lower blood 
pressure, angiotensin-converting enzyme (ACE) inhibitors and 
angiotensin receptor blockers (ARBs), have proven effective in slowing 
the progression of kidney disease in people with diabetes or high blood 
pressure.
    Because there is no way, at present, to restore kidney function 
once it is lost, NIH research focuses on early detection of kidney 
disease and strategies to slow or prevent the progression of disease. 
The Chronic Renal Insufficiency Cohort (CRIC) Study, one of the largest 
and longest ongoing studies of chronic kidney disease epidemiology in 
the United States, is examining the natural history of kidney disease 
as well as the broad range of illnesses experienced by people with 
kidney disease. NIH is supporting a study that aims to identify 
biomarkers that indicate a risk of progression of kidney disease. 
Research supported by NIH has enhanced our understanding of the origin 
of scar tissue that is common in many forms of kidney disease, how it 
can impair kidney function, and how it might be prevented or treated. A 
new initiative, currently in development, will address challenges 
associated with growing nephrons, the kidneys' basic filtering unit. 
NIH supports several studies that the private sector most likely would 
not undertake, including pilot studies of novel therapies for kidney 
disease.
                             emergency care
    Question. The NIH recently created a new division, the Office of 
Emergency Care Research. Considering that in New Hampshire, and 
throughout the United States, there is an epidemic of narcotic 
prescription abuse and overdose deaths, what can the this new office do 
to help emergency providers curtail excess narcotic prescribing? How 
can we increase awareness among providers to decrease medically 
unnecessary narcotic prescriptions?
    Answer. The Office of Emergency Care Research (OECR) was 
established in 2012 to coordinate and develop emergency care research 
across the National Institutes of Health. Emergency departments (EDs) 
are unique treatment settings in that they serve some patient 
populations that have little or no access to medical care, and who have 
few available resources. For example, EDs may be the only facilities at 
which poor and underserved populations receive care. For substance-
using populations, they provide a unique opportunity to assess the 
overall health needs of the patient and link them to the care and the 
support required to meet all of their health needs. OECR and the 
National Institute on Drug Abuse (NIDA) are concerned about the 
epidemic of narcotic abuse and are aware of the role of the emergency 
care system in reducing this abuse.
    NIDA is investing in research to develop clinical interventions 
tailored to the ED setting. The goals of these interventions are to 
facilitate accurate diagnoses and linkage to long-term care programs to 
protect the overall health of the individual. Halting accidental or 
unnecessary opioid prescriptions is a key component to thwarting the 
devastating rise in opioid overdoses. For this reason, NIDA is 
supporting research that will increase ED physician knowledge when 
treating opioid patients by:
  --identifying ways to effectively implement the use of prescription 
        drug monitoring programs (PDMPs) within the ED to decrease 
        prescription opioid prescribing, overdoses, and deaths. 
        Widespread use of PDMPs will provide ED physicians with the 
        information they need to prescribe opioids to those patients 
        who would benefit most from these essential medications, while 
        preventing these medications from reaching populations for 
        which they are not intended. (For more details see NIH grant 
        1R01DA036522-01.)
  --developing improved, non-invasive devices that can detect traces of 
        narcotics and alcohol. This will help ED physicians to diagnose 
        and treat patients with substance abuse issues, because an 
        accurate diagnosis of substance abuse is the first step to its 
        treatment. (For more details see NIH grant 5R44DA031530-03.)
    Since assuming the position of Director of OECR, Dr. Jeremy Brown 
has met with program officers and senior staff at NIDA to discuss 
strategies to increase research on drug abuse in the emergency care 
setting. In addition, in October 2013, OECR, CDC, and NIDA staff were 
scheduled to attend a special day training session on effective 
approaches to addressing substance abuse disorders in the Emergency 
Department. This conference was held as part of the annual meeting of 
the American College of Emergency Physicians. Although the Government 
shutdown prevented NIH staff from attending in person, this meeting 
emphasizes the way in which NIDA, OECR and professional organizations 
are cooperating to address the substance abuse epidemic.
    Funding for research on the narcotic epidemic is provided by NIDA, 
and the Office of Emergency Care Research will continue to work with 
staff from NIDA to support and grow initiatives in this area.
                                 asthma
    Question. In November Congresswoman DeLauro and I wrote to 
Secretary Sebelius to inquire about a provision in the National Heart, 
Lung, and Blood Institute's (NHLBI) 2007 Expert Panel Guidelines for 
the Diagnosis and Management of Asthma that recommends that physicians 
who treat the majority of children with asthma ``determine exposures, 
history of symptoms in presence of exposures, and sensitivities.'' They 
make this recommendation so that ``physicians can advise patients on 
ways to reduce exposure to allergens.'' While it has been many years 
since release of the guidelines, we are concerned that we are failing 
to meet this objective. I'd like your assurance that this work will 
remain a high priority for the NIH and that you will continue to work 
with all stakeholders to accelerate implementation of this laudable 
objective.
    Answer. NHLBI's National Asthma Education and Prevention Program's 
(NAEPP) Guidelines Implementation Panel Report offers suggested 
strategies to enhance dissemination and adoption of key recommendations 
in the Guidelines. These strategies were offered as a list of possible 
activities for NAEPP member organizations and other professional, 
private sector, state and local government, and patient groups to 
consider undertaking within their respective organizations in order to 
improve asthma care, which many organizations have done. All programs 
address exposures to environmental allergens and irritants as part of 
the comprehensive approach to asthma necessary to achieve and maintain 
asthma control.
    National professional societies and patient groups and local 
healthcare and community groups have made considerable progress in 
engaging primary care providers, allergists, and representatives of 
health plans to identify and overcome local barriers and accelerate 
implementation of recommendations in the Guidelines, including those 
relating to control of allergens. For example, the Centers for Medicare 
and Medicaid Services Health Care Innovation Awards Program included 
five awardees that address asthma; all of these programs incorporate 
attention to environmental allergens. The Environmental Protection 
Agency's (EPA) vibrant Community Network (http://
www.asthmacommunitynetwork.org/) and annual EPA leadership Awards 
program offer outstanding examples of community organizations, 
clinicians, and healthcare administrators, including Medicaid service 
providers, across the country working together on programs that 
incorporate measures to control environmental asthma triggers, 
including allergens, into comprehensive asthma management. The Centers 
for Disease Control and Prevention's National Asthma Program and the 
NHLBI's National Asthma Control Initiative showcase tools and programs 
developed by state public health and local community clinics that can 
be adapted by other stakeholders. These tools include home-visit 
guides, environmental assessment checklists, and clinical pathways for 
assessing, treating, and monitoring all aspects of asthma care.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
                   accelerating medicines partnership
    Question. The Accelerating Medicines Partnership (AMP) is expected 
to address the ``valley of death'' in drug development. How much with 
the Partnership shorten the current drug development timeline and how 
much money will be saved?
    If the Accelerating Medicines Partnership is successful, how will 
you determine what future disease and conditions will be added to the 
program?
    Answer. The Accelerating Medicines Partnership (AMP) is a unique 
type of public-private partnership of the National Institutes of Health 
(NIH), the Food and Drug Administration (FDA), nonprofit organizations, 
and biopharmaceutical companies. AMP is supporting research focused on 
identifying and validating biological targets for new therapeutics, a 
process called target validation. AMP was just launched in February and 
is beginning with three specific pilot projects, in Alzheimer's 
disease, type 2 diabetes, and rheumatoid arthritis/lupus.
    Over half of drugs fail in phase II and phase III clinical trials 
due to lack of efficacy, and improvements in the target validation 
process should reduce that failure rate. So while AMP may not affect 
the development timeline for a particular drug, it should increase the 
success rates of trials by increasing the chances that a particular 
drug will be effective. If AMP succeeds in validating a drug target for 
a particular disease, that could reduce drug development costs in that 
area, since companies should be less likely to conduct costly clinical 
trials with compounds that will fail in phase II or III because the 
targets of those compounds don't have the desired effect on the 
particular disease.
    The AMP partners intend to consider other project ideas later this 
year. As in the selection of the pilot projects, the AMP partners would 
need to agree that there is a scientific opportunity in target 
validation in a particular disease area with these characteristics: the 
research project would be amenable to a public-private partnership with 
joint scientific planning and governance; data would be shared broadly 
and not be patented; and industry or research foundations would be 
willing to commit substantial financial and other support. The 
Foundation for the NIH has a project proposal form on its Web site at 
http://fnih.org/work/key-initiatives-0/accelerating-medicines-
partnership to guide interested parties in developing project proposals 
for the AMP members to consider, and the AMP partners will also 
continue identifying and exploring their own areas of mutual scientific 
interest.
                           darpa-like program
    Question. I am concerned that researchers are now reluctant to take 
risks because of their concern that their research efforts will not be 
supported. How will NIH's new DARPA-like program address this concern?
    The new DARPA-like Program is funded at $30 million and would 
support high risk, goal-driven activities aimed to achieve rapid 
technology development. While I support this type of research, I am 
concerned that the funding for the new program is coming from another 
program that supports exceptionally creative scientists proposing 
innovative and transformative research--High-Risk High-Reward Research. 
The High-Risk High-Reward Research program's funding is reduced by 
$21.8 million. If funding ``maverick'' science is a priority for NIH, 
why does the budget cut one high risk research program's funding to 
start a new one?
    The Guardian ran a letter in March from a group of prominent 
researchers promoting additional funding to support scientific 
mavericks. The letter stated, ``Agencies claiming to support blue-skies 
research use peer review, of course, discouraging open-ended inquiries 
and serious challenges to prevailing orthodoxies.'' In a time when 
budget resources are constrained, how do you balance funding for high-
risk research projects with peer-reviewed science?
    Answer. Scientific progress often advances by building 
incrementally upon a strong foundation of previous research and 
preliminary data. However, rapid advances in progress may require 
approaches that foster innovation and risk taking. For certain 
objectives, where research teams need to be actively managed to achieve 
defined, high-risk goals so that new expertise can be added as initial 
high-risk attempts fail or as new discoveries are made, the DARPA-like 
Other Transaction Authority (OTA) provided to the Common Fund can be 
very helpful. The NIH Common Fund's Stimulating Peripheral Activity to 
Relieve Conditions (SPARC) program will use the OTA to support a high-
risk, goal-driven endeavor to develop proof of concept for an entirely 
new class of neural control devices that have the potential to 
precisely treat a wide variety of diseases and conditions. 
Neuromodulation to control end-organ system function has been 
recognized as a potentially powerful way to treat many diseases and 
conditions, such as hypertension and heart failure, gastrointestinal 
disorders, diabetes, and inflammatory disorders. However, the 
mechanisms of action for neuromodulation therapies are poorly 
understood. The SPARC program will support interdisciplinary teams of 
investigators to deliver neural circuit maps of several organ systems, 
novel electrode designs, minimally invasive surgical procedures, and 
stimulation protocols, driven by an end goal to develop new 
neuromodulation therapies. The program is expected to be iterative and 
dynamic, with the novel technologies informing mapping efforts, and 
mapping results defining new technology requirements. Rapid progress in 
this nascent field requires high levels of innovation and risk taking 
as well as aggressive project management to achieve these ambitious 
goals and capitalize on the therapeutic promise of this emerging 
research area.
    In addition to the SPARC program, several other initiatives within 
the Common Fund specifically support high-risk research. The High-Risk 
High-Reward program, which includes the Pioneer, New Innovator, 
Transformative Research, and Early Independence Awards, supports 
exceptionally creative scientists to undertake bold and innovative 
research projects in any scientific area relevant to the NIH mission. 
For these projects, NIH has no pre-defined objective other than to 
foster innovative, exceptionally high-impact research through 
investigator-initiated projects. Therefore, for these projects, a grant 
mechanism, rather than the OTA mechanism, is most useful. Although 
Common Fund support for the High-Risk High-Reward program decreases in 
fiscal year 2015, the successful track record of the High-Risk High-
Reward program has moved NIH's Institutes and Centers to increase their 
support of these awards, providing additional funding beyond the Common 
Fund investment.
    All NIH-supported research, including programs designed to support 
high-risk research, undergoes a rigorous peer-review process to 
identify the most scientifically meritorious projects. Programs 
designed to support high-risk research may emphasize different criteria 
during peer review compared to more traditional grant mechanisms, 
weighting innovation and potential impact more heavily than feasibility 
and preliminary data. Highly innovative ``blue skies'' research and 
peer review are not mutually exclusive. Although the specific review 
processes for SPARC and other OTA programs may be different from grant 
or contract reviews, external input will still be sought to help guide 
the decisionmaking process.
    The question of how to balance funding for high-risk research with 
research that is more grounded by preliminary data is perennial, and 
the answer varies across the NIH as scientific opportunities and 
challenges vary between fields of research. However, risk tolerance is 
a founding principle of the NIH Common Fund so that innovative 
solutions to the most pressing challenges may be reached.
               clinical and translational science awards
    Question. How has NCATS implemented the Institute of Medicine's 
Clinical and Translational Science Awards (CTSA) recommendations and 
how do you see the program growing over the next several years?
    Answer. In June 2013, the Institute of Medicine (IOM) issued a 
report following a review of the Clinical and Translational Science 
Awards (CTSA) Program. The report recommended that the National Center 
for Advancing Translational Sciences (NCATS) take a more active role in 
the program's governance and direction, formalize the evaluation 
processes of the program, advance innovation in education and training 
programs, and ensure community engagement in all phases of research.
    NCATS leadership is committed to implementing the recommendations 
of the IOM report. As a first step, NCATS has increased the 
programmatic and fiscal management of the grants that support this 
program and streamlined the way the consortium is governed, consulting 
closely with the CTSA Principal Investigators (PIs). For example, we 
have appointed a new steering committee that includes 12 CTSA PIs with 
staggered terms to replace the previous 90-member group.
    In parallel, NCATS assembled a Working Group of its Advisory 
Council to provide advice on measurable objectives for the CTSA 
program. The group was tasked with developing clear, measurable goals 
and objectives for the program that address critical issues across the 
full spectrum of clinical and translational research (i.e. ``what does 
success look like?''). The Working Group presented its report (http://
www.ncats.nih.gov/files/CTSA-IOM-WG-Draft-Report.pdf) at the NCATS 
Advisory Council meeting in May. Its report addressed four of the seven 
recommendations in the IOM report and focused on: (1) translational 
workforce development, (2) engagement and collaboration with patients 
and communities, (3) integration of translational science across its 
multiple phases and disciplines within complex populations and across 
the individual lifespan, and (4) systemic improvements in methods and 
processes of translation. The measurable goals and outcomes in this 
report are serving as a guide for NCATS as it moves forward in 
developing and implementing strategies to strengthen the CTSA program 
and for measuring progress.
    NCATS recently announced the selection of Petra Kaufmann, M.D., 
M.Sc., to head the NCATS Division of Clinical Innovation, which 
includes the CTSA program. Dr. Kaufmann served as Director of the 
Office of Clinical Research at NIH's National Institute of Neurological 
Disorders and Stroke (NINDS) and brings a wealth of expertise across 
the translational sciences spectrum.
    With the appointment of a permanent Director for the program, the 
recommendations of the IOM report, and the results of deliberations by 
the Advisory Council and its working group, NCATS is poised to work 
closely with the CTSA community to improve the effectiveness and 
efficiency of the process of translation from scientific discovery 
through clinical research to improved health outcomes.
   brain research through application of innovative neurotechnologies
    Question. We discussed the Brain Research through Application of 
Innovative Neurotechnologies (BRAIN) Initiative at last year's budget 
hearing. This is an exciting proposal that could revolutionize the 
field of neuroscience and advance therapies for numerous diseases, 
including Alzheimer's. The subcommittee provided funding for this 
initiative in fiscal year 2014 and requested a report on the goals, 
objectives, budget, and timeline for the BRAIN Initiative. Could you 
elaborate on the commitment we are undertaking and provide specific 
details on what the 10 year budget picture may entail?
    Answer. NIH charged a high-level working group of the Advisory 
Committee to the Director (ACD) to develop a rigorous plan for the 
Initiative that includes scientific milestones and budgetary 
projections (roster at http://www.nih.gov/science/brain/acd-
roster.pdf). This working group comprised visionary leaders across 
neuroscience disciplines that were expertly positioned to delineate 
bold, yet achievable, multi-year timetables, milestones, and cost 
estimates. Over the last year, the working group met with the 
scientific community, patient advocates, and the general public to 
ensure its plan would be sufficiently informed by stakeholder input.
    The working group delivered its final report for consideration by 
the ACD at its June 5-6 meeting. The scientific vision outlined in this 
report was unanimously supported by the Committee and subsequently 
endorsed by the NIH Director. In its findings, the group emphasized 
that the NIH efforts on the BRAIN Initiative should seek to map the 
circuits of the brain, measure the fluctuating patterns of electrical 
and chemical activity flowing within those circuits, and understand how 
their interplay creates our unique cognitive and behavioral 
capabilities. The following seven scientific goals were identified as 
high priorities for achieving this vision:
      1. Identify and provide experimental access to the different 
        brain cell types to determine their roles in health and 
        disease.
      2. Generate circuit diagrams that vary in resolution from 
        synapses to the whole brain.
      3. Produce a dynamic picture of the functioning brain by 
        developing and applying improved methods for large-scale 
        monitoring of neural activity.
      4. Link brain activity to behavior with precise interventional 
        tools that change neural circuit dynamics.
      5. Produce conceptual foundations for understanding the 
        biological basis of mental process through development of new 
        theoretical and data analysis tools.
      6. Develop innovative technologies to understand the human brain 
        and treat its disorders; create and support integrated brain 
        research networks.
      7. Integrate new technological and conceptual approaches produces 
        in Goals 1-6 to discover how dynamic patters of neural activity 
        are transformed into cognition, emotion, perception, and action 
        in health and disease.
    These scientific goals will be maximized through seven core 
principles:
      1. Pursue human studies and non-human models in parallel.
      2. Cross boundaries in interdisciplinary collaborations.
      3. Integrate spatial and temporal scales.
      4. Establish platforms for preserving and sharing data.
      5. Validate and disseminate technology.
      6. Consider ethical implications of neuroscience research.
      7. Create mechanisms to ensure accountability to NIH, the 
        taxpayer, and the community of basic, translational, and 
        clinical neuroscientists.
    The first year of the BRAIN Initiative, fiscal year 2014, was 
seeded by a $40 million commitment from NIH. The President has 
requested $100 million in his fiscal year 2015 budget for the second 
year of the Initiative. For the remaining years, the working group 
suggests an investment ramping up to $400 million a year for fiscal 
years 2016-2020 to focus on technology development and validation. They 
called for $500 million a year for years 2021-2025 to focus 
increasingly on the application of those technologies in an integrated 
fashion to make fundamental new discoveries about the brain. The 
working group emphasized that its cost estimates, which are 
provisional, assume that the budget for the BRAIN Initiative will 
supplement--not supplant--NIH's existing investment in the broader 
spectrum of basic, translational, and clinical neuroscience research.
    A full copy of the report can be found at http://www.nih.gov/
science/brain/2025/index.htm.
                          alzheimer's funding
    Question. Historically, NIH has opposed disease specific funding to 
allow research, not politics, to drive scientific funding decisions. 
However, this appears to cause a chicken and egg scenario. It is 
difficult for scientists to propose Alzheimer's research when there is 
not a robust funding stream to support their work, yet there is not a 
robust funding stream because scientists may not be proposing 
Alzheimer's research projects. So which comes first? The dedicated 
funding stream or the research ideas?
    Answer. NIH develops targeted funding initiatives to address areas 
of scientific need and opportunity as identified by program staff in 
consultation with experts in the scientific community. The resulting 
initiatives are strategically deployed to make every dollar count by 
establishing priorities, setting goals that are both ambitious and 
realistic, and identifying the most promising opportunities for 
progress through careful planning, coordination, and resource 
allocation.
    Although these targeted initiatives have enabled us to support a 
number of groundbreaking projects, it is important to note that the 
bulk of NIH's funding, in Alzheimer's disease and elsewhere, goes to 
investigator-initiated proposals--that is, proposals that are not 
developed in response to a specific funding initiative. For example, in 
fiscal year 2013, fewer than 10 percent of NIH's Alzheimer's-related 
research project grants were awarded under an Alzheimer's-specific 
funding opportunity announcement (FOA). The majority of Alzheimer's-
related studies were either awarded under a more general neuroscience-
focused FOA or an FOA in a related area, or were truly investigator-
initiated studies reflecting the creativity and innovation of 
researchers seeking to build on scientific advances or offering new 
ways of thinking about the disease.
    The importance of Alzheimer's disease research within the overall 
NIH research portfolio continues to be reflected in our strategic 
planning process and scientific funding initiatives. Our Alzheimer's-
related funding opportunity announcements (FOAs) are carefully 
developed to advance the field consistent with the priorities 
established under the National Action Plan for Alzheimer's Disease and 
the 2012 Alzheimer's Disease Research Summit. In addition, in the past 
5 years NIH has released over 40 FOAs directly relevant to Alzheimer's, 
and the response to each of these has been robust. In fact, each year 
we receive many more applications for meritorious research in 
Alzheimer's disease than we are able to fund.
    Question. How do you prioritize funding for a disease when you 
know, as in the case of Alzheimer's disease, that the disease burden is 
only going to increase over the next 20 years?
    Answer. Priority-setting processes at both the NIH and individual 
Institute levels are designed to maintain a balance among a wide array 
of diverse and compelling priorities, based on close monitoring of the 
scientific and medical landscapes by expert program staff and outside 
advisors. This enables us to use our funds efficiently and effectively 
in order to have the optimal impact both on the scientific field and on 
the public health. Alzheimer's disease is one such high-priority 
research area. Our planning, priority-setting, and funding initiatives 
fully take into account the projected increase in disease burden in 
this area.
    The NIH Director is responsible for program coordination across the 
NIH Institutes and Centers (ICs) and for ensuring a balanced overall 
research portfolio. In turn, each IC has a process for establishing 
research and funding priorities based on its specific mission and the 
long-term research goals articulated within relevant strategic plans. 
These priorities are reflected in the ICs' plans to distribute 
resources.
    To ensure that these priorities are harmonized with the wider NIH 
mission, the NIH Director provides centralized coordination and 
communication across NIH. During biweekly meetings with the IC 
Directors, the NIH Director considers the entire biomedical research 
landscape and discusses with his colleagues ways that NIH can be most 
effective with its investments. They hear from innovative scientists 
about cutting-edge results and deliberate potential new initiatives 
that could significantly advance the science in a particular field.
    NIH receives input from many sources when setting research and 
funding priorities for Alzheimer's. In addition to scientific 
workshops, international conferences, and other interactions with the 
scientific community, these sources include the National Advisory 
Council on Aging and the Advisory Council on Alzheimer's Research, 
Care, and Services, established under the 2011 National Alzheimer's 
Project Act. In addition, input from the 2012 Alzheimer's Disease 
Research Summit and the 2013 workshop on Alzheimer's Disease-Related 
Dementias has been instrumental in facilitating the development of our 
Alzheimer's research agenda.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran
                          jackson heart study
    Question. Dr. Collins, the Jackson Heart Study, located in Jackson, 
Mississippi, is the largest-ever investigation of cardiovascular 
disease in African Americans. In the National Heart, Lung and Blood 
Institute's congressional budget justification for this year, one of 
your focuses is on preventing and pre-empting chronic heart, lung, 
blood and sleep disorders. Can you tell me how the Jackson Heart 
Study's recent collaboration with the Framingham Heart Study can be 
leveraged to specifically address this particular theme?
    Answer. Since it began in 1998, the Jackson Heart Study (JHS) has 
provided extensive information on the causes of cardiovascular disease 
in African Americans. JHS is also one of the largest studies of the 
genetic factors that affect high blood pressure, heart disease, stroke, 
diabetes, and other diseases that disproportionately affect African 
Americans. A recent JHS-related paper, for example, showed that the 
gene APOL1, which is known to contribute to chronic kidney disease, was 
found to also increase risk of cardiovascular disease in African 
Americans. Genetic analyses such as this provide promise for targeted 
therapies that can pre-empt disease. In August 2013, NHLBI contracts 
supporting the JHS were renewed for another 5 years.
    A new collaborative research relationship has been established 
between the American Heart Association (AHA) and the University of 
Mississippi and Boston University, the academic coordinating center 
homes of the JHS and Framingham Heart study (FHS), respectively. The 
AHA-led study, called the Cardiovascular Genome Phenome Study (CVGPS), 
will expand upon the research taking place within the Framingham and 
Jackson Heart studies by investing in parallel genomic and genetic 
analyses among other research subjects, expanding diversity and 
enhancing new approaches to find more ``personalized'' treatment and 
prevention interventions that could pre-empt chronic cardiovascular 
disease and other conditions. The CVGPS will also seek to make new data 
available for analysis by qualified investigators.
    More generally, NHLBI is taking the necessary steps to transform 
its epidemiology research efforts in a way that builds on emerging 
scientific tools and data platforms. NHLBI has established an Advisory 
Council Working Group on Epidemiology Research to strategically examine 
how to maximize the potential of our epidemiological studies by joining 
complementary data across cohorts such as the FHS and the JHS for new 
scientific investigations. Leveraging our available resources, through 
strategic partnerships and collaborations, offers the best hope to 
address critical needs that will not only improve treatment but also 
change the course of disease before irreversible consequences occur.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
           science, technology, engineering, and mathematics
    Question. The fiscal year 2015 budget request, once again, proposes 
a reorganization of science, technology, engineering, and mathematics 
(STEM) education. While the STEM proposal kept the Science Education 
Partnership Awards program at NIH, the budget proposes to eliminate 
four other STEM initiatives throughout the agency. What metrics were 
used to decide these programs should be eliminated?
    Answer. The President's budget for fiscal year 2015 proposes a 
reorganization of all Federal Science, Technology, Engineering, and 
Mathematics (STEM) education programs. Consistent with the Government-
wide STEM reorganization, NIH decided to phase out four of its smaller 
STEM programs and notified grantees of the discontinuation of future 
new STEM programs supported by the National Institute on Drug Abuse 
(NIDA), the National Institute of Environmental Health Science (NIEHS), 
the National Institute of Neurological Disorders and Stroke (NINDS), 
and the National Institute of Allergies and Infectious Diseases 
(NIAID). This decision to discontinue or eliminate these programs 
follows the recommendations of the Federal STEM Education 5-Year 
Strategic Plan (Appendix Table A6: STEM Education Funding in Millions 
by Agency, page 98). Consistent with the report language accompanying 
the Consolidated Appropriations Act, 2014 (Public Law 113-76), NIH is 
continuing support of the Science Education Partnership Award program 
and the Office of Science Education.
               clinical and translational science awards
    Question. Dr. Austin, can you tell me how the Clinical and 
Translational Science Awards (CTSA) program is helping underserved 
populations, for example in my home state of Alabama, and in other 
underserved states in the Deep South?
    Answer. The University of Alabama at Birmingham (UAB) CTSA began a 
new program in 2010 called, ``The Deep South Network for Translational 
Research (DSNTR).'' It involves the UAB CTSA as the organizing hub, 
with participation of other institutions in the Deep South that do not 
have a CTSA including, Louisiana State University, Tulane University, 
Tuskegee University, University of Alabama-Tuscaloosa, University of 
South Alabama, and University of Mississippi Medical Center. It makes 
the sophisticated research capabilities of UAB available to 
investigators at these other institutions for use in multi-
institutional collaborative research projects, especially those that 
focus on underserved populations. Further, in collaboration with 
Alabama's Historically Black Colleges and Universities, the UAB CTSA 
has built an extensive network for training the next generation of 
health disparities researchers.
    The University of Arkansas Translational Research Institute (TRI) 
aims to translate successful healthcare research projects directly to 
patient care delivery regardless of where they live. The TRI partners 
with key community organizations across the state to facilitate 
research contacts and clinical care connections among rural and 
medically underserved populations. The TRI has leveraged and built upon 
Arkansas' statewide telemedicine program, in particular the Antenatal 
and Neonatal Guidelines, Education, and Learning System (ANGELS) 
program, which links obstetricians across the state to UAMS maternal-
fetal medicine specialists. Its partnership with the Tri-County Rural 
Health Network has connected elderly and adult disabled citizens with 
home and community-based services as alternatives to nursing homes. 
Finally, a nascent partnership with the Philips County Faith Task Force 
has enabled development of a community-based program for rural veterans 
in Jefferson County to build capacity to conduct participatory 
research. The project's overarching goal is to establish a community-
linked infrastructure that will increase minority participation in 
translational research intended to reduce racial and ethnic health 
disparities.
    At the Atlanta CTSA, experts in community engagement seek out 
community healthcaregivers that can articulate the heath needs of the 
local population, especially those who face disproportionately higher 
health risks. The Atlanta CTSA includes Emory University, the Georgia 
Institute of Technology, and the Morehouse School of Medicine, which is 
dedicated to improving the health and well-being of individuals and 
communities with emphasis on the underserved urban and rural 
populations in Georgia. Morehouse provides leadership in developing 
programs that specifically address healthcare needs in the Atlanta 
region. Examples include ``e-Healthy Strides,'' which partnered with 
Big Bethel AME Church to collect health data and transmit it to the 
parishioners' physicians; ``i-Adapt,'' a program designed to provide 
instruction and motivation to people with diabetes to facilitate self-
care; and EPICS (Educational Program to Increase Colorectal Cancer 
Screening), a program aimed at teaching primary healthcare teams about 
screening more effectively for colorectal cancer.
                   accelerating medicines partnership
    Question. Under the new Accelerating Medicines Partnership program, 
rheumatoid arthritis and lupus will receive $41.6 million in research 
funding over 5 years, with about half of this funding coming from the 
NIH and half from pharmaceutical companies. I am concerned that the 
funding for lupus is not new NIH funds, but redirected funding from 
current research projects. Are you concerned that AMP is taking away 
from current lupus research resources as opposed to allocating 
additional resources towards lupus?
    Will data generated as a result of the Accelerated Medicines 
Partnership be available to other scientists studying these diseases?
    What other diseases and conditions will this program be supporting 
in the future?
    Answer. The Accelerating Medicines Partnership (AMP) is a unique 
type of public-private partnership of the National Institutes of Health 
(NIH), the Food and Drug Administration (FDA), nonprofit organizations, 
and biopharmaceutical companies. AMP is supporting research focused on 
identifying and validating biological targets for new therapeutics, a 
process called target validation. AMP was just launched in February, 
and as noted, is beginning with three specific pilot projects, 
including a rheumatoid arthritis and lupus project.
    The AMP program offers an exceptional opportunity to leverage NIH 
investments in lupus research with substantial funds and intellectual 
support from industry and non-profit organizations. Recognizing the 
need and opportunity, NIH, after consulting with the research 
community, released two Requests for Applications (RFAs) to implement 
the AMP program in lupus and rheumatoid arthritis. The RFAs will not 
take money away from existing lupus projects. We expect that a number 
of researchers studying lupus will apply and be funded through the AMP.
    Because a major goal of the AMP is to generate pre-competitive, 
disease-specific data that will be accessible to the broad biomedical 
community, the program will also facilitate research by lupus 
investigators not funded through the AMP. AMP partners have also agreed 
that the research findings should not be patented.
    The AMP partners intend to consider other project ideas later this 
year. As in the selection of the pilot projects, the AMP partners would 
need to agree that there is a scientific opportunity in target 
validation in a particular disease area with these characteristics: the 
research project would be amenable to a public-private partnership with 
joint scientific planning and governance; data would be shared broadly 
and not be patented; and industry or research foundations would be 
willing to commit substantial financial and other support. The 
Foundation for the NIH has a project proposal form on its Web site at 
http://fnih.org/work/key-initiatives-0/accelerating-medicines-
partnership to guide interested parties in developing project proposals 
for the AMP members to consider, and the AMP partners will also 
continue identifying and exploring their own areas of mutual scientific 
interest.
                                 ______
                                 
              Question Submitted by Senator Lindsey Graham
                        breast cancer screening
    Question. From 1990 to 2010, deaths from breast cancer decreased by 
34 percent. However, in 2013, 230,000 new cases of breast cancer were 
diagnosed in the United States and almost 40,000 women died from breast 
cancer.
    Recent news coverage has focused on studies that called into 
question the value of screening for breast cancers. Although the 
majority of scientific studies have corroborated the value of early 
detection of breast cancers through screening, these recent articles 
have created a less clear picture of the benefits of screening and may 
lead women to avoid periodic mammography, an experience some women 
already view as uncomfortable.
    Given these current controversies, do you think the NCI should 
undertake a new study to clarify the benefits of screening so that 
women and their doctors will have a better idea of how breast cancer 
screening should fit into a woman's overall preventative health 
program?
    Answer. We are aware of the growing concerns about the balance of 
benefits and harms associated with screening mammography. Some of these 
concerns have recently been outlined by the Swiss Medical Board in its 
recommendation to end the national Swiss breast cancer screening 
program (Reference: Biller-Andorno N and Juni P: N Engl J Med 
2014;3760:1965-1967). The concerns fall into two categories. First, the 
reduction in cancer mortality by early detection of breast cancer using 
mammography may decline as more effective adjuvant chemotherapy has 
been developed for treatment of early- and mid-stages of breast cancer. 
(Much of this unequivocal progress in treatment came from NCI-sponsored 
randomized trials of adjuvant therapy.) Nearly all of the randomized 
trials testing the efficacy of mammography were conducted decades ago, 
in the pre-adjuvant therapy era. A recently reported and widely 
publicized Canadian trial started early in the era of adjuvant therapy 
and showed no reduction in breast cancer mortality associated with 
mammography screening as opposed to screening by physical examination 
(Reference: Miller AB, et al.: BMJ 2014; doi: 10.1136/bmj.g366). 
Second, new evidence of harms associated with mammography has emerged 
in recent years, particularly one known as overdiagnosis--the detection 
of non-life threatening tumors that caused anxiety and were treated 
with measures that carry risks, such as surgery, radiation, and 
chemotherapy (Reviewed in: Pace LE and Keating NL: JAMA 2014;311:1327-
1335).
    The emerging evidence has led to calls for additional studies in 
the current modern era of breast cancer therapy that would clarify the 
balance of benefits and harms of breast cancer screening. The ideal or 
``gold standard'' test would be a large randomized trial comparing 
screening mammography to a control group that does not receive 
screening mammography, but such a study would not be feasible in the 
United States. National surveys show that a large proportion of 
American women continue to get routine screening mammography, with no 
change in usage after the U.S. Preventive Services Task Force issued 
its recommendations against routine screening for women ages 40-49 and 
for spacing mammography for women age 50-74 from annually to every 2 
years (Reference: Pace LE, et al.: Cancer 2013;119:2518-2523). Given 
current practice, a true control group for an optimally informative 
``gold standard'' trial appears to be impossible.
    Therefore, NCI is actively funding and planning other types of 
studies to learn more about the benefits and harms of breast cancer 
screening, and to try to maximize any benefits while limiting the 
harms. First, NCI is taking several approaches to improve on the 
benefits of mammography as currently practiced. NCI funds a multi-
institutional Breast Cancer Screening Consortium, a collaborative 
network of seven research registries designed to track outcomes of 
screening mammography in the community, including recall and biopsy 
rates, and tumor stages at diagnosis. A goal is to explore ways to 
achieve optimal and reproducible mammography reading in the community. 
A recently developed inter-divisional NCI request for applications 
(RFA) will focus on studying the process of screening and subsequent 
therapy, with a focus on overdiagnosis, which, as noted above, often 
leads to inappropriate and potentially harmful treatment. This project 
will compare tumor biology and clinical aggressiveness with the method 
of detection, including breast imaging, and with the criteria used for 
diagnosis. The research aims to identify ways to ensure timely follow-
up of abnormal findings and institution of effective therapy when 
necessary.
    Additionally, in an effort to minimize the harms of overdiagnosis, 
several other methods for screening are under investigation. The Early 
Detection Research Network (EDRN) is studying new methods to identify 
the molecular ``fingerprints'' of screen-detected tumors with little 
lethal potential, so that more patients can be followed without 
institution of unnecessary aggressive treatments. A funding opportunity 
announcement (FOA) for a consortium of multidisciplinary scientists 
specifically focused on identification of early screen-detected ``non-
progressor'' lesions that can be safely followed is under 
consideration, with breast cancer as one of the four primary areas of 
emphasis of the proposed consortium.
    A related research area involves the study of other imaging 
modalities to detect breast cancer. The balance of benefits and harms 
of breast MRI in the general population is not known, so it is not 
usually considered to be suited to general screening. However, some 
experts have recommended it as an adjunct screening tool for women at 
extremely high risk of breast cancer, such as women who have high-risk 
inherited mutations of their BRCA 1 or 2 genes, a history of ionizing 
radiation treatments to the chest (administered to treat other 
malignancies), or a family history of breast cancer. The screening 
recommendations for these women include both an annual mammogram and 
MRI for the BRCA mutation carriers and an optional MRI or ultrasound 
for the rest. (An update on breast cancer screening and prevention. 
Cruz MS, Sarfaty M and Wender RC; Primary Care: Clinics in Office 
Practice Vol. 41, Issue 2, June 2014, Pages 283-306.).
    FDA has approved digital breast tomosynthesis or 3-D mammography 
devices, which use low dose x-rays for breast cancer screening but 
experts do not agree on its clinical use. A few small studies have 
shown that adding digital breast tomosynthesis to standard mammography 
screening may result in a significant reduction in patients being 
recalled for additional testing compared to routine screening 
mammography alone, but more research is needed. NCI is considering 
potential studies to see if breast tomosynthesis can improve 
sensitivity and lower recall rates.

                          SUBCOMMITTEE RECESS

    Senator Harkin. Thank you very much.
    [Whereupon, at 11:55 a.m., Wednesday, April 2, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]



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

                              ----------                              


                        WEDNESDAY, APRIL 9, 2014

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:06 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Tom Harkin (chairman) presiding.
    Present: Senators Harkin, Merkley, Moran, Alexander, and 
Johanns.

                          DEPARTMENT OF LABOR

                        Office of the Secretary

STATEMENT OF HON. THOMAS E. PEREZ, SECRETARY

                OPENING STATEMENT OF SENATOR TOM HARKIN

    Senator Harkin. The Appropriations Subcommittee on Labor, 
Health and Human Services, Education, and Related Agencies will 
come to order.
    Today, we welcome to our subcommittee our Secretary of 
Labor, Secretary Tom Perez.
    Again, I want to thank you, Mr. Secretary, for joining me 
in Iowa this past weekend. We had an interesting visit with the 
Job Corps Center in Ottumwa, one of the newer Job Corps 
Centers. It is kind of unique in how it is combined with the 
community college. It is one of those new setups, and it is 
working out really well. So I appreciate you coming out and 
looking at that, Mr. Secretary.
    I also want to say your commitment to working Americans is 
reflected in the subject we will discuss today, and that is the 
President's budget for fiscal year 2015 for the Department of 
Labor (DOL).
    This budget proposes critical investments that will equip 
Americans with the skills they need for today's jobs, something 
I know that you have been a great leader on.
    It recommends also increased funding to ensure that working 
Americans are paid what they have earned and not denied 
benefits to which they are entitled.
    As the Secretary knows, there are some tough choices to be 
made in our nondefense discretionary spending cap. The fiscal 
year 2015 spending cap is roughly the same as for the current 
fiscal year. It is tough. It is not draconian, but it is tough.
    Again, I hope that we can continue on with that budget, 
rather than the budget set forth by the Budget Committee in the 
House, which would cut nondefense discretionary spending by $43 
billion, or 9 percent, in fiscal year 2016. That would make it 
very, very tough on this subcommittee to do its job, and for 
you, I think, to do your job, if we were to have that kind of a 
huge cut in 1 year.
    Now, I won't be in the Senate for the fiscal year 2016 
appropriations process, but I think we can and must do better 
than to just continue to disinvest in programs critical to 
working families.
    I might, just at the outset, say I think one of the good 
places to start would be to replace the sequester. I have 
advocated for a long time just get rid of the darn thing, get 
it over with, and move on.
    I am also pleased to see several proposals in the 
department's budget request that address important priorities 
for working families, increases for protecting the rights of 
workers to take family and medical leave, ensuring that workers 
are paid what they have earned, enhancing oversight of the 
subminimum-wage program for workers with disabilities. I will 
have a question about that.
    These are important investments that build on key 
accomplishments of this department and this subcommittee.
    For example, the department's Wage and Hour Division has 
returned over $1 billion. Think about that. The Wage and Hour 
Division has returned over $1 billion in wages to more than 1.2 
million workers who have earned it, but had not been paid. This 
includes over 100,000 workers who had not been paid the minimum 
wage for all of the hours that they had worked.
    The budget also continues to invest in key employment and 
training activities, including increased funding to build on 
the success of the Reemployment and Eligibility Assessments 
(REAs) program. Since 2005, this subcommittee has provided more 
than $400 million for this activity.
    Research shows that REAs can help connect unemployment 
insurance beneficiaries with jobs faster. The budget request 
would expand and enhance services to help prevent these workers 
from joining the ranks of the long-term unemployed. I look 
forward to hearing more about this. Again, this is something 
that has endured through both Republican and Democratic 
administrations.
    So again, Secretary Perez, I want to thank you for your 
dynamic leadership of the Department of Labor and for being 
here today to discuss how the budget impacts American workers 
and what we can do to assist them in helping strengthen the 
middle class in America.
    And with that, I will turn to Senator Moran for his opening 
statement.

                    STATEMENT OF SENATOR JERRY MORAN

    Senator Moran. Mr. Chairman, thank you.
    Mr. Secretary, it was a pleasure to meet you this morning 
and I look forward to developing a good working relationship 
with you and your department. And we would welcome you to visit 
Kansas so that I can have stories to tell like the chairman 
does. Thank you very much.
    We all know we have a struggling economy and unemployment 
remains way too high. And my concern is that the 
administration's budget is not prioritizing employment and 
training programs that put Americans back to work.
    The unemployment national rate is 6.7 percent, and the 
fiscal year 2015 budget request provides virtually level 
funding for Workforce Investment Act programs, which are the 
cornerstone of our Nation's employment training.
    There have been significant increases during this 
administration's time in office that fund regulatory aspects of 
the Department of Labor, such as OSHA (Occupational Safety and 
Health Administration) and mine safety, and the Wage and Hour 
Division.
    But in looking at those numbers, there is a stark contrast 
to employment and training programs, which have decreased by 10 
percent. And I just want to emphasize that, for getting 
Americans back to work, we will be looking toward employment 
and training programs to help accomplish that goal, and that 
too often it seems to me that the regulations are part of the 
problem in creating job opportunities for Americans.
    It seems to me that really since 2010, the primary function 
and responsibility of Congress and the President is to put 
together an effort to create an environment in which more jobs 
are created, which Americans feel more secure and safe in their 
jobs and have a sense that they have an opportunity for 
economic mobility. And we want to make certain that the focus 
is on training and job creation, to begin with, and then 
training people to meet those jobs and their qualifications.
    A couple things that have happened in the last few months 
that I would like to highlight, and we can visit about during 
the questions, is the President's executive order directing the 
Department of Labor to redefine and expand current overtime 
regulations. I am worried that this move could drastically 
increase Labor costs and uncertainty for employers as well as 
employees.
    And also, it seems to me you have taken some steps to 
address this issue, and I am interested in hearing about it, 
the regulatory action that OSHA took against a Nebraska farm 
that has a consequence that is based upon, perhaps, a 
redefinition of what a farm is, as exempted under those labor 
laws.
    Again, 5 years of high unemployment, it seems to me that we 
have to focus on finding ways to work with employers to create 
a safe environment without creating penalties and fines and 
uncertainty. And I look forward to hearing your thoughts about 
the role of those regulators in that regard.
    Again, I look forward to working with you as we try to find 
ways to make certain that Americans feel safe and secure, have 
greater job opportunities, and can advance to the benefit of 
themselves and their families.
    Thank you for your presence today.
    Senator Harkin. Thank you, Senator Moran.
    It is my honor to welcome Secretary Perez to his first 
appearance before this subcommittee.
    Secretary Perez became the 26th Secretary of Labor on July 
23, 2013. Secretary Perez has experience serving in all levels 
of government, both at the county level, in Montgomery County 
nearby, also at the State level as the Secretary of Maryland's 
Department of Labor, Licensing, and Regulation. He was a member 
of the Montgomery County Council. And then at the Federal 
level, Secretary Perez served as a career attorney at the 
Department of Justice, as well as the Deputy Assistant Attorney 
General for Civil Rights in the Clinton administration. And 
just before this appointment, he was Assistant Attorney General 
for Civil Rights, again, at the Department of Justice.
    And again, the most important part of Secretary Perez's 
entire career was when he worked for this committee--no, on the 
HELP (Health, Education, Labor, and Pensions) Committee, not 
this committee. I always get confused which committee I am 
chairing here. On the HELP Committee.
    So, Secretary Perez, thank you very much for your lifetime 
of devotion to public service and for your stewardship now at 
the Department of Labor. Your statement will be made a part of 
the record in its entirety, and please proceed as you so 
desire.

               SUMMARY STATEMENT OF HON. THOMAS E. PEREZ

    Secretary Perez. Thank you, Mr. Chairman. And thank you, 
Senator Moran. It has been an honor to meet you, and I look 
forward to sitting down with you.
    Senator Alexander, it is great to see you again.
    Senator Harkin, Mr. Chairman, thank you for the visit last 
weekend to Iowa. And much more importantly, thank you for your 
service.
    As I said to the kids at the Job Corps Center, they have a 
Senator who has done great service to Iowa, has done a great 
service to America, and has done great service to vulnerable 
people around the world. And we will miss you dearly.
    Your common decency is one thing that I will always take 
away from you, and my experience being mentored by you. So 
thank you for everything that you have done for so many people.
    We also have a retirement. This woman to my right, Teri 
Bergman, has been around. This is her last approps cycle before 
she enters retirement; she refuses to allow me to tell you how 
many years of service. So I will just say she has been here 
awhile as well, and I want to thank Teri for her service.
    Senator Harkin. She is smiling.
    Secretary Perez. She is smiling. I asked if she was happy 
or sad today, and she said probably happier than sad. But we 
have valued from her service. You all know that you are only as 
good as your staff, and we have a great staff at the Department 
of Labor. We are going to miss Teri.

                  FISCAL YEAR 2015 PRESIDENT'S BUDGET

    The budget that we present today, like any other, is more 
than a compilation of dollar figures; it is an expression of 
our values. The Labor Department's values include helping 
people acquire the skills they need to succeed in the jobs of 
today and tomorrow, helping employers to get those skilled 
workers so they can grow their business; ensuring 
nondiscrimination in the workplace; making sure hard work is 
rewarded with a fair wage; and enhancing our enforcement 
capacity to protect workers' wages, benefits, and safety on the 
job.
    Our budget calls for the funding necessary to make 
meaningful progress toward these goals, and I would like to 
take a few minutes to highlight some of the key items.
    We continue our investment in training and employment 
services to more than 20 million Americans at our 2,500-plus 
American job centers nationwide.
    At the height of the recession, these centers were the 
Nation's emergency room for jobseekers, administering the 
critical care necessary to restore economic health and get 
people back to work.
    The American Job Centers are resources for businesses as 
well. During the State of the Union, the President singled out 
Andra Rush, a small-business woman from Detroit. Her 
manufacturing firm is thriving because she found roughly 700 of 
her workers through the local American Jobs Center. We 
effectively served as her human resources department. I often 
like to think of the Department of Labor as playing a Match.com 
kind of role, helping workers and employers find the right fit. 
And in that case, we were able to find the right fit for over 
700 people who are now thriving and have punched their ticket 
to the middle class.

                REVIEW OF THE NATION'S TRAINING PROGRAMS

    During my 8 months on the job, I have spent a lot of time 
speaking to dozens of business leaders and CEOs (chief 
executive officers). And to a person, they are bullish about 
the future.
    They also tell me that in order to grow and expand, they 
need a steady pipeline of skilled workers. So we need to build 
on our success, and we need to fix what is in need of being 
fixed.
    And that is why the President has tasked Vice President 
Biden with conducting a review of our Nation's training 
programs. I was with the Vice President recently, in New 
Hampshire, as part of this initiative.
    This review will be guided by the principle of job driven 
workforce investment. The goals of this effort are, number one, 
expanding employer engagement and ensure that our system is 
truly demand driven. If you are going to create jobs, you have 
to talk to the job creators. No more train and pray. We are not 
going to train widget makers if no one is hiring widget makers. 
We learn who is hiring for what by making sure we expand and 
sustain our employer engagement.
    Number two, making it easier for people to acquire those 
in-demand skills necessary to punch their ticket to the middle 
class.
    Number three, spurring innovation at all levels of the 
workforce system.
    Number four, promoting what works in the workforce settings 
and fixing what isn't working.
    And number five, growing and transforming registered 
apprenticeship programs to meet the increasing and exciting 
needs.
    I have had the good fortune of working on these issues at 
the local, State, and Federal level. In my experience, these 
issues have never been partisan issues. They don't need to be 
partisan issues.
    Senator Moran, I listened to what you said very carefully, 
and I would love to have a conversation with you, not only 
today, but in the weeks and months ahead, about how we can work 
together in a bipartisan fashion on the critical issue of 
making sure people have the skills to succeed.
    Our Opportunity, Growth, and Security Fund addresses many 
of the training concerns that you have brought to our attention 
here today.

                    COMBATING LONG-TERM UNEMPLOYMENT

    One of the most vexing challenges we are confronting is the 
plight of the long-term unemployed. Frankly, having met so many 
long-term unemployed, it is probably the one issue on my plate 
that keeps me up at night more than anything, because they keep 
telling me how hard they are working, in terms of looking for 
work.
    I had a guy in Cleveland last week who said to me, ``I have 
got no quit in me.'' When someone says that to you, and looks 
you in the eye, you are not going to quit on them. I had 
another person in New Jersey who said, ``I fought and licked 
cancer. Fighting cancer was far easier than fighting long-term 
unemployment.''
    So, I applaud the efforts in the Senate and the passage of 
the bipartisan bill on Monday. I hope the House follows suit.
    Unemployment benefits like this, while very important, 
certainly, aren't the end of the story. We need to work 
together on ways to get people back on the job and back in the 
workforce.
    Toward that end, I am very excited about the $158 million 
request for an enhanced, integrated, and expanded Reemployment 
and Eligibility Assessment and Reemployment Services program, 
which will use an evidence-based approach to help long-term 
unemployed workers and returning veterans find work faster.
    We also request $15 million in grants to support sector 
strategies, helping the long-term unemployed, and other 
targeted populations, receive the training or other services 
they need for careers in these areas. These recommendations are 
built on a growing understanding of what works. You can be 
assured that the budget assumes that we are incorporating 
rigorous evaluations in everything we do.
    We are measuring what we are doing to make sure it works. 
If it doesn't work, we either fix it, or we don't do it 
anymore.
    I hope we can work together to invest in these and other 
programs that have a demonstrated record of effectiveness in 
helping people get back on their feet.

              OPPORTUNITY, GROWTH, AND SECURITY INITIATIVE

    Although it is not before the committee, the President's 
2015 budget also sets forth an Opportunity, Growth, and 
Security initiative that includes a robust investment in our 
community colleges, one-third of which would be used to promote 
greater use of apprenticeships, a proven workforce development 
strategy that is still undervalued in the United States.
    We really need to change the national mindset on 
apprenticeships. A 4-year college degree is the right choice 
for so many people, but it isn't the only way to punch your 
ticket to the middle class. So, we need to let young people and 
their parents know that there is a bright future in America for 
people who want to work with their hands. Training and skills 
development is just one piece, an important piece, of the Labor 
Department's work.

       PROTECTING EMPLOYEE WAGES, SAFETY, AND RETIREMENT SECURITY

    As I have said before, we play a critical role in making 
sure that Americans get paid the wages they are due, that they 
are safe on the job, and that their benefits are secure.
    Our budget includes an increase of almost $30 million for 
the Wage and Hour Division to cover the cost of hiring new 
investigators. These resources will be used to ensure that 
people who work get paid a fair wage, and that employers who 
play by the rules aren't undercut by those who don't. No worker 
should have to sacrifice their life for their livelihood.
    So the 2015 budget calls for substantial investments in the 
ability of OSHA and its State partners to keep workers safe.
    To safeguard the retirement of American workers, we also 
request $188 million to protect more than 141 million people 
covered by the benefits plans together, which hold over $7 
trillion in assets.
    Mr. Chairman, we have come a long way since the depths of 
the great recession. The private sector has now created roughly 
9 million jobs over the past 49 months of consecutive private 
sector job growth. The economy is moving in the right 
direction, but there is no doubt that we need to pick up the 
pace.

                           PREPARED STATEMENT

    We need to do more. We need to invest in more skills for 
workers so they can get back on their feet. And the Labor 
Department stands ready to play a critical role in creating and 
expanding that opportunity.
    And with that opening statement, I look forward to hearing 
your questions and responding. Thank you very much, and thank 
you for your leadership.
    [The statement follows:]
               Prepared Statement of Hon. Thomas E. Perez
    Chairman Harkin, Ranking Member Moran and members of the 
subcommittee, thank you for the invitation to testify today. I 
appreciate the opportunity to appear before you to discuss the fiscal 
year 2015 budget request for the Department of Labor.
    President Obama's 2015 budget builds on his vision of opportunity 
for all Americans of which he spoke in January in the State of the 
Union address. The President's budget sets forth concrete, practical 
investments and proposals to achieve his vision by growing the economy, 
strengthening the middle-class, and empowering all those hoping to join 
the ranks of the middle-class. It is an agenda of opportunity, action, 
and optimism. It is the agenda for our work at the Department of Labor 
over the next 3 years.
    The core principle is as American as they come--if you work hard 
and play by the rules, you should have the opportunity to succeed. In 
America, your ability to get ahead should be determined by hard work 
and personal responsibility--not by the circumstances of your birth.
    Making good on the promise of opportunity has always been central 
to the Labor Department's mission to help create jobs and build a 
stronger middle class, to invest in human capital to build a skills 
infrastructure that supports business growth, to give every American 
the chance to retire with dignity and a measure of economic security, 
to promote a fair wage and safe working conditions, to help our 
Nation's veterans find a place in the civilian economy, and to help 
historically marginalized populations, like immigrant communities and 
people with disabilities, move into the economic mainstream. But now, 
more than ever, as the President's agenda is our agenda, working to 
fulfill the promise of opportunity is fundamental to what we do, and 
the budget proposal would provide the investments necessary to enable 
us to help fulfill the promise.
    We have come a long way since the depths of the Great Recession. We 
have seen 48 consecutive months of private sector job growth, which has 
added 8.7 million jobs, and the unemployment rate has reached its 
lowest point in over 5 years. Moreover, our manufacturing sector is 
experiencing the largest and most consistent growth since the mid-
1990s. Over 600,000 manufacturing jobs have been added since February 
2010. We have cut our deficits by more than half to their lowest share 
of GDP since before President Obama took office.
    By those measures, we are well on our way to a full recovery. But 
the statistics do not tell the whole story as economic growth is still 
hamstrung by stubbornly high unemployment. They are cold comfort to the 
underemployed construction worker who continues to be laid off in 
between sporadic jobs. They do not encourage the factory worker whose 
application never gets a second look after the human resources 
department sees she has been unemployed for 6 months; or the waitress 
or bank teller who works full-time but must depend on public assistance 
to feed her family. They do not help the country's youth for whom so 
much depends on that critical first job. So while we have come a long 
way, much work remains.
    The President's budget outlines a comprehensive agenda to make 
America a magnet for middle class jobs and business investment. 
Equipping workers with the skills they need and for which employers are 
hiring is not just a workforce development issue, it is an economic 
development issue. No matter what your political party, we can all 
agree on one thing: good jobs and low unemployment are good for the 
country. As part of the effort to achieve this shared goal, the 
President is acting on a set of specific, concrete proposals that will 
make sure American workers have the skills they need for in-demand jobs 
of today and the jobs of tomorrow. These initiatives will allow 
industry to identify the skills and credentials required for jobs they 
are seeking to fill now and tomorrow; give workers and job seekers 
access to education and training that meets those needs; and provide 
employers with easy ways to find workers who have or can acquire those 
skills. Some of these proposals will require new legislation while 
others can be done within existing program authorities. I am eager to 
work with all who are willing to roll up their sleeves with me to enact 
these critical programs.
    The President's budget also supports the extension of emergency 
unemployment benefits for the long-term unemployed. If not extended, 
3.6 million additional people are estimated to lose access to extended 
UI benefits by the end of 2014, despite remaining unemployed and 
looking for work.
    As I will explain, the President's budget request creates 
opportunity for all Americans while continuing long term deficit 
reduction through:
  --Opportunity, Growth and Security Initiative.
  --Investing in a Competitive Workforce.
  --Protecting American Workers and their Income and Retirement 
        Security.
              opportunity, growth and security initiative
    While the 2015 budget will adhere to the spending levels agreed to 
in the Bipartisan Budget Act of 2013 and reflect the tradeoffs that are 
required to maintain those levels of spending, the budget also presents 
the President's vision for an economy that promotes opportunity for all 
Americans. As part of this vision, the budget sets forth a fully paid 
for Opportunity, Growth, and Security Initiative (OGSI), which will 
include additional policies to grow the economy and create jobs without 
adding a dime to the deficit. The OGSI would increase the fiscal year 
2015 discretionary caps to make room for priority defense and 
nondefense investments, paying for $56 billion in funding with a 
balanced package of spending reforms and closed tax loopholes. It will 
increase employment, while achieving important economic outcomes in 
education, research, manufacturing and public health and safety. 
Although not included in our budget totals before the Committee, the 
OGSI envisions a significant role for the Department. At DOL, the OGSI 
includes:
  --Community College Job-Driven Training Fund.--The OGSI includes $1.5 
        billion per year to support a 4-year investment in a Community 
        College Job-Driven Training Fund that will offer competitive 
        grants to partnerships of community colleges and other entities 
        to reform curricula and launch new training programs. Of this 
        amount, $500 million per year will go toward a dedicated 
        apprenticeship training fund to provide grants to States and 
        regional consortia to work with employers to create new 
        apprenticeships and increase participation in existing 
        apprenticeship programs. Apprenticeship is a strategy that we 
        know works to provide good jobs and paths to the middle class. 
        This 4-year investment will support doubling the number of high 
        quality, registered apprenticeships in America over the next 5 
        years.
  --Supporting and Improving Training and Employment Services.--The 
        Initiative would provide $750 million to fully restore prior 
        cuts in job training and employment services, invest more 
        intensively in innovation, and target resources to populations 
        that face significant barriers to employment.
  --State Paid Leave.--The OGSI also proposes an additional $100 
        million for the State Paid Leave Fund to support States that 
        wish to establish paid leave programs. Currently, only 
        California, New Jersey, and Rhode Island offer such programs, 
        which they call family leave insurance. More States should have 
        the chance to follow this example.
                  investing in a competitive workforce
    To continue the economic recovery, the 2015 budget proposes a set 
of initiatives that would reduce long-term unemployment and hasten 
reemployment including the New Career Pathways program (formerly the 
Universal Displaced Workers initiative), reemployment services and 
eligibility assessments and services, and the three-pronged Job-Driven 
Training legislative proposal comprising the following programs: Bridge 
to Work; Back to Work Partnerships; and Summer Jobs Plus.
  --New Career Pathways.--The 2015 budget proposes mandatory funding 
        for a New Career Pathways (NCP) program that will provide 
        workers with a set of core services by combining the best 
        features of both the Trade Adjustment Assistance for Workers 
        (TAA) and Workforce Investment Act (WIA) Dislocated Worker (DW) 
        programs. Upon enactment, NCP will streamline administrative 
        steps and integrate proven practices, service delivery 
        platforms, and infrastructure of the TAA and WIA DW programs to 
        offer a universal suite of training and reemployment services 
        to a broader number of displaced workers.
    To invest in the Nation's youth and the long-term unemployed, the 
2015 budget also includes a package of mandatory funding for job-driven 
training proposals. These proposals would be designed with employer 
needs in mind, putting an end to what I call the ``train and pray'' era 
of training workers for jobs with limited demand or with credentials 
employers do not value. This $8.5 billion package of proposals 
includes:
  --Bridge to Work.--The $2 billion Bridge to Work program is designed 
        to provide States with flexible funding to implement Bridge to 
        Work and other innovative reemployment initiatives targeted to 
        the long-term unemployed and to design, develop, and implement 
        their own path-breaking strategies to encourage reemployment.
  --Back to Work Partnerships.--The Back to Work Partnerships will 
        support partnerships between education and training 
        institutions and businesses to get the long-term unemployed 
        back to work. Funded with $4 billion over 2 years, the program 
        would provide competitive grants that support promising and 
        innovative local work-based job and training strategies to 
        place low-income adults and youth in jobs quickly. Such 
        strategies include on-the-job training; sector-based training; 
        training in collaboration with an industry sector partnership; 
        connections to immediate work opportunities; career academies; 
        and/or adult basic education and integrated basic education and 
        training models.
  --Summer Jobs Plus.--This is a $2.5 billion one-time investment to 
        support opportunities for hundreds of thousands of low-income 
        youth. The first component is a $1.5 billion formula grant 
        program that will provide funds to States, available up to 2 
        years, to support summer and year-round jobs for 600,000 youth. 
        The second component is a $1.0 billion innovation fund to 
        provide competitive grants to support promising and innovative 
        employment and training strategies designed to improve outcomes 
        for low-income youth.
    I am working closely with the Vice President to continue other 
evidence-based efforts to replicate approaches that have been proven to 
work, move funds from those that have not, and continue to encourage 
and evaluate innovative and promising strategies. As that process 
unfolds, there are steps that we can take right away. The budget 
proposes to maintain a strong foundation with funding for existing 
programs, while taking steps to foster innovation and improvement. The 
budget includes:
  --Training and Employment Services.--The 2015 budget includes more 
        than $3 billion in formula and other grants to States and 
        localities to provide training and employment services to more 
        than 20 million Americans at over 2,500 American Job Centers 
        across the country. The budget maintains the State-wide reserve 
        at 8.75 percent, as enacted in fiscal year 2014.
  --Workforce Innovation Fund.--The 2015 budget proposes $60 million to 
        support innovative State and regional approaches to the design 
        and delivery of employment and training services that generate 
        long-term improvements in the performance of the public 
        workforce system, both in terms of employment outcomes and 
        cost-effectiveness.
  --Incentive Grants.--The 2015 budget requests $80 million for 
        revamped Incentive Grants for States and tribal governments. 
        These funds will be used to reward States and tribal 
        governments that demonstrate the greatest success in their WIA 
        programs serving subpopulations facing significant barriers to 
        employment, such as the long-term unemployed, disconnected 
        youth, individuals with disabilities, and veterans. A limited 
        number of grants would be awarded based on the extent to which 
        eligible entities improve their performance relating to 
        employment outcomes. Combined with the Workforce Innovation 
        Fund, the grants would invest an amount equal to 5 percent of 
        WIA formula grants to drive innovation and better performance 
        at the State and local level.
  --Reemployment and Eligibility Assessments/Reemployment Services 
        (REA/RES).--For those who have lost their jobs, the budget 
        request would reconnect unemployed workers to jobs more quickly 
        through an investment of $158 million in discretionary funds 
        for reemployment and eligibility assessments and reemployment 
        services (REA/RES), an evidence-based approach to speed the 
        return to work of UI beneficiaries. Research has shown that 
        when reemployment eligibility assessments are delivered 
        seamlessly with reemployment services, they are significantly 
        more effective, with claimants less likely to exhaust their UI 
        benefits, shorter UI durations and lower benefits paid, and 
        faster returns to work with higher wages and job retention. 
        Savings attributable to the program were almost three times 
        higher than the cost. Included in this proposal is dedicated 
        funding to ensure that all recently separated military 
        personnel receiving Unemployment Compensation for Ex-
        Servicemembers (UCX) get these services to help them 
        successfully transition to the civilian workforce. The request 
        is also sufficient to provide services to the top quarter of UI 
        beneficiaries most likely to exhaust benefits.
  --Sector Strategy.--The Department requests $15 million for grants to 
        States, consortia of States, or regional partnerships to 
        develop employment and training strategies targeted to 
        particular in-demand industry sectors in regional economies. 
        These grants will help ensure that the long-term unemployed and 
        other targeted populations receive the training they need for 
        careers for in-demand industry sectors.
  --Job Corps.--The 2015 budget proposes $1.7 billion for the Job Corps 
        program to prepare disadvantaged young people for jobs in high-
        demand occupations with good wage potential and to further 
        their education and training as well as their responsibilities 
        of citizenship and adulthood. The 2015 budget includes $13.8 
        million to open and fully enroll students in two new Job Corps 
        centers in New Hampshire and Wyoming, the last two States 
        without centers, and continues the Administration's commitment 
        to improving and reforming the Job Corps program. These reforms 
        include closing a small number of underperforming Job Corps 
        centers; focusing the program on the older youth for whom it 
        has been demonstrated to be effective; improving procurement 
        and financial oversight; modernizing operations with a revised 
        Policy and Requirements Handbook; and ongoing cost-savings 
        reforms.
 protecting america's workers and their income and retirement security
    Worker protection programs are crucial to protecting the health, 
safety, wages and working conditions of America's workers. The American 
people rely on the Department to fulfill our responsibility to make 
these protections not just words in the statute books, but real 
safeguards against threats to their lives and livelihoods. The budget 
includes nearly $1.9 billion for the Department's worker protection 
agencies. Some highlights of our worker protection request include:
  --Wage and Hour.--The 2015 budget proposes an increase of almost $30 
        million for the Wage and Hour Division (WHD) to hire 300 new 
        investigators to target the industries and employers most 
        likely to break laws that ensure workers receive a fair day's 
        pay for a fair day's work, including the minimum wage and 
        overtime pay, as well as the right to take leave to care for 
        their own or their families' medical needs. Included in this 
        increase are funds transferred from the Women's Bureau to 
        enhance enforcement of the Fair Labor Standards Act and the 
        Family and Medical Leave Act, two laws of critical importance 
        to women. An additional $0.8 million will be used to strengthen 
        the agency's training and professional development program, 
        ensuring that all new and existing investigators have the 
        information and skills they need to be effective. The budget 
        also provides $5.8 million for WHD to develop a new integrated 
        enforcement and case management system that will allow 
        investigators to better employ data analysis in identifying 
        violations, targeting investigations and compliance assistance 
        efforts, and evaluating the impact and quality of enforcement.
  --State Paid Leave Fund.--Too many American workers must make the 
        painful choice between the care of their families and a 
        paycheck they desperately need. While the Family and Medical 
        Leave Act allows many workers to take job-protected unpaid time 
        off, millions of families cannot afford this. A handful of 
        States have enacted policies to offer paid leave, but more 
        States should have the chance to follow their example. The 
        budget includes a $5 million State Paid Leave Fund to provide 
        technical assistance and support to States that are considering 
        paid leave programs. In addition, as discussed above, the 
        Administration's Opportunity, Growth, and Security Initiative 
        includes $100 million in additional funds for this Fund.
  --Employee Misclassification.--The 2015 budget provides nearly $14 
        million to help identify and combat the misclassification of 
        workers as independent contractors, which deprives workers of 
        the benefits and protections to which they are legally 
        entitled, such as minimum wage, overtime pay, unemployment 
        insurance, and antidiscrimination protections. This includes 
        $10 million in continued grants to States to recover unpaid 
        unemployment taxes and $3.8 million of the WHD increase for 
        personnel to investigate violations.
  --Occupational Safety and Health Administration.--No worker should 
        have his or her life on the line for a paycheck. Workers need 
        the Occupational Safety and Health Administration (OSHA) to 
        enforce their right to a safe and healthful workplace. The vast 
        majority of employers want to keep their workers safe and they 
        need OSHA to have the resources necessary to help them find the 
        best way to do so. The 2015 budget provides $565 million for 
        OSHA to inspect hazardous workplaces and foster employer 
        compliance with safety and health regulations. The request 
        includes an increase for State grants to ensure that State Plan 
        States can do the same. In addition, the request includes an 
        additional $4 million to strengthen OSHA's enforcement of the 
        22 whistleblower laws that protect workers against retaliation 
        for reporting unsafe and unscrupulous practices and to 
        centralize the agency's audit function and improve the 
        information technology used by investigators to collect case 
        data.
  --Mine Safety and Health Administration.--The 2015 budget requests 
        $377 million for the Mine Safety and Health Administration 
        (MSHA), to build on the remarkable progress MSHA has made to 
        bring the incidence of fatal injuries in the mining industry to 
        an all-time low in fiscal year 2013. The request includes 
        funding increases to improve the timeliness of special 
        assessments, support rulemaking activities, improve systems and 
        data analytics that support enforcement functions, and reform 
        Federal training delivery to help protect workers in one of our 
        Nation's most dangerous industries.
  --Federal Contract Compliance.--The 2015 budget proposes an 
        additional $1.1 million to strengthen efforts by the Office of 
        Federal Contract Compliance Programs (OFCCP) to combat pay 
        discrimination. OFCCP works to eliminate employment 
        discrimination on the basis of race, religion, color, national 
        origin, and sex, to eliminate employment discrimination for our 
        Nation's veterans and workers with disabilities, and to secure 
        equal employment opportunity for workers.
  --Defined Benefit Pension System.--The budget proposes to give the 
        Board of the Pension Benefit Guaranty Corporation (PBGC) the 
        authority to adjust premiums to take into account the risks 
        that different sponsors pose to their retirees and to PBGC. The 
        Board would be able to adjust premiums in both the single 
        employer and multiemployer programs. These premium increases 
        are crucial to improving solvency but will not be sufficient to 
        address the complex challenges facing these plans, and the 
        Administration looks forward to working with Congress on a more 
        comprehensive solution.
  --Employee Benefits Security Administration.--To protect the health 
        and retirement benefits of America's workers, the Department is 
        requesting $188 million for the Employee Benefits Security 
        Administration (EBSA). These funds will protect more than 141 
        million people covered by an estimated 684,000 private 
        retirement plans, 2.4 million health plans and a similar number 
        of other employee welfare plans, which all together hold $7.8 
        trillion in assets.
    In addition, the budget request includes legislative proposals to 
modernize two worker benefit programs to improve the operation of both 
programs.
  --Federal Employees' Compensation Act (FECA).--The fiscal year 2015 
        request for the Department of Labor proposes once again to act 
        on longstanding recommendations from the Government 
        Accountability Office, Congressional Budget Office, and DOL's 
        Inspector General to improve the Federal Employees' 
        Compensation Act (FECA), which has not been substantially 
        updated since 1974. These reforms will help workers return to 
        the dignity of work and will generate government-wide savings 
        of more than $340 million over 10 years.
  --Unemployment Insurance (UI) Reform.--The combination of chronically 
        underfunded reserves and the economic downturn has placed a 
        considerable financial strain on States' UI operations. It is 
        important to enhance the UI system's solvency and financial 
        integrity while maintaining benefits for job seekers. The 
        budget proposes to provide immediate relief to employers to 
        encourage job creation now, improve State fiscal responsibility 
        going forward, and work closely with States to eliminate 
        improper payments.
                         additional priorities
    The Department's budget request also includes other programmatic 
increases outside the training and employment services and worker 
protection areas that support the well-being of American workers.
  --Bureau of Labor Statistics (BLS).--BLS is the principal Federal 
        statistical agency responsible for measuring labor market 
        activity, working conditions, and price changes in the economy. 
        Its mission is to collect, analyze, and disseminate essential 
        economic information to support public and private 
        decisionmaking. These policies and decisions affect virtually 
        all Americans. The budget request of $610 million includes an 
        increase of $1.6 million to add one annual supplement to the 
        Current Population Survey that would collect information 
        relevant to labor force trends, including data on contingent 
        work and alternative work arrangements, and workplace 
        flexibility and work-family balance. The budget also includes 
        an increase of $2.5 million for the Consumer Expenditure (CE) 
        Survey to support the Census Bureau in its development of a 
        supplemental statistical poverty measure using CE data.
  --Information Technology Modernization.--The goal of the Department's 
        IT Modernization effort is to provide the foundation for the 
        technology needed to transform the way the Department provides 
        services to, and interacts with, the American public. It 
        continues the integration of the Department's many 
        infrastructures and consolidation of data centers to provide a 
        more robust, reliable, cost-effective, and energy-efficient 
        computing environment. Additional resources are being requested 
        for a new Digital Government Integrated Platform, which will be 
        used to provide a foundation of mobile computing and open data 
        services that can be leveraged by agencies to enhance and 
        deploy mission-specific applications and capabilities. These 
        services will contribute to improved customer service and 
        collaboration opportunities and maximize the return on 
        investment in technology to support agency business operations.
  --Evidence and Evaluation.--The Department continues its evidence-
        based approach incorporating rigorous evaluation in all 
        agencies and in every discretionary grant program, ensuring the 
        best and most secure technology is used to make administrative 
        data available for program management and evaluation. The 2015 
        budget proposes to continue the provision for a setting aside 
        funding for Departmental evaluations, preserves dedicated 
        funding for Labor's Chief Evaluation Office, and also includes 
        an additional $2.4 million and 5 FTE to create a department-
        wide data analytics unit, to create the capacity for the 
        Department to use its administrative data to assess 
        performance, analyze trends, and better target it work.
  --Legal Services.--The 2015 budget proposes an increase of $6.6 
        million to support initiatives proposed for the Wage and Hour 
        Division, OSHA's Whistleblower Protection Program, EBSA's 
        Health Benefits Security project, and to enable SOL to continue 
        to provide a full range of legal services to OWCP's Division of 
        Coal Mine Workers' Compensation.
  --Adjudication.--The 2015 budget proposes an increase of $2.0 million 
        for the Office of Administrative Law Judges to support 
        productivity increases and alleviate the growing backlog of 
        cases before the judges; an increase of $1.3 million from the 
        Black Lung Disability Trust Fund to fully fund adjudication of 
        claims under the Black Lung Benefits Act; and $0.2 million for 
        the annual maintenance and support funding of the DOL Appeals 
        Management initiative for the Adjudicatory Boards.
                               conclusion
    In fiscal year 2015 the Department of Labor will strive to advance 
our mission of serving American workers and employers and to build the 
foundation for our next 100 years. Our request helps create 
opportunities for working Americans by investing in skills and our 
enforcement infrastructure. The budget will help ensure that the 
Department has the resources to lead the job-driven workforce system to 
hone the job skills of American workers; bolster efforts that address 
long-term unemployment; maintain safe and healthy workplaces; 
strengthen worker voice in the workplace; safeguard critical minimum 
wage and overtime protections for workers; and ensure secure 
retirements. The Department's budget request is really a request to 
invest in the opportunity and potential of the American people.
    That's why I am so eager to tackle these challenges every single 
day. As it's been for all 101 years of our existence, I believe the 
work of the Labor Department is the work of America.
    Mr. Chairman, thank you for inviting me today. I look forward to 
working with you during the coming year and I am happy to respond to 
any questions that you may have.

    Senator Harkin. Thank you, Mr. Secretary.
    We will begin with a round of 5-minute questions.

    IMPROVING EMPLOYMENT OPPORTUNITIES FOR PEOPLE WITH DISABILITIES

    Mr. Secretary, I would just like to lead off with something 
I am sure you know has been an intense interest of mine for all 
my adult life, and that is the employment of people with 
disabilities.
    We worked together in fiscal year 2010 here to initiate the 
Disability Employment Initiative. This effort is helping to 
improve the physical and programmatic accessibility of our 
Nation's workforce system for individuals with disabilities.
    More than $80 million has been awarded to 26 States under 
this effort, from this committee. Last year, the Department of 
Education awarded grants for 11 States to undertake the PROMISE 
(Promoting the Readiness of Minors in Supplemental Security 
Income) Initiative, a more than $200 million effort.
    Your department has collaborated on this important 
initiative designed to improve education and employment 
outcomes for 14- to 16-year-olds with disabilities and their 
families.
    Now, again, we are working very hard. Senator Alexander and 
I and others have been working for a long time on the Workforce 
Investment Act bill to get it reauthorized. We are still 
working on it. Our staffs will be working on it while we are 
gone for the next 2 weeks. We hope to have something together 
shortly on this.
    Part of that will be focused on this issue of making sure 
that young people with disabilities get access to, or 
encouragement for, support for, integrated what we call 
competitive employment.
    I would just like to get your thoughts on the Department of 
Labor and how can we be more helpful to realize employment 
outcomes for people with disabilities, and ensuring that they 
just aren't all in 214(c) or 14(c) subminimum wage programs.
    I would just like to hear your thoughts on what the 
Department of Labor is looking ahead to do.
    Secretary Perez. Sure. Well, first of all, thank you for 
your leadership on this issue, Senator. You take a backseat to 
no one on this. When I think of the ADA (Americans with 
Disabilities Act), I think of Tom Harkin.
    I remember the 10-year anniversary when I was working in 
the Clinton administration. It was at the FDR Memorial, and you 
did your entire speech, you signed it, and I will never forget 
that.
    I will never forget the 20th anniversary where I got to 
celebrate it when I was in my old job with Governor Thornburgh, 
because he has become a good friend and he was a champion 
because this issue has always been bipartisan. And I want to 
commend President George Herbert Walker Bush for his 
leadership.
    And that tradition continues.
    Senator Harkin. Just to interrupt you, I want to say, last 
Friday, I was at the George H.W. Bush Library in College 
Station, Texas, for the 25th anniversary of the Bush 
presidency. You might say, what were you doing there?
    Secretary Perez. I know exactly what you were doing there.
    Senator Harkin. I was invited down by Fred McClure, who 
runs that, and Boyden Gray, and others. The first panel they 
had on Friday was on the ADA, so we had Lex Frieden, John 
Wodatch, Boyden Gray, and myself on the panel, talking about 
it. The President was there. And Barbara, the First Lady, was 
there. A huge crowd.
    And it was just wonderful to see the old crowd together 
again. The Dick Thornburghs and Lou Sullivans and the people 
who worked so much on getting the ADA passed. It was just an 
uplifting day last Friday. I just wanted to throw that in.
    Secretary Perez. We have come such a long way, not only 
eliminating physical barriers, but attitudinal barriers, and it 
is a result of the bipartisan leadership.
    However the area where I think we have a long way to go is 
in the area of employment of people with disabilities.
    Just yesterday, the Department of Justice, my old office, 
we had been working together with them on this, announced a 
statewide settlement with the State of Rhode Island. I want to 
commend Governor Chafee, because he was a big proponent of the 
settlement, which addresses the exact issue that you are 
talking about: People with disabilities, who can do so much 
more, were basically segregated into the sheltered workshops.
    What I have said repeatedly, and you said it last weekend 
when we were together, people with disabilities don't want 
pity; they want opportunity. The settlement yesterday that we 
reached, which has gotten a lot of good coverage, is based on 
the notion that if you can do the work, you should be allowed 
that opportunity to do so. And we have given people a 
significant raise, because they are no longer in the subminimum 
wage.

 WORKING WITH THE BUSINESS COMMUNITY TO EMPLOY PEOPLE WITH DISABILITIES

    Other things that we are doing, in addition to cases like 
that, is the 503 reg. I am very proud of the work we have done 
there. I am very appreciative of the leadership in our OFCCP 
(Office of Federal Contract Compliance Programs) office.
    Frankly, we have been doing a lot of outreach to the 
business community on this. Governor Ridge wrote an op-ed 
talking about how the process in the 503 reg is a model of how 
regulations should be produced.
    We are continuing to work there, and I want to commend 
Walgreens, because I have visited their place in Connecticut. 
This is their distribution center, Senator, that distributes 
all the Walgreens products from Maine down to Baltimore, and I 
think 45 percent of their employees are people with 
disabilities. It is the most productive facility that they 
have. Everyone is making a minimum of, I think, $14 an hour 
plus benefits.
    It was a remarkable experience, and I again commend the CEO 
of Walgreens, who has made an unflagging commitment to the 
empowerment of people with disabilities.
    Senator Harkin. Greg Wasson. He is wonderful, the CEO of 
Walgreens.
    My time is running out, but looking ahead, the business 
community has really stepped forward on this. I am having the 
CEO of Procter & Gamble in tomorrow at our hearing. A lot of 
them have visited that facility up there in Connecticut. I have 
been there myself.
    And so the business community is really moving ahead. I 
just would like to say, again, I hope you and the department 
will join together with the business community in making sure 
that they have people with disabilities that they can hire when 
they get out of school.
    There is a role for the Department of Labor to play in 
that, and I hope that we can join forces with these great 
leaders in the business community.
    Secretary Perez. And I will be meeting with many of them at 
the end of the month, because we are continuing that outreach.
    And Greg, I refer everybody to him, because if he can do 
it, you can do it. That is our mantra.
    Senator Harkin. Exactly. Thank you.
    Senator Moran.
    Senator Moran. Mr. Secretary, thank you again. I want to 
refer first to the farming activities and OSHA regulations, and 
then I want to talk to you about the fiduciary rule and ERISA 
(Employee Retirement Income Security Act).

   APPLICATION OF THE OCCUPATIONAL SAFETY AND HEALTH ACT TO FARMING 
                 OPERATIONS WITH LESS THAN 10 EMPLOYEES

    From 1976 forward, Congress has included specific 
appropriations language prohibiting OSHA from using taxpayer 
funds to apply requirements under the Occupational Safety and 
Health Act to farming operations with less than 10 employees in 
our Labor-HHS bill.
    In 2011, the director of OSHA's enforcement program issued 
a memorandum indicating that rider did not preclude OSHA from 
conducting enforcement activities, regardless of the type of 
operation performed on the farm.
    You have heard from 43 Senators in an effort led by the 
Senator from Nebraska, Senator Johanns, regarding this policy, 
expressing some concerns.
    And my question really is, and my understanding is: You 
have taken a step back, indicated that you do not want to 
change the intent of that rider, that the department is not 
intending to expand or to violate the intent of that rider 
since 1976. And I just would like for you to bring me up-to-
date on where this issue is within the department and in OSHA.
    Secretary Perez. Sure. Yes, sir.
    We have removed the memo, that is the 2011 memo, which was 
the source of confusion. We take these riders very, very 
seriously. We have instructed the team at OSHA that when you 
are in a circumstance where you discover that it is a family 
farm under 10 employees, that is the end of statement, and case 
closed.
    Senator Moran. I appreciate that answer.

REWRITING THE RULE DEFINING FIDUCIARY UNDER EMPLOYEE RETIREMENT INCOME 
                              SECURITY ACT

    Let me then turn to the fiduciary rule. This goes back to a 
proposed rule in 2010. The Department of Labor proposed 
regulations regarding the definition of a fiduciary, which is 
regulated under ERISA.
    According to the department, the intent of the proposed 
rule was to define more broadly the circumstances under which a 
person or entity is considered a fiduciary when giving 
investment advice to an employee benefit plan or the plan's 
participants.
    There was significant bipartisan opposition concerns raised 
with expanding the definition of fiduciary. And again, a rider 
was included in the Labor-H appropriation bill. That rider 
prohibited the department from moving forward with its proposed 
rule.
    And my questions here are, because of that rider--I assume 
you would say the same thing; you take those riders seriously; 
you can't go forward with that rule--but does the department 
intend to propose a rewrite of the rule?
    Secretary Perez. The original proposed rule was withdrawn, 
and the process has been slowed down at my direction 
significantly, because we wanted to take a step back, listen, 
and learn from everyone.
    The issue that we are trying to address, Senator, is the 
following: The most important two financial decisions that 
people make in their lives are the decision to buy a home, and 
now with the transformation from defined benefit plans to 
401(k) and others, the decision of how to invest your 
retirement nest egg.
    In both contexts, we want to make sure that people make 
informed decisions and that the person giving you that advice 
is working in your best interest. And so that is the needle 
that we are trying to thread. That is the goal that we are 
trying to achieve.
    The reason that we slowed this process down is that I want 
to make sure that we hear from everybody. We have been engaged 
in a significant amount of outreach, and I have met with a 
number of Senators on both sides of the aisle, and a number of 
Members of Congress on both sides of the aisle. We are going to 
continue to do that, because I am learning a lot.
    As I mentioned before, when Senator Ridge wrote about the 
work that we did, and the process that we undertook in the 
section 503 reg, that is the process that we want to undertake 
in everything we do. I am a big believer that you get the best 
results when you build a big table and make sure that 
everyone's voice is heard.
    Senator Moran. I appreciate that.
    How would you describe the status of that process now? You 
are taking input. Is there a draft of a rule in the works?
    Secretary Perez. We continue to take input, and again, I 
have had a number of meetings with folks in Congress, et 
cetera, and we are looking carefully at the best way to address 
this issue.
    One thing I would say to you, or ask of you, really, is, if 
you have a constituent that contacts you and says, ``I have 
been trying to talk to DOL, and I have been having trouble,'' I 
hope you will let me know, because I want to make sure that we 
hear every voice.
    Senator Moran. Let me ask this, I think for a second time, 
but maybe I wasn't clear the first time: Is there a rule that 
is being written now, or are you only in the stage of 
soliciting information about the possibility of a rule? Do you 
plan on writing a rule?
    Secretary Perez. Well, we are taking in all the information 
right now, because I want to hear from people in terms of what 
their perspectives are, what their thoughts are. The rider 
language allowed for a re-proposal, as I read it.
    This is different from the farm rule, which I interpret as 
pretty clear in terms of what you can and can't do. I think 
this is equally clear.
    That is what we are doing right now, trying to listen and 
learn.
    Senator Moran. No rule is being written at the moment?
    Secretary Perez. Well, again, we are taking in information 
right now, so that we can figure out what the best course of 
action is, and that is exactly where we are in the process.
    Again, we are also consulting with the SEC (Securities and 
Exchange Commission), because one of the sets of feedback I 
heard, Senator, was that the SEC has equities in this. I agree. 
The SEC has equities, and as recently as a week ago, I had a 
conversation with Chair Mary Jo White, and we continue to talk 
on a regular basis.
    We will continue to do that. I have read all the letters of 
concern. I have had numerous meetings on this. I probably have 
spent as much time on this as just about any issue, because I 
appreciate the stakes.
    Whenever you do a rulemaking, you have to be concerned with 
what I call the doctrine of unintended consequences. You are 
trying to solve a problem. In the course of solving a problem, 
you don't want to create new problems.
    Senator Moran. I almost appreciate your entire answer, and 
particularly appreciate the part about unintended consequences.
    I think we use that excuse way too often in Congress, in 
the administration. ``Well, that is an unintended 
consequence.'' ``Well, our job is to determine what the 
consequences----''
    Secretary Perez. Anticipate them.
    Senator Moran. Correct.
    Secretary Perez. Absolutely. I couldn't agree more.
    Senator Moran. So I appreciate your answer. I know that 
working with the SEC is important. They had some criticism of 
the proposed rule in the first place.
    Mr. Chairman, thank you very much.
    Secretary Perez. Thank you, Senator.
    Senator Harkin. Thank you, Senator.
    I will go to Senator Alexander, and then I will go to 
Senator Merkley, and then Senator Johanns.
    Senator Alexander. Welcome, Mr. Secretary.
    Secretary Perez. Good morning. Good to see you again, 
Senator.
    Senator Alexander. Good to see you again.
    I want to use my 5 minutes to talk just a little bit more 
about the fiduciary rule and some about what is going on with 
the overtime letter from the President.
    Secretary Perez. Sure.
    Senator Alexander. On the fiduciary rule, this seems to me 
to be the case, you talked about you have a background in 
States. And my experience is, with all respect, that States 
have a way of being more pragmatic. Sometimes up here, we are 
more ideological in Washington. And your experience in the 
State might be well-served as you try to deal with this 
fiduciary rule.
    Without relitigating an old issue, one of the unintended 
consequences we may have learned from the Affordable Care Act 
is that even though it sounds like a good idea to require 
people to buy more benefits with a health insurance policy, 
they end up costing more and get outside their budget.

         STRATEGIES FOR REWRITING THE DEFINITION OF A FIDUCIARY

    And in thinking about the fiduciary rule and the way you 
work on this, I think about the difference between the 
Government as an enabler and the Government as a mandater.
    I mean, we have maybe 75 million households who get 
investment advice from somebody. And what we are really talking 
about is the difference between the conversation they might 
have with an investment adviser and the conversation they might 
have with a fiduciary, someone who has a duty--a legal duty--to 
them to give them a certain amount of responsibility.
    Now all these people can have a fiduciary responsibility, 
if they want to pay for it. I mean, it is available, if they 
want to pay for it. But many don't want that much advice. Or 
they don't need that kind of fiduciary advice, and they can't 
afford that kind.
    So it would seem to me that one of the strategies for 
dealing with this might be to let people know that a higher 
level of advice is available to them, if they want it and if 
they want to pay for it, but not to suddenly turn just your 
everyday investment advice conversation into one that is 
fraught with all the legal responsibilities of the fiduciary 
duty, which is available to anybody who wants to pay for it, 
and who can afford to pay for.
    Is that a promising strategy?
    Secretary Perez. Senator, I very much agree with what you 
said at the outset, when you said that working at the State 
level sometimes is a useful set of experiences. What was useful 
about my experience as the Labor Secretary in Maryland is I was 
the Governor's point person on the foreclosure crisis.
    Working together with all the stakeholders, we enacted a 
series of forward-leaning reforms, all of which had virtually 
unanimous support in the State Senate and the State House and 
the support of the industry. The way we got there was: We built 
a big table.
    Points like the point you are making, I spent a lot of time 
with mortgage brokers, because there were a lot of concerns 
raised about whether brokers were providing information to 
potential lenders that was in that lenders' self-interest, or 
if they were trying to, frankly, line the brokers' pockets.
    We had a lot of open and frank conversations about this. We 
were able to thread the needle in a way that had the support of 
the brokers at the end, the support of the lenders, the support 
of the consumer groups.
    That is the process that we are undertaking here, listening 
to your points----
    Senator Alexander. I have about 30 seconds to ask----
    Secretary Perez. No, no. So your point is very well-taken, 
and those are examples of the types of things that we need to 
consider moving forward.
    Senator Alexander. I would encourage that. We have some big 
ideological differences on this committee, but we also get a 
lot done, sometimes unanimously, because we go through that 
process.
    Secretary Perez. I agree.

                    UPDATING REGULATIONS ON OVERTIME

    Senator Alexander. Now, what is going on here with the 
overtime? Normally, under the law, if you are going to change 
overtime regulations, which affect a maximum of 130 million--
you know, everybody, working Americans.
    The law says you are supposed to come out once in the 
spring and once in the fall with these big regulatory changes. 
And you typically, I am paraphrasing here, but basically, you 
summarize what you are about to do, and you often indicate a 
schedule of when you are going to do it. And it lets people all 
over the country know what you are going to do.
    But here came a memo from the President that was outside 
the law that was basically making it look like it came from his 
State of the Union Address, where he said, if Congress won't do 
it, I am going to do it anyway.
    There is a law here that says if you are going to affect 
overtime rules, there is a way to do it. Why aren't you doing 
it that way?
    Secretary Perez. Well, we are. In fact, it is my 
understanding that the day the President announced this, we 
contacted your staff and offered to brief them.
    Senator Alexander. Well, that has nothing to do with a law 
that says twice a year these kinds of regulations are supposed 
to be included in a document that is public to everybody, once 
in the spring and once in the fall.
    Shouldn't you get this back on that kind of track?
    Secretary Perez. Well, Senator, we are moving forward with 
the overtime rule, and we are doing so, and will continue to do 
so, in a way that is very consistent with how we did 503, and 
with how we are doing the other issue that you asked about, in 
terms of the conflict of interest.
    We have a long way to go. I have spoken to a lot of 
business leaders. I have spoken to other informed stakeholders, 
because I want to make sure that we get it right.
    We received your letter last night asking about this. We, 
certainly, intend to respond to you in short order. I read that 
letter at roughly 8 o'clock or so last night, and I will make 
sure that we respond to all your questions on the overtime 
rule.
    Senator Alexander. But what about the Regulatory 
Flexibility Act. Shouldn't you be doing this within the terms 
of the Regulatory Flexibility Act, which is a law?
    Secretary Perez. Well, we intend to have, and will continue 
to make sure that we are compliant with all of the regulatory--
--
    Senator Alexander. It is a yes or no, isn't it? Shouldn't 
you only be doing that within the terms of the law and not 
freewheeling this?
    Secretary Perez. Well, I wouldn't describe anything that we 
are doing as freewheeling, sir. Again, there is a reason why we 
offered to brief you the day that we announced it, because we 
wanted to go on a bipartisan basis----
    Senator Alexander. It does not say in the law, ``Go brief 
Senator Alexander.''
    Secretary Perez [continuing]. And we went above and 
beyond----
    Senator Alexander. This is a law. Do this according to the 
terms of this act. And so far as I know, you haven't done it. 
If you are doing it, I would like to know it.
    Secretary Perez. Well, sir, we received your letter last 
night, and we will respond as soon as possible to your letter.
    I am confident that this process is going to mirror the 
processes that we undertake in all of our regulatory work.
    Senator Alexander. Thank you.
    Senator Harkin. Thank you.
    Senator Merkley.
    Oh, I am just told we have a vote at 11 a.m. So Senator 
Merkley and then Senator Johanns.
    Senator Merkley.
    Senator Merkley. Thank you very much, Mr. Chairman.
    And thank you, Mr. Secretary.
    Secretary Perez. Good morning, Senator.

PROHIBITING WORKPLACE DISCRIMINATION ON THE BASIS OF SEXUAL ORIENTATION 
                           OR GENDER IDENTITY

    Senator Merkley. Last month, I joined more than 200 Members 
in the House and Senate to send a letter to President Obama 
renewing our request that the President issue an Executive 
order banning contractors from receiving Federal Government 
contracts unless they have a policy of prohibiting 
discrimination on the basis of sexual orientation or gender 
identity.
    According to various reports, your department has completed 
its preparatory work, and that decisionmaking now rests with 
the White House.
    Understanding that the department would play a critical 
role in implementing any Executive order, are there any 
additional actions the department is taking to prepare or that 
it could take to prepare for the possibility of such an order?
    Secretary Perez. I recall the letter. I read the letter. I 
believe we actually responded to the letter, if my memory 
serves me, or we are in the process of responding.
    I appreciate your longstanding leadership not only on ENDA 
(Employment Non-Discrimination Act), but on the whole issue of 
nondiscrimination.
    We are working very hard on this issue. I worked very hard 
on this issue at the Department of Justice (DOJ). The first 
hearing I had after I was confirmed to DOJ was on ENDA, the 
bill that you introduced, and was one of the original 
cosponsors of.
    We are going to continue those efforts, because I want to 
make sure that everybody gets judged by the content of their 
character and the quality of the work that they do and no 
irrelevant factors. This matter continues to be a matter of 
significant importance to the administration, to me, and to the 
Department or Labor.
    Senator Merkley. Thank you. I appreciate that.
    And I will just use this occasion to continue my urging 
that--I was very pleased that the Senate, on a bipartisan, 2-
to-1 basis, said it was time to end discrimination in the 
workplace.
    It doesn't appear that bill is going to get a vote in the 
House. I wish there would be a vote. There should be a vote on 
something as key to our Constitution as equality and 
opportunity.
    But in the absence of such action, I want to continue my 
encouragement for the President to consider issuing an 
Executive order in this regard.

  IMPLEMENTING REASONABLE BREAK TIME FOR NURSING MOTHERS PROVISION OF 
                          AFFORDABLE CARE ACT

    Let me turn to a second issue. The Affordable Care Act 
included a section called Reasonable Break Time for Nursing 
Mothers. It is a provision I took from work that I have done in 
Oregon State, that women going back to work who have just had 
babies have the privacy and flexibility and break time to 
express breast milk, which is not only wonderful for the health 
of the baby but is also wonderful for the health of the mother 
and has been widely embraced in Oregon.
    We have a clause that allows a company to exempt itself, 
and not a single company has exempted itself. They have all 
found ways to make this work.
    So it has been implemented at the national level through 
your department, and I just want to check in to see if 
appropriate resources for educating companies, assisting 
companies to find a way to make sure that this bill could work, 
are occurring, and whether you have any insights in the 
implementation.
    Secretary Perez. Well, again, thank you for your leadership 
on this. This is one of those really important issues that 
confront working mothers.
    I recall, when I was at DOJ, we took steps prior to passage 
of the Affordable Care Act to address these issues, because it 
was the right thing to do, and it was the smart thing to do.
    We continue to take our responsibility in this regard very 
seriously.
    I would say that our experience has been identical to how 
you describe your experience in Oregon, Senator, which is that 
technical assistance and education have been very, very 
successful. Employers recognize that this is, again, the right 
thing to do, the smart thing to do, and they are doing it.
    Senator Merkley. Thank you. And if there are challenges 
that arise, I, certainly, would like to hear about them, as we 
think about how to expand this, not just from the current law, 
which is for wage-earning workers, but we like to expand it to 
cover salaried workers as well.
    And I won't ask you now, but if you have any thoughts on 
challenges on such an expansion, it would be appreciated.
    Secretary Perez. Sure.

 CONVERTING THE EXPERIMENTAL CONSUMER PRICE INDEX FOR THE ELDERLY INTO 
                      AN OFFICIAL PUBLISHED INDEX

    Senator Merkley. With the balance of my time, I wanted to 
ask about the Consumer Price Index (CPI)-E (for the elderly). I 
would like to see the Department of Labor convert the 
experimental CPI-E into a fully official published index.
    The CPI-W (Urban Wage Earners and Clerical Workers) only 
represents about 32 percent of the U.S. population. It doesn't 
reflect the inflation experience of older Americans. And 
according to the Congressional Research Service, the cost of 
living under CPI-W rose at an average rate of 2.9 percent over 
that period of time, while the cost of living for seniors rose 
at 3.2 percent, or roughly, if you will, a 0.3 percent 
difference.
    Over time, that makes a difference, a significant 
difference, as we think about having accurate indexes for areas 
that it might be applied, such as in Social Security.
    So I just would like to express this interest in seeing the 
department pursue that conversion from the experimental to the 
officially published index, and whether you have any insights 
or comments on that.
    Secretary Perez. Sure. Well, this is not the first time I 
have heard this, and it is an important issue. I appreciate you 
bringing it to our attention. I meet regularly with the head of 
BLS (U.S. Bureau of Labor Statistics) to have this discussion.
    One of the challenges that we are working through is that 
there are some design issues, cost issues. However, I also 
recognize the point that you are making, and I look forward to 
talking to you and really getting your insight as we move 
forward to figure out what the best course of action is in this 
area.
    Senator Merkley. Thank you very much.
    Senator Harkin. Senator Johanns.
    Senator Johanns. Thank you, Mr. Chairman.
    Secretary Perez. Good morning, Senator.
    Senator Johanns. Good to see you, Mr. Secretary.
    Secretary Perez. Good to see you, Senator.

   FAMILY FARM EXEMPTION UNDER THE OCCUPATIONAL SAFETY AND HEALTH ACT

    Senator Johanns. Let me, if I might, just ask a question or 
two to follow-up on the questions that Senator Moran asked you 
about the family farm exemption.
    I thank the Senator from Kansas for bringing this up, 
because this is a very important issue, and not just in 
Nebraska, but across the country.
    As Senator Moran pointed out, for about 35 years, Congress 
has looked at this area and put language in that basically 
said, if you employ more than 10 outside employees, then you 
are subject to OSHA. If not, then you are not.
    And lo and behold, that world changed, and I appreciate the 
fact that the memorandum has now been pulled back, and I know 
the enforcement actions have been pulled back.
    Let me ask you this, just so I understand your testimony 
relative to what you were asked by Senator Moran. You said that 
if there are fewer than 10 outside employees, the inquiry is 
over. Is that the current position of the Department of Labor?
    So you are working with a farm, fewer than 10 outside 
employees, you take no further action?
    Secretary Perez. If it is a farming operation with fewer 
than 10 people, that is my understanding of what the rider was 
intended to get at, and that is the end of the story.
    Senator Johanns. Okay. And so long as that language is in 
the rider, that will continue to be the position of the 
Department of Labor?
    Secretary Perez. Yes, sir.
    Senator Johanns. Okay. Do you have any current plans, as 
you know, I would say, you were attempting or your department 
was attempting to get around this language by classifying 
certain pieces of the farming operation as not a part of the 
farming operation.
    In this case, it would be grain storage. Theoretically, it 
could be a whole host of things.
    Do you have any current plans that your goal would be to 
separate certain operations that I would regard as farming 
operations from that definition and thereby go in and regulate?
    Secretary Perez. We don't have current plans. What I have 
learned from my experience getting up to speed on this is that 
sometimes answering the question of whether you are a family 
farm is easier said than done.
    I spend a lot of time in rural Wisconsin. That is where my 
in-laws live, and we go up there two or three times a year. It 
is all farm country. And what we have seen in some cases is 
that when we go in, there was one facility that had a tomato 
canning operation on the side. There were others where their 
grain silos were actually servicing a number of other farms in 
the area. There was another case where when they were asked to 
define their operation, they used a code that was above and 
beyond what the definition of a family farm was.
    One of the things I have learned from this is that it is 
easier said than done. What we are trying to do, and make sure 
we do a better job of, is determine, at the outset, what is the 
operation that we are seeking to go into, and get that answer. 
If the answer is as we just discussed, then that is the end of 
the issue.
    The thing that was motivating us in this case, and I think 
we all have a shared interest, is making sure that we prevent 
deaths in grain silos; that was the issue that was out there. 
We have done a lot of work, very collaboratively, with farmers 
and associations to prevent these very tragic deaths that were 
the impetus for some of this work.
    Senator Johanns. Yes, and we, certainly, share that. I grew 
up on a farm myself. I have been around grain bins, power 
takeoff shafts, all of those things.
    Secretary Perez. Right.
    Senator Johanns. But having said that, here is what I am 
getting to: When it comes to family farms, haven't we, as 
Congress with this rider language, basically told you what we 
believe the situation is in terms of how to define a family 
farm? We have said, if you have more than 10 outside employees, 
guess what, you are no longer a family operation. According to 
our view of the world, you are something else, and subject to 
OSHA jurisdiction. If you are under 10, on the other hand, you 
are a family farming operation.
    Would you agree with that?
    Secretary Perez. I would agree with that. I would also note 
that you instructed us to consult with USDA (U.S. Department of 
Agriculture) on this issue and make sure that we have guidance 
that is consistent with your directive. I can tell you that we 
are in the middle of doing that as well, and that we have begun 
that process, pursuant to your request. That has been very, 
very helpful, so that we can make sure that we understand the 
situations that you have clearly defined, that the Department 
of Labor, OSHA should not be in, and that we can ensure we are 
in compliance.
    Senator Johanns. Right. Here is my thought on that, and I 
am out of time, so I will wrap up here very quickly, no one 
wants these deaths to occur. They are just hugely tragic. 
Oftentimes, they involve young people, and we don't want that 
to happen.
    I think if you would work with us, USDA, the Farm Bureau, 
FFA (Future Farmers of America), 4-H, on and on, about a 
program that says, look, here are some practices we would like 
to talk about in terms of protecting yourself, and kind of a 
self-education, education awareness program.
    I was in FFA growing up, 4-H, both. And I just think they 
would embrace it. I think they would say to you, yes, that 
makes so much sense to us. And they probably have programs like 
that going on anyway.
    That is where I really want you to focus your attention, 
because I think we have defined family farms as something less 
than 10 employees, outside employees.
    So I will continue to encourage you the way I did in my 
letter. Reach out, work with us. That is really what we are 
trying to achieve here, a safer environment for that kind of 
process.
    Secretary Perez. I look forward to working with you on 
that, because we have learned a lot and we have actually had 
some success working collaboratively. I would like to go to 
school on your experience, so that we can really fulfill our 
shared interest in preventing tragic deaths.
    Senator Johanns. Great. Thank you.
    Secretary Perez. Thank you.

                 FARM SAFETY FOR JUST KIDS ORGANIZATION

    Senator Harkin. If I might, I just want to add to that, I 
would encourage you, Mr. Secretary, and your staff, to reach 
out to an organization called Farm Safety for Just Kids. It was 
started by Marilyn Adams about, oh, about 30 years ago, I 
guess. Her son lost his life in a grain silo accident.
    So she started an organization to start teaching farmers 
about farm safety. A lot of kids work on farms. And kids, 
nothing can hurt you when you are a kid, you know. They take 
all kinds of chances.
    They have built up a great deal of expertise over the 
years. It has become a national organization. I don't know if 
their headquarters are still in Iowa or not, or where it is.
    Senator Johanns. I think in Iowa.
    Senator Harkin. It is still there? They have done great 
work in teaching farmers and farm families how to set up 
systems so that kids don't get hurt, young people don't get 
hurt.
    I will just say, as long as you are pursuing this thing, to 
check with that group. They really have developed a lot of 
expertise.
    Secretary Perez. I will make sure that we do that.
    Senator Johanns. Mr. Chairman, I am so glad you mentioned 
that, because she is outstanding. I met with her when I was 
Secretary of Agriculture.
    Senator Harkin. Is that so?
    Senator Johanns. This came about because of a very tragic 
event, but she has taken that as kind of a catalyst to really 
engage here. She has laid a tremendous foundation.
    I wasn't thinking about that when I was talking about whom 
to partner with here, but that would be perfect.
    Senator Harkin. Yes. I just found out she retired, so now 
the organization has taken on different people. It was taken 
over and continues, so she built quite an organization.
    But I just say, have your people look at that, because they 
have a lot of good background information on this.
    Secretary Perez. We have been doing a lot, and we can learn 
a lot more from all of you. So we look forward to doing that.
    Senator Harkin. I know we are going to be called for a vote 
pretty soon. I just have one short question, and that is on 
employee misclassification.
    Secretary Perez. Yes.

          IDENTIFYING AND COMBATING EMPLOYEE MISCLASSIFICATION

    Senator Harkin. You mentioned that the budget provides for 
$14 million to identify and combat misclassification, and you 
say this includes $10 million in continued grants to States to 
recover unpaid unemployment taxes at $3.8 million of the Wage 
and Hour Division increase for personnel to investigate 
violations.
    Is the total amount that you are putting in for employee 
misclassification $14 million? Or is it $27 million or $28 
million? I am trying to figure out----
    Secretary Perez. $14 million, sir.
    Senator Harkin. $14 million. Again, I just want to 
encourage you, I hear so much about employee misclassification, 
both as the chairman of the authorizing committee, but as a 
Senator from Iowa, too. I just hear a lot about this, about 
misclassification, and how workers are really, well, I will say 
it frankly, being cheated out of what they should be paid, 
because of misclassification. I encourage you to really pursue 
this.
    Secretary Perez. Thank you. I hear this as much as anything 
from business owners. There was a guy, he develops residential 
housing, and he tells me, ``Tom, I am playing by the rules. I 
am paying my employees. I pay their workers comp. I do all 
that. The guy down the road who is competing with me is paying 
everyone under the table. I keep getting undercut. I can't do 
this, and I don't want to cheat.''
    There are three victims: There is the worker, himself or 
herself; there are the business owners who are playing by the 
rules; and there is the tax collector.
    And I saw this in Maryland. We called it workplace fraud in 
Maryland.
    Senator Harkin. That is what it is.
    Secretary Perez. Because ``misclassification'' feels like a 
clerical error. You have to call it what it is.
    We are doing partnerships with States. We have MOUs 
(memoranda of understanding) with States across this country, 
and it is not a red state/blue state thing. We have 
partnerships with Utah. We have partnerships with other States, 
because it is a real issue across this country.
    Senator Harkin. A big issue.
    That is all I have.
    Senator Moran. Do I have time for one more?
    Senator Harkin. Sure you do.

            IMPROVING EMPLOYMENT OPPORTUNITIES FOR VETERANS

    Senator Moran. Mr. Secretary, what do we need to do to 
significantly improve the opportunities for veterans' 
employment? You have a number of tools. The Department of 
Veterans Affairs (VA) works on these issues. But we continue to 
have a significant challenge in this country with our veterans 
returning, with our military men and women returning and 
becoming veterans and unable to find employment.
    Secretary Perez. This is one of those things that I spend 
as much time on as any, Senator. There are a lot of tools in 
the toolbox.
    One of the tools, as it relates to the fiscal year budget 
request for this coming year, is the enhanced RES (Reemployment 
Services)/REA, that is targeted at two populations. It will 
enable us to target two populations, veterans coming out of 
service and the long-term unemployed, so that we can help them 
get the training they need.
    One other thing we are doing, and I know you have to run to 
a vote, but we are working very closely with the VA and DOD 
(Department of Defense) to get people further upstream. With 
the mandatory discharge, as the drawdown in Afghanistan picks 
up, what we are trying to do now is get them 6 months before 
they are actually out of the service, and then figure out, what 
are your goals? We don't want to get them for the first time 
when they are doing transition assistance a week before they 
are leaving. We want to get them 6 months upstream, so that we 
can help connect them perhaps to the apprenticeship program, so 
when they leave, they are ready to work.
    We are doing a lot of work upstream. We are doing a lot 
more work through the First Lady's office with the business 
community. We just had an event with the construction industry, 
and we have a lot of individual employers who stepped up.
    However, in the construction industry, what they did was 
they said that we are going to embed veteran hiring into the 
DNA of all of what we do, not just the ABC Company, but every 
employer.
    You have Helmets to Hardhats that the labor unions and 
others have put forth.
    I am really heartened by what I see in terms of the level 
of interest. The demand is growing and growing, and that is why 
this has been an all-hands-on-deck enterprise for the 
administration.
    I welcome any ideas you have about how we can do it better, 
because nobody has a monopoly on good ideas in this.
    Senator Moran. Mr. Secretary, let me suggest to you that a 
concept that I have a lot of interest in is entrepreneurship, 
the ability to start a business. We have worked with the 
Department of Veterans Affairs in trying to have them focus 
some of the benefits that a veteran is entitled to for 
education, for training, on the ability to create the capital 
necessary to start a business.
    And if there are ways that we can work with the Department 
of Labor to create an environment in which a startup, a new 
business origination, it very well may be a veteran's choice, 
but may not have the tools to accomplish that.
    So while I ask about employment, and that would lend itself 
to thinking about training and education, in addition to that, 
if you put into your broad thinking, are there ways to help a 
veteran who has an entrepreneurial idea pursue the American 
dream in their garage or their barn, take an idea to market? We 
want to explore those opportunities with the Department of 
Labor as well.
    Secretary Perez. I love it, and I would love to brainstorm 
with you.
    Senator Moran. Thanks very much.
    Secretary Perez. Great. Thank you.
    Senator Moran. Mr. Chairman, thank you.
    Senator Harkin. Thank you.
    Thank you, Mr. Secretary.

                           CLOSING STATEMENTS

    First, before you all leave, I also want to recognize Terri 
Bergman for all your years of public service, both at DOL, but 
also on the Hill when you were here and working with us and 
when you were over on the House side. You have been, I 
shouldn't say, just a familiar face; you have been an integral 
part of a lot of our appropriations processes for a long, long 
time.
    I understand you are retiring and relocating to Cape Cod. 
Let me know how it is up there. I am retiring next year, 
myself.
    But again, you have been a tremendous asset as the Deputy 
Assistant Secretary on our Congressional and Governmental 
Affairs. And I know I can speak on behalf of all of our staff 
in saying we are going to miss you. You have been a great asset 
to the smooth functioning of this process, and we thank you for 
your years of public service. We wish you well in your 
retirement.

                     ADDITIONAL COMMITTEE QUESTIONS

    Now, Mr. Secretary, thank you again for being here, for 
your forthrightness and your openness in responding to our 
questions.
    The record will remain open for additional statements and 
questions for 10 days.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
               Questions Submitted by Senator Tom Harkin
  bureau of international labor affairs efforts to combat child labor 
                             abuses abroad
    Question. Mr. Secretary, as you know, I have been a strong 
supporter of the Bureau of International Labor Affairs' (ILAB) efforts 
to protect labor rights and combat the worst forms of child labor 
around the world. In fact, you and I were together last week with the 
Ivorian and Ghanaian government representatives assessing some of the 
progress with have made in reducing the worst forms of child labor in 
the cocoa sector as a result of some technical assistance programs 
funded through ILAB. I want to give you an opportunity to comment on an 
element of ILAB's work that is particularly close to my heart: ILAB's 
technical assistance projects. Would you please share some of the ways 
that these projects are making a difference on the ground and, discuss 
some of the safeguards in place to ensure that project funds are well 
spent on this critical mission?
    Answer. ILAB's technical assistance funding is an essential element 
of its successful efforts to advance worker rights and livelihoods 
throughout the world. Since 1995, DOL has funded 278 projects in 94 
countries to address child labor. Currently, DOL is funding 37 active 
projects in 64 countries, worth over $240 million. These projects use 
an integrated approach that helps remove and prevent children from 
exploitative work, while offering them schooling alternatives and 
livelihood support for their families, so that they can overcome 
reliance on the labor of their children to meet basic needs. To date, 
DOL-funded child labor reduction projects have rescued approximately 
1.7 million children from exploitative child labor. DOL projects also 
play a major role in building the capacity of governments and other key 
actors to combat child labor at the national, district, and community 
levels. In addition, DOL projects train labor inspectors and law 
enforcement officials to improve child labor law enforcement.
    In addition, ILAB funds technical assistance projects that address 
broader worker rights issues, particularly in those countries with 
which the United States has free trade agreements and trade preference 
programs. These projects promote the effective enforcement of labor 
laws by strengthening labor inspections systems, raising awareness and 
capacity of employers to comply with labor law and of workers to 
exercise and claim their rights, improving occupational safety and 
health, promoting productive labor-management relations, and 
strengthening social safety nets for vulnerable workers.
    We consider oversight of technical assistance funding to be one of 
ILAB's most important responsibilities. We use a variety of tools to 
ensure proper oversight. Projects funded by DOL are required to submit 
regular technical and financial progress reports. DOL uses these 
reports to track the grantees' use of funds and implementation of 
agreed upon project activities. DOL also contracts with independent, 
external evaluators and auditors, who are charged with assessing 
project performance and compliance with required regulations. Through 
the use of this combination of oversight tools, DOL seeks to ensure 
proper use of USG funds and to maximize project benefits for workers, 
children, and families in target communities.
    wage and hour division plans to prevent abuses of workers with 
                              disabilities
    Question. Mr. Secretary, the Department plays a critical role in 
promoting ramps and ladders of opportunity for all Americans and in 
protecting their rights in the workplace. That's why I know you share 
my outrage about the abuse of workers with disabilities that occurred 
in Atalissa, Iowa. Please tell me what your specific plans are for 
making sure we never have another situation like that at Henry's Turkey 
Service?
    Answer. Since 2010, the Department has initiated a full review of 
its procedures for enforcement and administration of section 14(c). A 
number of changes have already been made. For example, Henry's Turkey 
Service allowed their certificate authorizing the payment of subminimum 
wages pursuant to section 14(c) to lapse and indicated they would 
choose to pay the full minimum wage equivalent to all workers, but we 
later learned that they did not do so. The Department's strategic 
enforcement protocols for 14(c) now includes a sampling of lapsed 
certificate holders to ensure these former certificate holders are not 
continuing to pay subminimum wages in violation of the law. In 
addition, the Department has initiated action to revoke certificates in 
certain circumstances, and is currently developing standardized 
protocols for dissemination to all staff on revocation of certificates 
for egregious or willful violations of the law. With an increase in FTE 
for the enforcement of section 14(c), the Department will be able to 
increase its directed enforcement activity and further develop 
strategies to address the most egregious violators.
    The Department also partners with other Federal agencies such as 
the Department of Justice, the Department of Education, and the 
Department of Health and Human Services to ensure that employers with 
14(c) certificates provide adequate protections to individuals with 
disabilities. These collaborations help to ensure that all protections 
are available to workers with disabilities as a part of a comprehensive 
and vigorous enforcement program.
    In addition to its enforcement efforts, the Department is committed 
to ensuring that all our stakeholders--employers, community 
rehabilitation programs, advocates, and workers--fully understand the 
rules that apply to employing workers with disabilities at subminimum 
wage rates. We have increased our outreach to stakeholders, conducting 
at least 10-day-long seminars on section 14(c) each year since 2012. 
These seminars are free and open to all interested parties. Finally, 
the Department has recently added a senior advisor to enforcement 
agency staff to help promote and connect the work we do in section 
14(c) with national, regional, and local organizations who work with 
people with disabilities. This key staff member will help ensure the 
agency has an open line of communication for workers and their 
advocates.
                  reemployment eligibility assessments
    Question. Mr. Secretary, since 2005, this subcommittee has provided 
more than $400 million to support Reemployment and Eligibility 
Assessments (REAs). As you know, the President's budget request 
includes $158 million, an increase of $78 million, to expand the 
existing REA program to include reemployment services. This enhanced 
model would provide personalized assistance to unemployed workers and 
target services to UI claimants most likely to exhaust their benefits 
and to all returning service members who are receiving unemployment 
benefits. Can you explain why the model of combining REAs and 
reemployment services as proposed in the President's budget is 
effective in helping people get jobs faster and preventing long-term 
unemployment?
    Answer. There is a compelling rationale for supporting an expanded 
integrated Reemployment Services and Reemployment and Eligibility 
Assessment (REA) program to support rapid reemployment of UI claimants 
and to reduce UI improper payments. Research has shown that both REAs 
and the provision of reemployment services to UI claimants--and 
particularly the combination of the two--are effective at reducing UI 
costs. Both models reduce UI duration and save UI trust fund resources 
by helping claimants find jobs faster and eliminating payments to 
ineligible individuals. REAs have been found to be effective in 
reducing duration and total benefits received by claimants in Florida, 
Idaho, and Nevada. Nevada's model was particularly effective in 
reducing benefit costs. A further study of the Nevada model, which 
delivered REAs seamlessly with reemployment services, found it to be 
significantly more effective than the other states studied in the 
following ways: \1\
---------------------------------------------------------------------------
    \1\ http://wdr.doleta.gov/research/
keyword.cfm?fuseaction=dsp_puListingDetails&pub_id=
2487∓=y&start=21&sort=7
---------------------------------------------------------------------------
  --Claimants were significantly less likely to exhaust their benefits;
  --Claimants had significantly shorter UI durations and lower total 
        benefits paid (1.82 fewer weeks and $536 lower total benefits 
        paid);
  --Claimants were more successful in returning to work sooner in jobs 
        with higher wages and retaining their jobs; and
  --The savings from the program were almost 3 times higher than the 
        cost.
    This integrated approach was also explored in the implementation of 
the Emergency Unemployment Compensation (EUC) program when it was 
extended through December of 2013.
    In addition, on February 14, 2014, Nevada's REA model was 
recognized as a ``Near Top Tier Initiative'' by the nonprofit, non-
partisan Coalition for Evidence-Based Policy.
                                 ______
                                 
                Questions Submitted by Senator Jack Reed
                  job corps program year 2012 surplus
    Question. The Job Corps Program ended Program Year (PY) 2012 with a 
substantial surplus. In January, 20 of my colleagues and I sent a 
letter urging the Employment and Training Administration (ETA) to 
prioritize increasing the number of students served with the surplus 
funds. We also asked that ETA develop a plan for increasing On Board 
Strength (OBS) in a transparent manner, in collaboration with Job Corps 
stakeholders. Please provide information on:
  --The exact dollar amount of the PY 2012 surplus;
  --The factors that led to the surplus;
  --How the surplus funds will be utilized, including the dollar 
        amounts that will be allocated for specific activities;
  --The plan for increasing OBS, including the timing and allocation by 
        Job Corps center of additional OBS; and
  --The steps that the Department is taking to maximize OBS for PY 2013 
        and PY 2014.
    Answer. The Exact Dollar Amount of the PY 2012 Surplus.--In 
consultation with the contractors, the Department determined that there 
were PY 2012 funds that remained unspent and uncommitted on the center 
operators' contracts for PY 2013. After an evaluation of the balances 
remaining on the contracts and negotiations with the contractors, we 
were able to reduce center operators' funding PY 2013 needs by 
$40,060,523 due to funds remaining available on these contracts and the 
ability to spend funds across fiscal or program years. This reduction 
in center operator needs in PY 2013 allows Job Corps to use the funds 
to address additional critical needs.
    The Factors That Led to the Surplus.--The underrun occurred due to 
cost savings measures implemented in Program Year (PY) 2012 and the 
slower than anticipated enrollment of students after the enrollment 
suspension was lifted in April 2013. Expenditures by contractors were, 
in a majority of cases, less than what was obligated to the contracts, 
and that funding remained available on those contracts after the end of 
PY 2012. DOL worked with the contractors to quantify how much funding 
remained available on their contracts, as well as to determine their 
funding needs for the remainder of both the contract year and PY 2013. 
This collaborative process resulted in the identification of 
approximately $40 million in obligated but unspent and uncommitted 
funds that remained on the contracts. We reached agreement with the 
contractors that this amount would be reduced from their remaining PY 
2013 allocations, allowing Job Corps to repurpose the money for the 
remainder of PY 2013.
    How the Surplus Funds Will Be Utilized, Including the Dollar 
Amounts That Will Be Allocated for Specific Activities.--As a result of 
the cost savings, Job Corps will re-allocate some PY 2013 funds for 
crucial needs, including ramping up on-board strength (OBS) to the 
proposed PY 2014 level, improving Job Corps infrastructure, examining 
program design, and strengthening procurement support.
    Because we are committed to ensuring that the Job Corps program 
serves as many students as affordable under the appropriation, we have 
allocated a portion of the recaptured funds to begin to ramp up to the 
PY 2014 OBS level supported by the Consolidated Omnibus Appropriations 
Act (Public Law 113-76). We recently announced the plan for increasing 
OBS to the PY 2014 levels, and have begun working with the Job Corps 
operators to implement it. The methodology considers performance, 
center capacity, and prioritization of high-performing Career Technical 
Training (CTT) programs.
    In addition to increasing OBS to the level that can be afforded in 
PY 2014, we are using the recaptured funds to make important 
investments in the Job Corps program that have not occurred in recent 
years due to the budget constraints. These program investments include:
  --Job Corps Infrastructure.--Job Corps has implemented a much-needed 
        modernization of equipment and technology at Job Corps Centers. 
        A recent survey of Job Corps operators indicated specific 
        equipment needs at Job Corps Centers, many of which were items 
        that are worn, broken, outdated, or have created safety 
        concerns. These equipment purchases were prioritized to help 
        ensure that our students have a safe and effective learning 
        environment where the students are trained on equipment that 
        can continue to meet accreditation standards. This investment 
        includes not only training equipment, but educational and 
        information technology (IT) upgrades that will benefit current 
        and future students.
  --Program Redesign and Streamlining.--The Program and Requirements 
        Handbook (PRH), the key guiding document for Job Corps 
        activities, is cumbersome and outdated. We are reexamining the 
        program's design to create a more cost-effective program model, 
        while also updating operational standards to better serve 
        today's students. We are dedicating a small portion of the 
        funds to a complete review of the program design and a revision 
        of the 1,371-page PRH. This will be a collaborative and open 
        process, and we have already begun collecting input from Job 
        Corps' many stakeholders.
  --Procurement Support.--A small portion of the funds is being 
        invested towards responding to a recommendation from the Office 
        of the Inspector General's Job Corps financial audit. This 
        funding will be used to acquire expert assistance through 
        contractors to assist with the preparation of Independent 
        Government Cost Estimates (IGCEs). See Federal Acquisition 
        Regulation (FAR) 15.404-1. An IGCE is the government's own 
        assessment of what a particular scope of work, activity, 
        service, or product needed should cost based on an evaluation 
        of a similar scope of work, activity, service, or product 
        available in the private marketplace. As part of the 
        acquisition process, this expertise will improve the 
        Department's estimate of the operating costs of contracts for 
        Job Corps centers, outreach and admissions, and career 
        transition assistance for students. This is one of many steps 
        we continue to take to ensure contracting integrity and sound 
        financial management.
  --Contract Closeouts.--ETA is working with Job Corps center operators 
        to reconcile historical obligations to actual costs incurred, 
        such as direct costs for serving students and adjustments to 
        indirect cost rates. We are currently working to review close-
        out claims submitted by contractors and want to ensure we have 
        funds available to pay all liabilities owed.
    The Plan for Increasing OBS, Including the Timing and Allocation by 
Job Corps Center of Additional OBS.--ETA recently announced the plan 
for increasing OBS to the PY 2014 levels, and we have begun working 
with the Job Corps operators to implement it.
    The Steps That the Department Is Taking to Maximize OBS for PY 2013 
and PY 2014.--The reduction in contracted OBS in PY 2012 was a critical 
step undertaken to ensure financial stability within the program and 
establish an OBS level for PY 2013 that was supportable under the 
fiscal year 2013 appropriation, including sequestration. We are 
continuing to monitor contractor expenditures against OBS levels as we 
evaluate the efficacy of our OBS levels and contract amounts. Based on 
an increased appropriation in fiscal year 2014 and reviews of the 
contract expenditures and OBS levels, DOL plans to increase OBS levels 
to a level supportable in PY 2014 to ensure the program serves the most 
students possible within the appropriation.
        revision of program requirements handbook for job corps
    Question. The Department has indicated that it plans to undertake a 
full revision of the Program Requirements Handbook for the Job Corps 
program. Please provide a detailed plan for the review process, 
including timelines, staffing requirements, and the estimated cost.
    Answer. Job Corps has launched an initiative to re-examine its 
policies and practices to create a more streamlined, focused and 
efficient system for the delivery of essential residential, job-based 
training services to youth to ensure they are prepared with the 
industry-recognized education and technical credentials to enter and 
remain attached to the workforce. The process is collaborative, 
leveraging the depth and breadth of knowledge and experience within the 
Job Corps community. It will result in a full revision of the program's 
Policy and Requirements Handbook (PRH). The process, timeline, staffing 
requirements and estimated costs are as follows.

------------------------------------------------------------------------
                  Action                              Timeline
------------------------------------------------------------------------
Initiate plan: develop scope, action plan   Complete
 & guiding principles.
Procure Support Contract: develop scope,    Spring 2014
 conduct procurement, award contract.
Launch initiative: conduct webinar series.  Complete
Collaborate with ETA partners: Contracting  Ongoing
 & Budgeting offices to address policy
 change implications.
Solicit Job Corps community input:
    --Conduct Opinion Request to solicit    Complete
     field policy recommendations.
    --Conduct series of Listening Forums    Complete
     to prioritize policy issues.
    --Hold policy discussions with Federal  Spring 2014
     Management Team.
    --Establish PRH Modernization           Spring 2014--ongoing
     Workgroup with operator
     representation. Conduct in-person &
     virtual meetings.
    --Develop and launch Web-based Job      Spring 2014--ongoing
     Corps Community of Practice.
Conduct policy review:
    --Form expert field practitioner        Summer 2014
     workgroups.
    --Review existing policy & develop new  Summer 2014
     policy recommendations.
    --Identify performance expectations,    Fall 2014
     assessment strategies, technical
     assistance resources.
    --Organize & consolidate all policy     Fall 2014
     recommendations.
Review& assess policy content               Winter 2014
 recommendations: Field review & comment;
 management decisionmaking.
Modify accountability systems to align      Fall 2014-Spring 2015
 with revised policy: outcome measures,
 student accountability, reporting;
 financial management.
Conduct training for the Job Corps
 Community:
    --Design & conduct face-to-face         TBD
     training conferences.
    --Develop virtual and online training   TBD
     courses.
Develop transition strategy:
    --Develop procurement transition        TBD
     timeline & revised Statement of Work.
    --Establish transition period & target  TBD
     date for implementation.
------------------------------------------------------------------------

    Staffing Requirements.--The work will be accomplished primarily 
within existing Federal and contract operator staffing resources. 
Assistance in soliciting input, organizing and conducting workgroups, 
consolidating recommendations, revising and indexing content to ensure 
consistency, and designing and conducting training for the Job Corps 
system will be provided through a National Office PRH support contract 
with approximately five FTE, as follows:

Project Director..........................  1 FTE
Project Assistant.........................  1 FTE
Senior Policy & Program Specialist........  2 FTE
Subject Matter Experts....................  1 FTE
 

    Cost.--We are still working on developing the scope of the 
solicitation, but we anticipate the base contract to be no more than $1 
million.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
      inspector general's report/corrective actions for job corps
    Question. Mr. Secretary, the Job Corps program ran significant 
funding shortfalls in Program Year 2011 and 2012. As a result, 
enrollment freezes and reductions in on-board strength occurred at Job 
Corps centers. The Department of Labor's Inspector General released an 
audit report in May 2013 that reviewed the internal controls in place 
and found that programmatic, budgetary, and managerial problems as a 
well as a lack of proper program integrity controls contributed to the 
budget shortfalls. The fiscal year 2014 Senate Labor/HHS report 
directed the Department to provide a report no later than December 1, 
2013, on the progress of the Department's implementation of the 
Inspector General's recommendations. While this report is delayed, I 
hope you can update us on the Department's progress.
    What changes have been made in the financial system after the 
budget shortfalls?
    Answer. The Department has implemented strong oversight and cost-
saving measures to ensure that the Job Corps program remains solvent 
and is able to deliver education and vocational services to 
participants served. ETA's Office of Financial Administration (OFA) has 
instituted several initiatives to strengthen and coordinate existing 
controls and create new controls to ensure that obligations stayed 
within budget and to track contractor expenditures against their 
submitted spend plans. Working closely with ETA's Office of Contracts 
Management (OCM), which was created in 2010 to consolidate all ETA 
contracting in the national and regional offices, OFA ensures that Job 
Corps' centers cost reimbursements are accounted for in a more timely 
and accurate way. The added coordination between OFA and OCM has 
resulted in significant improvements in the financial oversight of Job 
Corps. In addition, funds have been set aside to integrate the Job 
Corps program's financial reporting systems with those of ETA to 
further this critical coordination. Finally, additional training has 
been provided to staff members who monitor Job Corps contracts to 
enable them to provide better oversight and improve their ability to 
monitor these contracts.
    Progress toward resolving the issue has been a priority. Of the six 
recommendations in the Office of the Inspector General's (OIG) report, 
four are classified by the OIG as ``Resolved and/or Closed.'' ETA is 
committed to resolving the remaining two recommendations as soon as 
possible. Below is the status of the six recommendations. Additional 
details are available on the Job Corps Web site: http://
www.jobcorps.gov/AboutJobCorps/performance_planning/oigreport.aspx.
      1. Resolved.--Establish necessary criteria and thresholds for 
        detecting potential financial and program risks to be routinely 
        documented and communicated, and identify the appropriate 
        personnel within DOL to receive this periodic information.
      2. In Progress.--Develop and implement formal policies and 
        procedures or enhance existing policies and procedures.
      3. Resolved.--Conduct a formal assessment of human capital 
        resources needed for processes and internal controls over Job 
        Corps funds, and periodically update the assessment.
      4. In Progress.--Periodically review and update the policy for 
        developing cost models applied in determining the IGCE used in 
        Job Corps center contracting activities to incorporate the use 
        of more current guidance and assumptions.
      5. Resolved.--Formally reconcile data on a routine basis between 
        NCFMS, JFAS, and JC-FMS.
      6. Resolved.--Evaluate the cost-benefit of creating system 
        interfaces between NCFMS, JFAS, and JC-FMS.
    ETA currently is refining the process for OJC planning, 
requirements determination, budgeting, and evaluation in order to 
enhance internal controls beyond the actions already taken. This effort 
will lay out a more defined process for all aspects of OJC financial 
and contractual activity for a program year well in advance of the 
start of the year and allow for a more rapid response to OJC budget 
changes.
    Question. What assurances can you give us that additional budget 
shortfalls will not occur?
    Answer. In recent years, we faced a serious challenge when the 
Office of Job Corps projected a funding shortfall and was temporarily 
forced to suspend new student enrollment. Job Corps has adopted 
recommendations made by the Office of Inspector General (OIG) and has 
undertaken a variety of measures to strengthen contract oversight and 
financial management of the program. In particular, Job Corps and the 
Department's Office of the Chief Financial Officer (OCFO) have 
established mechanisms for detecting potential financial and program 
risks to improve related policies, procedures, and internal controls, 
and to routinely reconcile accounting systems data. In addition, Job 
Corps has adjusted student on-board strength OBS to levels that are 
sustainable within its appropriation and is using improved processes to 
prevent similar issues in the future as DOL takes steps to increase the 
OBS. The Employment and Training Administration (ETA) has developed a 
new on-board strength cost model to help the Job Corps program better 
track operational costs by center and project differences between 
centers' spending plans and actual expenditures. These actions, taken 
together, will ensure that Job Corps can prevent future issues and 
correct for past deficiencies. We are also committed to reviewing the 
contracting approaches for the program, and determining what type of 
contracts will allow us to deliver services at the lowest risk and best 
value to the Federal Government.
    Question. What steps have been taken to prevent Job Corps' 
financial problems from re-emerging?
    Answer. ETA has undertaken a variety of measures to strengthen 
contract oversight and financial management of the Job Corps program. 
These include thorough analysis and monitoring of programmatic and 
financial data; aligning the number of students with the levels 
supportable under the program's appropriation; improving communication 
between program, contracting, fiscal, and agency leadership; and 
improving contract administration and oversight as well as providing 
additional training for contracting staff. These necessary changes will 
ensure that we will not have this problem in the future.
                       job corps center closures
    Question. The Administration has stated in both the fiscal year 
2014 and fiscal year 2015 budget requests that it plans to close a 
``small number of centers that are chronically low-performing.'' In 
January 2013, the Department issued a notice seeking public comment on 
the proposed methodology for closing centers. However, no further 
public action has been taken. Yet, the President's fiscal year 2015 
budget request assumes a savings for the Job Corps program of $11.6 
million resulting from the closure of centers. Mr. Secretary, does that 
figure mean that the Department will close centers in fiscal year 2015?
    Answer. The Department continues to finalize the closure 
methodology and plans to issue a Federal Register Notice responding to 
comments received from the public and announcing the revised proposed 
methodology as the next public action. The Department has not yet 
established a date for publication of the final closure methodology.
    Question. If so, how many centers will close?
    Answer. The Department continues to finalize the closure 
methodology and has not yet determined the exact number of centers for 
closure or the individual centers that will be closed.
    Question. What methodology will be adopted for closing centers?
    Answer. The Department continues to finalize the closure 
methodology and will issue a Federal Register Notice responding to 
comments received from the public.
    Question. How will the slots at the centers closing be 
redistributed throughout the Job Corps program?
    Answer. We have not yet made a final decision about slot 
redistributions. As we move forward with this process, we will work 
with the Job Corps stakeholder community to take these considerations 
into account.
                 job corps new on-board strength model
    Question. In Program Year 2012, the Employment and Training 
Administration formulated a new on-board strength model. How will the 
new on-board strength model help the Job Corps program to better 
account for operational costs and prevent future budgetary shortfalls?
    Answer. The new on-board strength (OBS) model recognizes the 
relationship between students and costs. The key results of this 
recognition allowed Job Corps to create a methodology to better account 
for operational costs, prevent future budgetary shortfalls, and avoid a 
repeat of past ``savings drills.'' The model provides a new method for 
Job Corps' budgeting, provides a logical basis for decisionmaking, and 
recognizes that the center funding level should be based on OBS level--
i.e. number of student slots. This model was developed and implemented 
in February-March 2013. The assumptions of the model are listed below:
  --Relationship between center costs and the number of students;
  --Variation by each of Job Corps' 29 cost categories for each Center;
  --Tie inflation increases to projected increases in the budget;
  --Restore reductions to critical academic support areas;
  --Base Job Corps student slots on the appropriation level in each 
        Program Year.
    While the new model is essential to the continuity of operations, 
it requires a stable program of operation and accurate and timely 
submission of costs by Job Corps contractors to be evaluated. The 
Department continues to work on refining and improving the model.
    Question. Were stakeholders consulted in the process of developing 
this new on-board strength model?
    Answer. The on-board strength (OBS) model was developed to identify 
the affordable levels of OBS based on data supplied by contractors and 
the appropriated budget. A center's OBS level was initially based on 
the centers' previous OBS level. ETA and the Job Corps community have 
established a workgroup to examine current financial management 
reporting practices in the Job Corps community. ETA has shared the OBS 
model with that workgroup, though no decisions will come from the 
workgroup. This workgroup is comprised of Job Corps contractors and 
other stakeholders. Job Corps is committed to continued open 
communication with the Job Corps community to harness their expertise.
    Question. If so, how were they consulted?
    Answer. ETA and the Job Corps community have established a 
workgroup comprised of Job Corps contractors and other stakeholders to 
examine current financial management reporting practices in the Job 
Corps community, and ETA has shared the OBS model with that workgroup, 
though no decisions will come from the group. In addition, the 
Department has briefed Congressional staff on the model and continues 
to work with the contractor community on improving the data used in the 
model.
                           sector strategies
    Question. The President's fiscal year 2015 budget requests $15 
million for a new Sector Strategies competitive grant initiative that 
would encourage development and implementation of sector strategies, or 
partnerships, of local businesses, regional workforce boards, and 
educational organizations to support and develop the workforce needs of 
specific industries in that area. A January 2012 GAO report entitled 
``Innovative Collaborations between Workforce Boards and Employers 
Helped Meet Local Needs,'' highlighted Sector Strategies as an 
important workforce approach for meeting the skill needs of workers and 
employers within local or regional economies. Will you share with us 
the details of the Department's new Sector Strategies initiative?
    Answer. The Department's request for $15 million for a new Sector 
Strategies competitive grant initiative will provide funds to states, 
regions, or localities to implement sector-based strategies that meet 
the needs of small, medium, and large businesses in in-demand sectors.
    The Department anticipates awarding competitive grants to implement 
sector-based strategies to meet the dual goals of meeting the needs of 
businesses while providing training and career advancement 
opportunities for targeted populations. These grants would support the 
development of partnerships between the workforce system, business, 
community colleges, economic development, and others such as organized 
labor, the adult basic education system, and supportive service 
providers. The grants also would be used to modify existing training 
based on business demand as well as train and provide career 
advancement opportunities for targeted populations such as acutely or 
chronically long term unemployed, low-wage workers, new labor market 
entrants, and veterans.
    In addition, the Department will award smaller capacity building 
grants to States to support or promote the development of sector 
partnerships. State applicants would identify a local or regional area 
that would pilot the capacity-building activities during the grant 
period.
    Question. In particular, how many grants will be awarded and at 
approximately what amount per grant?
    Answer. Through the Sector Strategies competitive grant initiative, 
the Department anticipates awarding four to five grants potentially 
ranging in size from $2-3 million to implement sector-based strategies 
to meet the dual goals of meeting the needs of businesses while 
providing training and career advancement opportunities for targeted 
populations. The Department also anticipates awarding approximately 
five, smaller capacity building grants to states to support or promote 
the development of sector partnerships.
    Question. How do you plan to involve local industry leaders in this 
initiative?
    Answer. Local industry leaders would be partners and valued 
customers for all Sector Strategies competitive grants. These leaders 
would identify critical, immediate workforce needs, inform curriculum 
design and delivery, provide work-based learning opportunities, and 
receive integrated business services that meet their workforce needs. 
Integrated business services are the range of workforce development, 
economic development, regulatory compliance, and other services 
available from a variety of Federal, State, and local resources that 
meet business' needs.
        job-driven training for workers presidential memorandum
    Question. For the last several years, the Government Accountability 
Office (GAO) has cited duplication across job training programs. In 
addition to GAO's work, concerns have been raised by the subcommittee 
about evaluations of job training programs. It is my understanding that 
the Department continues to work on a ``Workforce Investment Act Gold 
Standard Evaluation,'' which it has been undertaking since 2011. 
However, the evaluation's first findings are not expected until the 
fall of 2015, and final impact findings will not be released until the 
summer of 2017. Can you explain how the new Job-Driven Training for 
Workers Presidential Memorandum will accomplish in 180 days what your 
Department has already been working on for 3 years and will not 
complete for three more?
    Answer. DOL views the Workforce Investment Act Gold Standard 
Evaluation and the overall job training review that is directed by the 
Presidential Memorandum as complementary but not identical efforts.
    In his State of the Union address, President Obama laid out a 
vision based upon the principle of opportunity for all. Key parts of 
that vision are helping people get the skills they need to succeed in 
good-paying jobs and ensuring that America's employers have the skilled 
workers they need to successfully compete in the global economy. On 
January 31, 2014, the President issued a memorandum tasking Vice 
President Biden to conduct a broad review of our Nation's employment 
and training programs to make this vision a reality, focusing on making 
workforce programs and policies throughout the government more focused 
on imparting relevant skills, more easily accessed by both employers 
and job seekers, and more accountable for positive employment and 
earning outcome results. This review is guided by the principle of job-
driven training for workers. The review will result in an action plan 
that identifies steps to make sure that programs throughout the Federal 
Government deliver on the promise of job-driven training for workers 
and for employers. The Department of Labor is working with the Vice 
President and our colleagues at the Departments of Commerce, Education, 
Health and Human Services, and in other agencies to implement this 
review and identify concrete ways to help more of American's workers on 
a faster path to valuable skills and credentials, good jobs, and 
meaningful careers.
    In contrast to the Vice President's review, the Gold Standard 
evaluation is a long-term evaluation that will determine the impact of 
services provided to adults and to dislocated workers under the 
Workforce Investment Act of 1998. The evaluation will produce the first 
impact estimates in December 2015 as scheduled, and the final impact 
results in the summer of 2017. The Vice President's review is also 
focused on improving the accountability for the outcomes of training 
programs.
    I look forward to discussing with the Committee the results of the 
Vice President's review.
    Question. Why have the reports from GAO on job training duplication 
not spurred any significant budget proposals from the Department on 
consolidation?
    Answer. The GAO report does not recommend that training and 
employment programs be consolidated. Rather, it recommends better 
collaboration across programs. The Administration is focused on 
improving coordination and alignment in the workforce system as GAO has 
suggested. The Vice President is currently leading an across-the-board 
review of employment and training programs. One of the key goals of 
that review is to improve workforce system coordination across program 
funding streams.
    The Administration is also taking steps to improve service delivery 
and increase coordination and alignment within its current authority as 
well as through proposals in the President's budget. For example, the 
Workforce Innovation Fund, launch last year, supports State, regional, 
and local efforts to wok across program silos to produce better 
employment outcomes for job seekers and workers. The latest 
solicitation for grant applications was released in mid-May of this 
year. The 2015 President's budget requests $60 million for the 
Workforce Innovation Fund in 2015. In addition, the budget requests $80 
million for WIA Incentive Grants, which would provide grants to states 
that demonstrate strong performance in serving populations with 
barriers to employment. Since these individuals are likely to be served 
by multiple programs, States that improve program coordination and 
alignment will be more likely to receive these grants. The 
Administration has also sought greater flexibility to blend funding in 
exchange for greater accountability for outcomes. The proposed 
Performance Partnership authority was enacted in the 2014 and will 
permit greater cross-program work to achieve better outcomes for 
disconnected youth. A slightly expanded version of this authority was 
reproposed in the 2015 budget.
    The 2015 President's budget also includes some proposals to 
consolidate employment and training programs in a targeted way that 
protect the most vulnerable populations. The public workforce system, 
authorized by the Workforce Investment Act, provides States and local 
areas flexibility in determining how best to implement their job 
training and employment programs by tailoring the system to meet the 
needs of local jobseekers and employers and support regional economic 
growth. Further, the Department's job training and employment programs 
are geared to serve diverse individuals with specific needs, including 
veterans, dislocated workers, individuals with disabilities, women, low 
income youth, Indians and Native Americans, and migrants and seasonal 
farmworkers. The Department is committed to working with its Federal 
partners to ensure access to services.
    Further, the fiscal year 2015 budget request includes several plans 
to streamline or align workforce and training services, and it also 
emphasizes building on what is working and encouraging innovation to 
improve service delivery and performance. We have proposed to transfer 
the Senior Community Service Employment Program to the Department of 
Health and Human Services, Administration for Community Living, placing 
the program in an agency that shares the mission of helping older 
Americans maintain their independence (both economic independence and 
living arrangements) and actively participate in their communities. 
Additionally, the budget proposes to consolidate the Trade Adjustment 
Assistance for Workers and the WIA Dislocated Worker programs into a 
single New Career Pathways program that will streamline the delivery of 
training and reach as many as one million displaced workers a year with 
a set of core services.
    The Department has also already eliminated some employment and 
training programs that it viewed as duplicative, including the 
Community-Based Job Training Grants and the Veterans Workforce 
Investment Act programs.
        community service employment for older americans program
    Question. The President's fiscal year 2015 budget requests $380 
million in funding for the Community Service Employment for Older 
Americans program. The budget also proposes transferring the program to 
the Department of Health and Human Services, which the subcommittee has 
consistently rejected. Mr. Secretary, how does this budget request 
account for the President's proposed minimum wage increase?
    Answer. The number of participants that can be served under the 
Senior Community Service Employment Program (SCSEP) depends on minimum 
wages at the national, State or local levels. Consistent with standard 
practices, the fiscal year 2015 Budget request assumes current law in 
estimating the number of participants served. As Congress considers 
raising the minimum wage, the Department of Labor, in conjunction with 
the Department of Health and Human Services, would be glad to discuss 
with Congress how various implementation and timing options for a 
minimum wage increase would affect SCSEP slots.
    Question. How would an increase in the minimum wage affect the 
number of slots available to program participants?
    Answer. At the fiscal year 2015 request level, an increase in the 
Federal minimum wage would increase the participant wage rate and 
decrease the number of participant slots in areas where the current 
minimum wage is not at least $10.10. As Congress considers raising the 
minimum wage, the Department of Labor, in conjunction with the 
Department of Health and Human Services, would be glad to discuss with 
Congress how various implementation and timing options for a minimum 
wage increase would affect SCSEP slots.
                           h-1b visa program
    Question. As part of the H-1B visa program, the Department of Labor 
currently receives a portion of the fees assessed to companies who 
apply for these temporary, high-skilled worker visas to provide 
training to U.S. workers. These training programs are designed to 
assist American workers in gaining the skills needed to obtain or 
advance employment in high-growth industries. In addition to annual H-
1B fees, the Department of Labor received additional funds from the 
American Recovery in Reinvestment Act (ARRA) to train Americans. Please 
provide the subcommittee the following information:
    What is the dollar amount distributed from H-1B fees to the 
Department of Labor for the past 5 fiscal years?
    Answer. The Department of Labor collected $668,231,275 in H-1B fees 
from fiscal year 2009 through fiscal year 2013 for the Job Training for 
Employment in High Growth Industries program. The distribution of 
collections by year follows:

----------------------------------------------------------------------------------------------------------------
                                                                    Fiscal year
                                 -------------------------------------------------------------------------------
                                       2009            2010            2011            2012            2013
----------------------------------------------------------------------------------------------------------------
H-1B collections................    $110,820,955    $114,026,359    $130,975,268    $161,232,760    $151,175,933
----------------------------------------------------------------------------------------------------------------

    Question. What is total amount of money provided to the Department 
of Labor from the ARRA?
    Answer. The Department of Labor received $4,806,000,000 in 
discretionary funds from the American Recovery and Reinvestment Act of 
2009.
    Question. What evidence is there to demonstrate the training 
funds--both H-1B fees and the ARRA funds--have resulted in meaningful 
employment for Americans?
    Answer. Since 2008, the Department has funded approximately $1.539 
billion through the following competitive grants using H-1B fees and 
American Recovery and Reinvestment Act of 2009 (ARRA) funds 
appropriated for high-growth and emerging industries (HGEI). 
(Approximately $750 million of ARRA funds were designated for HGEI 
grants, compared to over $4 billion in total ARRA funding for Training 
and Employment Services programs.) Several of these training grants 
include program evaluations, as described below:
High Growth Job Training Initiative (HGJTI)
    The High Growth Job Training Initiative, which began in 2001 and 
ended in 2013, engaged business, education, and the workforce 
investment system in the development of integrated solutions to the 
workforce challenges facing high-growth industries. These industries 
included Advanced Manufacturing, Geospatial Technology, Aerospace, 
Health Care, Automotive, Hospitality, Biotechnology, Information 
Technology, Construction, Retail, Energy, Transportation, and Financial 
Services. This program was funded by H-1B fees.
    The final report \2\ documents the national initiative, describes 
the structure and implementation of projects by selected grantees, and 
provides non-experimental analysis of the early training outcomes of 
HGJTI-funded programs, including some information on early impacts of 
job training activities. Some of these early impacts reported by the 
grantees demonstrate evidence of meaningful employment for 
participants. For example: 49 percent of 593 trainees in the Chicago 
Women in Trades program were placed in jobs with an average earnings of 
$17.62 per hour; 81 percent of 1,098 dislocated workers in the 
Community Center Learning Center entered jobs as full-time entry-level 
aircraft assembler positions earning $10 per hour, and 78 percent 
retained those jobs; and the High Plains Technology Center had 2,162 
training completers of which 74 percent were placed in jobs with an 
average wage of $14-$18 per hour for floor hands and $26 per hour for 
derrick hands.
---------------------------------------------------------------------------
    \2\ Available at: http://wdr.doleta.gov/research/
eta_default.cfm?fuseaction=dsp_resultDetails
&pub_id=2478&bas_option=Title&start=1&usrt=4&stype=basic&sv=1&criteria=
High%20Growth.
---------------------------------------------------------------------------
H-1B Technical Skills Training (TST)
    The H-1B TST Grant Program, which began in November 2011, provides 
education, training, and job placement assistance in the occupations 
and industries for which employers are using H-1B visas to hire highly-
skilled foreign workers on a temporary basis, and the related 
activities necessary to support such training. This program is intended 
to raise the technical skill levels of American workers so they can 
obtain or upgrade employment in high-growth industries and occupations. 
Over time, these education and training programs will help businesses 
reduce their use of skilled foreign professionals permitted to work in 
the U.S. on a temporary basis under the H-1B visa program. The grants 
represent significant investments in sectors, such as information 
technology, advanced manufacturing, and healthcare. These grants are 
currently active. The Department is funding an implementation study of 
this program that will provide a cross-cutting summary of grantees' 
program operations, including participant recruitment and enrollment 
practices, program services, and key partner roles and 
responsibilities, as well as detailed information on special topics of 
interest and lessons learned. The draft Final Report is expected in the 
spring of 2018.
H-1B Jobs and Innovation Accelerator Challenge (JIAC)
    The Jobs and Innovation Accelerator Challenge (JIAC), which began 
in October 2011, is designed to help regions achieve the demonstrated 
benefits of collaborative, cluster-based regional development. This 
initiative represents the implementation of Administration policy 
priorities to accelerate bottom-up innovation in urban and rural 
regions, as opposed to imposing ``one-size-fits-all'' solutions. The 
JIAC also meets Administration goals for smarter use of government 
resources through reduction of Federal silos and promotion of 
coordinated Federal funding opportunities that offer more efficient 
access to Federal resources. The three Federal funding agencies for 
this project include the Department of Labor, Employment and Training 
Administration (ETA); Department of Commerce, Economic Development 
Administration; and the Small Business Administration. These grants are 
currently active.
    The study being conducted of the JIAC is a process evaluation that 
focuses on the regional industry cluster implementation plans, as well 
as processes and strategies used to develop and accelerate regional 
economic development that translate into new jobs and increased wages 
through these regional partnerships. The draft Interim Report is due to 
ETA in November 2014, and the draft Final Report is expected in the 
spring of 2016.
H-1B Make it in America (MIIA)
    The Make it in America (MIIA) grant program, which began in October 
2013 and is funded by H-1B fees, seeks to encourage foreign and 
domestic businesses to build or expand their operations in the United 
States. This is intended to accelerate job creation by encouraging re-
shoring of productive activity by U.S. firms, foster increased foreign 
direct investment, encourage U.S. companies to keep or expand their 
businesses--and jobs--here at home, and train local workers to meet the 
needs of those businesses. The MIIA also meets Administration goals for 
smarter use of government resources through reduction of Federal silos 
and promotion of coordinated Federal funding opportunities that offer 
more efficient access to Federal resources. The three Federal funding 
agencies for this project include the Department of Labor, Employment 
and Training Administration; U.S. Department of Commerce's Economic 
Development Administration (EDA) and National Institute of Standards 
and Technology Manufacturing Extension Partnership (NIST MEP); and, 
Delta Regional Authority (DRA). These grants are currently active.
    The MIIA evaluation will examine partner infrastructures, strategic 
planning, technical assistance, workforce development resources used 
for workers to develop the needed skills, as well as the local 
community clusters. The evaluation will document successes in 
measureable project outputs, capacity-building outcomes, and realized 
outcomes that lead to building a highly skilled and diverse workforce 
to meet employer demand.
ARRA High growth and Emerging Industries (HGEI)
    Awarded through the Recovery Act, ARRA High Growth and Emerging 
Industries (HGEI) grants that focused on training and placement 
activities included the Energy Training Partnership Grants, Pathways 
Out of Poverty Grants, State Energy Sector Partnership and Training 
Grants, and Health Care Sector and Other High Growth and Emerging 
Industries Grants. These grants ended June 2013.
    ETA funded a random-assignment impact evaluation of four grants 
awarded from two of the ARRA Solicitations for Grant Applications 
(SGA): Pathways Out of Poverty/Green Jobs and Health Care Sector and 
Other High Growth and Emerging Industries SGA. The overall aim of this 
study is to determine the extent to which grantees' participants 
achieve increases in employment, earnings, and career advancement as a 
result of their participation in the training provided by the grantees, 
and to identify promising best practices and strategies for 
replication. The draft Interim Report is due to ETA in June 2015 and 
the draft Final Report is expected in December 2016.
Youth Career Connect
    These grants, awarded in April 2014, are designed to provide high 
school students with education and training that combines rigorous 
academic and technical curricula focused on specific in-demand 
occupations, particularly in science, technology, engineering, and math 
(STEM) related fields. An evaluation of these grants is in the early 
stages of planning at the Department.
H-1B Ready to Work Partnership Grants
    These grants, totaling approximately $150 million, are being 
competed in spring 2014 and expected to be awarded in fall 2014. They 
will be focused on providing long-term unemployed workers with 
individualized counseling, training and supportive and specialized 
services leading to rapid employment in occupations and industries for 
which employers use H-1B visas to hire foreign workers. The grants will 
support public-private partnerships that include the workforce 
investment system; training providers, such as community colleges and 
community-based and faith-based organizations; and businesses including 
at least three actively engaged employers. As part of its commitment to 
producing strong evidence on effectiveness its programs, the Department 
is requiring full participation in a planned impact evaluation as a 
condition of all grants awarded in this competition.
Quarterly Performance Reporting
    Grantees for the above programs report key outcomes (entered 
employment rate, employment retention rate, and average earnings) each 
quarter for participants who have exited the program. These outcome 
data are not yet available for the H-1B, TST, JAIC, or MIIA programs, 
as grantees complete a mandatory planning period before enrolling any 
participants, and most participants have not yet exited training 
programs. Quarterly performance outcomes from these programs will be 
posted as they become available at: http://www.doleta.gov/performance/
results/#etaqr. Archived outcome data are available at: http://
www.doleta.gov/performance/results/Archive_Reports.cfm for the HGJTI 
(see December quarterly reports for 2008-2012 and March 2013) and ARRA 
HGEI programs (see June 2013).
    Question. What percentage of individuals receiving H-1B funded 
training obtains employment after completing that training?
    Answer. Through the High-Growth Job Training Initiative (HGJTI) 
grants, which operated from 2003 through 2013, 63,716 participants 
completed training activities. Of these, 28,753 were placed into 
positions of new employment. The Entered Employment Rate for completers 
is 45 percent. Prior to new reporting requirements implemented in the 
quarter ending December 31, 2011, grantees only reported results for 
individuals who entered employment if those participants entered 
employment and completed training in the same quarter. As a result, the 
total number of individuals that ultimately entered employment and 
training-related employment are actually higher than the results above 
indicate.
    The current H-1B funded training grants, awarded at different times 
since October 2011, have served 43,606 participants as of December 31, 
2013, including 9,967 who were unemployed at enrollment. Of these 
unemployed participants, 8,835 began training by December 31, 2013, 
including 3,762 who completed training. Of these training completers, 
1,990 (52 percent) entered employment by December 31, 2013. These H-1B 
grants are at different stages of their grant periods of performance, 
including some that were still in the planning and startup phase and 
had not yet enrolled participants during the latest (December 2013) 
reporting period.
    Question. What is the average timeframe for receiving employment 
after receiving H-1B funded training?
    Answer. The Department cannot calculate an average time from 
training completion to entering employment because it does not collect 
data on individual hire dates. The Department tracks an entered 
employment rate based on the number of participants who are employed in 
the quarter after the quarter in which they exited the program. (See 
http://wdr.doleta.gov/directives/attach/TEGL17-05_AttachA.pdf.)
    Question. Does the Department collect data on whether individuals 
receiving H-1B funded training remain employed 1 year after they are 
trained?
    Answer. The Department collects employment retention data using the 
Common Performance Measures. The Employment Retention Rate is based on 
the number of people who were employed in the first quarter after they 
exited the program and are still employed up to 9 months after exit.
    For the current H-1B funded investments, the Employment Retention 
Rate (which includes both unemployed and incumbent worker participants) 
is 99 percent for the quarter ending December 31, 2013.
    Question. How does H-1B training help the long-term unemployed?
    Answer. Of the more than $340 million awarded in two rounds of H-1B 
Technical Skills Training (TST) grants in fiscal year 2012, the 
Department designated more than $200 million for grantees serving the 
long-term unemployed.
    In addition, in February 2014 the Department announced the Long-
term Unemployed H-1B Ready to Work (Ready to Work) Partnership grant 
program, currently open for solicitation of grant applications. The 
Ready to Work grant program will utilize approximately $150 million in 
H-1B funds for projects that recruit long-term unemployed workers and 
employ strategies that are effective in getting them back to work in 
middle to high-skill occupations. The Department is planning a rigorous 
evaluation of these grants.
                          governor's set-aside
    Question. The fiscal year 2014 omnibus increased the Governor's 
Set-Aside to 8.75 percent. This program has been successful with states 
that use the funding for state-wide or regional employment initiatives. 
In Kansas, it is my understanding that the State intends to use the 
additional funding from fiscal year 2014 to support employment services 
for veterans. Specifically, Kansas plans to hire a point person at Fort 
Riley, the state's largest military installation, to provide case 
management services to exiting service members. With improved 
coordination of services, the State is confident it can improve the 
employment outcomes of its veterans. However, there is concern from the 
State that until the Governor's Set-Aside is restored to its authorized 
level of 15 percent, limited resources will prevent the State from 
assisting more veterans in finding jobs as they transition to civilian 
life. Why does your Department not support restoring the Governor's 
State Set-Aside to its fully authorized level so that states will have 
the resources and flexibility they need to pursue promising ventures 
such as the one I have referenced?
    Answer. The 2015 budget adheres to the spending levels agreed to in 
the Bipartisan Budget Act of 2013, which was an important first step 
toward replacing the damaging cuts caused by sequestration with 
sensible long-term reforms. However, remaining at these levels 
necessitates difficult decisions, and means that we cannot accommodate 
additional investments in key areas like the job training formula 
grants. The Opportunity, Growth, and Security Initiative proposed in 
the 2015 budget acknowledges this, and included funds to restore prior 
cuts in the formula grants. The fiscal year 2015 budget does, however, 
request the continuation of the reserve at the fiscal year 2014 level, 
which allows for fundamental state oversight and accountability 
activities. Increasing the State reserve without increasing formula 
funding would cut into local funding. The Department will continue to 
work with States to identify ways to operate within these funding 
levels while continuing essential activities.
    The 2015 budget adheres to the spending levels agreed to in the 
Bipartisan Budget Act of 2013, which was an important first step toward 
replacing the damaging cuts caused by sequestration with sensible long-
term reforms. However, remaining at these levels necessitates difficult 
decisions, and means that we cannot accommodate additional investments 
in key areas like the job training formula grants. The Opportunity, 
Growth, and Security Initiative proposed in the 2015 budget 
acknowledges this, and included funds to restore prior cuts in the 
formula grants. The fiscal year 2015 budget does, however, request the 
continuation of the reserve at the fiscal year 2014 level, which allows 
for fundamental state oversight and accountability activities. 
Increasing the State reserve without increasing formula funding would 
cut into local funding. The Department will continue to work with 
States to identify ways to operate within these funding levels while 
continuing essential activities.
                                 ______
                                 
              Questions Submitted by Senator Thad Cochran
                 gulfport, mississippi job corps center
    Question. Secretary Perez, the Job Corps center in Gulfport, 
Mississippi was badly damaged during Hurricane Katrina in 2005. The 
former Secretary of Labor, Secretary Solis, committed to work with me 
to ensure that the Gulfport Job Corps Center is rebuilt and able to 
return to serving the number of young people that it once served. Here 
we are, nearly 9 years later, and this center has yet to be fully 
repaired. Is this acceptable to you?
    Answer. The Gulfport Job Corps Center was closed due to extensive 
damage caused by Hurricane Katrina in late 2005. The center occupies 
the former 33rd Avenue High School, which is eligible for inclusion in 
the National Registry of Historic Places as it dates back to 1921 as 
the only Gulfport high school that served African-American students 
until Gulfport schools were integrated in 1968. The property and 
buildings are owned by the City of Gulfport and leased to Job Corps. 
Work began in 2006 to determine whether existing buildings could be 
repaired and renovated. A determination was made in 2007 that this 
option was not feasible due to the condition of the structures and 
environmental remediation costs. DOL contracted a design/build 
contractor in 2008 to include demolition and construction of temporary 
modular facilities to reopen the Center. Temporary center facilities 
were completed in late 2009, a contract for a Center operator was 
procured, and the Center reopened with a reduced student population in 
2010 (the current OBS is 107). The construction design of the new 
permanent Center was completed and a construction contract was awarded 
in 2011. However, alumni of the 33rd Avenue school objected to the 
demolition of the historic buildings and invoked the historic 
preservation laws. DOL conducted extensive negotiations and meetings 
with the community, but when no agreement was reached, the construction 
contract was cancelled in March 2012. At the community's request, DOL 
hired a local contractor to assess issues regarding renovation and 
preservation, and the report was received in December 2013. Before the 
structural analysis can be completed, the site needs significant 
remediation to determine whether any of the buildings (or parts 
thereof) are structurally sound enough to be preserved. We are 
currently revising the scope of work for the assessment and 
stabilization of the buildings. Once the scope is completed, we 
anticipate issuing a request for proposal by June 30, 2014.
    Question. What are you doing to fix it?
    Answer. Job Corps has worked extensively to address the historic 
preservation concerns of the community. At the community's request, DOL 
hired a local contractor to assess options for renovation and 
preservation, and the report was received in December 2013. The site 
needs significant remediation before the structural analysis on whether 
any of the buildings (or parts thereof) are structurally sound enough 
to be preserved as part of the new Center can be completed. We are 
currently revising the scope of work for the assessment and 
stabilization of the buildings. Once the scope is completed, we 
anticipate a request for proposal by June 30, 2014.
    Question. Secretary Perez, we have three Job Corps centers in 
Mississippi that serve hundreds of underprivileged young people. How 
does the Department's budget request seek to resolve issues in the Job 
Corps program caused by poor planning by the Department so that Job 
Corps centers are not forced to continue to lay off employees and 
reduce the number of students they serve?
    Answer. In recent years, we faced a serious challenge when the 
Office of Job Corps projected a funding shortfall and was temporarily 
forced to suspend new student enrollment. Job Corps has adopted 
recommendations made by the Office of Inspector General (OIG) and has 
undertaken a variety of measures to strengthen contract oversight and 
financial management of the program. We have made necessary changes 
that will prevent similar issues in the future.
    In particular, Job Corps and the Department's Office of the Chief 
Financial Officer (OCFO) have established mechanisms for detecting 
potential financial and program risks to improve related policies, 
procedures, and internal controls, and to routinely reconcile 
accounting systems data. Improvements implemented since 2013 include 
thorough analysis and monitoring of programmatic and financial data; 
aligning the number of students with the levels supportable under the 
program's appropriation; improving communication between program, 
contracting, fiscal, and agency leadership; and improving contract 
administration and oversight as well as providing additional training 
for contracting staff.
    The reduction in contracted on-board strength (OBS) at the end of 
the enrollment suspension in April 2013, was undertaken to ensure 
financial stability within the program and establish an OBS level for 
Program Year (PY) 2013 that was supportable under the fiscal year 2013 
appropriation, including sequestration. Reducing OBS was a critical 
step in ensuring that we started PY 2013 with Job Corps' total 
financial and budgetary commitments aligned with our appropriation. We 
are continuing to monitor contractor expenditures against OBS levels as 
we evaluate the efficacy of our OBS levels and contract amounts to 
inform future discussions about increasing OBS system-wide.
    Question. Have you planned accordingly for the upcoming fiscal 
year?
    Answer. Yes, the reduction in contracted on-board strength (OBS) in 
2013 was undertaken to ensure financial stability within the program 
and establish an OBS level for PY 2013 that was supportable under the 
fiscal year 2013 appropriation, including sequestration. Reducing OBS 
was a critical step in ensuring that we started PY 2013 with Job Corps' 
total financial and budgetary commitments aligned with our 
appropriation. We are continuing to monitor contractor expenditures 
against OBS levels as we evaluate the efficacy of our OBS levels and 
contract amounts. Based on an increased appropriation and reviews of 
the contract expenditures and OBS levels, DOL plans to increase OBS to 
a level that is supportable in PY 2014.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
                               h-2b rules
    Question. The Department has repeatedly proposed H-2B rules that 
would add regulatory burdens and costs to American businesses. In 
particular, the 2011 wage rule could have increased H-2B hourly wages 
by upwards of 50 percent. Many small businesses that use the H-2B 
program cannot afford this regulation and may ultimately close, which 
will result in more job losses, including putting the American jobs at 
those businesses at risk. The fiscal year 2012 Labor/HHS appropriations 
bill prohibited the Department from moving forward with this dangerous 
rule. That prohibition was continued through fiscal year 2013. However, 
since that time, the Department announced it will move forward with a 
re-proposal of the 2011 wage rule. Mr. Secretary, why is your 
Department moving forward with a re-proposal of the 2011 wage rule, 
despite overwhelming opposition from Congress, industry leaders, and 
stakeholder interests who feel this rule is unworkable and will 
ultimately undermine the program?
    Answer. The Department does not plan to ``re-propose'' the 
prevailing wage rule issued in 2011, but will work off of its 
provisions in developing a proposal for consideration by the regulated 
community and other interested parties on a final wage rule in the H-2B 
program. Following litigation in which a court invalidated the 
regulatory provision setting forth skill levels to set the prevailing 
wage in the H-2B program, the Department issued an interim final rule 
in April 2013 (2013 IFR) that eliminated the use of skill levels in 
setting the prevailing wage. Instead, where there is not a collective 
bargaining agreement that governs the wage determination, the 
Department will set the prevailing wage as the mean of the wages of 
similarly employed workers in the geographic area of employment. Under 
the 2013 IFR, the Bureau of Labor Statistics' Occupational Employment 
Statistics (OES) Survey is used to determine the mean wage of similarly 
employed workers in the geographic area, unless the employer requests a 
wage determination based on another source, such as wage surveys for 
workers employed under Federal government contracts or statistically 
sound private surveys. The Department invited public input on the 2013 
IFR and received over 300 public comments. In light of those public 
comments, recent developments in the H-2B program, Congressional 
actions, and judicial decisions, the Department has determined that 
further notice and comment on setting the prevailing wage in the H-2B 
program is warranted. Therefore, DOL intends to publish a notice of 
proposed rulemaking on the proper wage methodology for the H-2B 
program, working off of the 2011 Wage Rule as a starting point. The 
Department will review comments on the 2013 IFR, along with comments we 
receive after we publish the notice of proposed rulemaking prior to 
issuing a final rule.
                          governor's set-aside
    Question. The Governor's Workforce Investment Act set-aside allows 
15 percent of Workforce Investment Act funding to be used by the 
Governor, at the state-level, to pursue creative workforce development 
initiatives. Limiting the amount of funds available to Governors' 
workforce training initiatives stifles state-wide and regional 
employment training efforts. Governors are uniquely equipped to 
identify and address the workforce training needs of their state's 
local employers and should be given the tools necessary to do so. Why 
does the Department not support increasing the set-aside to 15 percent?
    Answer. The 2015 budget adheres to the spending levels agreed to in 
the Bipartisan Budget Act of 2013, which was an important first step 
toward replacing the damaging cuts caused by sequestration with 
sensible long-term reforms. However, remaining at these levels 
necessitates difficult decisions, and means that we cannot accommodate 
additional investments in key areas like the job training formula 
grants. The Opportunity, Growth, and Security Initiative proposed in 
the 2015 budget acknowledges this, and included funds to restore prior 
cuts in the formula grants. The fiscal year 2015 budget does, however, 
request the continuation of the reserve at this level, which allows for 
fundamental state oversight and accountability activities. The 
Department will continue to work with States to identify ways to 
operate within these funding levels while continuing essential 
activities.
    Question. Are you concerned that under the reduced set-aside 
Governors no longer have the flexibility to implement innovative 
statewide projects?
    Answer. Investments in innovation are essential to helping the 
public workforce system identify and implement more efficient and 
effective ways of equipping workers with the skills employers' need. 
The Department is committed to spurring innovation in the public 
workforce system, and the fiscal year 2015 budget request includes 
several initiatives that directly support innovation, such as the 
Workforce Innovation Fund. The Department has taken care to design 
these initiatives in ways that ensure states are positioned to compete 
for or otherwise leverage these resources through partnerships. In 
addition, the 2015 budget proposes a revamped WIA Incentive Grant 
program, which would provide grants to states that demonstrate the 
ability to achieve positive outcomes for populations with barriers to 
employment. States that are innovative and work across program siloes 
will be best positioned to receive these grants. Although structurally 
different from the Governor's reserve, these national initiatives 
support significant increases in partnership, flexibility, 
dissemination, and coordination of strategies.
              bureau of international labor affairs (ilab)
    Question. Mr. Secretary, since this Administration took office in 
2009, the Bureau of International Labor Affairs' (ILAB) has grown 
significantly. Comparing fiscal year 2009 funding to the budget 
requested in fiscal year 2015, ILAB's budget will have increased 6.2 
percent, with the office growing by 22 full-time employees, a 26.5 
percent increase. In this constrained budget environment, wouldn't the 
Department's funding be better spent on training workers in the United 
States as opposed to using taxpayers' dollars to establish labor unions 
abroad?
    Answer. The Department of Labor is committed to supporting workers 
in the United States and ensuring that those workers, and the 
businesses in which they are employed, have a fair playing field with 
respect to worker rights in the global economy. These efforts seek to 
prevent workers and businesses in the United States from facing unfair 
competition based on the violation of worker rights. ILAB promotes 
respect for internationally recognized worker rights, improves working 
conditions and workplace safety, and combats exploitive child labor, 
forced labor, and human trafficking in other countries, particularly 
among key trading partners.
    The increases in ILAB's budget beginning in fiscal year 2009 were 
preceded by several years of sharply declining budgets for the bureau--
from nearly $150 million in fiscal year 2003 to $82.5 million in fiscal 
year 2008. These budget reductions occurred in the context of an 
increasing workload for ILAB related to expanded trade agreement 
monitoring, congressionally required reporting, and ongoing technical 
assistance oversight responsibilities. In fiscal year 2009, ILAB's 
budget was increased to enable it to more effectively carry out its 
mandates and to address strategic areas. Since fiscal year 2010, ILAB's 
budget has remained stable or has declined. The budget request for 
fiscal year 2015 of $91.3 million and 105 FTE remains at approximately 
the same level as the fiscal year 2014 appropriations.
    To meet its mandates and address strategic areas, ILAB has added 
full time employees since fiscal year 2008 primarily to the following 
three areas:
  --Research and analysis to meet statutory reporting responsibilities 
        related to child and forced labor;
  --Monitor labor conditions in current or prospective U.S. trading 
        partners, enforcement of labor provisions of free trade 
        agreements, and labor eligibility criteria of trade preference 
        programs; and
  --Monitor, evaluate, and audit grant-funded projects to ensure 
        effectiveness, impact, and management and financial 
        accountability.
                       workforce innovation fund
    Question. Mr. Secretary, I remain concerned that as more workforce 
training programs become competitively awarded they will not reach 
those for whom training programs are intended. I also have reservations 
specific to the competitively awarded Workforce Innovation Fund. The 
fiscal year 2015 budget requests a fifth year of funding for a program 
whose outcomes are unknown. In a time when our national unemployment 
rate is 6.7 percent, the Workforce Innovation Fund does not provide any 
direct services to jobseekers. Wouldn't funding be better utilized on 
programs that directly serve jobseekers?
    Answer. Almost all WIF grants directly serve job seekers, youth, 
and/or business customers, with the exception of two grants focused on 
the delivery of workforce information and integration of performance 
data systems. The Workforce Innovation Fund (WIF) invests in innovative 
approaches to the design and delivery of employment and training 
services that generate long-term improvements in the performance of the 
public workforce system, outcomes for job seekers and employers, and 
cost-effectiveness. The 28 current WIF grantees are testing a variety 
of innovations in four categories: sector strategies and business 
engagement (including entrepreneurship training); career pathways and 
system alignment; data systems and online service delivery; solutions 
for targeted populations; and Pay for Success, an innovative funding 
model. In addition, WIF grants leverage significant funds from Federal, 
state, and local workforce development programs, to support long-term 
sustainability of effective innovations. The goal of these grants is 
for these innovations, products, and models to help make the broader 
workforce system more effective, leading to better, more cost-effective 
services for individuals across the system.
    Because the WIF grants are testing a variety of innovations, 
performance measures vary by project. Examples include the DOL common 
performance measures (entry to employment, employment retention, and 6 
months average earnings), credential attainment, businesses started, 
number of businesses served, employer satisfaction with job candidates, 
and participants that attain permanent housing. In aggregate, the 
current WIF grantees are expected to serve nearly 38,000 adults, 2,800 
youth, and 6,600 businesses. Details about the WIF grants can be found 
at innovation.workforce3one.org.
    Question. Are you concerned that the Workforce Innovation Fund 
siphons off funding that could otherwise be distributed to every state 
for training efforts, but now is instead only awarded to a few 
grantees?
    Answer. The Workforce Innovation Fund (WIF) makes efficient use of 
scarce resources by awarding funds competitively to experiment and 
build information about effective approaches, and disseminating this 
knowledge to the broader workforce system. WIF findings, products, 
models, and results are then shared widely with the workforce 
investment system. The resources are improving the quality and 
efficiency of the entire workforce system. For example, through the 
``Eye on Innovation Stakeholder Engagement Series,'' the Employment and 
Training Administration will share promising practices from WIF 
grantees on business services, systems alignment and career pathways, 
data systems, and online service delivery with other WIF grantees and 
the public workforce system throughout this summer. Technical 
assistance provided to the WIF grantees is available to the entire 
workforce system at innovation.workforce3one.org.
   occupational safety and health administration's regional emphasis 
                                program
    Question. Mr. Secretary, it is my understanding that the 
Occupational Safety and Health Administration (OSHA) has announced 
formation of a Regional Emphasis Program targeting auto parts supply 
manufacturers in Alabama, Georgia, and Mississippi. OSHA is looking at 
excessive ``workplace exposures to safety hazards'' in the Southern 
states' auto parts manufacturing industry. What defines ``excessive 
workplace exposure to safety hazards,'' what data do you have to 
support this claim, and how is that data collected?
    Answer. OSHA has been conducting Regional Emphasis Programs (REPs) 
since the early 1980s. They are designed to focus OSHA's resources in 
areas where a regional or local office has determined that special 
attention is needed.
    In order to determine which industries may need special attention, 
OSHA uses a combination of data resulting from OSHA's recent inspection 
activity in the industry in that area, as well as injury and illness 
rates, when available. Over the past 5 years, OSHA has been responding 
to worker complaints, fatalities, and injuries in the automotive parts 
manufacturing industry in Georgia, Alabama, and Mississippi. In 
response to the complaints and referrals, OSHA conducted inspections in 
these regions.
    For example, in 2013 a worker employed at a plant in Alabama that 
had been inspected by OSHA on more than one occasion since 2006, 
suffered a double amputation. OSHA found eight violations of safety 
standards in those inspections. Another plant covered by the emphasis 
program had seven inspections since 2009, with findings of serious and 
willful violations. Inspections like these led to the decision to start 
the Regional Emphasis Program.
    Worker injury and illness data supports the decision to focus on 
worker safety in the auto supply parts industry. The most recent Bureau 
of Labor Statistics (BLS) data show that the auto parts supplier 
industry in Alabama has a higher injury and illness rate--4.6 per 100 
full-time workers--than the same industry nationwide, which had a rate 
of 3.0 per 100 full-time workers.
    Below are the rates for the auto supply industry, both nationally 
and in Alabama (2010 was the last year that Alabama data was available 
for this industry.)

----------------------------------------------------------------------------------------------------------------
                                                                           Annual
                DART Rates                 ---------------------------------------------------------------------
                                             2003   2004   2005   2006   2007   2008   2009   2010   2011   2012
----------------------------------------------------------------------------------------------------------------
NAICS 3363 US.............................    5.1    4.5    4.4    4.3    3.7    3.3    2.6    3.0    2.7    2.8
NAICS 3363 Alabama........................  .....  .....  .....    3.4    3.9    3.3    3.0    4.6
----------------------------------------------------------------------------------------------------------------

    Source: BLS SOII
    The all-industry private sector average injury and illness rate in 
Alabama and the United States in 2010 was 1.8 per 100 full-time 
workers, meaning that the Alabama auto supply industry has an injury 
and illness rate more than two and a half times higher than the overall 
injury and illness rate for all private workplaces in Alabama.
    Question. Your Department claims to have undertaken efforts to 
address these hazards through cooperative efforts and compliance 
assistance ``for several years'' prior to announcing formation of a 
Regional Emphasis Program. In exact terms, how many years did your 
department provide compliance assistance to these manufacturers?
    Answer. OSHA always stands ready to provide compliance assistance 
to businesses that request it. Most of OSHA's Area Offices have a 
Compliance Assistance Specialist whose sole job is to provide 
assistance to organizations that request assistance. You may also be 
aware that OSHA funds a free on-site consultation program for small and 
medium-sized businesses. (https://www.osha.gov/dcsp/smallbusiness/
consult.html)
    The REP was initiated after a long period of working cooperatively 
with the industry to address the safety and health problems in the 
workplace. OSHA began a partnership in 2005 with an auto manufacturer 
(Hyundai) and its suppliers. During the partnership, OSHA provided the 
auto supplier manufacturing industry with a great deal of compliance 
assistance and education to help correct serious safety and health 
hazards. OSHA, however, continued to find a high number of serious 
safety and health hazards during inspections (resulting from complaints 
or referrals) in the auto supplier manufacturing industry, so OSHA 
ended the partnership in 2010.
    OSHA's emphasis programs begin with compliance assistance. 
Employers are notified of the program and offered information and 
training on OSHA standards and the tools they need to assure that they 
can come into compliance before an OSHA inspection.
    Thirty days prior to launching the Regional Emphasis Program, OSHA 
sent a letter offering information about the hazards we were targeting, 
as well as training and presentations about how to prevent injuries and 
illness related to these hazards. This provided the employers the 
opportunity to seek assistance or contact the consultation services. 
The REP was also included in speeches presented by OSHA to different 
groups and organizations in the Southeast.
                                 ______
                                 
             Questions Submitted by Senator Lamar Alexander
                          proposed silica rule
    Question. My staff has heard from many different stakeholders who 
have testified during Occupational Safety and Health Administration's 
(OSHA) public hearing sessions, and each of these industries have 
signaled how difficult it would be to comply with the proposed rule.
    How can you assure us that OSHA will actually produce a Final Rule 
that reflects the concerns expressed at these hearings?
    Answer. OSHA carefully considers the concerns expressed by all 
stakeholders, along with supporting data and other evidence, in 
developing a final rule. The Occupational Safety and Health Act of 1970 
(the OSH Act) mandates that any final rule issued by OSHA must be 
feasible for affected industries, and must be supported by substantial 
evidence in the record considered as a whole [29 U.S.C. 655(b)(5); 29 
U.S.C. 655(f)]. Accordingly, OSHA will consider the concerns expressed 
by stakeholders regarding their ability to comply with the proposed 
rule in developing a final rule.
    Question. When do you expect OSHA to issue a Final Rule?
    Answer. OSHA has not established a target date for issuing a final 
silica rule. The Agency is accepting post-hearing comments on the 
proposed rule from hearing participants until June 3, 2014, and will be 
accepting post-hearing briefs until July 18, 2014. OSHA will then 
review the evidence in the record as a whole and develop a final rule, 
if appropriate, based on that evidence.
    Question. What would it cost a manufacturing plant, which operates 
in an enclosed environment, and employs 1,000 people, to comply with 
this proposed regulation?
    Answer. OSHA did not develop a cost estimate specific to the 
facility you describe. Manufacturing establishments vary enormously in 
their costs per employee depending on the nature of their operations.
    Question. The proposed rule requests commenters to submit 
information about their financial backers if they submit scientific or 
technical data. How many commenters have done that?
    Answer. After searching the public comments submitted to the silica 
docket, we found very limited information pertaining to such 
disclosures. Several commenters have either disclosed funding sources 
or indicated that they did not receive funding. We have also received 
general comments both supporting and objecting to OSHA's request for 
disclosure.
    Question. In what way has this information contributed to the 
rulemaking?
    Answer. The request for this information is voluntary, and not 
required for submitting comments. OSHA has a legal responsibility to 
review and consider all material submitted to the rulemaking record in 
its development of a final rule and supporting analyses and will do so. 
The Agency believes that this voluntary request will only serve to 
enhance the transparency of the process.
                 wage determinations on military bases
    Question. The National Restaurant Association said in a March 20 
letter to DOL, that the Wage and Hour Division, for the first time 
instituted a new health and welfare benefit of $3.81 per hour on fast 
food occupations under the Service Contract Act. These fast food 
franchises that operate on military installations, like Fort Campbell 
in Tennessee and Kentucky, or Fort Bragg in North Carolina provide 
military personnel and their families a fast alternative to eating at 
the cafeteria, while not to mention, employ a few dozen young workers 
at each location. This new health and welfare benefit, coupled with the 
President's Executive order increasing the minimum wage, has some fast 
food operators facing a 50 percent increase in wages.
    What is the reason for the first time application of this fringe 
benefit?
    Answer. The Department's Wage and Hour Division is responsible for 
determining what prevailing wages and benefits are under the Service 
Contract Act.
    In reviewing the fast food wage determinations last summer, the 
Wage and Hour Division determined that those fast food workers should 
receive fringe benefits. According to our long-standing regulations, we 
generally apply a standard fringe benefit amount of $3.81 to the wages 
of all workers covered by the Service Contract Act, and did so for fast 
food workers.
    Our regulations also provide that government agencies with 
contracts covered by the Service Contract Act may ask us to reconsider 
application of that nation-wide fringe benefit rate if they think that 
because of the special circumstances of a particular industry, a 
variation in fringe benefits is necessary and proper in the public 
interest or would avoid the serious impairment of government business. 
On May 16, 2014, we responded to a request from the Department of 
Defense that we review the wages, fringe benefits, and vacation/holiday 
pay for fast food workers on Federal contracts. After careful 
consideration of DOD's request, our regulations, and the relevant data, 
the Department determined that we will no longer require a fringe 
benefit rate of $3.81. Instead, contractors employing fast food workers 
on Federal contracts will be required to pay $.66 in fringe benefits, 
$.17 in vacation pay for workers who have been employed for more than a 
year, and $.09 in holiday pay. We believe that these wage and benefit 
rates more accurately reflect the conditions in the industry and the 
definitions of prevailing rates embodied in the statute.
    Question. Are you concerned that some fast food operators will have 
to close their location on military installations? And what will this 
do to small business operators?
    Answer. On May 16, 2014, we responded to a request from the 
Department of Defense that we review the wages, fringe benefits, and 
vacation/holiday pay for fast food workers on Federal contracts. After 
careful consideration of DOD's request, our regulations, and the 
relevant data, the Department determined that we will no longer require 
a fringe benefit rate of $3.81. Instead, contractors employing fast 
food workers on Federal contracts will be required to pay $.66 in 
fringe benefits, $.17 in vacation pay for workers who have been 
employed for more than a year, and $.09 in holiday pay.
                                 ______
                                 
              Questions Submitted by Senator Mike Johanns
        new whd rule and elimination of companionship exemption
    Question. In September 2013, the U.S. Department of Labor (DOL) 
announced a final rule that essentially eliminated the Companionship 
Exemption (minimum wage and overtime exemption for non-medical 
companion care workers). The new regulation is scheduled to go into 
effect on January 1, 2015. The final rule posted in the Federal 
register indicated that this new rule is likely to have an annual 
effect on the economy in excess of $100 million. Does your Department 
intend to issue further guidance to state Medicaid programs and other 
stakeholders on the complex implementation of this rule? If so, when 
does it plan to do so?
    Answer. The Department has been very active in providing compliance 
assistance to all stakeholders since issuing the companionship services 
rule, including webinars and meetings specifically for state Medicaid 
programs. The Department has also had a number of meetings and other 
communications with representatives from various states to discuss the 
regulation's impact on their particular Medicaid programs, and 
anticipates having more such conversations as implementation continues. 
The Department has engaged with the disability community around issues 
of particular importance to them, including the Medicaid services 
designed to allow people living with disabilities to remain in their 
homes and communities. The Department continues to develop and issue 
guidance, including the recent Administrator's Interpretation 
specifically regarding shared living arrangements, most of which are 
funded through Medicaid programs, and has additional webinars and 
meetings scheduled to further inform the regulated community about 
implementation matters. The Department will develop additional guidance 
as issues are brought to us for clarification. In all of these efforts, 
we continue to work closely with our colleagues at the Department of 
Health and Human Services, and in particular the Centers for Medicare 
and Medicaid Services.
    Question. Do you think that states will have enough time to 
implement this final rule without undermining quality and access to 
care for Medicaid beneficiaries?
    Answer. The Department adopted a 15-month delayed implementation 
when it published the regulation on October 1, 2013. This delayed 
effective date was intended to allow state Medicaid programs sufficient 
time to make adjustments to their programs so neither the quality of, 
or access to, the programs will be disrupted.
    Question. Would you consider delaying the rule if states assert 
that they will not have time to implement the rule without disrupting 
quality and access to care for Medicaid beneficiaries?
    Answer. The Department is constantly monitoring implementation of 
the companionship services rule and will make appropriate adjustments 
as indicated.
    Question. Under this final rule, do you believe it is likely that 
home care recipients will attempt to control costs by independently 
hiring caregivers other than those employed by home care companies?
    Answer. We have no information that indicates that consumers will 
hire home care providers directly rather than continuing to purchase 
these services through home care agencies.
    Question. If so, will this result in fewer caregivers being in a 
position to receive healthcare through an employer?
    Answer. We have no information that would indicate this result.
                 union presence during osha inspections
    Question. According to a February 2013 OSHA letter of 
interpretation, an unspecified number of employees in a nonunion 
workplace may designate a union as their representative during safety 
inspections, even though the majority of workers have not authorized 
the union as their representative for any purpose. Do you believe that 
OSHA inspectors can remain neutral enforcers of the law if they are 
accompanied by outside union organizers when they inspect nonunion 
employers' private property?
    Answer. The status of OSHA inspectors as neutral enforcers of the 
law does not change when they are accompanied by third party ``walk-
around'' representatives. Section 8(e) of the OSH Act provides that 
``[s]ubject to regulations issued by the Secretary, a representative of 
the employer and a representative authorized by his employees shall be 
given an opportunity to accompany the Secretary or his authorized 
representative during the physical inspection of any workplace . . . 
for the purpose of aiding such inspection.'' Allowing a third party 
representative to accompany OSHA compliance officers on an inspection 
is solely related to protecting workers by achieving an effective and 
thorough health and safety inspection and consistent with the law and 
long-standing OSHA regulations.
                    osha inspection of family farms
    Question. Regarding the inspection of family farms, in the letter I 
received from you dated February 10, 2014, you said ``DOL will issue 
new guidance after consulting with USDA and with organizations 
representing farmers.'' Could you provide me with a list of meetings 
and discussions you or your staff have had with USDA, farm 
organizations, and other relevant groups regarding revisions to the 
guidance on postharvest activities on farms with more than 10 
employees? Please include the name of the entity and the date of 
contact. I encourage you to actively consult with as many of the farm 
groups and producers throughout the country as possible before moving 
forward in this area. These are the people who know best what happens 
on a daily basis on America's farms. Finally, I encourage you to ensure 
that any revised guidance draws as bright a line as possible between 
OSHA regulations and farming operations with 10 or fewer employees in 
order to ensure that the agency abides by the law.
    Answer. On January 31st, Department of Labor staff met with 
representatives from the USDA to consult with them regarding OSHA's 
guidance defining farming operations. OSHA has developed draft revised 
guidance to ensure that OSHA inspectors understand the limitations on 
OSHA's authority to conduct enforcement activities involving farming 
operations and will consult with USDA and other groups before 
finalizing the guidance. OSHA is currently in the process of contacting 
other farming groups such as the Farm Bureau to discuss its revised 
guidance.
   redefining fiduciary under employee retirement income security act
    Question. As you know, there has been a lot of concern surrounding 
the Department of Labor's proposed rule to redefine who is a fiduciary 
for plans regulated under the Employee Retirement Income Security Act 
(ERISA). A rule was proposed and then withdrawn, and Assistant 
Secretary Borzi is reportedly working on a re-proposal. My colleagues 
and I, in a strong bipartisan fashion, have expressed concern about the 
rule's potential impact on small savers, investor choice and small 
business. All of us certainly want to ensure that beneficiaries receive 
unbiased financial advice and we want to protect investor interests, 
whether someone is saving for retirement or for a child's college 
education fund. Thus, we must ensure that a re-proposed rule will not 
ultimately harm the very beneficiaries we're trying to help. Can you 
assure us that the Department's re-proposal will not increase the cost 
of IRA accounts or harm investor choice?
    Answer. We have not made a decision on the proposed rulemaking, and 
we would not make any decisions before we had listened to all sides, as 
we have committed to do. We regularly engage with stakeholders and 
solicit their views on a range of issues, and we welcome input from 
those who want to help us improve this marketplace before we make any 
decisions. The President has been clear that he is committed to 
strengthening retirement security for all Americans and we continue to 
believe that the most secure retirement requires a three-legged stool 
of social security, pensions, and personal savings.
    Question. Will your expanded definition of fiduciary align with the 
SEC's definition? It is essential that any rule changes still allow 
broker-dealers to provide affordable financial advice to working class 
Americans.
    Answer. ERISA and the securities laws serve important 
complementary, but distinct, purposes. In July 2013, we renewed our 
Memorandum of Understanding (MOU) with the Securities and Exchange 
Commission (SEC) on sharing information on enforcement, policy, and 
regulatory projects related to retirement and investment matters. In 
line with standard process, DOL continues to consult with the SEC, 
consistent with its status as an independent agency. In addition to 
regular, ongoing staff-level discussions, I have spoken to Chair White 
on several occasions since I became Secretary.
    Question. Also, Ms. Borzi has said that the re-proposal will be out 
this year. When can we expect to see it?
    Answer. We have not made a decision, and we would not make a 
decision before we have listened to all sides, as we have committed to 
do.

                          SUBCOMMITTEE RECESS

    Senator Harkin. With that, the subcommittee stands 
adjourned.
    [Whereupon, at 11:10 a.m., Wednesday, April 9, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]



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

                              ----------                              


                       WEDNESDAY, APRIL 30, 2014

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:04 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Tom Harkin (chairman) presiding.
    Present: Senators Harkin, Landrieu, Merkley, Moran, 
Alexander, and Kirk.

                        DEPARTMENT OF EDUCATION

                        Office of the Secretary

STATEMENT OF HON. ARNE DUNCAN, SECRETARY
ACCOMPANIED BY THOMAS P. SKELLY, DIRECTOR, BUDGET SERVICE

                OPENING STATEMENT OF SENATOR TOM HARKIN

    Senator Harkin. The Appropriations Subcommittee on Labor, 
Health and Human Services, Education, and Related Agencies will 
come to order. Good morning and welcome, everyone.

        DEPARTMENT OF EDUCATION FISCAL YEAR 2015 BUDGET REQUEST

    Welcome back, Secretary Duncan. It is great to see you 
again. I am glad to have you here to talk about your 
Department's fiscal year 2015 budget request.
    Your budget's proposed $1.3 billion increase is one of the 
largest of any Federal agency, second only to Veterans Affairs. 
The increase proposed for the Department of Education 
demonstrates this administration's continued commitment to our 
Nation's future. And the budget goes a step further with the 
Opportunity, Growth, and Security Fund, which would fully 
replace sequester in fiscal year 2015 and the subsequent 6 
years of the budget.
    This stands in stark contrast with the approach of Chairman 
Ryan's budget. That budget would cut nondefense discretionary 
spending by $43 billion, or about 9 percent, in fiscal year 
2016 and $791 billion over 10 years.

              FISCAL YEAR 2014 OMNIBUS APPROPRIATIONS BILL

    The Ryan budget charts a different course than that 
established by the 2014 omnibus appropriations bill. Congress 
passed that bill on a bipartisan basis earlier this year. This 
subcommittee negotiated over $l billion in new funding for 
early learning programs at Education and the Department of 
Health and Human Services.
    We also secured over $1 billion total for title I and IDEA 
(Individuals with Disabilities Education Act), the core Federal 
programs for elementary and secondary education. The increases 
for these programs allowed us to restore most of the sequester 
cuts in fiscal year 2013.
    For higher education, we included a new investment of $75 
million for the First in the World initiative to address 
college affordability. Colleges and universities will be able 
to compete for funding to test and develop strategies that 
reduce college costs and improve student outcomes. This is the 
first competition to support innovation in higher education 
since fiscal year 2010.
    We made a good start in the bipartisan omnibus bill, and I 
think we need to continue these important investments, not cut 
them and leave fewer of our students served.

                 NONDEFENSE DISCRETIONARY SPENDING CAP

    However, as the Secretary knows, there are some tough 
choices to be made under our nondefense discretionary spending 
cap. The fiscal year 2015 spending cap is roughly the same as 
the funding level for the current fiscal year.
    As I noted earlier, the Education Department's proposed 
increase of $1.3 billion is more than the increase allowed for 
all of nondefense discretionary spending.
    This makes it very difficult to provide the kind of 
investments this budget so wisely advocates. But that is not 
our only challenge. I am hopeful that this hearing will give 
the Secretary an opportunity to answer those who question the 
necessity of continuing to support the important work being 
done by your Department at all levels of education.

                           PREPARED STATEMENT

    Again, Secretary Duncan, I want to thank you for appearing 
before the subcommittee.
    [The statement follows:]
               Prepared Statement of Chairman Tom Harkin
    The Subcommittee on Labor, Health and Human Services, Education and 
Related Agencies will now come to order.
    Welcome back, Secretary Duncan. It's great to see you again. I'm 
glad to have you here to talk about your Department's fiscal year 2015 
budget request.
    Your budget's proposed $1.3 billion increase is one of the largest 
of any Federal agency, second only to Veterans Affairs. The increase 
proposed for the Department of Education demonstrates this 
administration's continued commitment to our Nation's future. And, the 
budget goes a step further with the Opportunity, Growth, Security Fund 
which would fully replace sequester in fiscal year 2015 and the 
subsequent 6 years of the budget.
    This stands in stark contrast with the approach of Chairman Ryan's 
budget. That budget would cut nondefense discretionary spending by $43 
billion, or about 9 percent, in fiscal year 2016, and $791 billion over 
10 years.
    The Ryan budget charts a different course than that established by 
the 2014 Omnibus appropriations bill. Congress passed that bill on a 
bipartisan basis earlier this year. This subcommittee negotiated over 
$1 billion in new funding for early learning programs at Education and 
the Department of Health and Human Services.
    We also secured over $1 billion total for Title I and IDEA, the 
core Federal programs for elementary and secondary education. The 
increases for these programs allowed us to restore most of the 
sequester cuts in fiscal year 2013.
    For higher education, we included a new investment of $75 million 
for the First in the World initiative to address college affordability. 
Colleges and universities will be able to compete for funding to test 
and develop strategies that reduce college costs and improve student 
outcomes. This is the first competition to support innovation in higher 
education since fiscal year 2010.
    We made a good start in the bipartisan omnibus bill and I think we 
need to continue these important investments, not cut them and leave 
fewer of our students served.
    However, as the Secretary knows, there are some tough choices to be 
made under our nondefense discretionary spending cap. The fiscal year 
2015 spending cap is roughly the same as the funding level for the 
current fiscal year. As I noted earlier, the Education Department's 
proposed increase of $1.3 billion is more than the increase allowed for 
ALL of nondefense discretionary spending.
    This makes it very difficult to provide the kind of investments 
this budget so wisely advocates. But that's not our only challenge. I 
am hopeful that this hearing will give the Secretary an opportunity to 
answer those who question the necessity of continuing to support the 
important work being done by your Department at all levels of 
education.
    Again, Secretary Duncan, I want to thank you for appearing before 
the Subcommittee. I turn now to Senator Moran for his opening 
statement.

    Senator Harkin. I turn now to Senator Moran for his opening 
statement.

                    STATEMENT OF SENATOR JERRY MORAN

    Senator Moran. Secretary Duncan, thank you very much for 
joining us today.
    Thank you, Mr. Chairman.

                        VALUE OF EARLY LEARNING

    There is no doubt about the important role education plays 
in a child's life. As I walk the halls of Kansas schools, I am 
struck by the faces of students who have such high hopes for 
their future. Whether opening doors to new opportunities or 
serving as a catalyst to achieving the American dream, it is 
clear that the foundation of our society is access to a quality 
education.
    And like you, Mr. Secretary, I believe that begins in the 
early years of development.
    Decades of research demonstrate that access to quality 
early childhood programs produce lasting effects on children's 
cognitive and social development. Children who are not 
proficient in reading by third grade are four times more likely 
to drop out of high school than children who read at or above 
grade level. A child's brain grows to approximately 85 percent 
of its full capacity in the first 5 years of life. Simply put, 
early learning is essential to the success of our students and 
society.
    However, as we strive to ensure all students have access to 
quality early learning and pre-kindergarten through grade 12 
programs, we must refrain from simply proposing new programs as 
the only solution, especially new competitive programs.

          FUNDING OF COMPETITIVE VERSUS FORMULA GRANT PROGRAMS

    I remain concerned with this administration's continued 
emphasis on competitive grant programs. Once again, this budget 
directs new or increased funding primarily to competitive grant 
programs. Of the administration's proposed $1.3 billion 
increase to the Department of Education's budget, no increase 
is provided for title I of ESEA (Elementary and Secondary 
Education Act) or Special Education Grants that are distributed 
by formula to every State. In fact, rather than increasing base 
funding for Special Education Grants to States, the budget 
request provides $100 million in new funding for competitive 
incentive grants under special education. Students in every 
State should benefit from any increase in funding for the 
Department of Education, yet that is not what is supported by 
the Department's budget request.
    Further, the fiscal year 2015 budget request proposes $300 
million for a new Race to the Top: Equity and Opportunity 
competition at the expense of an increase in funding for ESEA 
Title I grants. This new competition, as envisioned by the 
administration, is aimed at improving academic performance of 
students in the Nation's highest poverty schools by closing 
opportunity and achievement gaps. Yet rather than increasing 
funding for ESEA Title I grants, the cornerstone of Federal 
education funding for disadvantaged students since 1965, this 
budget invests in another new component of Race to the Top, the 
fifth since the program was created. It is important to note 
that not one of the Race to the Top components has yet 
demonstrated sustainable results.
    Mr. Chairman, the success of every student in every State 
should be our goal. The Department of Education should not pick 
winners and losers by funding only a few States to the 
detriment of students in all States.
    I look forward to working with you and the Department to 
ensure that fiscal year 2015 funding is directed toward 
initiatives that benefit all students and support increased 
educational opportunities in every State.
    Thank you, Mr. Chairman.

                 INTRODUCTION OF SECRETARY OF EDUCATION

    Senator Harkin. This is Arne Duncan's sixth appearance 
before this subcommittee. He became the ninth Secretary of the 
U.S. Department of Education on January 20, 2009.
    Before his appointment, Secretary Duncan served as the 
chief executive officer of the Chicago Public Schools. Before 
serving in Chicago, he ran the Ariel Education Initiative, 
which covered college costs for a group of inner-city youth and 
was instrumental in starting a new public elementary school, 
which ranks among the top schools in Chicago.
    Secretary Duncan also played professional basketball in 
Australia. Secretary Duncan graduated from Harvard University 
and played basketball at Harvard. He stills plays the game, so 
I guess you could say he still shoots a mean hoop.
    Welcome, Secretary Duncan.

                 SUMMARY STATEMENT OF HON. ARNE DUNCAN

    Secretary Duncan. Chairman Harkin, Ranking Member Moran, 
and Senators, the story of American education today is a good 
news/bad news story.

                    GOOD AND BAD NEWS FOR EDUCATION

    Let me begin by thanking you for your work on the 2014 
budget, which increased our investment in education over the 
previous year.
    This investment is essential for the ``good news'' side of 
the story, which is that our students are making substantial 
progress in graduating from high school and enrolling in 
college.
    Our Nation's on-time high school graduation rate reached a 
record high in 2012 of 80 percent. That is a great testament to 
the hard work of our Nation's teachers, school leaders, 
students, and their families. College enrollment is up as well 
since President Obama took office, with Latino and African-
American students leading the way.
    The bad news is that we still have unacceptable opportunity 
gaps in America, and it will be very difficult to close those 
gaps when Federal discretionary funding for education, 
excluding Pell grants, remains below the 2010 level.
    Our international competitors are not making the mistake of 
disinvesting in education, and their students are making more 
progress than America's students, endangering our country's 
competitiveness and prosperity.
    In a knowledge-based, global economy, the need to close 
these opportunity gaps and strengthen our competitiveness is 
one of the most urgent challenges facing our Nation. To 
continue to fall behind would hurt our country economically for 
generations to come.

          BIPARTISAN SUPPORT NEEDED TO CLOSE OPPORTUNITY GAPS

    So I appeal to you today to continue America's 
longstanding, bipartisan commitment to investing in education.
    Dating back to our Nation's founding, the Federal 
Government has provided incentives to State and local 
governments to invest in education and expand educational 
opportunity. Before the States ratified the Constitution, the 
Continental Congress required townships to reserve money for 
the construction of schools and granted Federal lands to States 
to create and support public schools.

                  PRESCHOOL EDUCATION OPPORTUNITY GAP

    Despite the educational progress we have made as a Nation, 
large opportunity gaps remain at a time when education is more 
important than ever to accelerate economic progress, increasing 
upward mobility and reducing social inequality.
    President Obama's fiscal year 2015 budget would increase 
investment in education to boost that progress and close those 
opportunity gaps. Sadly, those opportunity gaps start with our 
youngest learners in early childhood education. If we could 
look at our first slide, America today is 25th, 25th in the 
world, in our enrollment of 4-year-olds in preschool.
    [The graphic follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                SUPPORT FOR HIGH-QUALITY EARLY LEARNING

    Secretary Duncan. Four in 10 public school systems in the 
United States don't even offer preschool, setting the stage for 
a huge gap in school readiness that not only President Obama, 
but most of our Nation's Governors, find unacceptable.
    In the real world, outside of Washington, and away from 
congressional dysfunction, this has become a truly bipartisan 
issue. In fact, last year alone, 30 Governors--17 Republicans 
and 13 Democrats--increased funding for preschool in their 
State budgets.
    In tough economic times, these leaders chose to use scarce 
taxpayer dollars to expand access to high-quality early 
learning opportunities. Budgets, not just words, not empty 
rhetoric, reflect our true values. And these 30 Governors, in a 
bipartisan way, chose to walk that walk.
    Just one quick example, this year, Governor Snyder of 
Michigan committed to putting $65 million more into the State 
program to ensure children in need of preschool actually have 
access to it. He said he was going to make Michigan ``a no-wait 
State for early childhood education.''

          PRESCHOOL EDUCATION FUNDS IN FISCAL YEAR 2015 BUDGET

    We need to help every State to be able to make that claim.
    And that is why the President requests $500 million for 
Preschool Development Grants and $75 billion in mandatory 
funding for the Preschool for All program; programs essential 
to our Nation's future. They would support State efforts to 
provide access to high-quality preschool through a mixed 
delivery system of both public and private providers, for all 
4-year-olds from low- and moderate-income families.

                    VALUE OF EARLY LEARNING PROGRAMS

    Very encouragingly, a diverse, highly unusual coalition is 
working together to support these efforts. State attorneys, 
sheriffs, and police associations all support high-quality 
early learning because it reduces crime when those young 
children grow up.
    Military leaders support it, because a staggering three-
quarters of young adults today are not able to serve in our 
voluntary military, because they have dropped out of high 
school, can't pass the entrance exam, are physically unfit for 
service, or have a criminal record. High-quality early learning 
reduces all of those problems.
    Our military has always been our strongest defense. Our 
education system must be our strongest offense.
    In addition, hundreds of hardheaded business leaders and 
CEOs are big advocates of early learning, because they know 
high-quality opportunities produce a better workforce and have 
a high ROI, or return on investment.
    In fact, Nobel Prize-winning economist Dr. James Heckman 
found a return of $7 to every $1 of public investment in high-
quality preschool programs. I would ask how many other uses of 
taxpayer dollars have such a high rate of return for the 
American people.
    Unfortunately, opportunity gaps in early learning continue 
all the way through high school, as new data from our civil 
rights data collection shows. I will show you the next slide, 
please.
    [The graphic follows:]
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
          OPPORTUNITY GAP IN ACCESS TO POSTSECONDARY EDUCATION

    Secretary Duncan. Today, students of color, students with 
disabilities, and English language learners simply don't get 
the same opportunity as their white and Asian-American peers to 
take the basic math and science courses necessary that figure 
so importantly in preparing for college and careers.
    Often, this lack of access means students can't take the 
required classes they need to apply to 4-year universities. Or 
it means they go to college but must burn through Pell grants 
and other financial aid taking noncredit-bearing remedial 
classes because they simply weren't ready. They weren't 
prepared.
    Nationwide, black and Hispanic students are close to 40 
percent of high school students overall, but just over a 
quarter of students taking AP (Advanced Placement) classes and 
only 20 percent of those enrolled in calculus classes.
    This dumbing down of expectations is devastating to 
students, their families, their communities, and ultimately to 
our Nation as a whole.

                 GAP IN ACCESS TO HIGH-SPEED BROADBAND

    And the final slide highlights opportunity gaps in access 
to high-speed broadband in our schools. Most schools today have 
nowhere near the bandwidth they need to support current 
applications and instruction. Fully two-thirds of our teachers 
wish they had more technology in their classrooms.
    Technology both empowers teachers and engages students in 
their own learning. Simply put, other nations take these 
responsibilities and these opportunities more seriously than we 
do here.
    [The graphic follows:]
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
            PERCENTAGE OF U.S. SCHOOLS WITH BROADBAND ACCESS

    Secretary Duncan. In South Korea, for example, 100 percent 
of schools have high-speed Internet. Here in the United States, 
it is only about 20 percent, so 20 percent versus 100 percent.
    So our students, our teachers, and our schools often lack 
the bandwidth to take advantage of new technologies and tools 
that could accelerate efforts to close those insidious 
achievement gaps, to individualize instruction, and ensure that 
all students graduate from high school truly college- and 
career-ready.
    How is that fair to our children or to their hardworking 
teachers? How is that in our Nation's self-interest?

         FISCAL YEAR 2015 BUDGET GOAL--CLOSING OPPORTUNITY GAPS

    Making progress in closing these opportunity gaps is the 
ribbon, the theme that runs throughout President Obama's 2015 
education budget request. It is the overarching goal of the 
Preschool Development Grants and Preschool for All. It is 
behind our request for a $300 million Race to the Top: Equity 
and Opportunity Fund to help States and districts develop 
roadmaps to ensure that all students can reach their potential, 
and our $200 million Connect Educators initiative to provide 
teachers with the expertise they need to use technology to 
teach students to high standards and to personalize 
instruction.

                    RYAN BUDGET IMPACT ON EDUCATION

    By contrast, the House Republican budget would widen, would 
increase, opportunity gaps. OMB (Office of Management and 
Budget) estimates that the Ryan budget would cut funding for 
education by 15 percent in 2016, or by about $10 billion.
    If that 15-percent cut were applied to this year, ESEA 
Title I would be cut by $2.2 billion, and IDEA grants to States 
would be cut by $1.7 billion. That is exactly the wrong 
direction to go for our children and for our Nation's future. 
We can and we must do better, and do better together.
    The American dream has always been about opportunity. 
Today, our Nation is failing to live up to that core American 
idea for all of our citizens. We must do more now to level the 
playing field and make great public education available to 
every child. That is who we are, and that is who we should be. 
As former Florida Governor Jeb Bush says, ``The sad truth is 
that equality of opportunity doesn't exist in many of our 
schools . . .  That failure is the great moral and economic 
issue of our time, and it is hurting all of America.''
    So I ask, can we please get back to working together to 
close those opportunity gaps that we all agree are deeply at 
odds with the American promise of equal opportunity?

              LEADERSHIP CONTRIBUTIONS OF CHAIRMAN HARKIN

    And just quickly, Mr. Chairman, before I close, I just want 
to thank you so much for your leadership. I know this is 
probably the last hearing that we will do together. I have 
learned so much from you over these past 5\1/2\ years. You have 
been a lifelong advocate on very tough issues and you have 
always had a heart for those folks who don't always have the 
strongest voice themselves.
    Your leadership in the disability community is just 
exemplary. Like so many of us doing this work, this work is 
very personal for you. I have heard you speak eloquently about 
the opportunities--or, frankly, the lack of opportunities--your 
brother missed out on because he was deaf. And you have helped 
create more opportunities for literally millions of children 
who needed a voice.

                           PREPARED STATEMENT

    And finally, both you and Mr. Moran, Senator Moran, spoke 
as well on this push on early childhood education. And if we 
think about return on investment, if we think about 
strengthening our families, strengthening our country, I can 
make a pretty compelling case that the best investment we can 
make is in high-quality, early learning opportunities. And no 
one has been a clearer and more passionate advocate for that 
than you, so thank you so much. It has been a fantastic journey 
together. I will miss working with you greatly.
    [The statement follows:]
                   Prepared Statement of Arne Duncan
    I want to begin by thanking Chairman Harkin, Ranking Member Moran, 
and other Members of this Subcommittee for your work on the 2014 
appropriation for education. I appreciate the funding increases that 
you included in the fiscal year 2014 appropriation. However, it's 
important to recognize that total discretionary funding for the 
Department of Education, excluding Pell Grants, remains below the 
fiscal year 2010 level, and I worry about the long-term impact of the 
continuing slide in Federal education funding on the health of our 
economy and our democracy.
                 president obama's 2015 budget request
    Turning to 2015, the overall discretionary request for the 
Department of Education is $68.6 billion, an increase of $1.3 billion, 
or 1.9 percent, over the 2014 level. Within this total, we have six key 
priorities: (1) increasing equity and opportunity for all students; (2) 
strengthening support for teachers and school leaders; (3) expanding 
high-quality preschool programs; (4) improving school safety and 
climate; (5) promoting educational innovation and improvement; and (6) 
ensuring access to affordable and quality postsecondary education.
                         equity and opportunity
    We are requesting $300 million for a new Race to the Top--Equity 
and Opportunity competition centered on improving the academic 
performance of students in our Nation's highest poverty schools. RTT--
Opportunity grantees would support: (1) developing systems that 
integrate data on school-level finance, human resources, and academic 
achievement; (2) developing and retaining effective teachers and 
leaders in high-poverty schools; (3) increasing access to rigorous 
coursework; and (4) other evidence-based activities that mitigate the 
effects of concentrated poverty.
                support for teachers and school leaders
    A second priority in our 2015 request is to provide significant 
support for school teachers and leaders who are implementing new 
college- and career-ready (CCR) standards, turning around our lowest 
performing schools, and using new evaluation systems to improve their 
practices. A key request in this area is $200 million that would help 
educators transition to using technology and data to personalize 
learning and improve instruction, in support of the FCC's ConnectED 
initiative to equip our Nation's schools and libraries with high-speed 
connectivity. The program would benefit educators and students by 
creating high-quality, open digital learning resources aligned to CCR 
standards; using digital tools to personalize learning and implement 
new assessments; analyzing real-time data to improve student outcomes; 
using technology to increase student engagement; and providing remote 
access to effective educators.
    We are requesting $2.3 billion for Excellent Instructional Teams, 
which would provide both formula grants and competitive awards to help 
States and LEAs increase the effectiveness of teachers and principals. 
This total includes $2.0 billion for Effective Teachers and Leaders 
State Grants to provide flexible, formula-based support for States and 
LEAs; $320 million for the Teacher and Leader Innovation Fund to reform 
school leader advancement and compensation systems; and $35 million for 
a transformed School Leadership program to expand the Department's 
focus on current school leaders aimed at strengthening essential 
leadership skills.
                    expanding high-quality preschool
    The third major priority in the 2015 request is to continue the 
President's commitment to expanding educational opportunity for 
millions of children through a $75 billion mandatory Preschool for All 
program that would partner with States to support universal access to 
high-quality preschool for all 4-year-olds from low- and moderate-
income families. Our preschool request also includes $500 million to 
expand the Preschool Development Grants program that would help build 
State and local capacity to implement high-quality preschool programs.
    In addition, we are requesting $441.8 million for the Grants for 
Infants and Families program under the Individuals with Disabilities 
Education Act (IDEA), an increase of $3.3 million to help States 
implement statewide systems of early intervention services for all 
eligible children with disabilities from birth through age 2 and their 
families.
          affordability and quality in postsecondary education
    Our 2015 request also includes key initiatives to improve 
affordability and quality in postsecondary education. For example, we 
are asking for $7 billion in mandatory budget authority over 10 years 
for new College Opportunity and Graduation Bonus grants to reward 
colleges that successfully enroll and graduate a significant number of 
low- and moderate-income students on time. This initiative would 
support innovations to further increase college access and success by 
providing funding to eligible institutions based upon the number of 
Pell students they graduate on time. The Satisfactory Academic Progress 
initiative would make changes to the Pell Grant eligibility provisions 
by strengthening academic progress requirements to encourage students 
to complete on time. The Budget would also provide Pell Grant 
eligibility to students who are co-enrolled in adult and postsecondary 
education as part of a career pathway program to allow adults without a 
high school diploma to gain the knowledge and skills they need to 
secure a good job.
    Second, we would use $4 billion in mandatory funding to create a 
State Higher Education Performance Fund that would make 4-year 
competitive grants to States to support the successful implementation 
of performance-based policy and funding reforms that encourage and 
reward college affordability and ensure that students attend and 
complete postsecondary education.
    Third, our 2015 request proposes $100 million to expand support for 
the First in the World fund to make competitive awards to support 
improving educational outcomes, including on time completion rates, and 
making college more affordable for students and families, particularly 
for low-income students. The request also asks for $75 million for 
College Success Grants for Minority-Serving Institutions, which would 
make competitive awards to minority-serving institutions designated 
under Title III and Title V of the Higher Education Act.
    Lastly, we are continuing our efforts to help student borrowers 
with existing debt to manage their obligations through income-driven 
repayment plans. Our 2015 request proposes to extend Pay As You Earn, 
which caps student loan payments at 10 percent of discretionary income, 
to all student borrowers.
                 educational innovation and improvement
    We continue to support innovation and improvement in elementary and 
secondary education, beginning with $165 million for Investing in 
Innovation (i3), an increase of $23.4 million, to maintain strong 
support for using an evidence-based approach to scale up the most 
effective approaches in high-need areas. The i3 request would provide 
up to $49.5 million for the Advanced Research Projects Agency for 
Education, an initiative that would pursue technological breakthroughs 
with the potential to improve the effectiveness and productivity of 
teaching and learning.
    Second, we are requesting $150 million for a new High School 
Redesign program to support the transformation of the high school 
experience by funding competitive grants to school districts and their 
partners to redesign high schools to help ensure all students graduate 
from high school with college credit and career-related experiences or 
competencies.
    Third, our 2015 request seeks $170 million in new funding for a 
comprehensive STEM Innovation proposal to transform STEM education. 
This total includes $110 million for STEM Innovation Networks to 
provide competitive awards to LEAs in partnership with institutions of 
higher education, other public agencies, and businesses to help 
increase the number of students who are effectively prepared for 
postsecondary education and careers in STEM fields. We also are asking 
for $40 million to support STEM Teacher Pathways that would make 
competitive grants for recruiting recent college graduates and mid-
career professionals in the STEM fields in high-need schools. An 
additional $20 million would support the activities of a National STEM 
Master Teacher Corps, which would identify models to help America's 
brightest math and science teachers make the transition from excellent 
teachers to school leaders and advocates for STEM education.
    In addition, the Budget provides a $100 million increase for 
Special Education State Grants. This increase would support Results 
Driven Accountability incentive grants to improve special education 
services for children with disabilities. States awarded these grants 
would identify and implement promising, evidence-based reforms while 
also building State and local capacity to improve long-term outcomes.
    Our 2015 request also includes a request of $1.1 billion for a 
reauthorized Carl D. Perkins Career and Technical Education program. 
The reauthorization proposal would build on the experience of the i3 
program by creating a discretionary fund aimed at promoting innovation 
and reform in CTE and replicating the success of proven models.
                  improving school safety and climate
    The 2015 request would continue support for the Now is the Time 
school safety initiative by providing $50 million for School Climate 
Transformation Grants to help create positive school climates that 
support effective education for all students; $45 million for a 
Successful, Safe, and Healthy State and Local Grants program that would 
award grants to increase the capacity of States, districts, and schools 
to create safe, healthy, and drug-free environments; and $25 million 
for Project Prevent grants to help LEAs break the cycle of violence 
through expanded access, school-based strategies that prevent future 
violence.
              opportunity, growth, and security initiative
    The Administration's Budget also includes a separate $56 billion 
Opportunity, Security, and Growth Initiative. Our Education Budget 
would use this initiative to include additional investments of $250 
million for Preschool Development Grants, $300 million for the Connect 
Educators initiative, and $200 million for Promise Neighborhoods. All 
of these funds are in addition to the discretionary requests under the 
caps.
                               conclusion
    In conclusion, our 2015 Budget reflects the President's 
determination to make the investments necessary to secure America's 
future prosperity. I look forward to working with the Subcommittee to 
secure support for the President's 2015 Budget for education.

               PRESCHOOL EDUCATION LEADERSHIP AND SUPPORT

    Senator Harkin. Well, thank you very much, Mr. Secretary. I 
will respond in kind and just say that it has been great 
working with you for these last 5 years. You have been a great 
Secretary. You have really pushed the envelope on a lot of 
different things. And I think there has been tremendous change 
for the better in our schools in America because of your 
leadership.
    And I especially appreciate your strong and forceful 
leadership on early education. As you mentioned, that is 
something that I think we all--bipartisan, bicameral, 
executive, legislative--all agree on.
    Hopefully, we can come up with a good funding level for the 
preschool program. I think it has finally caught on around 
America. I did not know the number that you stated about the 30 
Governors who have increased their funding for preschool. But I 
think finally the American people, and, certainly, the business 
community has been behind this forever. For 25, 30 years, the 
business community has been pushing for more funding for 
preschool.
    So now it is really catching on. It is not too late, but I 
wish we would have done this 25 years ago.
    But your leadership has been great on this. I appreciate it 
very much.
    And this is the last time I will chair a budget hearing 
with you, with the Department of Education. And wouldn't you 
know it, my last year here, we have a tough budget. So we have 
some tough things to work out, but we will. We will work them 
out, and we will do our best to meet our obligations and do our 
best to work out with you and the President a meeting of the 
minds between the interests of the people on this committee and 
the legislative branch and the interests of the executive 
branch. I am sure we will get that done.
    So again, Mr. Secretary, I thank you for your great 
leadership. I am going to miss our association a lot.

          SPECIAL EDUCATION IN FISCAL YEAR 2015 BUDGET REQUEST

    Mr. Secretary, we will start a 5-minute round of questions 
now. Let's start with kids with disabilities. We made great 
progress on access, thanks to IDEA. We are improving quality of 
services. We have lifted IDEA funding in the Recovery Act. We 
did up to 33 percent, which got us close to the 40 percent, 
which we had promised so many years ago when I was a House 
Member.
    But we have more to do to make sure that students with 
disabilities are graduating with the skills and knowledge 
needed to succeed in postsecondary education and the workplace.

             RESULTS DRIVEN ACCOUNTABILITY INCENTIVE GRANTS

    That is why I was concerned to see the lack of any increase 
in IDEA formula funds. However, you do have an increase 
proposed--targeted to the Results Driven Accountability (RDA) 
incentive grants, which I am all for, because we are trying to 
change, as I said to you one time before, the focus on kids 
with IEPs (Individualized Education Program), so that when they 
get out of school, they won't feel that the only place for them 
to go is into subminimum wage jobs, that they can actually go 
out for competitive, integrated employment in the workplace.
    So many businesses have found that these people with 
intellectual disabilities can do a lot more than what we 
thought they could do in the past.
    And so I want to know more about the RDA incentive grants, 
and how you are going to work with, let's say, Vocational 
Rehabilitation on the HHS (Health and Human Services) side and 
the Department of Labor side to mesh these, to look at what 
schools can do, how they can work with the States' workforce 
development programs, to get these kids ready for competitive, 
integrated employment when they get out of school.

                 CHANGING SPECIAL EDUCATION TO OUTCOMES

    Secretary Duncan. So I really appreciate the opportunity to 
talk about this. And Michael Yudin, who leads this office, I 
think is doing extraordinary work, and really challenging us to 
challenge the status quo.
    As you know, we try to push States and districts very hard 
to raise expectations and raise the bar, and we have to do the 
same internally. And while we have done some really good things 
and good things together, I think a pretty compelling case can 
be made that, in this area, there probably has been too much 
focus on compliance, too much focus on checking boxes, and not 
enough focus on exactly what you are saying. Are we preparing 
these young people to be successful, to be self-sufficient in a 
competitive workforce, and focusing not just on inputs and on 
compliance, but on outcomes?
    What are we doing to increase high school graduation rates? 
What are we doing to increase college graduation rates? What 
are we doing to increase a successful transition into the 
workforce? We want to challenge people to step up and do more 
here.
    We want to identify those best practices. We want to 
replicate them. We want to take them to scale.
    So I am happy to talk further off-line. It would be great 
to have you and Michael Yudin spend some time together.
    But we think there is a chance to take the hard work that 
is going on around the country to a different level, and we 
want to be part of the solution, not part of the problem.
    Senator Harkin. Thank you, Mr. Secretary. I look forward to 
working with Mr. Yudin and our staff, if not on this committee, 
on the authorizing side, too.
    But I am just very interested in this funding for that new 
initiative.

            COLLEGE OPPORTUNITY AND GRADUATION BONUS GRANTS

    Let me just ask about college affordability. As you know, 
this is one of the key things we are going to be looking at, 
both on the authorizing level and on the appropriations level, 
too.
    We included a new investment of $75 million for the First 
in the World initiative in last year's omnibus. It will provide 
competitive grants to colleges and universities to develop and 
test strategies to make college more affordable and improve 
student completion rates. The higher education community has 
not had an opportunity to compete for funds that support 
innovation since fiscal year 2010.
    So this recent investment represents a long overdue 
opportunity to start moving the needle on college costs and 
student success at campuses across the country.
    Can you just provide a few details on what the Department 
hopes to accomplish with the upcoming competition for these 
funds?
    Secretary Duncan. Well, I think that the cost of college 
and college affordability is just a hugely important issue and 
one that we have a lot of work on ahead of us.
    And hardworking American families, not just in 
disadvantaged communities, but middle-class families, in far 
too many places, people are starting to think that college is 
for the wealthy, not for them.
    And I always tell the story--it was actually a visit to 
Iowa--where we did a town hall meeting and a young girl came up 
to me afterward and was talking--very sharp, very committed--
and ended up saying, she is a twin. She was a senior in high 
school, and this is like 2 years ago. But she said her parents 
had been trying to decide which twin to send to college, her or 
her brother.
    It was absolutely devastating. And families should not be 
put in that position. So we all have a lot of work to do to 
make college more accessible, more affordable.

                FIRST IN THE WORLD IN COLLEGE COMPLETION

    What we are trying to do in First in the World is 
incentivize universities to move in that direction, to focus on 
keeping costs down, to focus not just on access but completion 
rates at the backend. The goal is not to go to college; the 
goal is to complete at the backend.
    We are going to put out a notice on the First in the World 
competition in probably the next month, in mid-May, and then 
awards would go out by the end of the fiscal year in September.
    Senator Harkin. Well, that is good. That is good to know. I 
didn't know that. Thank you very much, Mr. Secretary.
    Senator Moran.

                    COLLEGE RATINGS SYSTEM CRITERIA

    Senator Moran. Mr. Secretary, let me start with my 
questions about, in this case, higher education. The President 
has directed that the Department develop a new college rating 
system for the 2015-2016 school year. And in this budget 
request, the request is made for $10 million to further develop 
that program.
    Let me raise a couple questions and thoughts about this 
topic.
    First of all, I would like to know, to date, what has 
transpired. And if we don't specifically include the $10 
million in this appropriation bill, does the Department intend 
to continue to develop this college rating system?
    Secondly, let me raise the topic of performance information 
for the college rating system that could be used to determine 
that criteria. I know it is in the works. You don't have the 
criteria in place yet.
    But I am concerned that, depending upon that criteria or 
the incentive that is created by this rating program, will it 
discourage universities from encouraging students from 
difficult backgrounds to pursue a college education? I guess 
they don't discourage the student; they just discourage them 
from coming to their university.
    And then finally on this topic, depending upon those 
metrics, how will you take into account something that I think 
is very important for us to, certainly, not discourage and if 
we can encourage, it is good, but if there is any criteria that 
is based upon the college graduate's income, what we would call 
financial success, are we not excluding people who enter the 
military, young people who decide they want a faith-based 
career, missions work----
    Secretary Duncan. Teachers.
    Senator Moran. Teachers. Yes, I almost beat you to that 
word.
    Are we not discouraging some things that are very noble in 
our society, if there is any criteria based upon what we would 
call ``success'' by those college graduates?

             CONSIDERATIONS IN DEVELOPING RATINGS CRITERIA

    Secretary Duncan. Those are all great questions, and we are 
working through all of those very tough issues as we speak. 
Again, I would be happy to have these conversations with you 
and your staff in detail.
    So to be clear, if we come up with something that does 
those things that you talked about, then we would have failed. 
So we absolutely want to not discourage, but encourage 
universities to take young people who are Pell grant 
recipients, who are first-generation college-goers. And if we 
do the incentive structure wrong, that will be a problem.
    We have some very clear thoughts about how to do it, to 
encourage universities to do it, and not discourage it. But 
happy to do that.
    We need more teachers. We need more social workers. We need 
more people to go into Government service. We need more people 
to go into the Peace Corps. And so making sure we encourage 
that, rather than discourage that, will be key.
    So we are being very, very thoughtful in how we put this 
system together. We are taking a huge amount of time. I have 
said repeatedly, we are going into this work with a great sense 
of humility.
    We have had dozens and dozens of roundtables with college 
students and college presidents and boards. I am happy to sit 
down with you and your staff to work it through. And our only 
interest is getting this right.
    Let me talk to you about, as difficult and intellectually 
challenging as this is, why it is so important.

                EDUCATION INVESTMENT IN HIGHER EDUCATION

    Together, you and I, all of us, we put out about $150 
billion in grants and loans to support higher education each 
year, $150 billion. Similar to the IDEA special education 
grants conversation, virtually all of that is based on inputs. 
Virtually none of that is based on outcomes.

             NEED FOR FOCUS ON COMPLETION AS WELL AS ACCESS

    So taxpayers are supporting a massive investment each year 
and have very little sense of whether they are getting a good 
return on that or not.
    As you know, some universities do a great job of increasing 
access. Others, frankly, don't. Some do a great job of 
encouraging first-generation college students to come. Others 
don't.
    I am very focused not just on access, but on completion, on 
attainment. Some universities do a great job of supporting 
students through mentoring programs and bridge programs. Others 
let them walk in the door, and they sort of sink or swim on 
their own.
    So we think we have to do something better. We have to do 
it together. We have to do it very thoughtfully.
    But having none of our money moving toward universities 
that are taking these responsibilities that you and I think are 
so significant, so profound, the status quo doesn't make sense 
to me.

           COMMITTED TO DEVELOPMENT OF COLLEGE RATINGS SYSTEM

    Senator Moran. In the absence of that $10 million being 
included in our appropriation bill, do you have the money and 
the authority to pursue this program?
    Secretary Duncan. We absolutely need to pursue this. We 
will pursue it. The money would be very, very beneficial. It 
would be very helpful. But we are moving forward on this, yes.
    Senator Moran. Thanks very much, Mr. Secretary.
    I don't have enough time to ask a second question. I will 
have an opportunity later.
    Senator Harkin. Senator Alexander.
    Senator Alexander. Thanks, Mr. Chairman.
    Mr. Secretary, welcome. It is good to see you.
    Let me discuss something that I am sure we agree on, and 
something I am afraid we disagree on, and ask you a question 
about it.

              STUDENT PERFORMANCE-BASED TEACHER EVALUATION

    We agree that we want higher standards for our 100,000 
public schools. I am pretty sure we agree that teacher 
evaluation based on student performance is sort of the Holy 
Grail of elementary and secondary education.
    Where I am afraid we disagree is that I believe that is a 
State and local responsibility, and you believe it can be 
required from Washington, DC.

                 NO CHILD LEFT BEHIND WAIVER AUTHORITY

    For example, you revoked a waiver the other day for the 
State of Washington because the legislature there wouldn't 
enact a teacher evaluation system according to your standards. 
Now, I looked at the law, Federal law, and section 9527 of the 
Elementary and Secondary Education Act says: An employee of the 
Federal Government can't mandate, direct, or control a school's 
curriculum, program of instruction. Section 1232 of the 
Elementary and Secondary Education Act said: Any department or 
agency here cannot exercise any direction, supervision, or 
control over curriculum, program of instruction, personnel. 
Section 3403 of the Department of Education Organization Act 
prohibits any direction over curriculum, instruction, 
personnel.
    In other words, it is clear to me that Congress says no 
national school board.
    Looking for the authority for you to make decisions like 
this, I go to the Secretary's waiver under No Child Left 
Behind, which is very simple. It says you may waive any 
requirement of the act that a State asks you to waive.
    But it seems to me, if it were ``Mother, May I,'' the old 
childhood game, you have turned it into where the child says, 
``Mother, may I go outside and play,'' and you say, ``Yes, you 
may, but you need to sweep the floor, and make your bed, and 
cook the breakfast, and go to school, and do your homework, and 
be nice to your father,'' and do all these things. And the kid 
said, ``I didn't ask about that.'' And the mother said, ``Well, 
that is what you have to do.''

           REQUIREMENTS TO OBTAIN NO CHILD LEFT BEHIND WAIVER

    To get a waiver for No Child Left Behind, for example, your 
requirements say you have to adopt standards. There are two 
versions of that that are approved, only two. You have to adopt 
ambitious, achievable performance goals about whether schools 
are succeeding or failing. There are two versions of that, only 
two. You have to have prescriptive turnaround models if schools 
are low-performing and have significant achievement gaps. There 
are four types of that, only four. And you have to have a 
certain kind of teacher and principal evaluation. It has to 
meet each of seven Federal criteria. And this didn't happen in 
Washington State.
    Now you know how much I care about teacher evaluation. 
Tennessee became the first State to do it when I was Governor. 
But I don't think you can do it from here or order it from here 
or define it from here.
    And in my opinion, what you are doing with this very well-
intentioned overreach, I think, is creating a backlash among 
conservatives who don't like the Federal Government involved, 
and a backlash among teachers unions who don't want any form of 
student achievement related to teacher evaluation. And you are 
undermining, I am afraid, the very high standards and teacher 
evaluation systems that I think both of us want to do.
    In other words, I think the way to get to where both of us 
would like to go is not by ordering it from here, but by 
letting the Governors and the States have the responsibility to 
do it.

            TEACHER EVALUATION AND FEDERALLY GRANTED WAIVERS

    So my question is: Would you please explain to me how using 
your waiver authority to place conditions on States about 
common standards, about performance targets, about teacher 
evaluation systems that are not otherwise required by Federal 
law--and in the case of standards, in my opinion, is prohibited 
by the law--how does that not amount to, in effect, a national 
school board?
    Secretary Duncan. This is a conversation you and I have had 
a number of times. Just to be very, very clear, to paraphrase a 
former Senator, I know what it is to be a superintendent. As 
you know, I used to be a superintendent, and I am not a 
national superintendent now.
    And what we have tried to do is very simple. Where States 
want to move away from the onerous provisions of No Child Left 
Behind, where they want to partner with us, and where we want 
to provide some flexibility, we just say some very simple 
things. You have to have high standards. And they can be State-
developed. They can be common. We are open there. There is lots 
of flexibility there in terms of what folks have done. We just 
say you can't dummy down standards.
    Again, you have the right to do that. We are just not going 
to provide you additional flexibility, if you are dumbing 
things down.
    We think that the goal of teaching is not to teach. The 
goal of teaching is to actually have children learn and to have 
a piece of teacher evaluation be based upon student learning, 
we think, is just sort of basic common sense.
    I think it is very important that we use language very 
precisely, encouraging high standards. Again, common, or not 
common, our goal is high standards. We feel very good about 
that.

              NO FEDERAL ROLE OR INVOLVEMENT IN CURRICULUM

    We never have, never will, touch curriculum. Curriculum is 
not standards. Those things get conflated either through--well, 
I won't get into why they get conflated. But standards are the 
bar we want people to reach, which is college- and career-ready 
once they graduate from high school.
    How you teach to those standards is curriculum. And it 
would be the height of arrogance for us to say anything about 
it. We never have, and we never will. That is always best left 
up to local communities.
    And so again, I would just use as a case study of where I 
think we have been a very important, effective partner, Exhibit 
A, quite candidly, Senator, is your State, the State of 
Tennessee.
    I came to that State 2 or 3 years ago. Tennessee was one of 
the lowest performing States in the Nation. I challenged the 
State to figure out, could it be the fastest improving State in 
the Nation, not the highest performing, but the fastest 
improving.
    I think if you asked your Governor, who I have a tremendous 
relationship with, if you asked your State superintendent, who 
I have a tremendous relationship with, have I and my Department 
supported them in their efforts--not told them what to do, not 
mandated things, but supported them in their efforts--I think 
we will let their words speak for themselves.
    And we are thrilled--thrilled--that Tennessee is the 
fastest improving State in the Nation. And all the credit goes 
to the great work at the local level. But I would like to think 
a small bit of the help of support they got from us has been 
part of that story.
    So I will stop there.
    Senator Alexander. Thank you, Mr. Chairman.
    This is a longer conversation, and my time is up.
    Senator Harkin. Thank you, Senator.
    Senator Landrieu.
    Senator Landrieu. Thank you very much, Mr. Chairman. And 
let me begin by thanking you for your extraordinary leadership 
all these years on this committee. And as an appropriator and 
an authorizer, you have had just an enormous impact for good 
for our country, for our children's health and education. And 
it has been an honor to work with you, and I look forward to 
our next few months together in these roles.

                         CHARTER SCHOOL PROGRAM

    Mr. Secretary, you know that I have been, along with many 
Members of Congress, both Democrats and Republicans, a strong 
champion for charter schools, for public charter schools--
public, open access, free charter schools--that are really, in 
essence, independent, entrepreneurial, inspirational, exciting 
places in this country, for the most part. Not every charter 
school is inspirational or working. But the idea of it, the 
model of it, is very entrepreneurial.
    I know that you are familiar with the just unbelievable 
growth in grades and academic achievement happening in Orleans 
Parish, which is sort of ground zero in a positive way for the 
charter school movement that Senator Alexander has been so 
supportive of, and Representative Miller, Representative 
Cantor, and Representative Kline, and a growing number of 
Senators here of both parties.
    So it was perplexing to me, having been able to see so 
carefully and so closely the tremendous opportunity that kids 
of all races and backgrounds are achieving in public charter 
schools, to see in your budget flat funding for this 
initiative, the charter school program. It was disappointing to 
see the level of charter school funding flat.
    Can the Department outline your expectations for successful 
implementation of the charter school program, given the level 
of funding at $248 million for 2015?
    And the reason I say that is because I know that moving to 
charter schools is not the answer for every failing public 
school. I realize that there are other choices, good choices, 
that can be made.
    But the evidence is in and clear that charter schools that 
are operating with quality leadership, it is in--the evidence 
is in; it is indisputable. With quality leadership, with open 
enrollment, with choice, it is actually working. And I see it 
every day when I go home.
    So why did you all flat fund it? And do you not agree with 
the evidence that has been presented to you and your 
department?
    Secretary Duncan. I appreciate your tremendous leadership 
and courage on this issue and others.
    I think the charter community has felt very well-supported 
by me and our administration. I think we have lots of bows and 
arrows, slings, to show for some of the challenges we have 
faced in support of that.
    These are, obviously, very tough budget times. We are 
thrilled to be able to maintain funding there.
    I just want to be very clear, for the record, that I am 
just a huge proponent of high-performing public schools, be 
they traditional schools or charter schools. And so many of the 
extraordinary public schools that I have seen in disadvantaged 
communities are charters, where they are changing the 
opportunity structure for kids and families----

        FUNDS FOR CHARTER SCHOOLS AND SCHOOL IMPROVEMENT GRANTS

    Senator Landrieu. Let me ask you this, then, because you 
and I have had a long conversation about this, like you have 
with Senator Alexander over the issues that he raised.
    You always say that, ``I am a strong supporter of high-
performing public schools.'' So we have $248 million for public 
charters, which are a proven model, when they work correctly. 
We then gave you, over the last several years, billions of 
dollars for traditional public school improvement.
    Do you know how much money to date this administration has 
been given, to you by Congress, for that? What is it, $6 
billion? Is that the number for----
    Secretary Duncan. Which fund? Which item are you talking 
about?
    Senator Landrieu. School Improvement Grants.
    Secretary Duncan. Oh, okay.
    Senator Landrieu. How much money have you had for School 
Improvement Grants? How much?
    Secretary Duncan. Yes, that is the right ballpark, yes.
    Senator Landrieu. About $6 billion.
    Secretary Duncan. Yes.
    Senator Landrieu. Okay, for School Improvement Grants.
    So my question is: You have given a very small amount of 
money for public high-performing charters. The evidence is in 
that they work. We have given 10 times that much money to 
School Improvement Grants for traditional public schools. So 
can you take 30 seconds, and then submit in writing to me, what 
evidence do you have that the $6 billion that we have spent for 
general improvements in public schools, not charters, what 
other models are working? And are they working as well as 
charters?
    Secretary Duncan. A couple things. Let me just walk through 
the math.
    That $6 billion is aggregated over a couple years. If you 
aggregate the charter money, it would be closer to $1 billion 
or so.
    Senator Landrieu. Okay, so it is $1 billion versus $6 
billion.
    Secretary Duncan. Roughly.
    Senator Landrieu. That is good.

                    SCHOOL IMPROVEMENT GRANTS FUNDS

    Secretary Duncan. This funding is going to the bottom 5 
percent of schools in the Nation, to turn them around. This is 
tough work. It is challenging. No one ever has funded this 
before.
    Part of the reason high school graduation rates are up 
across the Nation is we are challenging those dropout 
factories.

          CHARTER SCHOOLS AS MEANS FOR TURNING AROUND SCHOOLS

    One of the potential models that Senator Alexander talked 
about for those turnarounds is to convert to charters. Quite 
honestly, one of the challenges we have faced is that I would 
love more folks in the charter community to think about turning 
around traditional schools, and there has not been a lot of----
    Senator Landrieu. That is exactly what we have done in New 
Orleans. And I know I am taking my time, but 20 more seconds.
    The charter community, which is $1 billion with 1 million 
kids on the waiting list, is turning around, in our State, the 
lowest performing schools, taking them from the lowest to the 
highest. It is a model that works. It has been proven, proven, 
proven, proven.
    Secretary Duncan. So charter----
    Senator Landrieu. Let me just finish.
    It is a proven model. So I am going to be pressing this 
budget to spend our money where it works, and stop spending 
money where it doesn't. It is just as simple as that.
    So I am going to be looking for some very hard evidence on 
the $6 billion that you all have spent on general turnaround 
models, because I want you to prove to me that those other 
models work, because I know the charter model works.

            CHARTER SCHOOL ACCESS TO SCHOOL TURNAROUND FUNDS

    Secretary Duncan. Okay, just to be very, very clear, 
charters can access that $6 billion as a turnaround, and we 
don't have many charter providers who want to do this work.
    Senator Landrieu. I don't agree with that, but we will look 
into it.
    Secretary Duncan. Okay.
    Senator Harkin. Senator Merkley.
    Senator Merkley. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary.

          COMPETITIVE GRANT VERSUS FORMULA ALLOCATION PROGRAMS

    Mr. Secretary, one thing I wanted to draw to your attention 
that I am sure you have heard many times before; we have 200 
school districts in Oregon, many of them very small. They 
consistently ask me to encourage the Department to focus on the 
formula funding distributions, simply because they don't have 
grant writers.
    They don't have extra administrators who can write grants. 
They are stressed as it is. This is something I can relate to. 
I ran small nonprofits, and I was a grant writer. And I was a 
grant writer between midnight and 2 a.m. to try to get those 
grants out. And after you write five or six of them, and 
nothing comes back, you kind of give up.
    So they feel like the emphasis on grant writing is highly 
disadvantageous to small schools. And I have heard that in 
every part of my State. So I just wanted to emphasize that 
message back to you.
    Is that something you are familiar with?

      COMPETITIVE GRANT PROGRAMS AS PERCENTAGE OF EDUCATION FUNDS

    Secretary Duncan. Very aware of. And just to be clear, and 
it is sometimes a misconception here, approximately 89 percent 
of our budget is formula based. Only about 10 percent or 11 
percent is competitive. So the majority of every dollar, $.89, 
is going out on a formula basis.
    Having said that, we feel very good about the few programs 
we have on the competitive side. We have seen, increasingly, 
rural districts come in. We have seen consortia of districts 
come in. And we can sort of walk through whether it is a 
Promise Neighborhoods initiative or the Investing in Innovation 
Fund, where we have gotten some very nontraditional players, 
folks who think they can't compete or can't play are able to 
come into the game and do very, very well.
    So please challenge us to make sure we continue to level 
the playing field when we do that. But we think we have 
actually gotten better at that over time.
    Senator Merkley. Well, I will just note that the 2015 
proposals take the discretionary grant funds from 10 percent of 
the budget to 16 percent of the budget, which is the opposite 
of the direction my school districts would like to see us go. 
So I would just share that back with you.

                  HIGH COST OF POSTSECONDARY EDUCATION

    One of the things I am extremely concerned about is the 
cost of higher education. In this regard, certainly, I support 
more Pell grants. I support tuition freezes. I support low 
interest rates on student loans.
    But even with all that, in working-class communities, there 
is a growing conversation about whether or not there is really 
a pathway for children to succeed. And they are worried. And 
their parents are worried about having their kids trapped 
between high loan payments and low wages, and being squeezed 
between those.
    And demographically, we are actually seeing this impact in 
terms of people living in their parents' spare bedrooms, their 
basement, and marriage being postponed. It is not just an 
unfounded fear; it is a real thing.
    And it goes to the heart of an aspirational society where 
every child has a path to succeed.

                    OREGON'S PAY IT FORWARD PROGRAM

    There is a concept that has started in Oregon called Pay It 
Forward, which is designed to address this. It basically says, 
instead of getting a loan, you get a Pay It Forward grant. And 
in exchange, you pledge to pay back 2 percent of your future 
income over 2 decades, roughly, roughly speaking.
    The details are more complicated to work it out, but I am 
proposing experimenting with this, because it solves that 
compression, because you can't be trapped between low wages and 
high loan payments, because if your wages are low, your 
payments are low. And if you are the next Bill Gates, then you 
have the blessing of putting $1 billion or $2 billion into the 
grant fund for the next generation.
    It would create a different message that, indeed, there is 
an aspirational path for every child to succeed.
    Do you support experimenting with this type of different 
approach? Are you willing to engage deeply in the conversation, 
because our current system is not working?
    Secretary Duncan. First of all, Senator, I just want to say 
how much I appreciate your sensitivity on these issues. You 
understand them at a level of detail and nuance that most folks 
don't. You have lived this. You represent folks who are living 
this. And so having your thoughts, having your advice on this, 
is hugely helpful.
    That Pay It Forward model is very, very interesting to me. 
As you may know, it is based on the Australian and New Zealand 
models. I spent 4 years in Australia. My wife is Australian. 
She went to school there. So I am very, very familiar with it. 
I am happy to discuss it further. I am happy to look at whether 
you can experiment or do an exercise or do something 
interesting there in Oregon.
    But together, whether it is that or something else, I think 
we all have to find ways to do something radically better than 
what is happening today.
    So thinking outside the box, thinking differently, this 
idea came not from a bunch of academics, but from students in 
Oregon who are very, very thoughtful in doing the research and 
looking internationally. So we would love to continue the 
conversation in a meaningful way.
    Senator Merkley. Thank you. I will take you up on that 
offer to continue that conversation, because for untold numbers 
of high school students right now, they are getting the message 
from their community that they might as well give up, because 
they are not going to be able to afford to go forward. And that 
is something that should concern all of us.
    This is the American dream just slipping through our 
fingers for millions of working Americans.
    Secretary Duncan. Just quickly, we have tried to do as much 
as we can. There is a lot of work to do. We had, as you know, a 
$40 billion increase in Pell grants, without going back to the 
taxpayers for a nickel. It went from 6 million Pell recipients 
to almost 9 million, a 50-percent increase, many first-
generation college-goers, probably many of the residents you 
represent.
    So we feel great about that, but we have a lot of hard work 
ahead of us. We are not where we need to be.
    Senator Merkley. Thank you, Mr. Secretary.
    Senator Harkin. Senator Moran.
    Senator Moran. Mr. Secretary, there is an irony here that 
at least I see as an irony, that I want to explore with you.
    The President announced the ConnectED initiative last June, 
and the goal was to get 99 percent of our schools across the 
country to be connected. And, certainly, I am pleased by that. 
We work hard at bringing broadband services to rural America. 
It is a high priority for me.
    You have a part of that, and your budget request is for 
$200 million for a new Connect Educators part of that program. 
It is to train and bring our teachers up to a level of 
understanding and appreciation for what may come when 
connectivity actually occurs.
    But 84 percent, almost 85 percent, of the money that you 
are requesting of that $200 million is based upon a competitive 
grant. So you are asking rural and underserved areas of the 
country to compete for the $200 million that is in your budget.
    The irony of that to me is this: That we have already 
determined that we have these rural schools that will struggle 
to connect. And then we are making them compete for the money 
to help them be prepared for the money that will come.

          ABILITY OF RURAL SCHOOLS TO COMPETE FOR GRANT FUNDS

    To me, this is the broader issue that I tried to raise in 
my opening statement, in which we have competitive grants--and 
this is in part me being an advocate for rural America, an 
advocate for a State like ours.
    I will speak at graduation in 1\1/2\ weeks. There are 11 
high school seniors graduating from the class. Those kind of 
circumstances can't lend themselves to being capable of 
competing for the grants that your Department so actively 
promotes.
    And it seems to me, the point I want to make and have you 
respond to, is here we have a program that is initially 
designed to help rural schools. But even rural schools have to 
compete for those dollars. And already the decision has been 
made that there is a disadvantage.
    And my point being that those disadvantaged schools, 
whether it is this interconnectivity issue or it is Title I or 
it is IDEA, we just have school districts that are unlikely to 
be able to compete. They don't have the personnel. They don't 
have the grant writing expertise. It is hard to find somebody.
    Many of our school districts in Kansas will have a school 
superintendent who is also the building principal. And yet, we 
are asking those schools to figure out how they can compete for 
dollars that you want to use to promote excellence. I want to 
promote excellence, but I want to make certain we don't leave 
behind those that we claim already are underserved or 
disadvantaged because they are rural.
    Secretary Duncan. Great questions. I actually think we have 
very good answers. Again, I would be happy to follow up with 
you later.
    So we have, frankly, thought all these things through. When 
we do these competitions, we are not going to the wealthy 
communities. When we do Promise Neighborhoods, we are going to 
the most disadvantaged communities.
    So we are very intentionally targeting in these 
competitions those areas of the greatest need, not of the 
greatest grant writers, not of the greatest wealth.
    And again, if you look program by program, School 
Improvement Grants, Promise Neighborhoods, the Investing in 
Innovation Fund, when we did the School Improvement Grants that 
Senator Landrieu talked about, there was a huge outcry that 
rurals couldn't compete, it wouldn't work in rural communities. 
Quite surprisingly, to us, rural communities actually got 
slightly more than their ``fair'' share; they got 
disproportionately more of the dollars than did urban and 
suburban areas and have, frankly, done very, very well.
    So you can look across what we have done. We have made some 
significant grants in places like Appalachia. We have made 
grants in poor rural communities in other parts of the Nation.
    We have done competitive priorities. We have done absolute 
priorities and set asides. And again, I would be happy to talk 
through the structure with you. But we think we have done, 
frankly, over time, a pretty good job of making sure those 
rural communities who don't have the fancy grant writers are 
being very well-served.

                  MAXIMIZING IMPACT WITH LIMITED FUNDS

    The other important point to make is that, as you guys 
know, $200 million sounds like a lot. Spread across 15,000 
school districts, that is like pennies. And trying to maximize 
the benefits with scarce tax dollars--we are asking for $200 
million. I could use $2 billion, $4 billion, pick a number. It 
is just not realistic in these financial times. I understand 
that.
    We are trying to make sure that we have maximum impact in 
the places that could use the money the most, again, not the 
wealthiest districts, not those with the best grant writers, 
but to have maximum impact in the places that could use it the 
most.
    The final thing I will say is that, as we do the Connected 
Educators part, as the FCC (Federal Communications Commission) 
looks to increase access to high-speed broadband, we know rural 
communities have the greatest need. We know that is where the 
greatest cost is going to be. Just know that we are absolutely 
committed to serving those communities.
    Senator Moran. I don't think that there is a set aside for 
rural districts in Connected Educators. It is a broad program 
for all schools across the country to compete.
    Secretary Duncan. Again, we are happy to work it through, 
but whether it is a set aside, whether it is a competitive 
advantage, we want to make sure that every competition we do is 
being used in very different communities because we are trying 
to create spots that can demonstrate best practices.
    So we can work through with you, technically, how we are 
going to set this up. But rest assured, we will make sure that 
rural communities get their fair share of those resources.
    Senator Moran. Thank you.
    Senator Harkin. Thank you, Senator Moran.
    We have been joined by our neighbor to the east, Senator 
Kirk.
    Welcome. I yield to you, if you are prepared.
    Senator Kirk. I am.

                  ALL YEAR SCHOOL STUDY ACT (S. 2029)

    Mr. Secretary, I have a present for you. I wanted to give 
you this chart, which shows countries that have all-year 
schools substantially outscoring the United States. It is for 
you and your office, so you can always look at it and be 
reminded of S. 2029, which Senator Booker and I have endorsed.
    [The chart and information on All Year School Study Act 
from Senator Kirk's office follow:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                ------                                

                  From the Office of Senator Mark Kirk
                   all year school study act, s. 2029
    Kirk-Booker bill to establish a pilot program for year-round 
schools to boost academic achievement in low-income, low-performing 
districts
The Problem
    A long summer vacation within the school calendar is an outdated 
relic from the agricultural economy of 19th century. We no longer need 
kids to bring in the harvest. Moreover, the long summer breaks of the 
traditional school calendar can be detrimental to academic achievement.
  --Over the course of the summer, students lose on average one-month 
        of math skills
  --Low-income students lose as much as 3 months of learning in reading 
        skills while their higher-income peers actually make gains in 
        the same skills
    However, very few schools have adjusted their calendars.
Year-Round Schools Are an Effective Solution
  --In Illinois, year-round schools have been consistently successful 
        at increasing academic achievement. At Alain Locke Elementary 
        in Chicago, 25% and 23% more low-income students hit state 
        benchmarks in reading and math than the state overall. It was 
        also recognized by the U.S. Department of Education as 1 of 7 
        schools in the nation best at ``Closing the Achivement Gap.''
  --A 2012 study of year-round schools in Virginia found that certain 
        student groups are more likely to improve faster. 74% and 65% 
        of African American students at year-round schools improved 
        faster than their traditional calendar peers in reading and 
        math respectively.
  --The United States overall has seen stagnant growth for student 
        performance in recent years, while other OECD countries that 
        employ year-round schools such as Singapore, Japan, and 
        Austrailia routinely dominate on international math testing.
  --According to 2013 PISA results, the U.S. average math score was 13 
        points below the OECD average, meanwhile Singapore, whose 
        average scores ranked 2nd overall, outscored the OECD average 
        by 79 points.
    We need to cultivate our future workforce to be prepared to master 
the skills of the 21st century information economy--and follow the 
example of some of our toughest competitors by embracing innovative 
approaches to education.
All Year School Study Act
  --Authorizes a $4 million multi-year pilot program to establish year-
        round schools in the U.S.
  --Target low-income, low-performing areas and focus on STEM 
        education.

    Staff Contact: Jordan Hynes

                          YEAR-ROUND SCHOOLING

    Senator Kirk. I just wanted to get you on the record: Do 
you endorse this legislation to encourage all-year school?
    Secretary Duncan. First of all, it is great to see you and 
to be able to work with you.
    And there are other areas where we need lots of studies. I 
am not sure if we need another study on summer reading loss. We 
have study after study after study, particularly in 
disadvantaged communities, where teachers work hard to get 
children to a certain point in June, and they come back in the 
fall, in September, and they are further behind than when they 
left. It is absolutely heartbreaking.
    So I will take it one more step. We don't need just longer 
years. We need longer days. We need longer weeks. We need to 
think about time in a very different way. And again, not for 
every single child.
    When Senator Landrieu, before you got here, Senator Kirk, 
talked about high-performing charter schools, many of those 
high-performing charter schools, they just have longer school 
days. They are working on Saturdays. They are working through 
the weekend.
    We talked a lot in my opening statement about opportunity 
gaps. We have to close those opportunity gaps with more time 
with great instruction, more time with great academic 
enrichment, more time for debate and academic decathlon, and 
yearbook, and drama, and sports, and robotics. All those types 
of things--summer months, after school, Saturdays--give us a 
chance to give children what they need to be successful.
    Senator Kirk. As you remember, in Chicagoland, we increased 
the learning time for Chinese to make sure that people could 
get some sophistication in that language, which was a key thing 
for Chicago Public Schools to make sure we had kids who were 
prepared for the 22nd century economy.
    Secretary Duncan. So when I talk about more time and longer 
days and longer weeks, adults usually cheer and kids usually 
boo or throw tomatoes at me. So be prepared for a few tomatoes 
to be thrown your way as you talk about this.
    Senator Kirk. I think Cory and I can handle it.
    Senator Harkin. Senator Kirk, anything else?
    Senator Kirk. That is it.

                       CHAIRMAN'S CLOSING REMARKS

    Senator Harkin. We are going to close up here. I will just 
say that I tend to think that we do need longer school days. I 
don't know about a longer week.
    Longer school days and a longer school year, I would agree 
with Senator Kirk on that. Our days are very, very short. I do 
think we need to look at longer school years also.
    Mr. Secretary, do you have anything else that you want to 
add?
    Secretary Duncan. Again, thank you very much for your 
leadership.
    Senator Harkin. Thank you.
    Secretary Duncan. And I know you, as a leader here, have 
some very tough budget decisions to make. But you have always 
been collaborative. You have always been thoughtful. And no one 
is more passionate about the closing of opportunity gaps, so 
thank you for your leadership.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Harkin. Well, thank you very much, Mr. Secretary, 
and we will work with you on getting this appropriations bill 
through in the next few months anyway.
    The hearing record will remain open for 1 week for Senators 
to submit other statements and questions.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
               Questions Submitted by Senator Tom Harkin
                      high quality early learning
    Question. Mr. Secretary, I applaud the President and you for your 
continued commitment to advance early learning in the United States. I 
have been calling for this kind of investment for a number of years, 
and I think it's just what we need. We've been able to move the needle 
some on the issue. Last year's omnibus included an increase of $1 
billion in Head Start. It included new resources and authority under 
Race to the Top for Preschool Development Grants. And, the 
administration's fiscal year 2015 budget request builds on these 
investments.
    Some have suggested that we don't need another Federal program or 
more Federal resources invested in high quality early learning 
programs. I disagree. I'd like to hear your response to that criticism 
of your budget proposal.
    Answer. It is important to understand that despite existing 
investments in programs like Head Start, there is tremendous unmet need 
in this country for access to high-quality preschool. There is near-
universal agreement on the importance of high-quality preschool 
education, and parents want what is best for their children, but there 
simply are not enough affordable, high-quality slots for children to 
attend these programs. Nationally, only 3 in 10 children are enrolled 
in high-quality preschool programs. In almost every State, the unmet 
need for early learning is enormous. For example, in Pennsylvania, 
6,700 children are waiting for openings in the State preschool program; 
in Colorado, districts report that over 8,000 eligible children cannot 
be served; and in Michigan, Governor Snyder reported last year that 
29,000 needy preschool age children didn't have an opportunity to go to 
subsidized preschool.
    In addition, we need to recognize that what parents and children 
need is access to high-quality early learning opportunities from birth 
through age 5. So we're not talking about just creating more slots, but 
slots in high-quality preschool programs. Very few existing programs 
are meeting the demand for both access and quality, whether you're 
talking about cities, suburbs, or rural communities.
                   high school graduation initiative
    Question. Mr. Secretary, I am pleased that your budget proposes to 
continue investing in high school reform, building on activities 
currently funded through the High School Graduation Initiative. Please 
tell me more about what we are learning through the high school 
graduation initiative and how this would inform high school reform 
activities proposed in the fiscal year 2015 budget request.
    Answer. High School Graduation Initiative grantees are implementing 
a variety of research-based and other promising strategies to keep at-
risk students from dropping out and re-engage out-of-school youth. 
These include using data tools to identify and serve at-risk students 
more effectively, such as early warning indicator systems; offering 
personalized support services, including graduation coaching and 
mentoring, through proven approaches like Check and Connect and 
Advancement Via Individual Determination (AVID); and implementing 
school climate interventions such as Positive Behavioral Interventions 
and Supports.
    Although targeted strategies such as these hold promise, the 
President and I believe that more fundamental reforms are needed if 
efforts to improve the graduation rates of our Nation's chronically 
underperforming high schools and to prepare students graduating from 
these schools truly for college and careers are to meet with lasting 
success. The proposed High School Redesign program, funded at $150 
million in the President's budget, would call on local educational 
agencies and their partners to provide a radically overhauled and more 
engaging high school experience through instruction that is 
personalized to the needs and interests of individual students; 
relevant for the careers of the 21st century, including through 
improved use of technology; and complemented by an array of support 
services, including those currently supported with High School 
Graduation Initiative funds. Similarly, College Pathways and 
Accelerated Learning, which under the administration's reauthorization 
proposal would consolidate the High School Graduation Initiative and 
other current-law programs and for which we request $75 million in 
fiscal year 2015, would support local efforts to improve and sustain 
student interest by introducing more challenging curricula in high 
schools with low graduation rates, such as Advanced Placement and 
International Baccalaureate courses, dual-enrollment programs, and 
early college high schools, while providing support services for 
students not on track to graduate.
           student outcomes and 21st century workforce needs
    Question. Also, how would the program address the misalignment 
between student outcomes and the needs of the 21st century workforce, 
particularly through partnerships among school districts, employers, 
and institutions of higher education?
    Answer. The High School Redesign program would incorporate a number 
of strategies to improve alignment between workforce needs and programs 
serving high school students. Under our proposal, eligible entities 
would have to include organizations that can help structure and 
facilitate career-related experiences for students as well as help 
schools prepare students to apply academic concepts to real-world 
challenges and entities. Such organizations might be nonprofits, 
community-based organizations, government agencies, or other business 
or industry-related organizations. In addition, all grantees would be 
expected to provide students with career-related experiences or 
competencies, obtained through organized internships and mentorships, 
structured work-based learning, and other related experiences. We would 
also give special consideration to projects that plan to work with 
employers that help participants attain career-related credentials.
    In addition, our fiscal year 2015 budget request also provides $1.1 
billion for a reauthorized Perkins Career and Technical Education (CTE) 
program that would increase alignment between CTE and labor market 
needs and strengthen collaboration among secondary and postsecondary 
CTE programs and business and industry.
 elementary and secondary education act waivers and student protections
    Question. Mr. Secretary, last month you responded to my February 
19, 2014, letter related to ESEA flexibility granted to State 
Educational Agencies. As you know, I expressed great concern about how 
waiver implementation may erode protections for our most vulnerable 
students. I was hopeful that the response would provide more details 
about the Department's plans to address the concerns I identified in my 
letter. Specifically, my letter outlined four main concerns:
      (1) Waiver States identifying drastically lower numbers of 
        schools for interventions;
      (2) Waiver States not providing interventions in schools that are 
        low-performing, but not identified as priority and focus 
        schools;
      (3) The use of super subgroups in States' accountability systems; 
        and
      (4) The lack of accountability for high school graduation rates 
        in States' accountability systems.
    Could you please provide more details about the Department's plans 
for addressing each of these concerns?
    Answer. I want to emphasize that I share your concern about 
improving educational opportunities for our most vulnerable students, 
including low-income and minority students, students with disabilities, 
and English learners. This concern was a driving force behind our ESEA 
flexibility initiative, under which we are working with States to 
ensure access to a high-quality education for all students, and I would 
be pleased to have my staff meet with yours to discuss how we are 
addressing your concerns in ESEA flexibility, to date. As we continue 
to develop, in the coming months, our plans for the ESEA flexibility 
renewal process, we will continue to closely examine the issues you 
raise in your letter, and look forward to continuing to work with you 
on behalf of America's students.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray
    guidance provided on use of title i funds for homeless students
    Question. The number of homeless students in America's public 
schools has increased 72 percent since the great recession. Although 
homeless students are eligible to be served under Title I, the 
Department of Education's guidance has actually made it challenging for 
school districts to effectively serve these vulnerable children. To 
address this, the fiscal year 2014 appropriations bill includes 
language specifically stating that funds under Title I can be used to 
provide homeless students with transportation to school, and to support 
homeless liaisons, and the school district staff that identify homeless 
students and help to stabilize their education during this time of 
extreme hardship for the students and their families.
    Guidance issued by the Department of Education in a March 21, 2014, 
Dear Colleague letter directly contradicts the language of the fiscal 
year 2014 appropriations bill. Specifically, the Department's guidance 
poses the question: May a local educational agency use funds it 
reserves under section 1113(c)(3)(a) of the Elementary and Secondary 
Education Act (ESEA) to pay for a homeless liaison or to provide 
transportation to the school of origin?
    The answer provided by the Department is: ``No,'' followed by 
additional commentary that undercuts the very clear congressional 
intent of our fiscal year 2014 bill language. Can you explain why the 
Department took this action, and what the Department will do to fix it 
so that the Department is in compliance with the law that was passed 
last year?
    Answer. Our intention was to make clear that, in addition to the 
new authority to pay for the liaison and school-of-origin 
transportation, the requirement to provide comparable Title I services 
remains. We are continuing to work with your staff on this issue.
   american printing house resources with enhanced accessibility for 
                             learning plan
    Question. The American Printing House for the Blind (APH) is the 
world's largest nonprofit organization creating educational, workplace, 
and independent living products and services for people who are blind 
and visually impaired. APH has worked in partnership with the Federal 
Government since 1879 to fulfill their mission. The Department of 
Education's fiscal year 2015 request for APH is $24.456 million, the 
same level the APH has received each year since fiscal year 2010.
    Digital technology is rapidly changing the ways in which 
educational materials are delivered to students. The APH has developed 
a ``Resources with Enhanced Accessibility for Learning'' (REAL) Plan to 
streamline and speed up the delivery of digital educational materials 
from publishers to students who are legally blind in accessible 
formats--both hard copy and digital braille and large print. This work 
is important for students who are blind and visually impaired to 
continue receiving the same educational content as their sighted peers.
    Secretary Duncan, given the high cost of developing technology, 
does the Department plan to increase funding for the American Printing 
House for the Blind's REAL Plan?
    Answer. The President's fiscal year 2015 budget request would 
provide a total of $24.5 million in discretionary funding to the 
American Printing House for the Blind (APH). The President recognizes 
the historical legacy of APH and its commitment to creating 
educational, workplace, and independent living products and services 
for people who are blind and visually impaired. ``Resources with 
Enhanced Accessibility for Learning (REAL) Plan'' is a new initiative 
for which APH has already proposed to use its endowment funds to cover 
costs associated with consultation and production for fiscal year 2015.
     ensuring timely access to printed text for blind and disabled
    Question. What additional investments can the Department make to 
ensure timely access to accessible content for students who are blind 
or have another disability affecting their ability to read printed text 
and graphics?
    Answer. Due to budgetary constraints, the President's fiscal year 
2015 budget request of $24.5 million would maintain level funding at 
the fiscal year 2014 level. The Department has met with APH to discuss 
the development of performance measures for APH's newest technologic 
innovations, with the intent to ensure timely access to accessible 
content for students who are blind or have another disability affecting 
their ability to read printed text and graphics.
  funding for high school equivalency program and college acceptance 
                            migrant program
    Question. The High School Equivalency Program (HEP) and the College 
Assistance Migrant Program (CAMP) are critical to promoting educational 
access, retention, and completion for children of migrant farmworkers 
which are some of the most underserved, disadvantaged, and at-risk 
students in the country. Frequent moves contribute to very high dropout 
rates and the low enrollments in higher education. Yet, according to 
the Department's own estimates, HEP and CAMP programs are very 
successful: 89 percent of all CAMP participants successfully completed 
their first year at an institution of higher education and 74 percent 
of HEP students who completed their course of study earned a GED. 
CAMP's freshman cohorts have higher continuation rates than most 
college's general freshman population.
    Given the success of this program, please explain why the 
Administration for fiscal year 2015 proposed $34.6 million for the HEP 
and CAMP programs which is the post-sequestration level, and did not 
propose the pre-sequestration level funding of $36.6 million for the 
HEP and CAMP programs in fiscal year 2015 which the Administration 
proposed in fiscal year 2014?
    Answer. We agree that the High School Equivalency Program and the 
College Assistance Migrant Program programs provide important support 
for helping individuals from migrant populations to receive their GED 
credential and to complete their first year of postsecondary education. 
There are many good, effective programs in the Department, but in order 
to maintain fiscal discipline and adhere to the spending levels set in 
the Bipartisan Budget Act of 2013, we had to make tough choices and set 
priorities for spending increases among programs, even increases that 
would only bring back program spending to pre-sequester levels.
    Please note that HEP and CAMP programs are not the only source of 
funding that can assist youths and adults from migrant farmworker and 
seasonal worker populations who are interested in obtaining their GED 
credential or completing their first year of postsecondary education. 
The administration's fiscal year 2015 budget request also provided 
$898.3 million for Federal TRIO programs and $597.7 million for Adult 
Education State grants.
       professional development through the connected initiative
    Question. I was very interested to see that your fiscal year 2015 
budget request proposes $200 million for a new Connect Educators 
initiative that helps educators transition to using technology and data 
to personalize learning and improve instruction and assessment. As a 
strong supporter of the Enhancing Education Through Technology program, 
which has not received funding since fiscal year 2010, as well as the 
ATTAIN Act--the Accelerating Technology Transfer to Advance Innovation 
for the Nation Act of 2014, I was pleased to see a renewed focus from 
your Agency on education technology.
    Can you please provide more information about the types of 
professional development that you envision being provided through this 
program?
    Answer. The administration's ConnectED initiative will connect 99 
percent of America's students to the digital age through next-
generation broadband and high-speed wireless in their schools and 
libraries. The initiative invests in improving the skills of teachers, 
ensuring that every educator in America receives support and training 
in using education technology tools that can improve student learning.
    ConnectED calls for additional funding and support for schools to 
improve their network connectivity and provide device access to all 
students. Connect Educators is designed to help teachers and principals 
understand how to use technology to help with the implementation of new 
assessments as well as to leverage technology to support needed 
professional development and increase access to online resources, 
including sample lessons and e-books that are aligned with college- and 
career-ready standards.
    The increased connectivity called for through ConnectED opens up 
opportunities for teachers and principals to engage and collaborate 
with other educators across the country to improve practice and share 
approaches. Becoming a connected educator can accelerate the adoption 
of best practices for all teachers and principals, but is crucial for 
teachers in schools where there may only be one teacher in a particular 
grade/subject in the school, who otherwise may have limited 
opportunities for collaboration, and for principals so that they can 
connect with other principals across schools. Connect Educators calls 
for funding for teachers and principals to receive ``at the elbow'' 
support in both of these areas as well as to get connected to online 
communities and personalized professional development that meets the 
individual learning needs of educators, much like personalized/blending 
learning is used to improve instruction and support for students.
               connect ed and teacher evaluation systems
    Question. How would this program support school districts as they 
implement new teacher evaluation systems?
    Answer. This program would support district efforts to align their 
professional development with new educator evaluation systems by 
offering teachers and principals access to personalized professional 
supports, in the form of Web-based professional development courses or 
online communities, that are designed to address needs identified in 
evaluations and help educators improve their practice and become more 
effective over time.
                 connect ed and common core assessments
    Question. How would this program support school districts as they 
implement new assessments linked to the Common Core State Standards?
    Answer. Providing schools with the connectivity and device access 
that they need is essential to helping them implement new assessments 
linked to college- and career-ready standards, whether they are in a 
State that has chosen to adopt the Common Core State standards or to 
use other college- and career-ready standards. There are a number of 
advantages of computer-based assessments, including more immediate 
feedback and the possibility for adaptive assessment (assessing 
students at the most appropriate level regardless of which grade they 
may be taking the assessment for). But these advantages require student 
access to devices and connectivity. ConnectED calls for additional 
funding and support for schools to improve their network connectivity 
and provide device access to all students. Connect Educators is 
designed to help teachers and principals understand how to use 
technology to help with the implementation of new assessments as well 
as to leverage technology to improve access to needed professional 
development and other online resources, including sample lessons and e-
books that are aligned to college- and career-ready standards.
           ensuring privacy of student data under connect ed
    Question. How would your agency ensure privacy of student data 
under this program; in particular, how would you ensure that student 
data would not be used for advertising and marketing purposes?
    Answer. As part of the requirement to receive eRate funding, 
schools must implement filtering software to restrict access to 
potentially harmful sites (such as those that might be using student 
personal information in inappropriate ways). ConnectED, administered by 
the FCC, will not require any new student data to be collected. 
However, as Internet access improves under the ConnectED Initiative, it 
is critical that school systems and educators understand the major laws 
and best practices protecting student privacy while using online 
educational services.
    The Department shares your concerns about commercialization of 
student data, and our Privacy Technical Assistance Center released 
guidance in February 2014 about how schools and districts can protect 
student data in connection with contracting for online educational 
services. The guidance clarifies that FERPA would not permit a school 
or district to give FERPA-protected data to a third party solely for it 
to develop a product to market to a school or district and that the 
Protection of Pupil Rights Amendment (PPRA) also provides parents with 
rights with regard to some marketing activities. This guidance can be 
found at the following Web link: http://ptac.ed.gov/sites/default/
files/Student%20Privacy%20and%20Online%20
Educational%20Services%20%28February%202014%29.pdf.
                                 ______
                                 
            Questions Submitted by Senator Mary L. Landrieu
                   funding for charter school program
    Question. For years I have been very supportive of the Charter 
Schools Program (CSP), and thus was disappointed that the 
administration level-funded the Charter Schools Program in its fiscal 
year 2015 budget. As you know, the most recent independent research 
confirms that charter schools have made significant strides in closing 
the achievement gap. In communities across the country, students are 
making significant learning gains in core academic subjects. In 
particular, I have continued to advocate for the Charter Management 
Organization (CMO) Replication and Expansion Grant, and appreciate that 
the President's budget does request $75 million for it. However, the 
President's budget does not allocate any new funds for the SEA grants 
program. Can the Department outline its expectations for a successful 
implementation of the Charter School Program given the level funding of 
$248 million for fiscal year 2015?
    Answer. The administration strongly supports efforts to expand the 
number of high-quality educational options available to our Nation's 
students, especially those living in poverty. The fiscal year 2015 
President's budget would help accomplish this by directing scarce 
Federal resources to a new charter schools program, Supporting 
Effective Charter Schools, which under the administration's proposal to 
reauthorize the Elementary and Secondary Education Act would support, 
through subgrants from State educational agencies (SEAs) or charter 
school authorizers and through grants directly from the Department, the 
start-up or expansion of high-quality charter schools, prioritizing 
projects that serve concentrations of students from low-income 
families.
    If the Elementary and Secondary Education Act is not reauthorized 
prior to enactment of fiscal year 2015 appropriations, the Department 
will conduct a competition for new grants to SEAs under current law. At 
level funding, we anticipate allocating approximately $100 million for 
10 to15 new SEA grants, in addition to the $46 million we will use for 
continuation awards to current SEA grantees. We expect to pursue 
rulemaking to ensure these grants support the start-up only of high-
quality schools.
    As you note, the fiscal year 2015 budget includes a request to use, 
absent reauthorization, up to $75 million for the high-quality charter 
school replication and expansion grants currently authorized in 
appropriations language, which in fiscal year 2014 requires that not 
less than $45 million be used for these grants. This request recognizes 
the need to increase students' access to proven charter school models 
while providing the Department with flexibility to direct funds to the 
most deserving projects across CSP competitions.
                   title ii funding for seed program
    Question. In my State of Louisiana, the Supporting Effective 
Educator Development (SEED) Grant program has been used to train 604 
teachers over the past 2 years, and will be used to train approximately 
230 additional teachers for placement next year. Can you tell the 
committee whether and why or why not, you think a percentage of Title 
II funding should be designated specifically for the SEED grant 
program, which supports evidence-based teacher preparation programs, 
such as Teach for America and the National Writing Project, who have 
won these competitive awards in the past?
    Answer. We think the current set-aside under Title II, Part A of 
the ESEA that supports the SEED program is one of the most effective 
uses of Title II funds, largely because, as you stated, it supports 
evidence-based teacher preparation programs. As you know, we have long 
sought to increase the size of this set-aside in order to expand our 
ability to support more effective teacher and principal preparation 
programs, help States raise standards for such programs, and recruit 
and retain school leadership teams with the skills and experience 
needed to turn around low-performing schools. We were pleased that this 
Committee supported a small increase in the set-aside in fiscal year 
2014, and we are hoping you will give serious consideration to our 
request to raise the set-aside to 10 percent in fiscal year 2015.
    use of performance and outcome information to inform policy and 
                              improvement
    Question. As our Nation continues to deal with shrinking budgets 
and growing demand for services, the Federal Government needs to find 
ways to invest scarce Federal resources more efficiently and more 
effectively in evidence-based, results-driven solutions. I am pleased 
to see programs like Investing in Innovation (i3) prioritized in the 
President's 2015 budget as they are focused on ensuring evidence-based 
practices are used to improve student outcomes.
    How is the Department using evidence, data and information about 
performance and outcomes to inform policy and drive continuous 
improvement in its programs and grantee interventions?
    Answer. Two key priorities in all of President Obama's budget 
proposals for education have been to use evidence and data to guide 
investment decisions and to structure both existing programs and new 
proposals to build the evidence base for what works in education. For 
example, many of our proposals to eliminate or consolidate education 
programs were based on evaluation and performance data, contributing to 
the elimination of 49 Department of Education programs since President 
Obama took office, for a total annual savings of more than $1.2 
billion. New programs such as Investing in Innovation (i3) were 
specifically designed to build the evidence base for effective 
instruction and improvement. We have built in rigorous evaluation 
requirements for key competitive grant programs, such as Race to the 
Top, School Improvement Grants, and Promise Neighborhoods. Finally, we 
recently amended the Education Department General Administrative 
Regulations (EDGAR) to strengthen the use of evidence in Department 
competitive grant competitions and to improve the quality of data 
generated and reported by grantees.
        funding for historically black colleges and universities
    Question. As we take stock of access and affordability to 
postsecondary educational options, it is critical that we take into 
consideration that historically black universities like Dillard 
University, Southern University, Grambling State University, and Xavier 
University in Louisiana are leading the way in the President's goal to 
graduate more students, boost the economy, and enhance global 
competitiveness. I applaud your ongoing efforts to ensure success for 
all students in their goals to pursue postsecondary options through 
programs like First in the World, TRIO, and Strengthening Historically 
Black Colleges and Universities (HBCUs).
    Can you tell the committee how the Department plans to continue to 
support the needs of HBCUs throughout the Nation with level funding at 
$223.8 million?
    Answer. The President recognizes that HBCU's play a unique and 
vital role in providing higher education opportunities for African 
American students and students from low-income backgrounds. However, 
due to current constraints on budgetary resources, the President's 
request for the Title III Strengthening HBCUs program, like the vast 
majority of Higher Education programs, is maintained at the fiscal year 
2014 level. In addition to the request of $223.8 million in 
discretionary funding, HBCUs will also benefit from $85 million in 
mandatory funding and $57.9 million in discretionary funding for the 
Title III Strengthening Historically Black Graduate Institutions. For 
over 150 years, these institutions have educated generations of 
Americans and produced many of the Nation's leaders in business, 
government, academia, and the military. The fiscal year 2015 budget 
request will enable these institutions to continue serving a growing 
population of students and encourage and prepare more of these students 
to pursue advanced study. The 2015 budget request includes $75 million 
for a new grant initiative designed to improve affordability, quality, 
and success in postsecondary education. The College Success Grants for 
Minority-Serving Institutions and Historically Black Colleges and 
Universities would provide competitive awards to minority-serving 
institutions to support implementation of sustainable strategies, 
processes and tools (including technology) to reduce costs and improve 
outcomes for students.
                   access to postsecondary education
    Question. What are some other ways that the Department intends on 
supporting low-to-moderate income students in pursuing their dream of 
attaining a postsecondary degree?
    Answer. In addition to fully funding the maximum Pell Grant Award 
to $5,830, continuing support for TRIO, GEAR UP, Title III and V 
programs, and making additional investments requested under First in 
the World and the new $75 million College Success Grants for MSIs, the 
President's fiscal year 2015 budget request includes significant 
initiatives to help expand college access and completion for low- and 
moderate-income students, such as:
  --Encouraging States to support, reform, and improve the performance 
        of their public higher education systems through the State 
        Higher Education Performance Fund, which would generate an $8 
        billion new investment to make college more affordable and 
        increase college access and success, especially for low-income 
        students;
  --Rewarding colleges that successfully enroll and graduate a 
        significant number of low- and moderate-income students on time 
        and encourage all institutions to improve their performance 
        through the new College Opportunity and Graduation bonus 
        program;
  --Reforming the campus-based programs to target those institutions 
        with a demonstrated commitment to providing a high-quality 
        education at a reasonable price that enroll and graduate higher 
        numbers of Pell-eligible students and offer an affordable and 
        quality education such that graduates can repay their 
        educational debt;
  --Reinstating the Ability to Benefit provision for students enrolled 
        in eligible career pathways programs, which will allow adults 
        without a high school diploma to gain the knowledge and skills 
        they need to secure a good job; and
  --Helping borrowers manage their debt by extending Pay As You Earn to 
        all student borrowers, ensuring the program is well targeted, 
        and simplifying the borrower's experience while reducing 
        program complexity.
  measuring the success of programs providing access to postsecondary 
                               education
    Question. How will the Department measure the success and impact of 
these programs to ensure a wise investment of Federal dollars?
    Answer. While specific measures for proposed programs have not yet 
been determined, the Department would make sure that the final measures 
are consistent with the overriding goal of the Federal student 
financial aid programs: To ensure that all Americans who wish to pursue 
a postsecondary education have access to high-quality postsecondary 
education by providing financial aid in an efficient, financially 
sound, and customer-responsive manner.
                race to the top--equity and opportunity
    Question. It is clear that the Department is focused on equity and 
opportunity especially in our lowest performing schools. In Louisiana, 
where 250,000 students are attending a school with a D or F letter 
grade rating, this issue rings true with me. Like the Charter School 
Program, it is evident that the Race to the Top--Equity and Opportunity 
is focused on ensuring that students who were once faced with 
inequities have the opportunity and option to reach their full 
potential.
    Can you talk about the impact that Race to the Top--Equity and 
Opportunity will have on our education system, particularly in a State 
like Louisiana?
    Answer. Race to the Top--Equity and Opportunity (RTT-O) will 
address key elements that contribute to persistent opportunity and 
achievement gaps, including those in the lowest performing schools. By 
developing, enhancing, and integrating fiscal, human capital, and 
achievement data systems, grantees will be able to identify LEAs, 
schools, and student groups with the greatest disparities in 
opportunity and outcomes and will be better able to direct resources 
based on need. Strategies for supporting the highest need students 
include attracting, retaining, and supporting high-quality teachers and 
leaders in high-need schools, increasing access to rigorous coursework, 
and providing additional student supports designed to help mitigate the 
effects of concentrations of poverty, which will particularly benefit 
areas with large proportions of students and schools that are 
struggling or failing. Additionally, using integrated data, grantees 
will measure the success of these and other strategies for program 
improvement and will examine the use and alignment of existing Federal 
education resources to ensure they are being used effectively and are 
aligned with their comprehensive plans.
        overview of implementation of school improvement grants
    Question. Since 2009, the Federal Government has spent nearly $6 
billion on school improvement dollars. Schools in Louisiana have had 
the opportunity to benefit from these grants, totaling over $95 million 
at over 90 schools. However, there seems to be a lack of adequate data 
informing Members of Congress and members of the community overall 
about strategies that work within School Improvement Grants (SIG) and 
therefore how we can best invest Federal dollars.
    Can you tell the subcommittee about the successes and challenges of 
SIG implementation over the last 4 years?
    Answer. In February 2014 the Department published an analysis of 
State assessment results for schools receiving School Improvement 
Grants funding from the fiscal year 2009 and 2010 competitions (see 
http://www2.ed.gov/programs/sif/
assessment-results-cohort-1-2-sig-schools.pdf).
    Comparing, where data permit, schools' average proficiency rates in 
the 2011-2012 school year to their rates in the year prior to receiving 
SIG funds, the analysis notably found that:
  --Proficiency rates in SIG schools have on average increased in both 
        reading/language arts and mathematics; and
  --Proficiency rates in 2009 cohort SIG schools continued to increase 
        on average in the second year of implementation.
    In May 2014, the Department's Institute of Education Sciences 
released the first report on its intensive studies of a sample of 25 
schools that began SIG implementation in the 2010-2011 school year (see 
http://ies.ed.gov/ncee/pubs/20144015/pdf/20144015.pdf). Among its 
findings, the report indicated that most schools with higher 
organizational capacity (as determined by ratings on a set of capacity 
indicators) reported perceived improvements in many areas during the 
first year of implementation, whereas schools with lower organizational 
capacity reported improvement in few or no areas.
    These and other findings suggest that the Department should 
continue to improve its support for local turnaround efforts, with a 
particular emphasis on schools struggling to implement interventions 
with fidelity and on key areas of need. For instance, many local 
educational agencies--particularly those in rural areas--have 
difficulty recruiting or developing school leaders with the specialized 
skills essential to carrying out successful school turnarounds. 
Accordingly, in March 2014, the Department initiated the Turnaround 
School Leaders Program, through which SIG national activities funds are 
being used to make competitive grants to support the development or 
expansion of high-quality leadership pathways serving 5 or more SIG or 
SIG-eligible schools. We expect to make 10-15 awards under the program 
later this fiscal year, totaling approximately $19 million. We will 
continue to monitor implementation and identify topic areas that may 
benefit from additional resources in future years.
                 successful school turnaround projects
    Question. What turnaround strategies have you observed making the 
largest impact in schools across the country?
    Answer. The February 2014 analysis of State assessment data 
mentioned above showed that the average proficiency gains of schools 
implementing the turnaround or restart models generally exceeded those 
of schools implementing the relatively less rigorous transformation 
model. The May 2014 case study report found that schools with higher 
levels of strategic leadership or that had experienced a disruption 
from past operations reported perceived improvement in more areas than 
schools without these characteristics, but did not identify 
relationships between perceived improvement and other examined school 
characteristics, including the SIG model implemented.
    With respect to specific improvement actions implemented in 
turnaround schools, the Department is currently developing a set of 
profiles of carefully selected SIG implementation sites that focus on 
topics such as data-based decisionmaking, school climate, and parent 
and community engagement. We expect that these profiles, which are 
scheduled for release in fall 2014, will serve as a helpful reference 
for stakeholders, including local educational agencies preparing school 
intervention plans under SIG.
 using performance information to turn around lowest performing schools
    Question. How does the Department intend to capture accurate data 
that can better inform the decisions of policy makers and 
implementation so that we can better invest Federal dollars and more 
quickly turn around our lowest performing schools?
    Answer. The Department has developed and continues to implement a 
coordinated strategy for obtaining and analyzing a variety of SIG data 
to inform policymaking and local implementation. In addition to the 
strategy-specific information provided by the profiles, the detailed 
implementation reports from the case studies, and the annual analyses 
of State assessment and leading indicator results discussed above, the 
Department is also conducting a formal evaluation of the SIG program 
that will focus, among other things, on the impact of the receipt of 
SIG funds on student outcomes and the relationship between the four 
school intervention models (and related improvement strategies) and 
student outcomes and school performance. The first full evaluation 
report is scheduled for release in late 2014.
                                 ______
                                 
                Questions Submitted by Senator Jack Reed
          innovative approaches to literacy grant application
    Question. This year, the Department will be holding a new 
competition for the Innovative Approaches to Literacy grant. For the 
first competition, the Department did not publish the application until 
July--a time when many school districts are not fully staffed to write 
grants.
    When will the Innovative Approaches to Literacy grant application 
become available?
    Answer. The Department is in the process of developing the 
Innovative Approaches to Literacy (IAL) grant application and plans to 
make it available in late June.
    department outreach for innovative approaches to literacy grant 
                              applications
    Question. What outreach does the Department have planned so that 
school districts and national nonprofit organizations have the time and 
information to submit quality proposals?
    Answer. The Department informed professional groups and 
associations when the Innovative Approaches to Literacy (IAL) Notice of 
Proposed Priorities, Requirement, And Definitions was published in the 
Federal Register on February 28, 2014 (Vol. 79. No. 40). In addition, 
professional groups, literacy professionals, and national not for 
profits involved with literacy were made aware of the proposed 2014 
competition in the call for reviewers for the competition. We currently 
are working to publish the final Notice and application package as soon 
as possible to ensure that eligible entities have sufficient time to 
prepare high-quality applications.
    We also are planning to conduct three webinars that will be 
designed to cover all aspects of the grant application process for the 
IAL program. Each of these presentations will include an opportunity to 
ask specific questions regarding the competition and its requirements.
    learning from previous innovative approaches to literacy grant 
                              competition
    Question. As the first round of grants finishes this year, can you 
share with us some preliminary information about what was successful 
and what could be improved for future competitions?
    Answer. The first round of Innovative Approaches to Literacy (IAL) 
grants was enthusiastically received by parents, school administrators, 
reading specialists, library workers, content area teachers, and 
students. The Department gathered data from June through December of 
last year from the annual performance report, project specific goals, 
and the GPRA measures, but needs more time for an in-depth analysis of 
these data due to varying approaches taken across grantees and their 
projects. However, the initial review indicates that the IAL program 
has led to increased parent involvement, improved instructional 
practices, greater access to high quality literacy resources in both 
traditional and digital print, extended library hours, increased 
technology-based instruction, and increased reading ability in both 
reading classes and content area classes. The greatest gains have been 
in programs that combine parent involvement, print distribution (either 
traditional books or digital text), and good instructional practice.
    For future competitions, the Department will explore ways to 
improve the evaluation of the program and identify leading indicators 
of successful programs.
                  access to effective library programs
    Question. We know that student achievement is correlated with 
having access to effective school library programs as well as books in 
the home. This is an important piece of the equity agenda.
    What, specifically, does the Administration plan to do to ensure 
that disadvantaged children have access to effective and well-equipped 
school libraries staffed by well-trained school librarians and books at 
home?
    Answer. The administration's reauthorization proposal for the 
Elementary and Secondary Education Act includes a new Effective 
Teaching and Learning: Literacy program that would make competitive 
grants to State educational agencies to support comprehensive State and 
local efforts to develop and implement high-quality literacy programs. 
Such programs may include efforts to strengthen access to well-equipped 
school libraries as well as home-based literacy instruction, which 
could include making books available to low-income families.
                    college access challenge grants
    Question. Congress gave the Administration a great deal of 
flexibility in determining what waivers under the College Access 
Challenge Grant would be equitable and what constitutes ``significant 
effort'' in redressing a violation of maintenance of effort. Instead of 
using its flexibility, the Department has developed a rigid approach to 
reviewing and approving waiver requests, which resulted in more than 
half of the available funds being returned to the Treasury last year.
    According to an analysis by the American Association of State 
Colleges and Universities, 28 States that were denied a waiver or did 
not receive funds last year had increased higher education 
appropriations in fiscal year 2013. Twenty-one of these States had 
increased funding in fiscal year 2012.
    How many States are in danger of losing their College Access 
Challenge Grant this year, and, how is the Department working with 
States to address this issue?
    Answer. Section 137 of the Higher Education Act (HEA) requires 
States to maintain financial support for higher education at least at a 
level equal to the average amount provided over the 5 preceding fiscal 
years for public institutions of higher education (excluding capital 
expenses and research and development costs), and also for financial 
aid for students attending private institutions of higher education. If 
a State fails to meet these requirements, the Department must withhold 
any funds that would otherwise be available to that State under the 
College Access Challenge Grant (CACG) Program, authorized by section 
781 of the HEA. The Department may waive the maintenance of effort 
requirements for a State if the Department determines that doing so 
would be equitable due to exceptional or uncontrollable circumstances. 
However, we execute this waiver authority carefully and reluctantly, 
given the importance we place on States maintaining fiscal support for 
higher education.
    Unfortunately, the number of requests the Department has received 
for waivers of the requirements of section 137 of the HEA has increased 
dramatically in the past 4 years. In Federal fiscal year 2013, 41 
States failed to meet the maintenance of effort requirements in State 
fiscal year 2012; 33 of these States requested a waiver. Ultimately, 
the Department granted six of the 33 requests it received. Of the 27 
States whose requests were denied, 17 had increases in their revenues 
over the preceding 5-year period and two additional States had sizeable 
surpluses. In such instances, the Department determined that these 
States did not meet the statutory standard of a ``precipitous and 
unforeseen decline in . . . financial resources.''
                 use of maintenance of effort standard
    Of the remaining waiver request denials, the Department applied the 
standard used across the Department's programs with maintenance of 
effort requirements, including the Individuals with Disabilities 
Education Act (IDEA). Under this standard, States requesting a waiver 
that demonstrate a precipitous and unforeseen decline in resources must 
also demonstrate that higher education spending was not 
disproportionately targeted for reductions. The Department believes 
that this standard plays a critical role in preventing harmful cuts to 
higher education spending at the State level and ensuring that higher 
education is treated equitably as States are confronted with difficult 
budget decisions.
    When States fail to meet the maintenance of effort requirements and 
do not receive a waiver of those requirements, section 137(d) of the 
HEA allows States that make a significant effort to correct their 
violations to receive their full College Access Challenge Grant funds. 
Of the 27 States whose waiver requests were denied last year, five 
ultimately received CACG funding by reinvesting in higher education.
    While we recognize that States must prioritize and sometimes make 
tough choices when making budget decisions, we continue to believe that 
granting waivers to States that do not treat higher education equitably 
is contrary to the intent of Congress in drafting section 137 of the 
HEA.
    We are still in the process of determining the number of States 
that have met the maintenance of effort requirements in State fiscal 
year 2013. As in prior years, the Department will continue to work with 
States to ensure that our decisions are based on complete information, 
including providing States with ample opportunities to provide 
additional information in support of their waiver requests. This 
outreach will include extensive contact with State program and budget 
officials via conference call and e-mail to clarify information 
submitted in conjunction with the waiver request, updating the State on 
the Department's assessment of the data, and discussing the State's 
options for meeting the maintenance of effort or waiver requirements, 
or making a significant effort to correct their maintenance of effort 
violation.
    As we begin this year's review of maintenance of effort waiver 
requests, we will continue to work with States to gather information 
and release decisions as expeditiously as possible.
                     postsecondary support programs
    Question. What alternatives has the Department considered to avoid 
having millions of students miss out on the college outreach, student 
aid awareness, financial literacy, and other vital student supports 
provided under these grants?
    Answer. The Department annually invests over $1.1 billion in 
college preparation programs targeted at disadvantaged students through 
the Federal TRIO ($838 million in fiscal year 2014) and GEAR UP ($302 
million in fiscal year 2014) programs. Collectively, these programs 
provide approximately 3,000 grants to States, institutions of higher 
education, local education agencies, and other nonprofit entities to 
undertake activities designed to assist disadvantaged students in 
enrolling and succeeding in postsecondary education.
             teacher quality partnership grants application
    Question. This year, there will be a new round of competition for 
the Teacher Quality Partnership grants. When will the grant application 
become available?
    Answer. Applications for funding under the Teacher Quality 
Partnership program became available on May 28, 2014. Applications will 
be due to the Department July 14, 2014. The Department also is 
currently planning two pre-application webinars for potential 
applicants--Tuesday, June 10, 2014, at 10:00 a.m. and Thursday, June 
12, 2014, at 2:00 p.m.
       teacher quality partnership grants application priorities
    Question. Will the Department be including any new priorities for 
this round of competition, for example, a competitive priority for 
programs that address both teacher and principal preparation?
    Answer. The fiscal year 2014 Teacher Quality Partnership 
competition includes two absolute priorities from the statute, and two 
competitive preference priorities from the notice of final supplemental 
priorities and definitions for discretionary grant programs published 
in the Federal Register on December 15, 2010 (75 FR 78486) and 
corrected on May 12, 2011 (75 FR 27637). Under this competition, the 
Department will support projects training teachers and early childhood 
educators at (a) the pre-baccalaureate level, and (b) in teacher 
residency programs. These two project types are outlined in the 
statute.
    In addition, the Department will provide a competitive preference 
to applications promoting effective science, technology, engineering, 
and math (STEM) teacher preparation and to applications for projects 
designed to support the implementation of internationally benchmarked, 
college- and career-ready academic standards, including the development 
of professional development aligned to those standards as well as 
strategies that translate those standards into classroom practice. The 
Department believes that these priorities will ensure a robust 
competition and effective targeting of Teacher Quality Partnership 
program funds in critical areas of teacher preparation.
                                 ______
                                 
               Questions Submitted by Senator Mark Pryor
              data collection on online learning programs
    Question. Distance learning plays an increasing role in 
postsecondary education. Millions of college students take at least one 
online course in a given year. The number of students utilizing online 
courses continues to increase rapidly each year.
    Online learning has the potential to expand access to higher 
education to students who might not otherwise have access to physical 
classes. Given the increased use of distance and online learning, what 
steps is the Department of Education taking to collect data on online 
learning and the effectiveness and how institutions could help improve 
and promote online learning and, if not, does the Department have any 
plans to begin collection of this information? Given the importance of 
distance learning in my State, I would like to work with you to focus 
efforts on collecting this data in an effort to improve delivery and 
outcomes of online and distance learning.
    Answer. The Department plans to announce in late spring/early 
summer a new competition for the Center for Distance Education and 
Technological Advancements program. This competition, funded by 
Congress in fiscal year 2014 under the Fund for the Improvement of 
Postsecondary Education, will award a grant to an institution of higher 
education to develop a research agenda that would yield rigorous 
research increasing our knowledge in the area of online learning. The 
Department is still in the process of determining the design and focus 
of the competition.
    In addition, the Department's Institute of Education Sciences 
recently published a Request for Applications under the Education 
Research and Development Center program that includes as one of three 
topic areas a focus on Virtual Learning. The successful applicant will 
establish a Virtual Learning Laboratory to conduct a focused program of 
research that will (1) use experimental methods to evaluate and improve 
the instructional practices, content, and/or learning tools offered by 
one or more widely used online instructional delivery platforms, with a 
particular focus on making improvements for low-income and low-
performing students in K-12; and, (2) advance the field's understanding 
of how the large amounts of data generated within online instructional 
delivery platforms may be used to address important research questions 
and improve teaching and learning.
    In addition, the lab will provide leadership and outreach that 
will: (1) inform policymakers, practitioners, and other nontechnical 
audiences about big data for education research and practice, (2) 
create a hub where researchers, developers and practitioners will come 
together--both virtually and in person--to discuss research goals and 
methods related to online learning, review emerging research findings, 
and support new partnerships and collaborations; and, (3) build the 
field's capacity to conduct well-designed studies of online learning 
and to use big data by offering workshops and other activities.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
  competitive programs and competitive ability of small, rural states
    Question. The fiscal year 2015 Department of Education Budget 
contains a number of important priorities that will continue to improve 
the education received by students throughout the country and in turn 
prepare them for college and the workforce. Focusing on educational 
equity is particularly important as we begin to anticipate the changing 
needs of our future workforce.
    The education community in New Hampshire remains concerned about 
the Department's shift to competitive funding, and as a former teacher 
and governor, I appreciate the unique needs that arise in all schools 
and communities, not only those traditionally defined as most in need 
that often receive funding under competitive programs. States like New 
Hampshire do not necessarily have the resources, such as staff, to 
submit competitive applications for many of the programs that could 
make critical improvements in our State's educational system.
    Stakeholders in New Hampshire indicate that formula-driven grant 
programs provide a more sustained impact that allows educators and 
administrators to perform their critical work. This continued 
investment is critical to ensuring that States and school districts can 
reasonably depend upon the funding source for continuity and can be 
relied on to institute desired changes.
    Your budget request for fiscal year 2015 proposes an increase of 62 
percent for competitive grant programs over the amounts appropriated 
for such programs in fiscal year 2014. Can you provide information 
regarding the number of competitive grant programs that you propose in 
your fiscal year 2015 budget request and the specific steps that you 
are taking to ensure that small, rural States would be supported should 
these programs be funded and implemented?
    Answer. Most competitive grant programs that would be funded under 
our 2015 budget request arise from authorizing statutes such as the 
Elementary and Secondary Education Act. We do believe strongly in the 
use of competitive grants to promote innovation and maximize the impact 
for students of limited Federal education funding by funding the 
highest quality applicants, and this strategy has informed such key 
Administration education reform initiatives as Race to the Top, 
Investing in Innovation, and Promise Neighborhoods. We also believe 
that we have been increasingly successful in structuring our 
competitive grant programs--through such strategies as the use of 
absolute and competitive preference priorities--to maximize the 
opportunities for success by rural applicants. For example, rural 
applicants have demonstrated considerable success in winning grants in 
the Race to the Top--District competitions and the School Improvement 
Grant program. We intend to use similar strategies to ensure that we 
meet the needs of rural States and communities under new competitive 
grant proposals in our 2015 request, such as Race to the Top--Equity 
and Opportunity, STEM Innovation, High School Redesign, and Connect 
Educators. We also are proposing hybrid programs where such an approach 
makes sense. Our Connect Educators proposal, for example, includes both 
formula grant funds aimed at increasing State capacity and competitive 
funds for LEAs prepared to use high-speed networks and related devices 
to improve instruction for all students. Finally, approximately 89 
percent of the discretionary funding for elementary and secondary 
education programs included in our 2015 budget request would continue 
to be allocated to States and school districts by formula.
     participation rate of states and seas in competitive programs
    Question. What data is the Department of Education currently using 
to determine whether all eligible States and districts apply for 
opportunities that they qualify for?
    Answer. The Department does not collect or use such data because no 
State or school district is required to apply for any discretionary or 
formula-based Federal education program. We have, however, provided 
targeted technical assistance to entities that are experiencing 
difficulty developing and submitting high-quality applications for our 
competitive grant programs.
 competitive grant awards and recipients in fiscal years 2013 and 2014
    Question. Can you please provide a comprehensive list of 
competitive grants awarded in fiscal year 2013 and fiscal year 2014 and 
the States or districts that received them?
    Answer. The report included below, 2013 New Discretionary Grant 
Awards to States and LEAs, lists the new fiscal year 2013 discretionary 
grant awards to States and school districts that were identified in the 
Department of Education's financial data base. Fiscal year 2014 
information was not included because few 2014 discretionary awards have 
been made at this time; most awards are made at the end of the fiscal 
year. Note that information on all Federal grant awards is available on 
www.usaspending.gov. Federal agencies provide regular updates to this 
system, so that current award information is available to the public.
    [The report follows:]

            FISCAL YEAR 2013 NEW DISCRETIONARY GRANT AWARDS TO STATES AND LOCAL EDUCATIONAL AGENCIES
                              New Discretionary Grants Awarded in Fiscal Year 2013
   NOTE: Funding is the amount in the year of award only and may include funds from multiple fiscal years for
                                         programs with multi-year funds.
----------------------------------------------------------------------------------------------------------------
                                   Name from                                            Type of
         Award number             application          City             State          recipient        Amount
----------------------------------------------------------------------------------------------------------------
Account name:  English Language Acquisition
Program name:  Language Acquisition State Grants
----------------------------------------------------------------------------------------------------------------
T365C130001..................  Kashunamuit       Chevak..........  AK.............  LEA............     $355,638
                                School District.
T365C130015..................  Yukon-Koyukuk     Fairbanks.......  AK.............  LEA............     $243,256
                                School District.
T365C130022..................  Painted Desert    Flagstaff.......  AZ.............  LEA............     $285,398
                                Demonstration
                                Project.
T365C130008..................  Arlee Joint       Arlee...........  MT.............  LEA............     $299,984
                                School District
                                #8.
T365C130009..................  Arlee High        Arlee...........  MT.............  LEA............     $188,730
                                School.
T365C130005..................  Missouri River    Mandan..........  ND.............  LEA............     $250,000
                                Educational
                                Cooperative
                                (MREC).
T365C130023..................  Stilwell Public   Stilwell........  OK.............  LEA............     $253,825
                                Schools.
T365C130024..................  Tenkiller         Welling.........  OK.............  LEA............     $203,287
                                Elementary
                                School.
T365C130025..................  Chief Leschi      Puyallup........  WA.............  LEA............     $289,850
                                Schools, Inc.,
                                Puyallup Tribe
                                of Indians.
----------------------------------------------------------------------------------------------------------------
Account Name:  Higher Education
Program Name:  Federal TRIO Programs
----------------------------------------------------------------------------------------------------------------
P047A130829..................  Coffeeville       Coffeeville.....  MS.............  LEA............     $236,925
                                School District.
----------------------------------------------------------------------------------------------------------------
Account Name:  Impact Aid
Program Name:  Impact Aid: Construction
----------------------------------------------------------------------------------------------------------------
S041C130002..................  Lower Kuskokwim   Bethel..........  AK.............  LEA............   $2,616,974
                                School District.
S041C130004..................  Red Mesa Unified  Teec Nos Pos....  AZ.............  LEA............   $6,800,440
                                School District.
S041C130018..................  Ganado Unified    Ganado..........  AZ.............  LEA............   $1,076,433
                                School District
                                #20.
S041C130022..................  All Tribes        Valley Center...  CA.............  LEA............   $3,881,900
                                Charter aka All
                                Tribes American
                                India.
S041C130009..................  Harlem High       Harlem..........  MT.............  LEA............      $68,500
                                School District
                                #12.
S041C130012..................  Lodge Grass       Lodge Grass.....  MT.............  LEA............     $470,700
                                Elem. School
                                Dist. #27.
S041C130014..................  Douglas School    Box Elder.......  SD.............  LEA............   $4,000,000
                                District #51-1.
S041C130008..................  Wellpinit School  Wellpinit.......  WA.............  LEA............     $532,689
                                District #49.
----------------------------------------------------------------------------------------------------------------
Account Name:  Indian Education
Program Name:  Special Programs for Indian Children
----------------------------------------------------------------------------------------------------------------
S299A130007..................  Chugach School    Anchorage.......  AK.............  LEA............     $299,943
                                District.
S299A130020..................  Blackwater        Coolidge........  AZ.............  LEA............     $266,314
                                Community
                                School.
S299A130051..................  Magdalena         Magdalena.......  NM.............  LEA............     $293,741
                                Municipal
                                School District.
S299A130037..................  Tahlequah Public  Tahlequah.......  OK.............  LEA............     $298,591
                                Schools.
S299A130077..................  Ada City Schools  Ada.............  OK.............  LEA............     $295,989
----------------------------------------------------------------------------------------------------------------
Account Name:  Innovation and Improvement
Program Name:  Arts in Education
----------------------------------------------------------------------------------------------------------------
U351D130013..................  Rockford Public   Rockford........  IL.............  LEA............     $325,000
                                Schools.
U351D130010..................  Neighborhood      Dorchester......  MA.............  LEA............     $245,609
                                House Charter
                                School.
U351D130015..................  Everett Public    Everett.........  MA.............  LEA............     $293,450
                                Schools.
U351D130039..................  Independent       St. Paul........  MN.............  LEA............     $314,988
                                School District
                                #625.
U351D130020..................  Mt. Vernon City   Mt. Vernon City.  NY.............  LEA............     $314,532
                                School District.
----------------------------------------------------------------------------------------------------------------
Program Name:  Charter Schools Grants
----------------------------------------------------------------------------------------------------------------
U282B130014..................  Innovative        Wilmington......  DE.............  LEA............     $175,000
                                Schools
                                Development
                                Corporation.
U282B130030..................  Innovative        Wilmington......  DE.............  LEA............     $175,000
                                Schools
                                Development
                                Corporation.
U282B130065..................  Chief Tahgee      Pocatello.......  ID.............  LEA............     $192,066
                                Elementary
                                Academy, Inc.
                                (CTEA).
U282B130037..................  Intrinsic         Chicago.........  IL.............  LEA............     $199,760
                                Schools.
U282B130063..................  Catalyst Schools  Chicago.........  IL.............  LEA............     $192,414
U282B130012..................  Madison-Tallulah  Tallulah........  LA.............  LEA............     $200,000
                                Education
                                Center.
U282B130004..................  Cornville         Cornville.......  ME.............  LEA............     $242,329
                                Regional
                                Charter School.
U282B130020..................  Columbus          Columbus........  OH.............  LEA............     $175,000
                                Collegiate
                                Academy, Inc..
U282B130006..................  York Academy      York............  PA.............  LEA............     $207,750
                                Regional
                                Charter School.
U282B130071..................  Utah              Salt Lake City..  UT.............  LEA............     $140,000
                                International
                                Charter School.
U282C130006..................  Arts & College    Columbus........  OH.............  LEA............     $123,975
                                Preparatory
                                Academy.
----------------------------------------------------------------------------------------------------------------
Program Name:  FIE Programs of National Significance
----------------------------------------------------------------------------------------------------------------
S215G130158..................  Lake Worth        Lake Worth......  TX.............  LEA............     $668,249
                                Independent
                                School District.
S215G130159..................  Poteet            Poteet..........  TX.............  LEA............     $416,420
                                Independent
                                School District.
----------------------------------------------------------------------------------------------------------------
Program Name:  Investing in Innovation
----------------------------------------------------------------------------------------------------------------
U411C130060..................  ASU Preparatory   Tempe...........  AZ.............  LEA............   $2,969,338
                                Academy.
U411C130116..................  Maricopa County   Phoenix.........  AZ.............  LEA............   $2,969,722
                                Education
                                Service Agency.
U411C130025..................  Carroll County    Carrollton......  GA.............  LEA............   $2,969,517
                                Schools.
U411C130073..................  Cabarrus County   Concord.........  NC.............  LEA............   $2,969,641
                                Schools.
----------------------------------------------------------------------------------------------------------------
Program Name:  Magnet Schools Assistance
----------------------------------------------------------------------------------------------------------------
U165A130055..................  Texarkana         Texarkana.......  AR.............  LEA............   $3,142,066
                                Arkansas School
                                District.
U165A130031..................  SAN DIEGO         San Diego.......  CA.............  LEA............   $3,853,939
                                UNIFIED SCHOOL
                                DISTRICT.
U165A130049..................  Los Angeles       Los Angeles.....  CA.............  LEA............   $3,714,306
                                Unified School
                                District.
U165A130070..................  Oxnard School     Oxnard..........  CA.............  LEA............   $4,000,000
                                District.
U165A130084..................  Napa Valley       Napa............  CA.............  LEA............   $2,834,293
                                Unified School
                                District.
U165A130094..................  Pasadena Unified  Pasadena........  CA.............  LEA............   $3,141,770
                                School District.
U165A130097..................  Ventura Unified   Ventura.........  CA.............  LEA............   $3,379,273
                                School District.
U165A130042..................  Pueblo City       Pueblo..........  CO.............  LEA............   $3,433,666
                                School District
                                #60.
U165A130027..................  New Haven, City   New Haven.......  CT.............  LEA............   $3,733,989
                                of (inc) DBA
                                New Haven
                                Public School
                                System.
U165A130037..................  Bridgeport City   Bridgeport......  CT.............  LEA............   $3,239,384
                                School District.
U165A130023..................  Seminole County   Sanford.........  FL.............  LEA............     $737,626
                                Public Schools.
U165A130039..................  School Board of   Miami...........  FL.............  LEA............   $3,532,735
                                Miami-Dade
                                County, FL.
U165A130083..................  The School Board  Fort Lauderdale.  FL.............  LEA............   $3,993,290
                                of Broward
                                County, Florida.
U165A130087..................  School Board of   Bartow..........  FL.............  LEA............   $3,997,000
                                Polk County.
U165A130092..................  Brevard Public    Viera...........  FL.............  LEA............   $3,999,747
                                Schools.
U165A130009..................  Unified School    Wichita.........  KS.............  LEA............   $3,999,993
                                District 259
                                (DBA Wichita
                                Public Schools).
U165A130071..................  Springfield       Springfield.....  MA.............  LEA............   $3,850,000
                                Public Schools.
U165A130051..................  Lansing School    Lansing.........  MI.............  LEA............   $3,396,230
                                District.
U165A130088..................  Clarksdale        Clarksdale......  MS.............  LEA............   $1,995,391
                                Municipal
                                School District.
U165A130013..................  NYC Department    Brooklyn........  NY.............  LEA............   $3,150,000
                                of Education--
                                Community
                                School District
                                13.
U165A130022..................  NYC Community     Jamaica.........  NY.............  LEA............   $2,836,829
                                School District
                                28.
U165A130007..................  Richland School   Columbia........  SC.............  LEA............   $1,683,734
                                District Two.
U165A130095..................  School District   Irmo............  SC.............  LEA............   $3,990,500
                                Five of
                                Lexington and
                                Richland
                                Counties.
U165A130045..................  Houston           Houston.........  TX.............  LEA............   $3,999,597
                                Independent
                                School District.
U165A130047..................  Galveston ISD...  Galveston.......  TX.............  LEA............   $4,000,000
U165A130077..................  Waco Independent  Waco............  TX.............  LEA............   $2,199,120
                                School District.
----------------------------------------------------------------------------------------------------------------
Program Name:  Race to the Top
----------------------------------------------------------------------------------------------------------------
S412A130039..................  Office of the     Atlanta.........  GA.............  State..........  $51,739,896
                                Governor, State
                                of Georgia.
S412A130045..................  Office of the     Frankfort.......  KY.............  State..........  $44,348,482
                                Governor, State
                                of Kentucky.
S412A130044..................  Office of the     Lansing.........  MI.............  State..........  $51,737,456
                                Governor, State
                                of Michigan.
S412A130049..................  Office of the     Trenton.........  NJ.............  State..........  $44,286,728
                                Governor, State
                                of New Jersey.
S412A130040..................  Commonwealth of   Harrisburg......  PA.............  State..........  $51,734,519
                                Pennsylvania
                                Governor's
                                Office.
S412A130038..................  Office of the     Montpelier......  VT.............  State..........  $36,931,076
                                Governor, State
                                of Vermont.
B416A130097..................  Galt Union        Galt............  CA.............  LEA............   $9,999,973
                                School District.
B416A130108..................  Lindsay Unified   Lindsay.........  CA.............  LEA............  $10,000,000
                                School District.
B416A130266..................  New Haven         Union City......  CA.............  LEA............  $29,351,345
                                Unified School
                                District.
B416A130131..................  St. Vrain Valley  Longmont........  CO.............  LEA............  $16,589,553
                                Schools.
B416A130341..................  KIPP DC.........  Washington......  DC.............  LEA............   $9,999,844
B416A130077..................  School Board of   Miami...........  FL.............  LEA............  $31,993,016
                                Miami-Dade
                                County.
B416A130156..................  Metropolitan      Indianapolis....  IN.............  LEA............  $28,570,886
                                School District
                                of Warren
                                Township.
B416A130137..................  Guilford County   Greensboro......  NC.............  LEA............  $35,222,004
                                Schools.
B416A130160..................  Iredell-          Statesville.....  NC.............  LEA............  $19,999,703
                                Statesville
                                Schools.
B416A130158..................  Carson City       Carson City.....  NV.............  LEA............  $10,000,000
                                School District.
B416A130040..................  Middletown City   Middletown......  NY.............  LEA............  $19,995,588
                                School.
B416A130264..................  Charleston        Charleston......  SC.............  LEA............  $19,388,399
                                County School
                                District.
B416A130117..................  IDEA Public       Weslaco.........  TX.............  LEA............  $31,228,967
                                Schools.
B416A130301..................  Harmony Science   Houston.........  TX.............  LEA............  $29,866,938
                                Academy.
B416A130186..................  Puget Sound       Renton..........  WA.............  LEA............  $39,964,930
                                Educational
                                Service
                                District.
----------------------------------------------------------------------------------------------------------------
Program Name:  School Leadership
----------------------------------------------------------------------------------------------------------------
U363A130115..................  Wheaton R3        Wheaton.........  MO.............  LEA............     $428,734
                                School District.
U363A130057..................  Tulsa             Tulsa...........  OK.............  LEA............     $990,874
                                Independent
                                School District
                                No. 1 Tulsa
                                Public Schools.
U363A130164..................  Shelby County     Memphis.........  TN.............  LEA............     $623,402
                                Board of
                                Education.
U363A130077..................  Region 5          Beaumont........  TX.............  LEA............     $725,463
                                Education
                                Service Center.
U363A130106..................  Granite School    Salt Lake City..  UT.............  LEA............     $996,743
                                District.
U363A130143..................  The Board of      Welch...........  WV.............  LEA............     $816,915
                                Education of
                                the County of
                                McDowell.
----------------------------------------------------------------------------------------------------------------
Program Name:  Teacher Incentive Fund
----------------------------------------------------------------------------------------------------------------
S374A130171..................  New York State    New York........  NY.............  State..........   $4,242,719
                                Education
                                Department.
----------------------------------------------------------------------------------------------------------------
Account Name:  Rehabilitation Services and Disability Research
Program Name:  Assistive Technology Programs
----------------------------------------------------------------------------------------------------------------
H224D130016..................  Missouri          Blue Springs....  MO.............  State..........     $621,778
                                Assistive
                                Technology
                                Council.
----------------------------------------------------------------------------------------------------------------
Program Name:  Special Education PROMISE Initiative
----------------------------------------------------------------------------------------------------------------
H418P130007..................  Arkansas          Little Rock.....  AR.............  State..........  $18,870,843
                                Department of
                                Education.
H418P130003..................  California        Sacramento......  CA.............  State..........  $20,422,782
                                Department of
                                Rehabilitation.
H418P130005..................  Maryland          Baltimore.......  MD.............  State..........  $19,394,303
                                Department of
                                Disabilities.
H418P130011..................  Research          Albany..........  NY.............  State..........  $19,500,000
                                Foundation for
                                Mental Hygiene,
                                Inc.
H418P130009..................  Utah State        Salt Lake City..  UT.............  State..........  $20,330,901
                                Office of
                                Rehabilitation.
H418P130004..................  Wisconsin         Madison.........  WI.............  State..........  $20,529,147
                                Department of
                                Workforce
                                Development.
----------------------------------------------------------------------------------------------------------------
Account Name:  Safe Schools and Citizenship Education
Program Name:  Elementary and Secondary School Counseling
----------------------------------------------------------------------------------------------------------------
S215E130298..................  County of         Phoenix.........  AZ.............  LEA............     $396,780
                                Maricopa Osborn
                                School District
                                #8.
S215E130003..................  Willits Unified   Willits.........  CA.............  LEA............     $396,373
                                School District.
S215E130012..................  Alhambra Unified  Alhambra........  CA.............  LEA............     $396,657
                                School District.
S215E130185..................  Cajon Valley      El Cajon........  CA.............  LEA............     $399,304
                                Union School
                                District.
S215E130223..................  Mountain Empire   Pine Valley.....  CA.............  LEA............     $397,320
                                Unified School
                                District.
S215E130233..................  Elk Grove         Elk Grove.......  CA.............  LEA............     $398,498
                                Unified School
                                District.
S215E130274..................  Summerville       Tuolumne........  CA.............  LEA............     $340,547
                                Elementary
                                School District.
S215E130303..................  Earlimart School  Earlimart.......  CA.............  LEA............     $249,738
                                District.
S215E130305..................  Montebello        Montebello......  CA.............  LEA............     $395,768
                                Unified School
                                District.
S215E130407..................  Desert Sands      La Quinta.......  CA.............  LEA............     $267,922
                                Unified School
                                District.
S215E130451..................  Sierra Sands      Ridgecrest......  CA.............  LEA............     $200,000
                                Unified School
                                District.
S215E130519..................  Cutler-Orosi      Orosi...........  CA.............  LEA............     $322,694
                                Joint Unified
                                School District.
S215E130025..................  Southington       Southington.....  CT.............  LEA............     $389,789
                                Public Schools.
S215E130073..................  Bloomfield        Bloomfield......  CT.............  LEA............     $308,740
                                Public Schools.
S215E130534..................  School Board of   Gainesville.....  FL.............  LEA............     $317,305
                                Alachua County.
S215E130338..................  Calhoun City      Calhoun.........  GA.............  LEA............     $394,458
                                Board of
                                Education.
S215E130034..................  Geary County      Junction City...  KS.............  LEA............     $399,940
                                United School
                                District #475.
S215E130384..................  Harlan County     Harlan..........  KY.............  LEA............     $400,000
                                Board of
                                Education.
S215E130420..................  Northern          Cold Spring.....  KY.............  LEA............     $371,377
                                Kentucky
                                Cooperative for
                                Educational
                                Services.
S215E130186..................  Terrebonne        Houma...........  LA.............  LEA............     $397,386
                                Parish School
                                District.
S215E130148..................  Everett Public    Everett.........  MA.............  LEA............     $382,900
                                Schools.
S215E130467..................  Harford County    Bel Air.........  MD.............  LEA............     $382,037
                                Public Schools.
S215E130080..................  Academy for       Dearborn........  MI.............  LEA............     $395,267
                                Business and
                                Technology.
S215E130142..................  Eastern Upper     Sault Ste Marie.  MI.............  LEA............     $372,944
                                Peninsula ISD.
S215E130143..................  Salamanca City    Salamanca.......  NY.............  LEA............     $312,009
                                Central School
                                District.
S215E130364..................  Eastern Suffolk   Patchogue.......  NY.............  LEA............     $365,590
                                BOCES.
S215E130047..................  Bellaire Local    Bellaire........  OH.............  LEA............     $169,173
                                School District.
S215E130153..................  Meigs Local       Pomeroy.........  OH.............  LEA............     $379,397
                                School District.
S215E130431..................  Columbus          Columbus........  OH.............  LEA............     $399,160
                                Preparatory
                                Academy.
S215E130137..................  Rattan Public     Rattan..........  OK.............  LEA............     $254,042
                                Schools.
S215E130172..................  Kershaw County    Camden..........  SC.............  LEA............     $394,372
                                School District.
S215E130215..................  Navasota ISD....  Navasota........  TX.............  LEA............     $399,922
S215E130477..................  Waco Independent  Waco............  TX.............  LEA............     $399,584
                                School District.
S215E130241..................  Tooele County     Tooele..........  UT.............  LEA............     $399,649
                                School District.
S215E130355..................  Milton Town       Milton..........  VT.............  LEA............     $204,143
                                School District.
----------------------------------------------------------------------------------------------------------------
Program Name:  Physical Education
----------------------------------------------------------------------------------------------------------------
S215F130110..................  Springdale        Springdale......  AR.............  LEA............     $735,081
                                Public School
                                District.
S215F130160..................  Alameda County    Hayward.........  CA.............  LEA............     $661,906
                                Office of
                                Education.
S215F130165..................  Diego Hills       Lancaster.......  CA.............  LEA............     $211,023
                                Charter School
                                aka Diego Hills
                                Public Charter
                                Sc.
S215F130171..................  Desert Sands      Lancaster.......  CA.............  LEA............     $422,942
                                Public Charter,
                                Inc..
S215F130017..................  New London        New London......  CT.............  LEA............     $687,138
                                Public Schools.
S215F130373..................  Westport Public   Westport........  CT.............  LEA............     $616,157
                                Schools.
S215F130329..................  District of       Washington......  DC.............  LEA............     $570,942
                                Columbia Public
                                Schools.
S215F130109..................  School Board of   Largo...........  FL.............  LEA............     $775,179
                                Pinellas
                                County, FL.
S215F130255..................  Brevard Public    Viera...........  FL.............  LEA............     $311,955
                                Schools.
S215F130260..................  School Board of   Miami...........  FL.............  LEA............     $763,761
                                Miami-Dade
                                County, FL.
S215F130020..................  Cedar Falls       Cedar Falls.....  IA.............  LEA............     $605,083
                                Community
                                School District.
S215F130040..................  Marshalltown      Marshalltown....  IA.............  LEA............     $494,201
                                Community
                                School District.
S215F130099..................  Marion            Marion..........  IA.............  LEA............     $354,001
                                Independent
                                School District.
S215F130148..................  Iowa City         Iowa City.......  IA.............  LEA............     $263,408
                                Community
                                School District.
S215F130012..................  Middleton School  Middleton.......  ID.............  LEA............     $441,228
                                District.
S215F130218..................  Chicago Public    Chicago.........  IL.............  LEA............     $750,000
                                Schools,
                                District 299.
S215F130283..................  Hononegah         Rockton.........  IL.............  LEA............     $615,733
                                Community High
                                School District
                                207.
S215F130150..................  Newport           Newport.........  KY.............  LEA............     $478,403
                                Independent
                                Schools.
S215F130261..................  ERLANGER-ELSMERE  ERLANGER........  KY.............  LEA............     $725,893
                                INDEPENDENT
                                SCHOOL DISTRICT.
S215F130019..................  Watertown Public  Watertown.......  MA.............  LEA............     $391,269
                                Schools.
S215F130056..................  North Brookfield  North Brookfield  MA.............  LEA............     $390,196
                                Public Schools.
S215F130194..................  Maine School      Gray............  ME.............  LEA............     $465,133
                                Administrative
                                District 15.
S215F130198..................  LIVONIA PUBLIC    LIVONIA.........  MI.............  LEA............     $593,365
                                SCHOOLS SCHOOL
                                DISTRICT.
S215F130119..................  Stillwater Area   Stillwater......  MN.............  LEA............     $727,030
                                Public Schools
                                ISD #834.
S215F130368..................  Winona R-III      Winona..........  MO.............  LEA............     $190,358
                                School District.
S215F130064..................  Buncombe County   Asheville.......  NC.............  LEA............     $752,093
                                Schools.
S215F130102..................  Public Schools    Lumberton.......  NC.............  LEA............     $698,129
                                of Robeson
                                County.
S215F130145..................  Charlotte-        Charlotte.......  NC.............  LEA............     $599,514
                                Mecklenburg
                                Schools.
S215F130211..................  Iredell-          Statesville.....  NC.............  LEA............     $749,916
                                Statesville
                                Schools.
S215F130154..................  South Orange-     Maplewood.......  NJ.............  LEA............     $542,081
                                Maplewood
                                School District.
S215F130023..................  Mexico Academy &  Mexico..........  NY.............  LEA............     $640,727
                                Central School
                                District.
S215F130043..................  Holland Central   Holland.........  NY.............  LEA............     $605,957
                                School District.
S215F130105..................  Greater           Amsterdam.......  NY.............  LEA............     $633,071
                                Amsterdam
                                School District.
S215F130221..................  Palmyra-Macedon   Palmrya.........  NY.............  LEA............     $328,417
                                Central School
                                District.
S215F130232..................  Watkins Glen      Watkins Glen....  NY.............  LEA............     $592,110
                                Central School
                                District.
S215F130238..................  Queensbury Union  Queensbury......  NY.............  LEA............     $547,829
                                Free School
                                District.
S215F130258..................  The Renaissance   Jackson Heights.  NY.............  LEA............     $471,986
                                Charter School.
S215F130269..................  South Colonie     Albany..........  NY.............  LEA............     $714,708
                                Central School
                                District.
S215F130309..................  Caledonia-        Caledonia.......  NY.............  LEA............     $448,469
                                Mumford Central
                                School District.
S215F130321..................  City School       New Rochelle....  NY.............  LEA............     $675,000
                                District of New
                                Rochelle.
S215F130418..................  Freeport Union    Freeport........  NY.............  LEA............     $326,416
                                Free Schools.
S215F130158..................  Perry Local       Perry...........  OH.............  LEA............     $762,811
                                Schools.
S215F130311..................  Southern Local    Racine..........  OH.............  LEA............     $384,507
                                Schools.
S215F130326..................  Wickliffe City    Wickliffe.......  OH.............  LEA............     $384,522
                                Schools.
S215F130180..................  Beggs Public      Beggs...........  OK.............  LEA............     $422,176
                                School District.
S215F130153..................  PAWTUCKET SCHOOL  Pawtucket.......  RI.............  LEA............     $575,244
                                DEPARTMENT.
S215F130111..................  Beresford School  Beresford.......  SD.............  LEA............     $398,590
                                District 61-2.
S215F130122..................  Crockett          Crockett........  TX.............  LEA............     $640,012
                                Independent
                                School District.
S215F130324..................  IDEA Public       Weslaco.........  TX.............  LEA............     $747,092
                                Schools.
S215F130281..................  Ogden City        Ogden...........  UT.............  LEA............     $719,869
                                School District.
S215F130022..................  Newport           Newport.........  WA.............  LEA............     $378,000
                                Consolidated
                                School District
                                #56-415.
S215F130065..................  Mead School       Mead............  WA.............  LEA............     $430,409
                                District 354.
S215F130116..................  NorthEast         Spokane.........  WA.............  LEA............     $369,783
                                Washington
                                Educational
                                Service
                                District 101.
S215F130025..................  School District   Monroe..........  WI.............  LEA............     $423,080
                                of Monroe.
S215F130067..................  Southern Door     Brussels........  WI.............  LEA............     $461,590
                                County School
                                District.
S215F130336..................  School District   Wild Rose.......  WI.............  LEA............     $497,431
                                of Wild Rose.
----------------------------------------------------------------------------------------------------------------
Account Name:  School Improvement Programs
Program Name:  State Assessments
----------------------------------------------------------------------------------------------------------------
S368A130003..................  Maryland State    Baltimore.......  MD.............  State..........   $4,999,994
                                Department of
                                Education.
S368A130002..................  North Carolina    Raleigh.........  NC.............  State..........   $6,131,422
                                Department of
                                Public
                                Instruction.
S368A130004..................  Texas Education   Austin..........  TX.............  State..........   $3,988,124
                                Agency.
----------------------------------------------------------------------------------------------------------------
Account Name:  Special Education
Program Name:  Special Education PROMISE Initiative
----------------------------------------------------------------------------------------------------------------
H418P130003..................  California        Sacramento......  CA.............  State..........      $86,498
                                Department of
                                Rehabilitation.
----------------------------------------------------------------------------------------------------------------
Program Name:  Special Education Technical Assistance and Dissemination
----------------------------------------------------------------------------------------------------------------
H326T130036..................  Arkansas          Little Rock.....  AR.............  State..........     $118,534
                                Department of
                                Education.
H326T130032..................  Arizona State     Tucson..........  AZ.............  LEA............     $175,338
                                Schools for the
                                Deaf and the
                                Blind.
H326T130024..................  Colorado          Denver..........  CO.............  State..........     $154,079
                                Department of
                                Education.
H326T130040..................  Delaware          Dover...........  DE.............  State..........      $83,362
                                Department of
                                Education.
H326T130038..................  Iowa Braille and  Vinton..........  IA.............  LEA............      $97,054
                                Sight Saving
                                School.
H326T130081..................  Illinois State    Springfield.....  IL.............  State..........     $335,444
                                Board of
                                Education.
H326T130016..................  Education, KS     Kansas City.....  KS.............  LEA............     $128,122
                                State Board of
                                DBA KS School
                                for the Blind.
H326T130085..................  Kentucky          Frankfort.......  KY.............  State..........     $165,145
                                Department of
                                Education.
H326T130037..................  Maryland State    Baltimore.......  MD.............  State..........     $229,366
                                Department of
                                Education.
H326T130020..................  State of          Roseville.......  MN.............  State..........     $171,335
                                Minnesota,
                                Minnesota
                                Department of
                                Education.
H326T130018..................  Missouri          Jefferson City..  MO.............  State..........     $197,129
                                Department of
                                Elementary and
                                Secondary
                                Education.
H326T130010..................  North Carolina    Raleigh.........  NC.............  State..........     $313,649
                                Department of
                                Public
                                Instruction.
H326T130034..................  North Dakota      Bismarck........  ND.............  State..........      $65,000
                                Department of
                                Public
                                Instruction.
H326T130021..................  Nebraska          Lincoln.........  NE.............  State..........      $78,471
                                Department of
                                Education.
H326T130083..................  Montgomery        Norristown......  PA.............  LEA............     $371,952
                                County
                                Intermediate
                                Unit.
H326T130092..................  Department of     San Juan........  PR.............  State..........      $65,000
                                Education,
                                Associated
                                Secretariat of
                                Special Ed.
H326T130082..................  The South         Columbia........  SC.............  LEA............     $154,204
                                Carolina School
                                for the Deaf
                                and the Blind.
H326T130086..................  Texas Education   Austin..........  TX.............  State..........     $575,000
                                Agency.
H326T130009..................  Utah State        Salt Lake City..  UT.............  State..........      $92,039
                                Office of
                                Education.
H326T130029..................  Office of         Olympia.........  WA.............  State..........     $195,750
                                Superintendent
                                of Public
                                Instruction.
H326T130027..................  Wisconsin         Madison.........  WI.............  State..........     $173,484
                                Department of
                                Public
                                Instruction.
H326T130028..................  West Virginia     Charleston......  WV.............  State..........     $125,020
                                Department of
                                Education.
H326T130093..................  Wyoming           Rawlins.........  WY.............  State..........      $65,000
                                Department of
                                Education.
----------------------------------------------------------------------------------------------------------------

              grant periods of competitive grant programs
    Question. Can you indicate the periods of investment that are 
involved in competitive awards?
    Answer. Project periods for Department of Education competitive 
grant programs generally range from 3 to 5 years. There are exceptions, 
such as when an applicant does not request funding for the full 
proposed project period, and one recent grant competition made 2-year 
grants.
   assessing the impact of formula versus competitive grant programs
    Question. Furthermore, stakeholders are looking for further 
justification for how the Department of Education assesses the impact 
of the dependability and sustained impact of formula grant programs 
versus the unpredictability that can be associated with grants awarded 
competitively. Can you provide your justification for this shift?
    Answer. Formula grant programs typically are intended to provide 
ongoing support to States and school districts in areas where they 
often struggle to produce positive educational outcomes, such as in 
serving students from low-income families, students with disabilities, 
and English Learners. Competitive grant programs, by contrast, 
generally are designed to provide extra resources for a limited period 
of time that allow a State or district to develop and demonstrate 
innovative approaches to meeting educational challenges. Successful 
innovations then may be supported, following the end of the project 
period for a competitive grant program, through a combination of 
Federal, State, and local funding. We see a robust portfolio of 
competitive grant programs as a critical complement to our much larger 
investment in formula grant programs, providing much-needed incentives 
and resources to support State and local innovation and build the 
evidence base for effective educational practice.
              effective teachers and leaders state grants
    Question. Your budget proposal includes a request for the Excellent 
Instructional Team initiative, and a component of this proposal is 
Effective Teachers and Leaders State grants. New Hampshire's higher 
education institutions that train educators are currently working with 
stakeholders in the State toward implementing a program that not only 
trains teachers for the workforce, but also follows them for at least 2 
years post-graduation to provide them with additional support and 
preparation to effectively manage a classroom as they begin their 
careers. This can help ensure that teachers receive the preparation and 
support they need and help keep young educators in the profession.
    The Department's Effective Teachers and Leaders State Grant program 
provides a number of overarching goals that States can implement to 
improve the profession and ensure the highest quality educators are 
working with students. Would your formula grant distribution take into 
consideration the work currently being done by States to support 
quality teacher preparation efforts and ensure that such efforts would 
not be duplicative but could rather build off of the work that is 
already being done?
    Answer. Consistent with the current Title II, Part A statute, under 
the Effective Teachers and Leaders State Grants program, the Department 
would allocate funds to States based on each State's relative share of 
the population, age 5 to 17, and on each State's share of children, age 
5 to 17, from low-income families. States would be able to reserve 
State-level funds for activities such as those you describe, and would 
have flexibility to build on existing work to support and prepare 
teachers as they embark upon their new careers.
incorporating nontraditional science, technology, engineering, and math 
                  activities in after-school programs
    Question. As we continue to look at the jobs of the future in our 
country, it is clear that a strong comprehension of STEM subjects will 
be increasingly important. I believe we need to do more to expand 
understanding of STEM subjects through all facets of education, and I 
view out-of-school time as a critical period during which students can 
participate in nontraditional STEM activities like FIRST robotics in 
New Hampshire. How do you envision your Department incorporating more 
nontraditional STEM activities into federally supported afterschool 
initiatives as you work to provide our Nation's children with the 
skills they will need to succeed in the future?
    Answer. After school programs like 21st Century Community Learning 
Centers are an important example of how we are able to provide flexible 
Federal funding for initiatives that meet State and local needs and 
help States and communities lead the way in innovations that help 
prepare our children for college and careers in our globally 
competitive economy. In the STEM space, of course, we also believe that 
our STEM Innovation Networks proposal could provide significant support 
for the kind of out-of-school learning opportunities offered by 
participation in programs like the First Robotics Competition.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
                      preschool development grants
    Question. I recognize the important role that early childhood 
education plays in helping all students enter the classroom prepared to 
learn. That said, I am concerned the administration may direct funding 
for Preschool Development Grants to States that are willing to 
implement administration-driven approaches rather than allow for 
flexibility in funding on State and local identified needs for 
preschool education. Is the Department concerned that predetermined 
approaches would restrict flexibility for State and local entities to 
meet the unique conditions or needs of their communities?
    Answer. The Department is committed to funding high-quality 
preschool programs that meet State and local needs. Although programs 
funded by Preschool Development Grants would be required to meet 
nationally recognized program quality standards, grantees would have 
the flexibility to determine which local communities they wish to serve 
and how these programs should be delivered. For example, preschool 
services could be delivered through a mixed-delivery system of 
providers including schools, licensed child care centers, Head Start, 
or other community-based organizations. In addition, only preschool 
programs funded through this program will need to meet the 
competition's criteria for high-quality preschool programs. Other 
preschool programs within the State will not be required to meet these 
criteria.
    preschool development grants--programs requirements and student 
                                outcomes
    Question. The fiscal year 2015 budget request states that Preschool 
Development grantees will be required to meet minimum standards to 
receive funding, such as specific staff qualifications, training, and 
employee salaries that are comparable to K-12 teachers, among other 
requirements. There are local programs in States currently that are 
making impressive strides in early child education, but may not be able 
to comply with all of these standards based on how they are customized 
to serve their unique communities. Again, while I support early 
childhood education, I am concerned that this approach will not provide 
necessary flexibility. How does this focus on specific requirements 
reconcile with a Department that continuously asserts that it is 
focused on outcomes in education?
    Answer. The Preschool Development Grant program would not require 
States to meet the criteria of a high-quality preschool program to be 
eligible for funds. All States will be eligible to apply. Rather, 
grantees will need to show how the programs implemented with these 
funds will meet the competition's criteria for high-quality preschool 
programs. Preschool Development Grants are intended to support the 
creation of high-quality model programs in select high-need 
communities. Given the scope and scale of these awards, the Department 
believes that grantees should be able to direct resources to the 
highest quality programs--including those that meet high staff 
qualifications and other high-quality benchmarks--in a few communities. 
Research has shown that early childhood teachers' education and 
training have been linked to global measures of program quality, 
language and social interaction between teachers and children, and 
improved student outcomes.
            preschool development grants--funding subgrants
    Question. Will the Department commit to allowing funding to be 
subgranted to entities by States that will work toward meeting high-
quality standards, but may not meet all of the minimum standards at 
this time?
    Answer. The Department is committed to funding high-quality 
preschool programs. Early learning providers do not need to meet all of 
the standards when they apply for a Preschool Development grant. 
However, subgrantees must use grant funds to implement a program that 
meets the high-quality benchmarks outlined in the competition. For 
example, a subgrantee may not currently offer a full-day program or 
maintain a staff:child ratio of 1:10, but would need to commit to doing 
so upon receipt of program funding.
                sustaining preschool development grants
    Question. Given the high cost of implementing some of these 
standards, what assurances will there be that these preschool programs 
will be sustainable after the grant period?
    Answer. The Department is very interested in funding high-quality 
projects that are sustainable after the grant period ends and will 
consider ways to further that goal.
     preschool development grants--encouraging state and community 
                              cooperation
    Question. Flexibility at the State and local levels will be key to 
the success of the grant and the early childhood education systems in 
the States. Is there an expectation that collaborative local councils 
will or can use existing high quality programs at the State and local 
levels to move toward a State early childhood system? And, how will the 
Department encourage opportunities for schools and community programs 
to work together?
    Answer. The Department is very interested in encouraging 
collaboration, both between States and local entities, and among local 
preschool providers and is planning to include such measures in the 
selection criteria for Preschool Development Grants.
            preschool development grants--family engagement
    Question. Please provide clarification as to the Department's 
expectations for family engagement implementation using Preschool 
Development Grants? Will States have the flexibility with funds to 
include evidence-based home visiting with preschool classroom families 
to extend learning and facilitate parent engagement and partnership?
    Answer. The Department is committed to supporting family engagement 
efforts through the Preschool Development Grants program, and is 
considering including family engagement strategies throughout the 
priorities, requirements, definitions, and selection criteria sections 
of the Notice Inviting Applications.
        preschool development grants--students with disabilities
    Question. Will Preschool Development Grants encourage States to use 
funding to maximize more inclusive opportunities so that children who 
have disabilities and the programs that serve them can participate 
fully in this funding opportunity?
    Answer. Yes; one of the elements of the Department's definition of 
high-quality preschool programs is the full inclusion of children with 
disabilities.
          preschool development grants--comprehensive services
    Question. Please provide clarification as to the specific 
comprehensive services that will be required to be provided onsite by 
preschool programs to qualify for Preschool Development Grant funding. 
Will a preschool program be eligible to receive funding should it 
commit to providing comprehensive services in the future under the 
grant if they are not currently provided?
    Answer. Early learning providers delivering a high-quality 
preschool program would need to offer comprehensive services that meet 
children's needs across a range of domains of development, including: 
education, health, mental health, nutrition, and family engagement. 
Comprehensive services must be accessible or delivered on site.
    While the Department believes that providing comprehensive services 
should be a part of a high-quality preschool program, States and 
subgrantees do not have to currently provide comprehensive services to 
be eligible to receive Preschool Development Grant funds.
                college ratings system development funds
    Question. Please provide a detailed breakdown of funding that has 
been used to date to develop a college ratings system. This should 
include the source of funding for each activity, including funds 
relating to the information collection request on development of a 
college ratings system, funds relating to the actual development of the 
system, funds relating to travel and cost of conducting symposiums, 
among all other activities.
    Answer. The costs to date associated with the college ratings 
system, officially the Postsecondary Institutions Ratings System, or 
PIRS, are provided below, excluding full-time equivalent employee (FTE) 
costs.

                  COLLEGE RATINGS SYSTEM COSTS TO DATE
------------------------------------------------------------------------
            Activity                     Costs          Funding Source
------------------------------------------------------------------------
Planning and Development Costs..  N/A...............  N/A
Operations and Maintenance......  Not Yet Developed.  N/A
Symposium Costs (includes         Approximately       Student Aid
 travel).                          $23,500.            Administration
------------------------------------------------------------------------

     college ratings system in the fiscal year 2015 budget request
    Question. Could the Department please provide additional detail on 
the proposed use of $10 million in fiscal year 2015 to develop the 
college ratings system, as well as any planned use of funds beyond the 
$10 million?
    Answer. The college ratings system's development and refinement 
will require ongoing costs beyond the initial costs associated with the 
first iteration that we are currently in the process of developing. 
That is why the President's fiscal year 2015 budget request includes 
$10 million to support further development and refinement of a new 
college ratings system, including Web site design and continuous 
improvement, and validation of the data and methodology. Specifically, 
we anticipate costs for a contractor to design, maintain, and update 
the Web site of the college ratings system; research and data costs 
associated with designing different methodologies and models, and for 
obtaining, validating, and analyzing data for the ratings system; as 
well as ``data-runs'' of rating methodologies and models.
          alternate funding sources for college ratings system
    Question. Please provide detailed information on the source, use, 
and amount of funding that will be utilized by the Department to 
develop the college ratings system if $10 million is not provided in 
fiscal year 2015 specifically for this purpose?
    Answer. If any amount less than the $10 million request is 
provided, the Department would need to utilize a combination of 
existing resources to make up for the shortfall.
                race to the top--equity and opportunity
    Question. In a time of tight fiscal budgets, I question why the 
fiscal year 2015 budget request creates yet another new, competitive 
program under Race to the Top. Why fund the Race to the Top: Equity and 
Opportunity program when it provides duplicative services with ESEA, 
Title I grants that already reach all disadvantaged students?
    Answer. The Elementary and Secondary School Act (ESEA), Title I 
program provides essential support for State and local efforts to meet 
the educational needs of disadvantaged students in high-poverty 
schools. We think that the modest $300 million investment we have 
proposed for Race to the Top--Equity and Opportunity will generate 
innovative approaches and promising practices aimed at increasing 
educational equity that could have a meaningful impact on improving the 
performance and outcomes of the $14 billion Title I program.
 students benefiting from race to the top and elementary and secondary 
                      school act, title i services
    Question. Since Race to the Top was created, over $6 billion has 
been appropriated for initiatives which have been aimed at ultimately 
reducing achievement and opportunity gaps for students. How many more 
students, especially in States like Kansas that have yet to benefit 
from Race to the Top funding, could have benefited from $6 billion in 
additional Title I services?
    Answer. Race to the Top is focused on helping States and school 
districts develop and implement systemic education reforms that can 
transform their ability to improve educational outcomes for all 
students. If an additional $6 billion had been allocated through Title 
I over the past 5 years, we estimate that Kansas might have been able 
to serve, on average, an additional 8,500 students annually. However, 
Kansas' share of that $6 billion--an estimated $42 million--would have 
been considerably less than the nearly $71 million that the State 
received in additional Title I funds provided in fiscal year 2009 
through the American Recovery and Reinvestment Act (ARRA). ARRA 
provided $10 billion for ESEA, Title I, along with $4 billion for Race 
to the Top State Grants, or the bulk of the $6 billion total referenced 
in your question. In other words, ARRA allowed us to invest in 
transformational reform programs like Race to the Top while still 
keeping faith with traditional sources of Federal formula grant support 
relied upon by States and school districts.
                    equity and competitive programs
    Question. How is equity achieved for all students when competitive 
programs, by their nature, result in only some students receiving 
services?
    Answer. The goal of the Race to the Top--Equity and Opportunity 
proposal is to create incentives for States and school districts to 
make comprehensive changes in how they identify and close opportunity 
and achievement gaps. In other words, equity in education is not just 
about equalizing expenditures or services, but also about using data to 
identify the needs of individual students and developing strategies to 
meet those needs. We think competitive grants are a more efficient and 
effective way to target these limited resources on this goal than 
spreading the funds thinly through formula grants. A key purpose of our 
Race to the Top proposal for fiscal year 2015 is to generate a set of 
evidence-based practices and interventions that successfully address 
disparities in educational opportunity and improve outcomes, so that 
those practices and interventions can be scaled up with existing 
Federal resources, such as our annual $14 billion investment in Title 
I, to provide equitable educational opportunities to all students.
 competitive programs and the reduction of achievement and opportunity 
                                  gaps
    Question. How will another $300 million for a new Race to the Top 
program that only reaches students in States and local school districts 
that successfully compete for funding, further the goal of reducing 
achievement and opportunity gaps for students?
    Answer. These funds would be awarded to States and school districts 
that submit high-quality applications demonstrating the greatest 
promise of using data to (1) identify the greatest disparities in 
opportunity and performance and (2) develop effective strategies and 
practices for addressing those disparities. Our goal is to identify a 
set of evidence-based practices and interventions that successfully 
address disparities in educational opportunity and improve outcomes. 
Then we would encourage States and school districts to use existing 
Federal resources, such as ESEA, Title I funding, to scale up those 
proven practices and interventions to provide equitable educational 
opportunities to all students.
   special education--results driven accountability incentive grants
    Question. Why did the Department choose to include $100 million for 
an Incentive grants competition under Special Education at the expense 
of increasing formula funding for Special Education Grants to States?
    Answer. While protecting funding for foundational programs like 
Special Education State Grants, under the Individuals with Disabilities 
Education Act (IDEA) and ESEA, Title I State grants is incredibly 
important, we also need to invest in reform. The reform dollars we 
invest in competitive grants encourage States and districts to rethink 
their existing ways of doing things, including their use of formula 
funds, to produce better outcomes for students--especially students 
that have historically been underserved, like students with 
disabilities. Our new $100 million Results Driven Accountability 
Incentive Grants (RDA) competition will improve special education 
services for children with disabilities while also building State and 
local capacity to continuously improve outcomes.
    Funds under the IDEA, Part B program are primarily used for program 
and services at the local level. The Department believes that these new 
competitive grants can be used together with formula funds to drive 
meaningful, targeted and systemic reforms to address gaps in 
performance that will have a significant and long-term impact on 
results for children with disabilities. RDA would support State efforts 
to identify and implement reforms that would improve results for 
children with disabilities, such as school readiness, academic 
performance, and graduation rates.
                 career and technical education funding
    Question. Given the critical role that hands-on experiences play in 
helping students prepare for future careers, why does the fiscal year 
2015 Department of Education Budget Request only provide level funding 
for Career and Technical Education (CTE)?
    Answer. We agree that the programs authorized under the Perkins 
Career and Technical Education Act provide important support for 
helping students prepare for future careers. The President's budget 
proposal for education represents hard choices for funding among 
multiple worthy programs in a difficult fiscal environment. The fiscal 
year 2015 budget request respects the spending levels set in the 
Bipartisan Budget Act of 2013, with new discretionary funding dedicated 
to areas where we think it will have the greatest impact on improving 
educational outcomes. We also believe that a reauthorized Act that 
strengthens alignment between secondary and postsecondary education and 
enhances accountability will enhance the quality of CTE programs 
available to students at the current funding level.
 impact of innovation fund set-aside on career and technical education 
                   state funding levels and students
    Question. What would be the impact to individual States if Career 
and Technical Education Grants to States are reduced by a $100 million 
set-aside for a new innovation fund? And, how many less students will 
be served in States that are not successful in competing for this 
proposed use of funding?
    Answer. The Department's fiscal year 2015 budget request for Career 
and Technical Education (CTE) State Grants presumes that the fiscal 
year 2015 appropriation would support a reauthorized Perkins program 
consistent with the Department's reauthorization proposal. We envision 
that a reauthorized Perkins program would incorporate revisions to the 
State allocation formula so that the formula drives funds to States 
based on current data. If Congress were to enact the set-aside absent 
reauthorization, we would be happy to work with Congress to explore 
ways to fairly distribute the impact on individual State allocations. 
The impact of the reduction in the amount of funds distributed to 
States would vary due to the provisions of the State allocations 
formula, particularly the hold-harmless provision that ensures that no 
State's share of the appropriation is less than its share of the fiscal 
year 1998 appropriation. We are unable to estimate the impact on 
students served because States do not track the number of students 
served with Federal funds versus State and local CTE funding, and 
Perkins Career and Technical Education program funds constitute a small 
percentage of the total funding used for CTE programs; the majority of 
the funding for CTE programs comes from State and local sources.
    Note that although directing funds to an innovation fund would 
reduce the amount of funds distributed to State and local entities, 
activities carried out through an innovation fund would help to 
strengthen CTE for all students by expanding the availability of CTE 
programs that work and encouraging States to establish policies that 
ensure that CTE programs are of high quality and lead to positive 
academic and career outcomes.
                impact aid payments for federal property
    Question. Mr. Secretary, this subcommittee demonstrated its 
commitment to the Impact Aid program by restoring funding in fiscal 
year 2014 for all sections of the program to 99.8 percent of the fiscal 
year 2012 level. Given strong congressional support, why has the 
Department proposed to once again eliminate Payments for Federal 
Property?
    Answer. The policy of the Administration is to use available Impact 
Aid funds to help pay for the education of federally connected 
children, including children of members of the uniformed services, 
children of Federal employees who both live and work on Federal 
property, children of foreign military officers, children living on 
Indian lands, and children residing in federally assisted low-rent 
housing projects. Given the continued need for fiscal discipline, the 
Administration has proposed to maintain $1.2 billion in funding to four 
Impact Aid programs (Basic Support Payments, Payments for Children with 
Disabilities, Construction and Facilities Maintenance) as part of its 
continued commitment to improving the educational outcomes of federally 
connected students supported by those Impact Aid programs.
    Unlike other Impact Aid programs, Payments for Federal Property are 
made to local educational agencies (LEAs) without regard to the 
presence of federally connected children and do not necessarily support 
educational services for such children. When the Payments for Federal 
Property authority was first established in 1950, its purpose was to 
provide assistance to LEAs in which the Federal Government had imposed 
a substantial and continuing burden by acquiring a considerable portion 
of real property in the LEA. The law applied only to property acquired 
since 1938 because, in general, LEAs had been able to adjust to 
acquisitions that occurred before that time. Over 64 percent of 
districts that currently receive Payments for Federal Property first 
applied before 1970. We believe that the majority of LEAs receiving 
assistance under this program have now had sufficient time to adjust to 
the removal of the property from their tax rolls.
    In addition, many LEAs receiving funds under this authority consist 
of two or more LEAs that consolidated, at least one of which originally 
met the eligibility criterion of a loss of 10 percent of the aggregate 
assessed value of real property removed from the tax rolls. The current 
statute allows such LEAs to retain eligibility even though they are no 
longer demonstrably burdened.
     student impact of elimination of payments for federal property
    Question. What impact would the elimination have on the educational 
opportunities of students in districts that currently benefit from such 
payments?
    Answer. It is not possible to estimate the direct impact on 
educational opportunities of students in districts that currently 
receive Payments for Federal Property as each district's budget 
situation would need to be considered individually. Please also note 
that these funds do not necessarily support educational services to 
federally connected children and are calculated without regard to such 
children.
cost to impact aid program of reduced department of defense funding of 
                        domestic defense schools
    Question. Has the Education Department (ED) discussed with the 
Defense Department the impact on public schools should the Defense 
Department reduce its commitment to the Domestic Defense schools? As I 
am concerned about the strain that would be put on the Impact Aid 
program to offset the increased cost to school districts of educating 
additional students, does the Department have similar concerns and what 
would be the estimated cost to the Impact Aid program?
    Answer. There have been no discussions between the Department of 
Defense and ED regarding the impact of the Department of Defense's 
potential reduction in commitment to Domestic Defense schools. The 
Department of Defense was conducting an independent needs study 
regarding Department of Defense schools in 2012, however, we were not 
informed of its results.
                            entrepreneurship
    Question. As we think about the current fiscal environment, one way 
we can help reduce the Federal deficit is to grow the economy. To do 
this, I have advocated for the need to strengthen our support of 
entrepreneurs given that new businesses account for the creation of an 
average of 3 million jobs each year. Support for entrepreneurship 
begins with developing our next generation of American talent and 
independent thinkers. What specific activities and programs at the 
Department of Education focus on helping students attain the skills 
necessary to become entrepreneurs and compete in a global economy?
    Answer. Nearly all of our programs are aimed at helping students 
attain the college- and career-ready skills they need to be successful 
in our 21st century globally competitive economy, including traditional 
employment in business and industry as well as more entrepreneurial 
activities. In particular, our emphasis on new college- and career-
ready standards and aligned assessments reflects the growing need for 
all students to master the higher-order thinking and reasoning skills 
that are essential for the creative work involved in entrepreneurship. 
And two key proposals in our 2015 request--STEM Innovation Networks and 
High School Redesign--would provide significant new support for locally 
determined activities consistent with your interest in 
entrepreneurship. For example, the $150 million request for High School 
Redesign would support the redesign of high schools in innovative ways 
that better prepare students for college and career success so that all 
students graduate from high school with college credit and career-
related experiences or competencies, obtained through project or 
problem-based learning, real-world challenges, and organized 
internships and mentorships. And a $110 million request for STEM 
Innovation Networks would encourage partnerships of LEAs, higher 
education, nonprofit organizations, and business to increase 
opportunities for students to engage in hands-on STEM learning 
activities that will give them the skills to help America compete and 
innovate in our technology-driven world.
                   education research and development
    Question. I am pleased that the University of Kansas (KU) has been 
a leader in special education research. Currently KU is receiving 
funding from the Office of Special Education programs to develop a 
national center to assist schools in educating general and special 
education students together and improving school-wide academic 
outcomes. Given the tight fiscal budget, what resources can the 
Department direct towards research and development in teaching, use of 
technology and student learning, including learning of special 
education and high-risk students, to make certain that American schools 
are at the forefront of educational progress?
    Answer. The Department's Institute of Education Sciences (IES) 
supports research and development through the National Center for 
Education Research (NCER) and the National Center for Special Education 
Research (NCSER). Since 2002, NCER has invested over $1.5 billion to 
fund a wide variety of studies focused on strategies to improve student 
outcomes. These include research grants on effective teaching, 
education technology, and cognition and student learning, among other 
topics. Since its initial grant competitions in 2006, NCSER has 
invested about $530 million to build a comprehensive program of special 
education research designed to expand the knowledge and understanding 
of children with disabilities from birth through the transition from 
high school. Active grants include those addressing the development and 
testing of interventions and assessments, as well as innovative uses of 
technology, to help children with or at risk of disabilities and their 
families, teachers and other professionals who provide support or 
services. Major NCSER investments in the last few years have included, 
for example, National Research and Development Centers on improving 
mathematics instruction for students with mathematics difficulties; 
developing and testing a comprehensive school-based intervention for 
secondary students with autism; and strategies for accelerating the 
academic achievement in reading and math of students with learning 
disabilities. While budget constraints prevented NCSER from holding 
grant competitions in fiscal year 2014, new proposals for research 
funding will be accepted for fiscal year 2015. Fewer awards are 
anticipated based on available funding. Finally, IES runs a Small 
Business Innovation Research (SBIR) program that offers funding to for-
profit small business for the research and development of commercially 
viable education technology products to support students and teachers. 
For example, one awardee developed iPrompt, which allows teachers to 
customize and present different visual supports for students with 
autism using various mobile devices.
          higher education services for disadvantaged students
    Question. While I support the goals of increasing college access 
and attainment for disadvantaged students, why did the Administration 
choose to create the new $75 million College Success Grants for 
Minority-Serving Institutions program when the proven TRIO programs 
already exist to provide support services to disadvantaged students to 
assist with college completion?
    Answer. TRIO projects provide essential services to help students 
from disadvantaged backgrounds to enter and succeed in undergraduate 
and graduate education. The Administration's request maintains funding 
for these essential programs. However, we also believe that new 
approaches are needed to increase college attainment, particularly 
among under-resourced Minority-Serving Institutions (MSIs) that face 
unique challenges, serve a large share of low-income students, and are 
in need of additional support.
    The College Success Grants for MSIs initiative would provide 
funding for high-quality proposals by individual MSIs or consortia to 
implement evidence-based strategies that are designed to increase the 
numbers of students, particularly Pell Grant recipients, completing 
postsecondary education. While certain aspects of the College Success 
Grants for MSIs program may be similar to the Federal TRIO programs, 
successful applicants would use funding to undertake a much broader set 
of activities than are permitted under TRIO, including the following:
  --Partnering with school districts and schools to provide college 
        recruitment, awareness, and preparation activities, to enable 
        students to enter and complete postsecondary education.
  --Establishing high quality dual-enrollment programs.
  --Implementing evidence-based course redesigns of high enrollment 
        courses to improve student outcomes and reduce costs.
  --Reforming institutional need-based aid policies to enhance 
        educational opportunities for low-income students and provide 
        incentives for on-time completion.
  --Providing comprehensive student support services, both academic and 
        non-academic.
  --Reducing the need for, and improving the success of, remedial 
        education.
         mandatory funding--teacher and principal effectiveness
    Question. I am aware that the Department has requested $5 billion 
in mandatory funding for Recognizing Education Success, Professional 
Excellence, and Collaborative Teacher (RESPECT) grants which would be 
used to address teacher recruitment, overhaul tenure and evaluation 
systems, and link salaries to performance. Recognizing that mandatory 
funding is not likely to be provided this fiscal year, could you 
elaborate on whether the Department intends to use any discretionary 
funding under Title II or other funding streams to begin undertaking 
these activities?
    Answer. Under the Effective Teachers and Leaders State Grants 
program, States would have a limited amount of State-level funds with 
which to provide support for effective teacher career ladders, reform 
certification and licensure requirements, increase professional 
development opportunities, and reform teacher and school leader 
compensation systems. The Supporting Effective Educator Development 
(SEED) program, part of a set-aside under the State Grants program, 
would allow the Department to make additional grants to national 
nonprofit organizations to support teacher and school leader 
enhancement projects. Also, under the State Grants program, the 
Department would make competitive awards to States and school districts 
for the purpose of raising standards for teacher and principal 
preparation. In addition, the proposed Teacher and Leader Innovation 
Fund would support State and school district efforts to develop and 
implement innovative approaches to improving human capital management 
systems through a competitive grant process.
               use of title ii national activities funds
    Question. Mr. Secretary, could you provide the subcommittee with a 
specific breakdown on use of funds to date for any Title II funding for 
national activities in fiscal year 2014?
    Answer. Commitments for Title II National Activities in fiscal year 
2014 are:
  --Impact Evaluation of Teacher and Leader Performance Evaluation 
        Systems (5-year study, ending in 2016).
  --Study of Teacher Quality Distribution and Measures of Teacher 
        Quality (mathematics) (5-year study, ending in 2015).
  --Study of Teacher Prep Experiences and Early Teacher Effectiveness 
        (6-year study, ending in 2016).
  --Impact Evaluation of Math Professional Development for Elementary 
        School Teachers (3.5 year study, ending in 2016).
  --Analytic and Technical Support to the Improving Teacher Quality 
        State Grants Program (Support for data collection, monitoring, 
        and an annual meeting of State coordinators).
  --Support for Connected Educators Month.
  --Impact Evaluation of Data-Driven Instruction: Professional 
        Development for Teachers (4-year study, ending in 2017).
  --Impact Evaluation of Support for Principals (5-year study, ending 
        in 2018).
  chief information officer role in information technology investments
    Question. Describe the role of your Department's Chief Information 
Officer in the oversight of information technology (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. The Chief Information Officer (CIO) has the primary 
responsibility to ensure that Information Technology (IT) is acquired 
and information resources are managed in a manner consistent with 
statutory, regulatory, strategic departmental requirements, and 
priorities. The CIO oversees the Lifecycle Management process (LCM) 
that is used to manage systems from concept through retirement. This 
process includes funding, acquisition, design, implementation, 
operation, and retirement of IT systems. The CIO manages the LCM 
process using the Department's IT governance process, which measures 
the value and priority of IT investments and their alignment to 
departmental strategic objectives. The CIO also ensures that projects 
are managed in accordance with Federal and departmental IT policies and 
industry best practices for IT project management throughout their 
lifecycle.
 funding of demonstration, modernization, and enhancement of it systems
    Question. How much of the Department's fiscal year 2015 budget 
request would be for Demonstration, Modernization, and Enhancement of 
IT systems as opposed to supporting existing and ongoing programs and 
infrastructure? And, how has this changed in the last 5 years?
    Answer. Over the past 5 years, the Department has placed a high 
priority on ensuring its IT programs are able to fund Development, 
Modernization, and Enhancement (DME) activities. The table below shows 
the Department's DME funding over the past 5 fiscal years. Data is 
derived from the OMB Exhibit 53, which is a report of all Federal 
agency IT investments, and Exhibits 300A and 300B, which report on 
budgetary and management information necessary for sound planning, 
management, and governance of IT investments.

                               DEVELOPMENT, MODERNIZATION, AND ENHANCEMENT FUNDING
                                              [Dollars in million]
----------------------------------------------------------------------------------------------------------------
                                                                                        DME funding
               Source                 OMB Exhibit 53  fiscal  Fiscal year   Total DME    as % of IT    Total IT
                                            year column                      funding     budget (%)    funding
----------------------------------------------------------------------------------------------------------------
OMB Exhibit 53 BY 2015..............  BY....................         2015       $124.1        17.80       $697.3
OMB Exhibit 53 BY 2015..............  CY....................         2014        141.9        20.80        683.0
OMB Exhibit 53 BY 2015..............  PY....................         2013         99.2        16.80        590.4
OMB Exhibit 53 BY 2014..............  PY....................         2012         65.2        11.91        547.8
OMB Exhibit 53 BY 2013..............  PY....................         2011         49.1         9.20        536.6
----------------------------------------------------------------------------------------------------------------
NOTE: OMB Exhibit 300A includes IT-related full-time equivalent (FTE) funding.

     department technology applications--cloudfirst and sharefirst 
                              initiatives
    Question. Describe the progress being made in the Department to 
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. The Department is in the process of implementing its Access 
Anywhere transformation initiative. This initiative will allow the 
Department's users to benefit from access to Department IT systems, 
applications and shared IT services from anywhere, at any time, and 
from any device. ED employs multiple virtual private network (VPN) 
technologies to enable remote access to email, files, intranets, and 
applications from a variety of tablet, phone, and PC platforms. Since 
calendar year 2012, ED has offered Bring-Your-Own-Device (BYOD) access 
upon the employee's acceptance of the terms of service for BYOD access.
    During fiscal year 2014 through fiscal year 2017, the Office of the 
Chief Information Officer (OCIO) plans to provide the following cloud 
computing services:
    Infrastructure-as-a-Service (IaaS).--The Department will provide 
fundamental computing resources such as processing, storage and 
networks so that Department users can deploy and run software, 
operating systems and applications. IaaS will increase utilization of 
existing investments, reduce infrastructure investments, and decrease 
IT expenses.
    Platform-as-a-Service (PaaS).--The Department will provide an 
integrated platform-based computing solution on the cloud consisting of 
specific operating systems, applications software and development 
tools; that will be available via the Web. PaaS will improve the 
management and procurement of IT systems development capabilities.
    Software-as-a-Service (SaaS).--The Department will migrate some of 
its desktop software applications and data to the cloud infrastructure. 
The software is accessible from various client devices through a thin 
client interface, such as a Web browser. SaaS will improve the 
management, cost, and accessibility of software applications.
    Additional migration of technology services to the cloud will be 
evaluated on an ongoing basis.
    The table below outlines some of the shared services the Department 
currently utilizes:

                                SELECTED DEPARTMENT OF EDUCATION SHARED SERVICES
----------------------------------------------------------------------------------------------------------------
                                                                                              Shared Service
               Service                      Service model           Deployment model          Provider (SSP)
----------------------------------------------------------------------------------------------------------------
Hiring Services......................  SaaS...................  Shared Service Provider  OPM
Office of Personnel Management (OPM)
 (via Monster Government Solutions)
 supports the ED-HIRES system for
 completing employee job descriptions
 and postings with USAJOBS.GOV.
Personnel Folders....................  SaaS...................  Shared Service Provider  OPM
OPM supports the Department through
 its Electronic Office Personnel
 Folder (eOPF) system, which provides
 secure access to employee personnel
 files in support of human resources/
 human capital.
Talent/Learning Management Services..  SaaS...................  Shared Service Provider  DOI/IBC
Department of Interior/Interior
 Business Center (DOI/IBC) provided
 ED with a Learning Management Module
 (online learning, instructor-led
 course sign-up and SF-182 processing
 for external training) and the
 Performance Management Module (for
 employee performance appraisals) via
 https://tms.nbc.gov/.
Payroll Services.....................  SaaS...................  Shared Service Provider  DOI/IBC
DOI/IBC hosts the Federal Personnel
 Payroll System (FPPS), which is used
 for payroll, time & attendance for
 the Department's employees.
Workforce Transformation and Tracking  SaaS...................  Shared Service Provider  DOI/IBC
 System (WTTS) Services & On-boarding
 Services.
ED is leveraging the DOI/IBC Tracking
 System (WTTS)/Entrance On-Duty
 System (EODS), which integrates with
 FPPS and ED-HIRES for hiring.
Implementation of Invoice Process      SaaS...................  Shared Service Provider  Department of the
 Platform (IPP).                                                                          Treasury
OCIO has collaborated with the
 Department's Office of the Chief
 Financial Officer (OCFO) to support
 the implementation of the Department
 of the Treasury's Invoice Processing
 Platform (IPP). The implementation
 of IPP will allow vendors to submit
 their invoices electronically within
 the IPP application. In addition to
 being Web-based and supporting
 electronic submissions, IPP enables
 the Department to define invoice
 workflow for approval routing. OCIO
 has completed all application
 changes required for Financial
 Management Support System (FMSS) to
 support the IPP. OCIO will work
 collaboratively with OCFO to develop
 and deliver training to the
 procurement staff in a three-phased
 approach, beginning with the pilot
 on Monday, April 8, 2013.
----------------------------------------------------------------------------------------------------------------

    ED leverages cloud computing services for best-of-class solutions 
in support of the CloudFirst initiative. ED is leveraging the Federal 
Risk and Authorization Management Program (FedRAMP) to establish a 
standard approach to assess and authorize cloud services to migrate to 
an end-state that features agile, secure, and cost effective services 
that can rapidly respond to changing mission needs.
      departmental central processing system and fafsa-on-the-web
    Question. One of the major IT investments for the Department of 
Education is the Central Processing System, which is responsible for 
FAFSA-On-The-Web. This project has an appropriated cost of $59.14 
million and is scheduled to be completed by 2015, but has faced 
significant challenges, resulting in both cost variance and schedule 
variance. Recent developments have improved the status of the project; 
however, the Federal IT Dashboard indicates the project is moderate-to-
high risk, and the most recent information submitted to the Dashboard 
was for December 2013.
    Please provide an update about the progress of this project.
    Answer. The Front End Business Integration (FEBI) contract was 
restructured under an initiative called FEBI Modernization during 
fiscal year 2012 to better align the way FSA manages the FAFSA-on-the 
Web releases and other contracted products and services that support 
the Central Processing System (CPS). Prior to modernization, the CPS 
was invoiced as a separate component of the contract, but with the 
contract changes, CPS was included as part of a tiered pricing 
structure where FSA is invoiced based on the volume of FAFSAs 
processed. These structural changes to the contract affected the way 
schedule and cost should be tracked in the OMB Exhibit 300 even though 
the project remained on schedule and at the planned cost. Around this 
same time, FSA underwent an organizational realignment where the 
management of the FEBI contract, funding, and OMB Exhibit 300 were 
shifted to another business unit which caused a disruption in timely 
reporting. In fiscal year 2013, there was also a strategic change to 
the FAFSA on the Web release schedule to allow for the deployment of 
multiple releases throughout the year. Under this multi-release 
schedule, there were further changes to the way the schedule and cost 
should be tracked in the OMB Exhibit 300 even though schedule and cost 
remained on target.
    Since fiscal year 2012, development work has been completed on 
schedule and at the contracted price with no overruns despite the 
reporting discrepancies in the OMB Exhibit 300. Schedule and cost are 
tracked monthly through the invoicing process as new development work 
occurs on CPS and its related products and services. A billing schedule 
with dates for delivery, associated deliverables, and the contracted 
cost is issued as part of the contract modification and when invoices 
are received, the date of completion, contracted cost and associated 
deliverables are verified before payment is made. To date, the 
completion dates and contracted cost of development work have been on 
schedule.
                      fafsa-on-the-web management
    Question. Additionally, the Federal IT Dashboard indicates the 
project manager does not have the required certification. What has the 
Department done to address this?
    Answer. As per Department of Education policy, major IT investment 
project managers have 1 year to complete certification requirements and 
the CPS project manager was granted a waiver. The required FAC-PP/M 
certification approved waiver is effective until November 2014.
    While the current project manager had the necessary experience, she 
needed to complete some additional training. Her waiver application 
contained a training plan, which has been executed over the period of 
her waiver. As soon as all necessary training is complete, she will 
submit her FAC-PP/M application for certification.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran
  title ii funding and the supporting effective educator development 
                             grant program
    Question. In Mississippi, the Supporting Effective Educator 
Development (SEED) grant program has been used to train 384 teachers 
over the past 2 years, and will be used to train approximately 175 
additional teachers for placement next year. Needless to say, the 
positive impact that these teachers have had on Mississippi children 
has been remarkable. Can you speak to the importance of the investment 
Congress has made by requesting the Department to designate a 
percentage of Title II funding for this program?
    Answer. We believe the SEED program is an excellent example of the 
kind of innovative and effective work that Congress can support through 
a set-aside of funds under Title II, Part A of the Elementary and 
Secondary Education Act (ESEA). We hope to increase this set-aside from 
the current level of 2 percent in fiscal year 2014 to 10 percent in 
fiscal year 2015, to expand our ability to support similarly effective 
teacher and principal preparation programs, help States raise standards 
for such programs, and recruit and retain school leadership teams with 
the skills and experience needed to turn around low-performing schools.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby
 science, technology, engineering and mathematics competitive programs
    Question. If American students are going to compete in a global 
economy, they must succeed in the science, technology, engineering, and 
math (STEM) fields. While I am a leading proponent of STEM instruction, 
it is difficult to understand why the Administration would prioritize 
the consolidation of STEM programs across the Federal Government, but 
then create new, competitive STEM programs within the Department of 
Education.
    Why did the Department choose to direct scarce Federal resources 
toward the creation of new, competitive STEM programs, rather than 
increase investments in the proven Math and Science Partnerships 
program which support services for students in all States?
    Answer. The Administration's STEM Innovation proposal is a key part 
of the Governmentwide strategy for delivering STEM education that is 
more cohesive and coordinated and, thus, more likely to improve STEM 
outcomes for more students. The Mathematics and Science Partnerships 
program in current law--as it primarily supports teacher professional 
development projects that may be implemented in isolation from other 
STEM education efforts--is not designed to support the comprehensive 
reforms our Nation needs to improve our supply of STEM talent.
   prioritizing and funding stem initiatives within competitions of 
                       existing federal programs
    Question. Can the Department elaborate on efforts to prioritize 
STEM initiatives within competitions across existing Federal programs 
within the Department? And, how will the Department continue these 
efforts with fiscal year 2015 funding?
    Answer. The Department continues to carefully identify 
opportunities to target limited program funds on the Administration's 
core education reform areas, including STEM education. In fiscal year 
2013, we included an absolute priority for STEM-focused projects in 
competitions for new grants under Investing in Innovation (grants under 
the competitions totaled $135.7 million) and gave competitive priority 
to STEM-focused projects under Magnet Schools Assistance ($89.8 
million) and Supporting Effective Educator Development ($29.8 million). 
In fiscal year 2014, we are maintaining an absolute priority for STEM 
under Investing in Innovation's Scale-Up grants and including a STEM 
invitational priority in new competitions under Special Programs for 
Migrant Students, Strengthening Alaska Native and Native Hawaiian-
Serving Institutions, and Arts in Education. We expect to maintain a 
STEM focus in Investing in Innovation in fiscal year 2015 and may 
prioritize STEM reforms in making new grants under other programs as 
funding permits.
                          veterans' education
    Question. As our Nation's veterans return from overseas, many will 
take advantage of the education benefits they earned while serving our 
country by pursuing an undergraduate or graduate degree. How does the 
fiscal year 2015 budget request for the Department of Education ensure 
that adequate resources are dedicated to assisting veterans on college 
and university campuses with successful degree completion?
    Answer. The fiscal year 2015 President's budget would enable the 
Department to continue to support approximately 50 Veterans Upward 
Bound projects nationwide. Veterans Upward Bound projects assist 
veterans in preparing for postsecondary education by providing 
comprehensive student support services, including tutoring; mentoring; 
cultural enrichment activities; work-study programs; assistance in 
course selection, preparing for college entrance exams, and in 
completing college applications; and information on available financial 
aid and assistance in completing the FAFSA.
           postsecondary education veterans' resource centers
    Question. In the past, the Department of Education provided funding 
for a Centers of Excellence for Veteran Student Success program that 
specifically assisted veterans. This program supported the 
establishment and development of university-based programs to support 
military veteran student success. Given our Federal responsibility to 
the veterans that have served this country, wouldn't the Department 
agree that these resource centers play a critical role in helping 
veterans achieve postsecondary education success?
    Answer. In fiscal year 2010, Congress provided $6 million to 
support the Centers of Excellence for Veteran Student Success program, 
authorized under Title VIII of the Higher Education Act (HEA). With 
this funding, the Department made 3-year awards to 15 institutions of 
higher education to support the development of Centers to coordinate 
services to address the academic, financial, physical, and social needs 
of veteran students.
    It is absolutely essential that we make certain that veterans can 
access crucial services to enable them to enter and succeed in 
postsecondary education. In 2015, the Administration proposes to 
allocate $14 million to support 50 Veterans Upward Bound projects 
designed to provide veterans with the support they need to maximize the 
educational opportunities that are available to them.
                race to the top--equity and opportunity
    Question. This Administration has touted the Race to the Top 
program as critical to the development and testing of model education 
reform strategies, as well as the implementation of these reforms 
throughout the country. However, to what extent has this over $6 
billion investment led to reform strategies being replicated in States 
that have yet to receive any Race to the Top funding? Please provide 
specific, meaningful, impactful, and sustained examples as to how 
students in States that have yet to receive funding have benefited from 
Race to the Top.
    Answer. Race to the Top has changed the debate around education 
across the Nation and reinforced next-generation reforms launched by 
States. One reason that more than 40 States have been approved for 
Elementary and Secondary Education Act (ESEA) flexibility is that the 
competition for Race to the Top helped initiate key reforms that 
positioned the majority of States to move beyond No Child Left Behind 
(NCLB) and commit to far-reaching changes around standards and 
assessments, new differentiated accountability systems emphasizing 
turning around the lowest-performing schools and closing achievement 
gaps, and developing and implementing educator evaluation systems that 
take into account student growth data. Race to the Top has contributed 
to the fact that, since 2009, 46 States and the District of Columbia 
(DC) have developed statewide reform plans and 42 States and DC have 
adopted high college- and career-ready standards.
    Race to the Top States have led the way in many of these important 
reform efforts and other States can learn from their experiences. For 
example, Race to the Top States collaboratively created a Student 
Learning Objectives (SLO) Toolkit. The SLO Toolkit helps States and 
Local Educational Agencies (LEAs) implement measures of student growth 
in tested and non-tested grades and subjects. It provides resources 
related to making SLO policy, providing SLO tools, selecting or 
creating assessments and setting targets, communicating with teachers 
and principals, training district staff and school administrators, and 
ensuring continuous improvement. The Toolkit is available at https://
rtt.grads360.org/services/PDCService.svc/
GetPDCDocumentFile?fileId=4504.
    Additionally, there are numerous publications and case studies that 
the Department has compiled and made available to all States. These 
resources include lessons learned and other materials from Race to the 
Top States that are applicable to all States and LEAs and are available 
at http://www2.ed.gov/about/inits/ed/implementation-support-unit/tech-
assist/index.html.
                              pell grants
    Question. While I have reservations about the direction that this 
Administration is headed in with respect to the proposed college 
ratings system, I think we all agree that graduation rates for Pell 
Grant recipients are a serious concern. It is important that we work 
together to not only increase graduation rates for Pell Grant 
recipients, but to also address the sustainability of the program 
before it experiences discretionary shortfalls in future years. Yet, 
proposing a $7 billion mandatory funding proposal for a College 
Opportunity and Graduation Bonus program is unrealistic and does not 
represent a good faith effort towards working together to achieve these 
goals. Mr. Secretary, what can the Department of Education do at this 
moment to help increase the graduation rate of Pell Grant recipients 
without linking it to a controversial college ratings system or 
drastically increasing mandatory or discretionary funding and thereby 
exacerbating the pending shortfall in the Pell Grant program?
    Answer. Let me start by clarifying that the 2015 cost of the 
proposed College Opportunity and Graduation Bonus program would only be 
$647 million; $7 billion would be the cost of the program over the (10-
year) budget window.
    I strongly believe that rewarding colleges for results through this 
program would advance our shared goal of increasing graduation rates 
for Pell Grant recipients and promoting on-time completion. The College 
Opportunity and Graduation Bonus program would reward colleges that 
successfully enroll and graduate a significant number of low- and 
moderate-income students on time, and encourage all institutions to 
improve their performance, but also incentivize eligible institutions 
to continue improving their performance and graduate even more low-
income students by providing a larger bonus amount for additional Pell 
graduates. Grants would be used for making key investments and adopting 
best practices that will further increase college access and success 
for low-income students, such as by awarding additional need-based 
financial aid, enhancing academic and student support services, 
improving student learning and other outcomes while reducing costs, 
using technology to scale and enhance improvements, establishing or 
expanding accelerated learning opportunities, as well as other 
innovations, interventions, and reforms.
    In addition to this program, the fiscal year 2015 President's 
budget proposes to make two reforms to the Pell Grant program. First, 
it will strengthen academic progress requirements in the Pell Grant 
program in order to encourage students to complete their studies on 
time. Second, it would reinstate the Ability to Benefit provision for 
students enrolled in eligible career pathways programs, which would 
allow adults without a high school diploma to gain the knowledge and 
skills they need to secure a good job.
    Finally, the 2015 President's budget proposes to reform Federal 
allocation in the campus-based programs to target those institutions 
that enroll and graduate higher numbers of Pell-eligible students, and 
offer an affordable and quality education such that graduates can repay 
their educational debt. If adopted, these reforms would have a 
significant impact on increasing the graduation rate of Pell Grant 
recipients.
 regulations affecting management and disbursement of federal student 
                                  aid
    Question. I understand that a Negotiated Rulemaking Committee was 
established by the Department to consider how Federal Title IV student 
loan credit balances are distributed. While I support the need for 
transparency, I am also concerned about the overregulation of higher 
education institutions and already heavily regulated banks.
    Is it the Department's intent to cover all accounts held by a 
student who receives a Federal student aid disbursement? If so, why 
does the Department presume jurisdiction over privately held accounts 
that may be unrelated to Title IV funds?
    Answer. The Department's primary goal in formulating draft 
regulations and conducting negotiated rulemaking governing payment of 
Title IV credit balances has been to ensure that students have access 
to their credit balances, and to protect students from the concerning 
banking practices identified by the Government Accountability Office 
(GAO) (see the related report at http://www.gao.gov/products/GAO-14-
91), the Department's Office of Inspector General (OIG) (see the 
related report at http://www2.ed.gov/about/offices/list/oig/
auditreports/fy2014/x09n0003.pdf), and the U.S. Public Interest 
Research Group (see the related report at this site http://
www.uspirg.org/sites/pirg/files/reports/thecampusdebitcardtrip_may2012_
uspef.pdf), among others. The Department is trying to ensure that 
students have easy, free, and convenient access to their full Title IV 
credit balances so they can afford academically related expenses and 
complete their academic programs in a timely manner.
    regulated banks and non-bank campus financial service providers
    Question. How will the Department take into account the difference 
between regulated banks and non-bank campus financial service providers 
when considering regulations?
    Answer. Over the course of the negotiated rulemaking process, 
negotiators discussed a number of possible approaches to ensure 
sufficient student protections within the context of Title IV credit 
balance disbursements without expanding the regulations beyond the 
Higher Education Act's purview. The committee made significant progress 
on this front and the Department will carefully consider all proposals 
in drafting a Notice of Proposed Rulemaking (NPRM). From the point of 
view of the Department, practices that erode credit balances pose the 
same risk to student, Department, and taxpayer interests regardless of 
whether they are engaged in by banks or non-bank campus financial 
service providers.
                    regulatory cost-benefit analysis
    Question. The proposed rule may have measurable costs to all 
parties should it be promulgated. Will the Department commit to 
undertaking and making public a cost-benefit analysis of the impact of 
additional regulations on students, higher education institutions, and 
financial institutions prior to their implementation?
    Answer. As required under Executive Orders 12866 and 13563, the 
Department will include a regulatory impact analysis (RIA) in the 
Notice of Proposed Rulemaking (NPRM). The Executive Orders require that 
the Department propose or adopt regulations only upon a reasoned 
determination that their benefits justify their costs, tailor the 
regulations to impose the least burden possible, and select those 
approaches that maximize net benefits. The public is free to comment on 
this RIA and provide the Department feedback on the impact of the 
proposed regulations.
      disbursement of federal student aid--debit and prepaid cards
    Question. A recent Government Accountability Office (GAO) report 
acknowledged that the benefits of college debit and prepaid cards can 
include convenience for students and cost savings and efficiencies for 
schools. Did the Department take into account the impact on 
efficiencies in the disbursement of Federal student aid when proposing 
changes to the management and disbursement of Title IV Higher Education 
Act funds? If so, please explain in detail.
    Answer. The Department recognizes that, as noted in the GAO and 
Office of Inspector General (OIG) reports, the debit and prepaid cards 
offered to students provide certain benefits to students and 
institutions, especially compared with the sole use of credit balance 
disbursements via paper checks. During the negotiated rulemaking 
process, we repeatedly solicited feedback from representatives of 
students, institutions, third-party servicers, and the banking sector, 
and made significant progress in amending our regulatory proposals to 
meet the goals of these various constituencies. However, we were also 
troubled by the primary findings of the GAO and OIG reports, which 
noted a fee structure that often deprives students of a significant 
portion of their Federal student aid funds, a lack of convenience 
access to those funds, and a lack of neutrality both in the 
presentation and delivery of credit balances. In its regulatory 
proposals presented at the negotiations, therefore, the Department 
sought to maintain the advantages to students of choice of financial 
accounts while ensuring that easy, free, and convenient student access 
to Title IV credit balances remained the primary goal.
  transparency and consumer choice in provision of federal student aid
    Question. Additionally, the GAO report included a recommendation 
that schools and college debit and prepaid card providers present 
students with objective and neutral information on their options for 
receiving Federal student aid payments. Recognizing that transparency 
is important to consumer choice, regulated banks often already provide 
transparent disclosures related to their accounts and card usage. Will 
the Department commit to working with financial institutions and 
schools to improve existing transparency disclosures prior to issuing 
final regulations, especially given that this issue may be addressed 
without the need for new and burdensome regulations?
    Answer. One of the unique aspects of the negotiated rulemaking 
process is that it affords both the Department and representatives of 
affected constituencies the opportunity to discuss regulatory proposals 
and work toward a draft regulatory proposal that is better for students 
and takes into account the important perspectives of those who provide 
services to students. One of the committee's areas of agreement was the 
importance of neutral presentation of information relating to financial 
accounts, so students could make an informed and individualized choice 
that is best for them. As the NPRM is drafted, the Department will 
continue to consider the feedback received at the negotiating table and 
the numerous supporting documents submitted by the nonFederal 
negotiators. Once an NPRM is published, the Department will carefully 
consider all comments that are submitted regarding the NPRM as part of 
the rulemaking process.
                                 ______
                                 
             Questions Submitted by Senator Lamar Alexander
          costs associated with gainful employment regulation
    Question. The proposed Gainful Employment (GE) regulation 
represents an unprecedented expansion of administrative and regulatory 
functions at the Department of Education. Given the complexity of the 
regulation and reporting requirements for the nearly 8,000 affected 
programs, I am interested in understanding the costs associated with 
this new scope of work for the Department.
    Please provide exactly how much the Department has spent to date on 
promulgating this rule, beginning with the first rulemaking process in 
2010 and including an itemization of how much taxpayers spent defending 
the regulation before the U.S. District Court for the District of 
Columbia.
    Answer. In fiscal years 2011-2012, prior to work stoppage in August 
2012, Federal Student Aid obligated a total of $5,783,561. The table 
included below excludes full-time equivalent (FTE) costs.

      DISTRIBUTION OF FSA GE OBLIGATIONS IN FISCAL YEARS 2011-2012
------------------------------------------------------------------------
                                          Fiscal year
                                  --------------------------    Totals
                                       2011         2012
------------------------------------------------------------------------
Data Collection, Calculations and   $3,083,298   $1,019,463   $4,102,762
 Distribution....................
Social Security Agency                 250,000  ...........      250,000
 Interaction.....................
Challenge Solution...............  ...........    1,430,800    1,430,800
                                  --------------------------------------
      Total by fiscal year.......    3,333,298    2,450,263    5,783,561
------------------------------------------------------------------------

    In addition to the amount spent above by Federal Student Aid for a 
system, the Department estimates that it spent over $100,000 on the 
first negotiated rulemaking process that began in 2010, and 
approximately $125,000 on the second negotiated rulemaking process for 
non-FTE related expenses including facilitation, logistical support and 
travel for some of the negotiators.
 estimated costs associated with implementation of gainful employment 
                               regulation
    Question. Additionally, please provide a comprehensive estimate of 
the annual financial costs and the number of full-time equivalents 
(FTEs) that will be needed to administer the regulations if the rule is 
implemented as proposed, including a breakdown of the costs associated 
with each step in the process such as interactions with the Social 
Security Administration (SSA) and data computations related to wages, 
earnings and programmatic default rates.
    Answer. The proposed Gainful Employment (GE) regulations are 
estimated to provide budgetary savings between $666 million and $973 
million over 10 years (http://www.gpo.gov/fdsys/pkg/FR-2014-03-25/pdf/
2014-06000.pdf). In addition to producing these savings, additional 
benefits include: Improving quality of programs, reducing student debt, 
assisting prospective and current students and their families to make 
more informed decisions, and eliminating poor performing programs. The 
Department of Education and the Office of Federal Student Aid (FSA) 
anticipate needing additional staff, as well as non-pay budgetary 
resources, in order to successfully implement the proposed regulations.
    Specifically, Federal Student Aid (FSA) anticipates the need for 
approximately 28 FSA full-time equivalent employees (FTEs). This total 
includes FTEs for the GE Operations Team (16) to manage the challenge 
process and approvals and the challenge systems solution and labor 
pool; FSA systems teams National Student Loan Data Systems (NSLDS-4); 
and FSA's Program Compliance Regions (8).
    Separately, FSA expects to spend approximately $46 million in non-
pay on implementing GE regulations in fiscal years 2013-2016. This 
includes the following expenses:
  --GE Data Collection and Calculations of Debt Measures and 
        Disclosures-$10 million.--We estimate the National Student Loan 
        Data System (NSLDS) and other current systems will need 
        approximately $10 million for FSA system updates to collect GE 
        data from schools, receive and store additional data from the 
        Social Security Administration (SSA), calculate three debt 
        measures and eight disclosure metrics, distribute the data to 
        schools, make recalculations based on challenges, and 
        distribute data to other FSA systems.
  --Social Security Administration (SSA) Interactions-Less Than 
        $100,000.--Based on an interagency agreement with SSA, FSA will 
        receive aggregate earnings information from SSA on an annual 
        basis. This data will be used in the calculations of any Debt 
        to Earnings ratios and Median Earnings disclosure information. 
        The estimate for the interagency agreement is less than 
        $100,000 over 4 years.
  --Challenge Solution With Labor Pool-$35 million.--FSA is currently 
        looking at solution alternatives for the management of student 
        level data challenges that will be received from institutions 
        for individual programs that have evidence that data elements 
        within the calculations are inaccurate. To manage a high level 
        of challenges, FSA is looking at solution alternatives that 
        will include a system with workflow capabilities, interfaces 
        with FSA and other partner data systems, analytical 
        capabilities for basic checks in challenge data, and contracted 
        staffing to resolve challenges within the timeframe indicated 
        in the regulation. To resolve the challenges, we estimate 
        needing 50 contractors, making it the primary cost driver for 
        challenge management. While this is a current estimate, the 
        variability of challenge volume (i.e., how many challenges FSA 
        actually receives) may increase or decrease the overall total 
        cost.
  --Contractor Support for Program Management of GE Implementation-Less 
        Than $1 million.--This includes contractor support for the 
        program management of implementing the gainful employment 
        requirements. The contractor(s) would manage the schedule, 
        documentation, and other aspects of program management for 
        implementation.

                          ESTIMATED GAINFUL EMPLOYMENT REGULATION IMPLEMENTATION COSTS
----------------------------------------------------------------------------------------------------------------
                                                                     Fiscal year
                                                ----------------------------------------------------    Totals
                                                     2013         2014         2015         2016
----------------------------------------------------------------------------------------------------------------
Data Collection, Calculations and Distribution.  ...........   $3,000,000   $4,500,000   $2,500,000  $10,000,000
SSA Interaction................................      $18,849       20,000       20,000       20,000       78,849
Challenge Solution.............................      199,521    2,500,000   18,410,000   13,910,000   35,019,521
Contractor Support for Program Mgmt............      209,946      169,946      169,946      169,946      719,784
                                                ----------------------------------------------------------------
      Total by fiscal year.....................      428,315    5,689,946   23,099,946   16,599,946   45,818,153
----------------------------------------------------------------------------------------------------------------

        gainful employment institutional accountability metrics
    Question. I generally believe that all regulations should be 
implemented prospectively. In the case of the Department of Education's 
Gainful Employment regulation, it is my understanding that although the 
Department is providing a transition period for the regulation's 
implementation, the proposed transition period still uses student loan 
debt levels from previous years that institutions may not be able to 
influence. What steps is the Department taking to ensure that the 
accountability metrics, such as the student debt levels in the debt-to-
earnings ratio, are constructed to provide institutions with ample 
opportunity to revise policies and procedures to improve program 
performance?
    Answer. Several provisions in the proposed rule would give 
institutions time and opportunity to improve programs that do not meet 
the standards. First, all programs are given multiple years to pass the 
accountability metrics before they would become ineligible for Title 
IV, HEA program funds. Second, for marginal programs, the Department 
proposes to create a ``zone'' status where programs are given more time 
to improve before they would lose access to Federal student aid. And, 
finally, the proposed rule includes a transition period for the first 4 
years after implementation of the regulations during which, in 
calculating a program's debt-to-earnings rates, we will take into 
account any immediate cost, and in turn student debt, reductions that 
institutions make.
       gainful employment--calculation of debt-to-earnings ratios
    Question. The Department of Education is taking an unprecedented 
step by using personal student data to calculate program eligibility 
for Title IV, including calculating a debt-to-earnings ratio using 
individualized direct wage data from the Social Security Administration 
(SSA).
    Please provide an overview of the steps involved in the matching of 
personal student loan debt levels to the Social Security 
Administration's wage database to calculate the debt-to-earnings 
ratios.
    Answer. For each program, the Department will develop a list of 
students in the applicable cohort period based on information submitted 
by the institution. The list is subject to a corrections process. Once 
the list is final, the Department will submit it to SSA. The Department 
will obtain from SSA the aggregate mean and median earnings for the 
program--and not individualized earnings data--for those students on 
the list whom SSA has matched to its earnings data. If SSA is unable to 
match certain students on the list, the Department will exclude from 
the calculation of the median loan debt the same number of students 
with the highest loan debts as the number of students whose earnings 
SSA did not match. The information used to calculate the median loan 
debt is from the Department's National Student Loan Data System (NSLDS) 
and is not submitted to SSA. The debt-to-earnings rates are then 
calculated based on the program-level median debt and mean or median 
earnings--and not calculated on an individual level.
                gainful employment--privacy protections
    Question. Additionally, please describe the steps that the 
Department is taking to ensure that personal information is not 
compromised during the calculation of the debt-to-earnings metrics 
during the data transfers between the Department and the Social 
Security Administration (SSA).
    Answer. The SSA and the Department will comply with the 
requirements of the Federal Information Security Management Act 
(FISMA), 44 U.S.C. 3541-3549; related Office of Management and Budget 
(OMB) circulars and memoranda, such as Circular A-130, Management of 
Federal Information Resources (November 28, 2000), and Memorandum M-06-
16, Protection of Sensitive Agency Information (June 23, 2006); 
National Institute of Standards and Technology (NIST) directives; and 
the Federal Acquisition Regulations. These laws, directives, and 
regulations include requirements for safeguarding Federal information 
systems and personally identifiable information (PII) used in Federal 
agency business processes, as well as related reporting requirements.
    The file transmitted through a secure batch process from the 
Department to the SSA will contain items of PII necessary to complete 
the match with SSA records. The return file from SSA will not contain 
any PII. The data files exchanged remain the property of the providing 
agency. SSA will retain the electronic files received from the 
Department only for the time required for any processing related to the 
information exchange under the agreement and will electronically 
dispose of the data. SSA will destroy the data received from the 
Department after completing the information exchange activity.
    The Department and SSA will each follow their own procedures for 
reporting loss of data or breach of PII notifications. The Department 
and SSA will use administrative, physical, and technical safeguards to 
ensure the data provided or created in this process is under the 
immediate supervision and control of authorized personnel in a manner 
that will protect the confidentiality of the data. Electronic files 
will be encrypted using the FIPS 140-2 standard. The Department and SSA 
will store the data provided or created in an area that is physically 
and technologically secure from access by unauthorized persons during 
duty hours as well as non-duty hours or when not in use (e.g., door 
locks, card keys, biometric identifiers, etc.). Only authorized 
personnel will transport the data provided or created.
            institutional access to debt-to-earnings metrics
    Question. It is my understanding that the proposed Gainful 
Employment (GE) regulation offers very little visibility to 
institutions on the performance of their programs prior to the 
Department of Education's release of the metrics for accountability 
purposes. In particular, institutions will have no visibility into the 
direct earnings information from the Social Security Administration 
that will be used to generate the debt-to-earnings metrics. What 
alternative measures of earnings, including those outside of the 
transition period, such as the use of Bureau of Labor Statistics salary 
information, will be available to institutions to help them understand 
where they stand on the metrics and provide institutions with some 
ability to improve program performance?
    Answer. To help institutions understand how their programs might 
fare under the debt-to-earnings metric, the Department has published 
two sets of informational results that include program-level earnings: 
The first in connection with the previous rulemaking, and the second 
with the release of the Notice of Proposed Rulemaking in March 2014. 
These data sets are an estimated 1-year snapshot of potential results 
under the proposed rule for informational purposes only and are not 
intended to predict long-term outcomes for programs. In addition, 
institutions will be able to approximate a program's program cohort 
default rate by breaking its institutional cohort default rate down by 
program level.
    Once the regulations are implemented, for programs without an 
earnings history, an institution will have available, through the 
required disclosures for GE programs, earnings and other performance 
information of comparable programs that can be used as a benchmark for 
estimating the performance of a program. Institutions would also have 
the ability to appeal their debt-to-earnings rates results by 
submitting alternate measures of earnings from two sources, data 
obtained from a State earnings database or data collected through a 
survey of students who completed the program.
    congressional provisions for school improvement grants program 
                              flexibility
    Question. Since 2009, this Administration has spent more than $6 
billion through the School Improvement Grants (SIG) program to help 
States turn around low-performing schools. States receiving these 
grants must agree to implement one of four federally defined turnaround 
models. The latest results released by the Department of Education 
confirm that schools receiving grants have made little progress in 
improving student achievement.
    Recently, Congress granted greater program flexibility to the 
School Improvement Grants by allowing States to develop and present for 
approval, their own models for turning around low-performing schools. 
What steps has the Department of Education taken to implement this 
provision in a manner consistent with congressional intent? And, will 
you confirm that States, which have received waivers through the 
Administration's ESEA Flexibility program, will be able to take 
advantage of this provision?
    Answer. The Department is currently developing a notice of proposed 
requirements that would implement the new SIG program provisions in the 
fiscal year 2014 appropriations act, make other changes that reflect 
lessons learned from 4 years of implementation under the current 
requirements, and help ensure consistency across the Department's 
programs. We anticipate publishing the proposed requirements in August 
2014 and finalizing the requirements no later than the end of the 
calendar year. The requirements would apply to the subgrant 
competitions that States conduct in spring 2015 using fiscal year 2014 
funds.
    A local educational agency applying for fiscal year 2014 funds in a 
State implementing ESEA flexibility would not be prevented from taking 
advantage of the provision allowing implementation of an alternative 
school improvement strategy established by the State and approved by 
the Department.
        innovation in evaluation of teacher preparation programs
    Question. You recently announced your intention to issue new 
Federal regulations governing the evaluation of teacher preparation 
programs. Ensuring that teachers are well-prepared to lead their 
classrooms has traditionally been left to the States, and many States 
are currently developing new policies in this area. For example, 
Tennessee and Louisiana are using data from teacher evaluation systems 
to improve their teacher preparation programs. But given that we don't 
have proven models of effective policy in this area, I am concerned 
that the Department's plans to impose a one-size-fits-all Federal 
mandate that States use data from teacher evaluation systems to assess 
their teacher preparation programs will discourage State innovation. 
What efforts will the Department make to ensure that States have the 
flexibility to develop innovative ways to assess the performance of 
their teacher preparation programs?
    Answer. This summer we will release a proposal to support the 
pipeline of future teachers by strengthening teacher preparation 
programs; importantly, we will seek additional input on this plan 
through a public comment process. This proposal will encourage all 
States to develop their own meaningful systems to identify high- and 
low-performing teacher preparation programs across all kinds of 
programs, not just those based in colleges and universities, while also 
asking States to move away from current input-focused reporting 
requirements, streamline the current data requirements, incorporate 
more meaningful outcomes, and improve the availability of relevant 
information on teacher preparation. These changes will help to improve 
systems-level accountability for supporting the high-quality 
instruction all students deserve. Moreover, strengthened preparation 
and support will help to make teaching an increasingly desirable and 
rewarding career.
                                 ______
                                 
                Questions Submitted by Senator Mark Kirk
  support for year-round school programs--i3 and promise neighborhoods
    Question. As you noted during the hearing, extended day education 
and year-round schools are a proven way to improve student achievement. 
Given this, is the Department of Education providing funding for any 
year-round school models through any of its programs aimed at 
innovation in education, such as your Investing in Innovation (i3), or 
Promise Neighborhoods programs? If not, why not?
    Answer. For the 2014 competition for i3 Development grants, the 
Department included a priority for improving low-performing schools by 
either (1) changing elements of the school's organizational design to 
improve instruction by differentiating staff roles and extending and 
enhancing instructional time; or (2) changing elements of the school's 
organizational design to improve instruction by differentiating staff 
roles and extending and enhancing instructional time.
    This year's pre-application competition for Development grants 
closed on April 14, 2014, and of the 94 applications submitted under 
the priority for improving low-performing schools, 14 applications 
addressed the subpart for extending and enhancing instructional time. 
At this time, the review process is still in progress. Although the 
Department had not included a priority that explicitly focuses on 
extended day education and year-round schools on any of the i3 
competitions to date, in 2011 Boston Public Schools received an i3 
Development grant to focus on extended learning time under a priority 
for improving low-performing schools.
    Under the Promise Neighborhoods program, there are currently two 
grantees that provide support for year-round schools. The program has 
not included a specific priority or requirement for year-round schools, 
but they are an accepted model.
                  year-round school programs research
    Question. Is more research needed to show how these year-round 
programs are effective?
    Answer. My understanding is that research on the academic benefits 
of year-round schools has been inconclusive. As with other approaches 
to restructuring the school day, week, or year, the success of year-
round schools may depend on both the particular State and local context 
and the details of implementation. For example, if a year-round 
schedule is adopted primarily to address overcrowding and other 
facility constraints, and is not accompanied by an effort to rethink 
the delivery of instruction to take advantage of the new schedule, it 
may not produce improved academic outcomes.
             other program support for year-round schooling
    Question. With what other existing grant programs could the 
Department fund year-round schools? I am particularly interested in a 
school model of shorter breaks spread out throughout the year. I have 
seen this model improve student achievement in Chicago charter schools.
    Answer. Most Federal elementary and secondary education program 
funds may be used to support year-round schools, as eligibility for 
these programs is not dependent on the structure of the school year. 
However, we do not have any programs that specifically support State 
efforts to restructure the school year, such as by implementing year-
round schools.
          year-round schools and student achievement outcomes
    Question. Does the Department track or collect information 
regarding year-round schools in any way, including which areas of the 
country have such schools and what are the student achievement 
outcomes?
    Answer. The Department does not track separately information on 
year-round schools.
foreign language immersion programs and investing in innovation funding
    Question. Does the Investing in Innovation (i3) Fund support any 
foreign language immersion programs for grades K-6? And, if not, why?
    Answer. The i3 program does not include a priority or subpart that 
specifically reference foreign language immersion, and there is not 
currently a grantee in the portfolio whose project has this focus. 
However, the i3 program does include an absolute priority focused on 
English learners (and has included a competitive preference priority in 
previous i3 competitions). Currently 46 of the 117 grants include a 
focus (either explicitly under an absolute or competitive preference 
priority, or implicitly through the project's work) on English 
learners.
    The Department's process for developing priorities for the i3 
competition is complex and considers, among others, policy needs, 
urgent needs, the quality of the evidence base on particular topics, 
and the availability of models. To date, foreign language immersion 
programs have not emerged as a pressing area to be addressed through 
the i3 program during our consideration of topics for past 
competitions.
                       uses of i3 program funding
    Question. What is the i3 program spending its money on?
    Answer. The Department has awarded approximately $1.07 billion to 
117 projects since 2010. Five of those 117 projects have been Scale-Up 
grants, for a total of $219.9 million; 35 have been Validation grants, 
for a total of $575.6 million; and 77 have been Development grants, for 
a total of $277.4 million.
    The table below shows the main topic areas for which the Department 
has provided funding, mostly through absolute priorities. The 
information in this table does contain duplication because grantees 
sometimes address more than one of these topic areas. The table shows 
aggregated information for all the cohorts that have received funding 
to date. The first cohort was funded in fiscal year 2010, and no grants 
have ended yet. The first set of grants to expire will do so later in 
2014.

                             TOPIC AREAS FUNDED BY THE INVESTING IN INNOVATION FUND
----------------------------------------------------------------------------------------------------------------
                          Topic Area                                Number of grants          Total funding
----------------------------------------------------------------------------------------------------------------
Teacher and Principal Effectiveness...........................                       23             $314,483,707
Turning Around Low-Performing Schools.........................                       22              264,027,914
Science, Technology, Engineering, and Mathematics (STEM)......                       26              220,158,904
Standards and Assessments.....................................                       21              180,805,322
Use of Data...................................................                        9               66,422,464
Parent and Family Engagement..................................                        8               22,216,648
Serving Rural Communities.....................................                       24              249,503,263
English Learners..............................................                       38              351,635,234
Students with Disabilities....................................                       17               98,176,186
Technology....................................................                        3               17,991,838
----------------------------------------------------------------------------------------------------------------

               successful and effective i3 program models
    Question. The i3 program, or the Investing in Innovation Fund, is 
now 4 years old; what are the successes and effective models that the 
Department has seen as a result of this program?
    Answer. The first cohort of i3 grantees was funded in September 
2010. These projects are 4 to 5 years in length, and complete findings 
about their implementation and effect will not be available until 2015 
at the earliest, when the first cohort concludes its project 
activities. While most i3 grantees will be sharing findings in a formal 
evaluation report at the end of their grant projects (and the i3 
program will have a report of the national evaluation of i3 in spring 
2016), some grantees are releasing interim reports with interim 
findings. Grantees with interim reports that show positive findings 
include Reading Recovery (The Ohio State University), Success for All 
Foundation, and AppleTree Institute. In the 2013 grant competition, we 
found that one of the projects funded under the Validation competition 
used evidence produced under a 2010 Development grant to meet the 
moderate evidence requirement and receive the Validation grant. We are 
very excited about seeing the progression of i3 grantees across the 
evidence pipeline.
    In addition, the Department has made modifications to grant 
competitions based on lessons learned from previous competitions. 
Specifically, we give careful consideration to priorities we use each 
year to identify gaps in the portfolio where a competition would help 
us find projects with potential for success and effective models.
                                 ______
                                 
              Questions Submitted by Senator John Boozman
              investment in career and technical education
    Question. I am very proud of the career and technical education 
(CTE) classes offered across the State of Arkansas. I constantly hear 
about the programs and their strong collaborations with employers and 
businesses in their communities, full classes and many students who are 
honor students and both career- and college-ready. In striving to 
provide the best possible education for our students and prospects for 
their future, why aren't there further investments in CTE, in many 
cases a proven successful program, in the fiscal year 2015 President's 
budget request?
    Answer. We agree that the programs authorized under the Perkins 
Career and Technical Education Act provide important support for 
helping students prepare for future careers. The President's budget 
proposal for education represents hard choices for funding among 
multiple worthy programs in a difficult fiscal environment. The fiscal 
year 2015 President's budget request respects the spending levels set 
in the Bipartisan Budget Act of 2013, with new discretionary funding 
dedicated to areas where we think it will have the greatest impact on 
improving educational outcomes. We also believe that a reauthorized Act 
that strengthens alignment between secondary and postsecondary 
education and enhances accountability will enhance the quality of CTE 
programs available to students at the current funding level.
         ensuring widespread benefits from competitive programs
    Question. In testimony you have delivered to both the House and 
Senate Appropriations Committees, it is clear there is a focus and 
investment in competitive funding and grants, and a desire for 
innovation with these new competitive grants. Since the President has 
not requested any increases in ESEA, Title I and IDEA formula funding 
which are so crucial to a majority of districts across the country, 
especially in a rural State like Arkansas which has a more difficult 
time finding resources to compete for these grants, I'm concerned about 
the focus of your budget. How are you planning on disseminating 
innovative ideas and best practices from all of these new grants to 
ensure that schools who aren't beneficiaries of these grants will 
benefit in some way from these investments?
    Answer. The Reform Support Network (RSN), which was created to 
support the Race to the Top grantees as they implement reforms in 
education policy and practice, also shares promising practices and 
lessons learned with other States attempting to implement similarly 
bold education reform initiatives. Similarly, the School Turnaround 
Learning Community supported by the School Improvement Grants program 
shares turnaround resources with all schools, districts, and States.
          competitive programs and equity and opportunity gaps
    Question. Do you have any concerns that further competitive funding 
will create more opportunity gaps and less equity?
    Answer. We believe targeted, competitively awarded investments can 
produce innovative models of effective instruction and improvement that 
can shrink opportunity gaps and increase educational opportunity for 
all students, and serve as models on how to use existing funds to 
improve equity.
             support for successful charter school programs
    Question. In many cases, public charter schools operate at best 
with around 80 percent of funding that traditional public schools have, 
and these high-performing charters are doing exceptional work even 
within these financial constraints, like one rural public charter in my 
State, the KIPP Delta Collegiate which was recently ranked by US News 
and World Report as the 2nd Best High School in Arkansas. What 
investments or policies in this budget or actions is the Department 
taking to help successful charters spread their impact?
    Answer. The fiscal year 2015 President's budget supports efforts to 
expand the number of high-quality educational options available to our 
Nation's students in several ways. Most notably, the budget includes 
$248 million for a new charter schools program, Supporting Effective 
Charter Schools, which under the Administration's proposal to 
reauthorize the Elementary and Secondary Education Act would support 
grants to State educational agencies (SEAs), charter school 
authorizers, charter management organizations, local educational 
agencies (LEAs), and other nonprofit organizations for the start-up or 
expansion of high-quality charter schools. Funds could also be used for 
grants to SEAs, LEAs, and financial institutions to improve access by 
high-quality charter schools to facilities and facilities financing.
    Successful charter schools also would benefit from other key 
proposals in the budget. For instance, charter high schools are well-
positioned to access the $150 million requested for the proposed High 
School Redesign program, which would support innovative approaches for 
improving the high school experience and increasing the number of 
students prepared for college and careers without the need for 
remediation. The effective practices of high-performing charter schools 
could also be further developed, validated, and scaled up with 
resources from Investing in Innovation, for which the Administration 
has requested $165 million for fiscal year 2015.
                              trio funding
    Question. Given that the Administration has focused so heavily on 
expanding the numbers of low- and moderate-income, first generation 
students entering into college and on their successful graduation, is 
there a reason why TRIO funding in the fiscal year 2015 budget is 
maintained at fiscal year 2014 levels?
    Answer. The President has articulated a bold vision for the United 
States to once again lead the world in college attainment by 2020. We 
regard the Federal TRIO programs as a key component of the President's 
strategy to realize this ambitious goal. In fiscal year 2014, Congress 
restored most of the sequester reduction to the Federal TRIO programs, 
providing $838.3 million, a level the Administration has proposed to 
maintain in the fiscal year 2015 President's Budget Request. At this 
level, the Department expects to support approximately 2,790 TRIO 
projects serving nearly 800,000 students nationwide.
    However, the Administration believes that such a bold objective 
also requires new Federal approaches to stimulate States and 
institutions of higher education to pursue innovative college access 
and completion strategies. To that end, the President's 2015 budget 
request includes the following:
  --Encouraging States to support, reform, and improve the performance 
        of their public higher education systems through the State 
        Higher Education Performance Fund, which would generate an $8 
        billion new investment to make college more affordable and 
        increase college access and success, especially for low-income 
        students;
  --Rewarding colleges that successfully enroll and graduate a 
        significant number of low- and moderate-income students on time 
        and encourage all institutions to improve their performance 
        through the new College Opportunity and Graduation Bonus 
        program;
  --Reforming the campus-based programs to target those institutions 
        with a demonstrated commitment to providing a high-quality 
        education at a reasonable price, that enroll and graduate 
        higher numbers of Pell-eligible students, and that offer an 
        affordable and quality education such that graduates can repay 
        their educational debt;
  --Reinstating the Ability to Benefit provision for students enrolled 
        in eligible career pathways programs, which will allow adults 
        without a high school diploma to gain the knowledge and skills 
        they need to secure a good job; and
  --Helping borrowers manage their debt by extending Pay As You Earn to 
        all student borrowers, ensuring the program is well-targeted, 
        and simplifying borrowers' experience while reducing program 
        complexity.

                          SUBCOMMITTEE RECESS

    Senator Harkin. Thank you very much, Senator Kirk.
    Thank you, Senator Moran.
    Thank you, Mr. Secretary.
    Secretary Duncan. Thank you.
    Senator Harkin. The meeting will stand adjourned.
    [Whereupon, at 11:06 a.m., Wednesday, April 30, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]



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

                         CONCLUSION OF HEARINGS

    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 hearings 
were concluded, and the subcommittee was recessed, to reconvene 
at the call of the Chair.]


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

                              ----------                              

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    [Clerk's note.--The subcommittee was unable to hold 
hearings on departmental and nondepartmental witnesses. The 
statements and letters of those submitting written testimony 
are as follows:]

                         DEPARTMENTAL WITNESSES

Prepared Statement of the Association of Public Television Stations and 
                    the Public Broadcasting Service
    On behalf of America's 170 public television licensees, we 
appreciate the opportunity to submit testimony for the record on the 
importance of Federal funding for local public television stations and 
PBS. We urge the Subcommittee to support level funding of $445 million 
in 2-year advance funding for the Corporation for Public Broadcasting 
(CPB) in fiscal year 2017, and pre-sequester level funding of $27.3 
million for the Ready To Learn program at the Department of Education 
in fiscal year 2015.
Corporation for Public Broadcasting--fiscal year 2017 Request: $445 
        million, 2-year advance funded
    Local stations and PBS are committed to serving the public good in 
education, public safety, creating a well-informed citizenry, 
preserving and promoting American history and culture, and other 
essential fields. Federal funding for CPB makes these services possible 
and is deserving of continued support. The overwhelming majority of 
Americans agree. In a bi-partisan Hart Research Associates/American 
Viewpoint poll, nearly 70 percent of American voters, including 
majorities of self-identifying Republicans, Independents, and Democrats 
support continued Federal funding for public broadcasting. In addition, 
polls show that Americans consider PBS to be the second most 
appropriate expenditure of public funds, behind only military defense.
    Over 70 percent of the Federal funding for CPB goes directly to 
local stations, resulting in a nationwide system of locally owned and 
controlled, trusted, community-driven and community-responsive media 
entities that form an incredibly successful public-private partnership 
providing unique and essential local public services.
Education
    Local public television stations are America's largest classroom, 
meeting their communities' lifelong education needs by providing the 
highest quality educational content and resources on multiple media 
platforms and in person. Public television's exceptional content, 
available to nearly every household in America, has helped more than 90 
million pre-school age children get ready to learn and succeed in 
school.
    PBS, in partnership with local public television stations, has 
created PBS LearningMedia, an online portal where educators can access 
more than 35,000 standards-based, curriculum-aligned interactive 
digital learning objects created from public television content, as 
well as material from the Library of Congress, National Archives and 
other high-quality sources. More than 1.3 million teachers are 
registered to use PBS LearningMedia in K-12 classrooms serving millions 
of students throughout the country. In addition, twenty-eight thousand 
homeschoolers use PBS LearningMedia to enrich their curriculum in 
history, science, the arts and other subjects. Public television 
stations also operate virtual high schools that bring high-quality 
instruction in the most specialized fields to the most remote locations 
in our country.
    Through the American Graduate Initiative, CPB and public media 
stations are working to confront the dropout crisis in America's high 
schools by providing resources and services to raise awareness, 
coordinate action with local community partners, and work directly with 
students, parents, teachers, mentors, volunteers and leaders to lower 
the drop-out rate in their respective communities. In addition, by 
operating one of the most comprehensive non-profit GED programs in the 
country, public television stations have helped hundreds of thousands 
of second-chance students and adult learners get their high-school 
equivalency certificates and prepare themselves for meaningful work in 
a competitive marketplace.
    Public television stations have made it a top priority to help 
retrain the American workforce, including veterans, by providing 
digital learning opportunities for those looking for training, 
licensing, continuing education credits and more.
Partners in Public Safety
    Public broadcasting stations throughout the country are also 
leading innovators and irreplaceable partners to local public safety 
officials--working in communities with schools, businesses and 
stakeholders to provide real-time emergency support for local law 
officials in times of crisis. In many communities, public broadcasting 
stations are the last locally-owned and operated media outlets--serving 
as a critical public safety life line.
    The Nation's digital presidential alert and warning system depends 
on the backbone infrastructure of local public television stations to 
deliver critical national messages. This same digital infrastructure 
provides the backbone for emergency alert, public safety, first 
responder and homeland security services in many states and local 
communities. Stations are partnering with their local emergency 
responders to customize and utilize public television's infrastructure 
for public safety in a variety of critical ways: equipping police cars 
with school blueprints when a crisis arises, providing access to 24/7 
camera feeds for a variety of security challenges, connecting public 
safety agencies in real time, and more. Local public television 
stations are also using their broadcast equipment to help send 
emergency alert text messages to cell phone subscribers through their 
providers--reaching citizens wherever they are, even when the power is 
out. Many local stations are serving as their states' primary Emergency 
Alert Service (EAS) hub for weather and AMBER alerts.
Supporting an Informed Citizenry
    Public television strengthens the American democracy by providing 
citizens with access to the history, culture and civic affairs of their 
communities, their states and their country. Local public television 
stations serve as the ``C-SPAN'' of many state governments, providing 
the most remote corners of the country with access to the state 
legislative process, Governors' messages, court proceedings and more. 
As one of the only locally-owned and operated media remaining in 
America, public television provides more public affairs programming, 
local history, arts and culture, candidate debates, specialized 
agricultural news, and citizenship information of all kinds than anyone 
else in the media universe.
Public Broadcasting is a Smart Investment
    All of this is made possible by the Federal funding to CPB which 
amounts to an annual cost of about $1.35 per year for each American. On 
average, Federal funding for CPB makes up approximately 15 percent of 
local television station's budgets. However, for many smaller and rural 
stations, Federal funding represents more than 30-50 percent of their 
total budget. This funding is particularly important to rural stations 
that struggle to raise local funds from individual donors due to the 
smaller and often economically strained population base. At the same 
time it is often more costly to serve rural areas due to the topography 
and distances between communities. As a result, public broadcasters, 
with their commitment to universal service, are often the only local 
broadcaster serving rural communities. For all stations, Federal 
funding is the ``lifeblood'' of public broadcasting, providing critical 
seed money to local stations that enables them to build additional 
support from state legislatures, private foundations and corporations, 
and ``viewers like you.''
    Public broadcasting creates important economic activity while 
providing an essential educational and cultural service. For every 
Federal dollar, local public media stations raise an additional six 
dollars in non-Federal funding, providing a strong public-private 
partnership and an impressive 6 to 1 return on investment. In addition, 
public broadcasting supports approximately 20,000 jobs, with the vast 
majority in local public television and radio stations in hundreds of 
communities across America.
Two-Year Advance Funding
    Two-year advance funding is essential to the mission of public 
broadcasting. This longstanding practice, proposed by President Ford 
and embraced by Congress in 1976, establishes a firewall insulating 
programming decisions from political interference, enables the 
leveraging of funds to ensure a successful public-private partnership, 
and provides stations with the necessary lead time to plan in-depth 
programming and curriculum coordination with educational institutions
    Public television's history of editorial independence has been 
rewarded in unprecedented levels of public trust--for the eleventh 
consecutive year, the American people have ranked PBS as one of the 
most trusted national institutions. Advance funding and the firewall it 
provides between the development of content and extraneous interference 
and control is vital to maintaining this credibility among the American 
public.
    In addition, local public broadcasting stations leverage the 2-year 
advance funding to raise state, local and private funds, ensuring the 
continuation of this strong public-private partnership. These Federal 
funds act as essential seed money for fundraising efforts at every 
station, no matter its size, and since many state legislatures are 
part-time institutions that budget State funds on a 2-year cycle and 
relate state funding to Federal funding, advance Federal funding is 
essential to the success of this unique partnership
    Finally, the 2-year advance funding mechanism also gives stations 
and producers the critical lead time needed to partner with local 
community organizations and plan and produce high-quality programs. The 
signature series that demonstrate the depth and breadth of public 
television, like Ken Burns's The Civil War, take several years to 
produce. In addition, 2-year advance funding is essential to the 
creation of local programming over multiple fiscal years as stations 
convene the community to identify needs, recruit partners, conduct 
research, develop content and deliver services.
Ready To Learn--fiscal year 2015 Request: $27.3 million (Department of 
        Education)
    The Ready To Learn (RTL) competitive grant program uses the power 
of public television's on-air, online, mobile, and on-the-ground 
educational content to build the literacy and STEM skills of children 
between the ages of two and eight, especially those from low-income 
families. Through their RTL grant, CPB and PBS are delivering evidence-
based, innovative, high-quality transmedia content to improve the math 
and literacy skills of high-need children via broadcast television, the 
Internet, mobile and other dynamic new technologies. CPB and PBS, in 
partnership with local stations, have been able to ensure that the kids 
and families that are most in need have access to these groundbreaking 
and proven effective educational resources. In addition to the content, 
CPB and PBS are creating new tools like a sophisticated progress 
tracking system that gives parents the means to measure student 
progress, in real time.
Results
    RTL is rigorously evaluated for its appeal and efficacy so the 
program can continue to offer America's youngest citizens the tools 
they need to succeed in school and in life. Studies show that RTL 
content has a significant and positive effect on the educational lives 
of children who use it. Highlights of recent studies show that: use of 
PBS KIDS content and games by low-income parents and their preschool 
children improves math learning and helps prepare children for entry 
into kindergarten; \1\ use of RTL content has been associated with a 29 
percent improvement in reading ability in children grades K-2; \2\ and 
parents who used RTL math resources in the home became considerably 
more involved in supporting their children's learning outcomes.\3\ In 
combination, RTL games, activities and videos provide early learners 
with the critical math and literacy skills needed to succeed in school, 
and in the process, help level the academic playing field.
---------------------------------------------------------------------------
    \1\ McCarthy, B., Li, L., Schneider, S., Sexton, U., & Tiu, M. 
(2013). PBS KIDS Mathematics Transmedia Suites in Preschool Homes and 
Communities. A Report to the CPB-PBS Ready to Learn Initiative. Redwood 
City, CA: WestEd. McCarthy, B., Li, L., Tiu, M. (2012). PBS KIDS 
Mathematics Transmedia Suites in Preschool Homes. Redwood City, CA: 
WestEd
    \2\ Public Broadcasting Service (2012). KBTC Ready To Learn 
Initiative 2012 Summary Report, pp. 15,16.
    \3\ McCarthy, B., Li, L., Schneider, S., Sexton, U., & Tiu, M. 
(2013). PBS KIDS Mathematics Transmedia Suites in Preschool Homes and 
Communities. A Report to the CPB-PBS Ready to Learn Initiative. Redwood 
City, CA: WestEd. McCarthy, B., Li, L., Tiu, M. (2012). PBS KIDS 
Mathematics Transmedia Suites in Preschool Homes. Redwood City, CA: 
WestEd
---------------------------------------------------------------------------
An Excellent Investment
    In addition to being research-based and teacher tested, the RTL 
Television program also provides excellent value for our Federal 
dollars. In the last 5-year grant round, public broadcasting leveraged 
an additional $50 million in funding to augment the $73 million 
investment by the Department of Education for content production. 
Without the investment of the Federal government, this supplemental 
funding would likely end.
The Dangers of Consolidation
    The President's fiscal year 2015 budget proposes consolidating RTL 
into a larger grant program. APTS and PBS oppose this proposal as it 
would abandon the unique national-local partnership that has resulted 
in RTL's ground-breaking educational impact on kids nationwide, 
particularly those with limited access to other educational resources. 
The current model effectively uses an economy of scale to create high-
quality television and online content at the national level and then 
distribute it through local stations who can tailor outreach to the 
specific needs of their communities. This model allows PBS and local 
stations to annually reach 80 percent of America's children ages 2 to 8 
through television and another 13 million per month online and on 
mobile apps. The national-local partnership has made RTL tremendously 
efficient and effective and consolidation or elimination of the program 
would severely affect the ability of local stations to respond to their 
communities' educational needs, eliminating the critical resources 
provided by this program for children, parents and teachers. RTL 
symbolizes the mission of public media and is a successful public-
private partnership that leverages Federal funds to create the most 
appealing and impactful children's educational content that is 
supplemented by online and on-the-ground resources. Without the RTL 
program, millions of families would lose access to this incredible 
high-quality education content, especially the low-income and 
underserved households that are a particular focus of this program.
Conclusion
    Americans across the political spectrum rely on public 
broadcasting--on television, on the radio, online, and in the 
classroom--because we provide essential education, public safety, and 
informed citizenry services that are not available anywhere else. And 
none of this would be possible without the Federal investment in public 
broadcasting. A 2007 GAO report concluded that these Federal Community 
Service Grants are an irreplaceable source of revenue for public 
broadcasting, and a 2012 study requested by this Subcommittee and 
conducted by an independent third party for CPB came to the same 
conclusion as the GAO: Federal funding for public broadcasting is 
irreplaceable.
    For all of these reasons we request that Congress continue its 
commitment to the highly successful, hugely popular public-private 
partnership that is public broadcasting by providing level funding of 
$445 million in fiscal year 2017 for the 2-year advance of the 
Corporation for Public Broadcasting and pre-sequester level funding of 
$27.3 million in fiscal year 2015 for the stand alone Ready To Learn 
Program.
                                 ______
                                 
            Prepared Statement of the National Public Radio
    Dear Chairman Harkin, Ranking Member Moran and Members of the 
Subcommittee: Thank you for this opportunity to urge the Subcommittee's 
support for an annual Federal investment of $445 million in America's 
public media system through annual appropriations to the Corporation 
for Public Broadcasting (CPB). With your support, the public radio 
system, consisting of some 950 locally managed, locally controlled and 
locally programmed stations, serves communities all across America. And 
these stations are as diverse as the communities they represent. Public 
radio is committed to being America's public radio, bringing the 
diverse and changing voices of Americans to the airwaves and the new 
platforms that so many Americans are using. We strive to create a more 
informed public, one challenged and invigorated by a deeper 
understanding and appreciation of events, ideas, and culture within the 
United States and across the globe.
    The public radio system, a uniquely American public service, non-
commercial, media enterprise, includes stations in every State capitol 
and hundreds of American communities, large and small, urban and rural. 
Producers and distributors of public radio programming, including 
American Public Media (APM), Public Radio International (PRI), the 
Public Radio Exchange (PRX) and NPR are united by a commitment to the 
highest standards of journalist ethics. Every minute of every program 
broadcast to some 38 million Americans weekly is routed through the 
Public Radio Satellite System (PRSS), a content distribution utility 
owned by the public radio system.
    Partnerships and collaborations are integral components of the 
programming and service found in the public radio system. Available on 
air, online, and on new and emerging mobile platforms, public radio is 
expanding its ability to reach audiences. And as traditional media 
undergoes dramatic changes, public radio is positioning itself to serve 
the needs of a growing audience in a shifting media landscape and 
rapidly changing world.
    A clear example of these new adaptations to improve journalism and 
meet audience needs comes from the recently formed merger between St. 
Louis Public Radio and the St. Louis Beacon newspaper, the area's two 
largest nonprofit news organizations. This move combines newsrooms and 
significantly changes the face of independent local news in the region 
by providing more depth and perspective on issues and stories that 
impact the community. The consolidation creates an innovative model for 
a multiplatform news operation that results in more in-depth coverage 
of urban events and issues. St. Louis Public Radio's move to join 
forces and expand serves as an example of how public radio news 
organizations are adjusting to an ever-changing media environment that 
involves greater competition for consumers and financial support.
    This new merger is just one among a growing list of public 
broadcasters teaming up with other nonprofit news outlets to beef up 
their local and investigative journalism. In Denver, Rocky Mountain 
PBS, public radio station KUVO, and I-News, the Rocky Mountain 
Investigative News Network, merged to create a cross-platform news 
operation that could better cover Colorado. WWNO in New Orleans hired 
its first-ever news director last spring to expand its coverage of 
stories. Oregon Public Broadcasting is building a statewide news 
network with 40 to 50 small news outlets across Oregon. Lastly, Harvest 
Public Media, a reporting collaboration of public radio stations KCUR, 
KBIA, Iowa Public Radio, Nebraska Public Broadcasting, KUNC and WUIS, 
focuses on issues of food, fuel and field. Based at KCUR in Kansas 
City, Harvest covers these agriculture-related topics through an 
expanding network of reporters and partner stations throughout the 
Midwest.
    But the partnerships don't stop there for public radio. A recent 
collaboration includes Boston's WBUR and NPR joining forces to expand 
and re-launch the daily public radio show Here & Now as a two-hour 
national news program for audiences in the middle of the day. The 
program airs weekday afternoons and is aggressively updated to provide 
local audiences with live, updated news coverage during mid-day.
    Public radio's partnerships with public safety officials play a 
critically important role when natural or man-made disasters strike. 
Public radio stations provide essential and timely public emergency 
information, such as evacuation routes, shelter locations and severe 
weather updates. Effective emergency warnings allow people to take 
actions that save lives, and reduce damage and human suffering. Federal 
funding helps to bring crucial news and alerts to millions of 
Americans.
    Public radio's innovative partnerships also expand our public 
service mission by enabling radio reception to all Americans during 
local emergency situations. This year, 26 public radio stations based 
in Alabama, Florida, Louisiana, Mississippi and Texas are working with 
NPR Labs, the Public Radio Satellite System (PRSS) and the U.S. 
Department of Homeland Security/FEMA to demonstrate the delivery of 
emergency alerts to people who are deaf or hard-of-hearing. This is the 
first effort to deliver real-time accessibility-targeted emergency 
messages, such as weather alerts, via radio broadcast texts. Our hope 
is to expand the pilot over time to other regions of our country thru 
the use of radio equipment to reach people who are both deaf and blind 
and non-English speaking.
    In addition, many public radio stations provide critical services 
through partnerships with radio reading services. These long 
established centers are in every major market in the United States to 
provide millions of visually impaired persons the ability to function 
more independently in their communities.
    Music in America would sound very different without public radio. 
Local stations take creative risks, nurture new talent, and give 
emerging artists a chance to be heard. They celebrate traditional music 
genres like classical and jazz, and partner with local music 
organizations to take these art forms to new heights of performance 
excellence and new audiences. And they play a key role in their local 
music economies, sustaining and growing the careers of musicians by 
connecting them to local listeners. Across the country, more than 180 
local public radio stations have full-time music formats and more than 
650 stations air play music as part of their programming lineups.
    Mr. Chairman and Senator Moran, public radio is essential in 
providing news, information and cultural programming to America and 
connecting with audiences wherever they are. We're embracing America's 
changing demographics and using digital media to connect better, more 
quickly and in more diverse ways. Today's public radio isn't going 
away, it's going everywhere and we are working every day to earn the 
trust of the 38 million Americans who rely on us for news and insights 
that guide and inform. We ask for your continuing support in funding 
for stations that serve your communities, your constituents and 
America's Democracy.

    [This statement was submitted by Michael Riksen, Vice President--
Policy & Representation, National Public Radio.]
                                 ______
                                 
          Prepared Statement of the Railroad Retirement Board
    Ms. Chairwoman and Members of the Committee: We are pleased to 
present the following information to support the Railroad Retirement 
Board's (RRB) fiscal year 2015 budget request of $112,150,000 for our 
retirement, unemployment and other programs.
    The RRB administers comprehensive retirement/survivor and 
unemployment/sickness insurance benefit programs for railroad workers 
and their families under the Railroad Retirement and Railroad 
Unemployment Insurance Acts. The RRB also has administrative 
responsibilities under the Social Security Act for certain benefit 
payments and Medicare coverage for railroad workers. The RRB has also 
administered special economic recovery payments and extended 
unemployment benefits under the American Recovery and Reinvestment Act 
of 2009 (Public Law 111-5) and extended unemployment benefits under the 
Worker, Homeownership, and Business Assistance Act of 2009 (Public Law 
111-92). More recently, we have administered extended unemployment 
benefits under the Tax Relief, Unemployment Insurance Reauthorization, 
and Job Creation Act of 2010 (Public Law 111-312), the Temporary 
Payroll Tax Cut Continuation Act of 2011 (Public Law 112-78), the 
Middle Class Tax Relief and Job Creation Act of 2012 (Public Law 112-
96) and the American Taxpayer Relief Act of 2012 (Public Law 112-240).
    During fiscal year 2013, the RRB paid $11.7 billion, net of 
recoveries, in retirement/survivor benefits to about 568,000 
beneficiaries. We also paid $84.5 million in net unemployment/sickness 
insurance benefits to more than 26,000 claimants. Temporary extended 
unemployment benefits paid were $6.8 million. In addition, the RRB paid 
benefits on behalf of the Social Security Administration amounting to 
$1.4 billion to about 113,000 beneficiaries.
               proposed funding for agency administration
    The President's proposed budget would provide $112,150,000 for 
agency operations, which would enable us to maintain a staffing level 
of 860 full-time equivalent staff years (FTEs) in 2015. The proposed 
budget would also provide $2,500,000 for information technology (IT) 
investments for the conversion of a legacy Program Accounts Receivable 
(PAR) system to a modern accounts receivable module within our cloud-
based core financial system that was implemented October 1, 2013.
                            agency staffing
    The RRB's dedicated and experienced workforce is the foundation for 
our tradition of excellence in customer service and satisfaction. Like 
many Federal agencies, however, the RRB has a number of employees at or 
near retirement age. About 63 percent of our employees have 20 or more 
years of service, and over 28 percent of our current workforce will be 
eligible for retirement by fiscal year 2015. As we continue to 
modernize our information technology infrastructure to automate and 
convert manual workloads, our agency will also improve training 
delivery and reporting within our workforce. We plan to acquire and 
implement a Learning Management System that will provide a 
comprehensive functionality for training administration, documentation, 
tracking, reporting and delivery of e-learning education and training 
programs. This will allow the agency to improve all aspects involved in 
the learning process to meet our human capital needs as we experience a 
high rate of change in personnel. Furthermore, we will complement this 
initiative by implementing an executive training program to prepare and 
mentor future agency leaders that are ready to replace a significant 
number of senior leaders within the agency that are eligible to retire.
    In connection with these workforce planning efforts, the 
President's budget request includes a legislative proposal to enable 
the RRB to utilize various hiring authorities available to other 
Federal agencies. Section 7(b) (9) of the Railroad Retirement Act 
contains language requiring that all employees of the RRB, except for 
one assistant for each Board Member, must be hired under the 
competitive civil service. We propose to eliminate this requirement, 
thereby enabling the RRB to use various hiring authorities offered by 
the Office of Personnel Management. Also, our budget request includes a 
legislative proposal to clarify the authority of the Railroad 
Retirement Board to retain in the competitive civil service attorneys 
hired prior to a change in OPM policy in 2013.
                  information technology improvements
    We are actively pursuing further automation and modernization of 
the RRB's various processing systems to support the agency's mission to 
administer benefit programs for railroad workers and their families. In 
fiscal year 2015, funding is included for contractor support to 
complete the full design of the Financial Management Integrated System 
(FMIS) by migrating a benefit payment feeder system named Program 
Accounts Receivable (PAR) to FMIS. FMIS migration from an obsolete 
financial system was started Oct 1, 2012 and completed Oct 1, 2013. Due 
to reduction in funds of the FMIS program during the sequestered fiscal 
year, PAR migration into FMIS was delayed. Once completed, the PAR 
migration to FMIS will enhance the processing of debt transactions for 
improper benefit payments in an integrated financial system hosted in a 
cloud environment. We expect PAR migration to FMIS to reduce staffing 
requirements and improve efficiency of the improper payment process.
                        other requested funding
    The President's proposed budget includes $34 million to fund the 
continuing phase-out of vested dual benefits, plus a 2 percent 
contingency reserve, $680,000, which ``shall be available proportional 
to the amount by which the product of recipients and the average 
benefit received exceeds the amount available for payment of vested 
dual benefits.'' In addition, the President's proposed budget includes 
$150,000 for interest related to uncashed railroad retirement checks.
                  financial status of the trust funds
    Railroad Retirement Accounts--The RRB coordinates its financial 
needs with the National Railroad Retirement Investment Trust (Trust), 
the Trust was established by the Railroad Retirement and Survivors' 
Improvement Act of 2001 (RRSIA) to manage and invest railroad 
retirement assets. Pursuant to the RRSIA, the RRB has transferred a 
total of $21.276 billion to the Trust. All of these transfers were made 
in fiscal years 2002 through 2004. The Trust has invested the 
transferred funds, and the results of these investments are reported to 
the RRB and posted periodically on the RRB's website. Through December 
2013, the Trust had transferred approximately $15.4 billion to the 
Railroad Retirement Board for payment of railroad retirement benefits. 
The net asset value of Trust-managed assets on September 30, 2013, was 
approximately $25.0 billion, an increase of almost $1.4 billion from 
the previous year.
    In June 2012, we released the 25th Actuarial Valuation of the 
railroad retirement system required by Sections 15(g) of the Railroad 
Retirement Act of 1974. That report also met the requirements of 
Section 22 of the Railroad Retirement Act of 1974, and Section 502 of 
the Railroad Retirement Solvency Act of 1983. The report addressed the 
75-year period 2011-2085, including projections of the status of the 
retirement trust funds under three employment assumptions. It concluded 
that barring a sudden, unanticipated, large decrease in railroad 
employment or substantial investment losses, the railroad retirement 
system would experience no cash flow problems for the next 23 years. 
Even under the most pessimistic assumption, the cash flow problems 
would not occur until the year 2035. The report did not recommend any 
change in the rate of tax imposed by current law on employers and 
employees.
    The RRB's latest annual report required by Section 502 of the 
Railroad Retirement Solvency Act of 1983 was released in June 2013. The 
overall conclusion was that barring a sudden unanticipated, large 
decrease in railroad employment or substantial investment losses, the 
railroad system will experience no cash flow problems during the next 
25 years.
    Railroad Unemployment Insurance Account--The RRB's latest annual 
report on the financial status of the railroad unemployment insurance 
system was issued in June 2013. The report indicated that even as 
maximum daily benefit rates will rise approximately 42 percent (from 
$66 to $94) from 2012 to 2023, experience-based contribution rates are 
expected to keep the unemployment insurance system solvent, except for 
small, short-term cash-flow problems in 2015 and 2016 under the most 
pessimistic assumption. However, projections show quick repayment of 
any loans by the end of each fiscal year.
    Unemployment levels are the single most significant factor 
affecting the financial status of the railroad unemployment insurance 
system. However, the system's experience-rating provisions, which 
adjust contribution rates for changing benefit levels, and its 
surcharge trigger for maintaining a minimum balance, help to ensure 
financial stability in the event of adverse economic conditions. No 
financing changes were recommended at this time by the report.
    Thank you for your consideration of our budget request. We will be 
happy to provide further information in response to any questions you 
may have.

    [This statement was submitted by Michael S. Schwartz, Chairman, 
Walter A. Barrows, Labor Member, and Jerome F. Kever, Management 
Member, Railroad Retirement Board.]
                                 ______
                                 
 Prepared Statement of the Inspector General, Railroad Retirement Board
    Mr. Chairman and Members of the Subcommittee: My name is Martin J. 
Dickman, and I am the Inspector General for the Railroad Retirement 
Board. I would like to thank you, Mr. Chairman, and the members of the 
Subcommittee for your continued support of the Office of Inspector 
General.
                             budget request
    The President's proposed budget for fiscal year 2015 would provide 
$8,750,000 to the Office of Inspector General (OIG) to ensure the 
continuation of the OIG's independent oversight of the Railroad 
Retirement Board (RRB). During fiscal year 2015, the OIG will focus on 
areas affecting program performance; the efficiency and effectiveness 
of agency operations; and areas of potential fraud, waste and abuse.
                         operational components
    The OIG has three operational components: the immediate Office of 
the Inspector General, the Office of Audit (OA), and the Office of 
Investigations (OI). The OIG conducts operations from several 
locations: the RRB's headquarters in Chicago, Illinois; an 
investigative field office in Philadelphia, Pennsylvania; and five 
domicile investigative offices located in Virginia, Texas, California, 
Florida, and New York. These domicile offices provide more effective 
and efficient coordination with other Inspector General offices and 
traditional law enforcement agencies, with which the OIG works joint 
investigations.
                            office of audit
    The mission of the Office of Audit (OA) is to promote economy, 
efficiency, and effectiveness in the administration of RRB programs and 
detect and prevent fraud and abuse in such programs. To accomplish its 
mission, OA conducts financial, performance, and compliance audits and 
evaluations of RRB programs. In addition, OA develops the OIG's 
response to audit-related requirements and requests for information.
    During fiscal year 2015, OA will focus on areas affecting program 
performance; the efficiency and effectiveness of agency operations; and 
areas of potential fraud, waste, and abuse. OA will continue its 
emphasis on long-term systemic problems and solutions, and will address 
major issues that affect the RRB's service to rail beneficiaries and 
their families. OA has identified four broad areas of potential audit 
coverage: Financial Accountability; Railroad Retirement Act and 
Railroad Unemployment Insurance Act Benefit Program Operations; 
Railroad Medicare Program Operations; and Security, Privacy, and 
Information Management. OA must also accomplish the following mandated 
activities with its own staff: Audit of the RRB's financial statements 
pursuant to the requirements of the Accountability of Tax Dollars Act 
of 2002, evaluation of information security pursuant to the Federal 
Information Security Management Act (FISMA), and an audit of the RRB's 
compliance with the Improper Payments Elimination and Recovery Act of 
2010.
    During fiscal year 2015, OA will complete the audit of the RRB's 
fiscal year 2014 financial statements and begin its audit of the 
agency's fiscal year 2015 financial statements. OA contracts with a 
consulting actuary for technical assistance in auditing the RRB's 
``Statement of Social Insurance'', which became basic financial 
information effective in fiscal year 2006. In addition to performing 
the annual evaluation of information security, OA also conducts audits 
of individual computer application systems which are required to 
support the annual FISMA evaluation. Our work in this area is targeted 
toward the identification and elimination of security deficiencies and 
system vulnerabilities, including controls over sensitive personally 
identifiable information.
    OA undertakes additional projects with the objective of allocating 
available audit resources to areas in which they will have the greatest 
value. In making that determination, OA considers staff availability, 
current trends in management, Congressional and Presidential concerns.
                        office of investigations
    The Office of Investigations (OI) focuses its efforts on 
identifying, investigating, and presenting cases for prosecution, 
throughout the United States, concerning fraud in RRB benefit programs. 
OI conducts investigations relating to the fraudulent receipt of RRB 
disability, unemployment, sickness, and retirement/survivor benefits. 
OI investigates railroad employers and unions when there is an 
indication that they have submitted false reports to the RRB. OI also 
conducts investigations involving fraudulent claims submitted to the 
Railroad Medicare Program. These investigative efforts can result in 
criminal convictions, administrative sanctions, civil penalties, and 
the recovery of program benefit funds.

              OI INVESTIGATIVE RESULTS FOR FISCAL YEAR 2013
------------------------------------------------------------------------
                      Indictments/                         Recoveries/
 Civil Judgments      Informations       Convictions       Receivables
------------------------------------------------------------------------
             37                 47                 81   \1\ $414,254,000
------------------------------------------------------------------------
\1\ This total includes the results of joint investigations with other
  agencies.

    OI anticipates an ongoing caseload of about 400 investigations in 
fiscal year 2015. During fiscal year 2013, OI opened 156 new cases and 
closed 238. At present, OI has cases open in 48 States, the District of 
Columbia, and Canada with estimated fraud losses of nearly $217 
million. Disability fraud cases represent the largest portion of Ol's 
total caseload. These cases involve more complicated schemes and often 
result in the recovery of substantial amounts for the RRB's trust 
funds. They also require considerable resources such as travel by 
special agents to conduct surveillance, numerous witness interviews, 
and more sophisticated investigative techniques. Additionally, these 
fraud investigations are extremely document-intensive and require 
forensic financial analysis.
    Of particular significance is an ongoing disability fraud 
investigation in New York. To date, 33 individuals have been indicted; 
28 of these have pleaded guilty and five more were convicted in Federal 
court. In addition, 44 former railroad employees avoided prosecution by 
admitting their role in the fraud and agreeing to the termination of 
their benefits. OI agents will likely have to spend a substantial 
amount of time traveling to New York for continuing investigations and 
trial preparation in fiscal year 2015.
    During fiscal year 2015, OI will continue to coordinate its efforts 
with agency program managers to address vulnerabilities in benefit 
programs that allow fraudulent activity to occur and will recommend 
changes to ensure program integrity. OI plans to continue proactive 
projects to identify fraud matters that are not detected through the 
agency's program policing mechanisms.
                               conclusion
    In fiscal year 2015, the OIG will continue to focus its resources 
on the review and improvement of RRB operations and will conduct 
activities to ensure the integrity of the agency's trust funds. This 
office will continue to work with agency officials to ensure the agency 
is providing quality service to railroad workers and their families. 
The OIG will also aggressively pursue all individuals who engage in 
activities to fraudulently receive RRB funds. The OIG will continue to 
keep the Subcommittee and other members of Congress informed of any 
agency operational problems or deficiencies.

    [This statement was submitted by Martin J. Dickman, Inspector 
General, Railroad Retirement Board.]
                                 ______
                                 

                       NONDEPARTMENTAL WITNESSES

      Prepared Statement of the Academy of Nutrition and Dietetics
    Dear Subcommittee on Labor, Health and Human Services, Education, 
and Related Agencies:
    The Academy of Nutrition and Dietetics appreciates the opportunity 
to submit testimony for the fiscal year 2015 appropriations. The 
Academy is the world's largest organization of food and nutrition 
professionals, and is committed to improving the Nation's health with 
nutrition services and interventions provided by registered dietitian 
nutritionists. Nationwide, The Academy has over 75,000 members.
    As Congress begins work on fiscal year 2015 appropriations, we 
strongly urge you to fully fund Federal nutrition programs that will 
provide a return on investment to improve health. Investment in these 
programs through the appropriations process will help prevent costly 
healthcare expenses due to chronic diseases.
Senior Nutrition Funding: Administration for Community Living (ACL)
    The congregate and home-delivered (commonly known as Meals on 
Wheels) senior nutrition programs, the Native American Nutrition 
Program, and the Nutrition Services Incentive Program (NSIP) are the 
largest and most visible components of the Older Americans Act. We 
strongly believe that the funding levels for the senior nutrition 
programs under the Administration for Community Living must be 
adequate, as these programs are key to keeping this population 
independent and in their homes. The President's budget proposes no 
increase for the senior nutrition programs in fiscal year 2015, yet we 
know that fuel and food costs--primary costs borne by senior nutrition 
programs--continue to increase. This is extremely alarming as these 
programs ensure that vulnerable older adults can continue to receive 
cost-effective nutrition services, ultimately saving Medicare and 
Medicaid dollars. Due to an ever-increasing demand for services, even 
flat funding will result in several million fewer home-delivered and 
congregate meals served, which could lead to more expensive 
hospitalizations or a need for long term care for older adults who 
cannot safely prepare meals themselves.
    The Academy strongly supports the President's fiscal year 2015 
request for $20 million for Preventive Health Services under the Older 
Americans Act. This program provides grants to States and Territories 
to support activities that educate older adults about the importance of 
health lifestyles and promotes healthy behaviors that can help to 
prevent or delay chronic disease and disability, thereby reducing the 
need for costly medical interventions.
    The Academy also supports the Administration's proposal for 
standalone funding of $8 million for Chronic Disease Self-Management 
Programs (CDSMP) in the Administration for Community Living. CDSMP is a 
low-cost, evidence-based disease prevention model that utilizes state-
of-the-art techniques to help older Americans with chronic diseases 
better manage their conditions and improve their health status, thus 
reducing their need for more costly medical care such as hospital care 
and hospital readmissions. According to the National Center for Chronic 
Disease Prevention and Promotion, seven out of ten deaths and more than 
three-quarters of all health expenditures for older adults are the 
result of preventable chronic conditions such as diabetes, obesity, 
cancer, arthritis and depression.
    In addition, the Academy supports the President's fiscal year 2015 
request for $25 million in funding for the Elder Justice Act. Cases of 
elder abuse, neglect and exploitation are on the rise in this country; 
recent studies estimate that 14.1 percent of older adults face some 
sort of abuse, and another study estimates seniors lose a minimum of 
$2.5 billion each year as a result (MetLife and the National Committee 
for the Prevention of Elder Abuse). Elder abuse is a major threat to 
the health of our elderly population.
Centers for Disease Control and Prevention (CDC) Funding
    The Academy respectfully requests adequate funding for CDC's fiscal 
year 2015 ``core programs.'' We strongly believe that the activities 
and programs supported by CDC are essential to protect the health of 
the American people. CDC is faced with enormous challenges and 
responsibilities, from bioterrorism preparedness to chronic disease 
prevention and eliminating health disparities. In addition, CDC funds 
effective community programs including health promotion efforts and 
nutrition interventions that help prevent heart and lung disease, 
cancer, diabetes, stroke, and other chronic diseases. More than 70 
percent of CDC's budget supports State and local health organizations 
and academic institutions.
    We support the President's budget proposal to reduce chronic 
diseases through diabetes funding totaling $140 million and heart 
disease funding totaling $130 million. These expenditures will help 
reduce the heavy healthcare cost burden of these two diseases.
    We also ask that you maintain the fiscal year 2014 funding of $8 
million (not the reduced level in the fiscal year 2015 President's 
Request) for Hospitals Promoting Breastfeeding. According to the CDC, 
childhood obesity is an epidemic. One in five preschoolers in our 
country is overweight, and half of these are obese. A baby's risk of 
becoming an overweight child is reduced with each month that the baby 
is breastfed. In the US, most babies start breastfeeding, but within 
the first week, half have already been given formula, and by 9 months, 
only 31 percent of babies are breastfeeding at all. Hospitals play a 
critical role in encouraging new moms to breastfeed.
Food and Drug Administration (FDA) Funding
    The Academy supports the President' budget of $1.48 billion for 
food safety. A robust food safety system and the continued 
implementation of the Food Safety Modernization Act will help reduce 
food-borne illness that costs the U.S. healthcare system $88 billion 
annually.
    Again, thank you for reviewing these comments and please feel free 
to contact us for any additional information.

    [This statement was submitted by Mary Pat Raimondi MS, RD, Vice 
President, Strategic Policy and Partnerships Academy of Nutrition and 
Dietetics.]
                                 ______
                                 
                  Prepared Statement of AcademyHealth
    AcademyHealth is pleased to offer this testimony regarding funding 
for Federal agencies that support health services research and health 
data, including the Agency for Healthcare Research and Quality (AHRQ), 
the National Center for Health Statistics (NCHS), and the National 
Institutes of Health (NIH). AcademyHealth's mission is to support 
research that leads to accessible, high value, high-quality healthcare; 
reduces disparities; and improves health. We represent the interests of 
more than 5,000 scientists and policy experts and 180 organizations 
that produce and use health services research to improve our Nation's 
health and the performance of the healthcare and public health systems. 
For fiscal year 2015, we recommend funding levels of $375 million for 
AHRQ, $182 million for NCHS, and $32 billion for NIH.
    The United States spent $2.8 trillion--17.2 percent of our 
economy--on healthcare in 2012. Finding new ways to get the most out of 
every healthcare dollar is critical to our Nation's long-term fiscal 
health. Like any corporation making sure it is developing and providing 
high quality products, the Federal Government--as the Nation's largest 
healthcare purchaser--has a responsibility to get the most value out of 
every taxpayer dollar it spends on Medicare, Medicaid, Children's 
Health Insurance Program, and veterans' and service members' health.
    Health services research is our Nation's R&D enterprise for health 
improvement. Just as medical research discovers cures for disease, 
health services research discovers cures for the health system (see 
Figure 1). This research diagnoses problems in healthcare and public 
health delivery and identifies solutions to improve outcomes for more 
people, at greater value. And while biomedical and clinical research 
discoveries can take years and even decades to reach patients, 
discoveries from health services research can be used now by patients, 
healthcare providers, public health professionals, hospitals, 
employers, and public and private payers to improve care today.
    Put plainly, health services research helps Americans get their 
money's worth when it comes to healthcare. We need more of it, not 
less. Despite the positive impact health services research has had on 
the U.S. healthcare system, and the potential for future improvements 
in quality and value, the United States spends less than one cent of 
every healthcare dollar on this research; research that can help 
Americans spend their healthcare dollars more wisely and make more 
informed healthcare choices.
    AcademyHealth realizes the pressure Congress and the administration 
face to reduce the national debt. We respectfully ask that the 
subcommittee consider the value of health services research in 
achieving that goal, and to strengthen its capacity to address the 
pressing challenges America faces in providing access to high-quality, 
efficient care. The following list summarizes AcademyHealth's fiscal 
year 2015 funding recommendations for agencies that support health 
services research and health data under the subcommittee's 
jurisdiction.
Agency for Healthcare Research and Quality
    AHRQ is the only Federal research agency with the sole purpose of 
producing evidence to make healthcare safer; higher quality; more 
accessible, equitable, and affordable; and to ensure that the evidence 
is understood and used. AHRQ funds health services research and 
healthcare improvement programs in universities, medical centers, 
research institutions, hospitals, health clinics, and medical practices 
that are transforming people's health in communities in every State 
around the Nation. The science funded by AHRQ provides consumers and 
their healthcare professionals with valuable evidence to make 
healthcare decisions. For example, medical societies use AHRQ-funded 
research to inform their recommendations for treatment of type 2 
diabetes and rheumatoid arthritis. These evidence-informed 
recommendations give physicians a foundation for describing what the 
best care looks like, so millions of patients living with these and 
other conditions may determine what the right care might be for them.
    AHRQ's research also provides the basis for strategies that prevent 
medical errors, reduce hospital-acquired infections (HAI), and improve 
patient experiences and outcomes. For example, AHRQ's evidence-based 
Comprehensive Unit-based Safety Program to Prevent Healthcare-
Associated Infections (CUSP)--first applied on a large scale in 2003 
across more than 100 ICUs across Michigan--saved more than 1,500 lives 
and nearly $200 million in the program's first 18 months. The protocols 
have since been expanded to hospitals in all 50 States, the District of 
Columbia, and Puerto Rico to continue the national implementation of 
this approach for reducing HAIs.
    AcademyHealth joins the Friends of AHRQ--an alliance of health 
professional, research, consumer, and employer organizations that 
support the agency--in recommending a base discretionary funding level 
of $375 million for AHRQ in fiscal year 2015.
National Center for Health Statistics
    NCHS is the Nation's principal health statistics agency. Housed 
within the Centers for Disease Control and Prevention (CDC), it 
provides critical data on all aspects of our healthcare system through 
data cooperatives and surveys that serve as a gold standard for data 
collection around the world. AcademyHealth appreciates the 
subcommittee's support of NCHS in recent years. Such efforts have 
allowed NCHS to reinstate data collection and quality control efforts, 
continue the collection of vital statistics, and modernize surveys to 
reflect changes in demography, geography, and health delivery.
    We join the Friends of NCHS--an alliance of health professional, 
research, consumer, industry, and employer organizations that support 
the agency--in recommending an overall funding level of $182 million 
for NCHS in fiscal year 2015. This funding level will support the 
agency's core data collection activities, as well as new initiatives to 
enhance death data timeliness and security, restore survey expansions 
to better assess access to and utilization of healthcare services, and 
determine ``what works'' in the organization, financing, and delivery 
of public health services.
National Institutes of Health
    NIH spends approximately $1 billion on health services research 
annually--roughly 3 percent of its entire budget--making it the largest 
Federal sponsor of health services research. We join the research 
community in seeking at least $32 billion for NIH in fiscal year 2015. 
NIH has an important role in the Federal health services research 
continuum, and is well-positioned to ensure that discoveries from 
clinical trials are effectively translated into healthcare delivery. 
AcademyHealth supports efforts to help NIH foster greater coordination 
of its health services research investment among its institutes and 
across other Federal agencies to avoid duplication.
    AcademyHealth also recommends that the Clinical and Translational 
Science Awards (CTSA) through the National Center for Advancing 
Translational Sciences (NCATS) sustain investment in the full spectrum 
of translational research (T1-T4). The CTSA program enables innovative 
research teams to speed discovery and advance science aimed at 
improving our Nation's health. The program encourages collaboration in 
solving complex health and research challenges and finding ways to turn 
their discoveries into practical solutions for patients. Finally, 
AcademyHealth supports continued investment by NIH and its many 
Institutes and Centers in dissemination and implementation research. 
This research helps us understand which approaches work to improve 
population health.
    In conclusion, the accomplishments of the field of health services 
research would not be possible without the leadership and support of 
this subcommittee. We hope the subcommittee gives strong consideration 
to our fiscal year 2015 funding recommendations for the Federal 
agencies funding health services research and health data. If you have 
questions or comments about this testimony or wish to know more about 
health services research, please contact Dr. Lisa Simpson, President 
and CEO of AcademyHealth or [email protected].

                 FIGURE 1: THE HEALTH RESEARCH CONTINUUM
------------------------------------------------------------------------
 
------------------------------------------------------------------------
These components of the health research continuum work in concert, and
 each plays an essential role--any one type of research on its own
 cannot effectively or appreciably improve health. Take heart disease as
 one example ...
------------------------------------------------------------------------
Basic research     Clinical research  Population-based  Health services
 discovered the     determined which   research          research
 contributions of   treatments were    identified        determined how
 elevated blood     safe and           strategies to     to best deploy
 pressure,          effective to       reduce the        these
 elevated           treat              risks of heart    discoveries to
 cholesterol, and   hypertension,      disease in        achieve the
 tobacco use to     hypercholesterol   communities       best health
 heart disease.     emia, tobacco      through non-      outcomes. This
                    addiction, and     medical           research helped
                    to prevent and     interventions,    identify who
                    treat heart        such as           had the least
                    disease, in        reduction of      access, what
                    general.           trans fats in     barriers
                                       food and          existed, and
                                       tobacco control   how to mitigate
                                       measures to       them. This
                                       reduce smoking.   research also
                                                         led to the
                                                         development of
                                                         quality
                                                         measures that
                                                         are now used to
                                                         report on the
                                                         quality of
                                                         cardiac care.
------------------------------------------------------------------------
Source: AHRQ: 15 Years of Transforming Care and Improving Health,
  AcademyHealth, Jan. 2014. Available at: http://academyhealth.org/files/
  AHRQReport2014.pdf.


    [This statement was submitted by Dr. Lisa Simpson, President & CEO, 
AcademyHealth.]
                                 ______
                                 
      Prepared Statement of the Ad Hoc Group for Medical Research
    The Ad Hoc Group for Medical Research is a coalition of patient and 
voluntary health groups, medical and scientific societies, academic and 
research organizations, and industry. We appreciate the opportunity to 
submit this statement in support of enhancing the Federal investment in 
biomedical, behavioral, social, and population-based research conducted 
and supported by the National Institutes of Health (NIH).
    The Consolidated Appropriations Act of 2014 included a welcome and 
much needed increase for the NIH. However, this increase did not 
restore all of the funds cut by sequestration in fiscal year 2013 or 
the purchasing power NIH has lost over the past decade due to 
inflation. We hope fiscal year 2014 represents a first step toward 
restoring our Nation's preeminence in medical research.
    The Ad Hoc Group for Medical Research recommends that NIH receive 
at least $32 billion in fiscal year 2015 as the next step toward a 
multi-year increase in our Nation's investment in medical research. The 
Ad Hoc Group also urges Congress and the Administration to work in a 
bipartisan manner to end sequestration and the continued cuts to 
medical research that squander invaluable scientific opportunities, 
discourage young scientists, threaten medical progress and continued 
improvements in our Nation's health, and jeopardize our economic 
future.
    The Ad Hoc Group is deeply grateful to the Subcommittee for its 
long-standing and bipartisan leadership in support of NIH. We continue 
to believe that science and innovation are essential if we are to 
continue to improve our Nation's health, sustain our leadership in 
medical research, and remain competitive in today's global information 
and innovation-based economy.
NIH: A Public-Private Partnership to Save Lives and Provide Hope
    The partnership between NIH and America's scientists, medical 
schools, teaching hospitals, universities, and research institutions is 
a unique and highly-productive relationship, leveraging the full 
strength of our Nation's research enterprise to foster discovery, 
improve our understanding of the underlying cause of disease, and 
develop the next generation of medical advancements. Approximately 84 
percent of the NIH's budget goes to more than 300,000 research 
positions at over 2,500 universities and research institutions located 
in every state.
    The Federal Government has an irreplaceable role in supporting 
medical research. No other public, corporate or charitable entity is 
willing or able to provide the broad and sustained funding for the 
cutting edge research necessary to yield new innovations and 
technologies of the future.
    Research funded by NIH has contributed to nearly every medical 
treatment, diagnostic tool, and medical device developed in modern 
history, from a new treatment for cystic fibrosis to an awareness 
campaign that resulted in a dramatic decrease in the number of infants 
lost to Sudden Infant Death Syndrome to a new vaccine to prevent 
cervical cancer. We are all enjoying longer, healthier lives thanks to 
the Federal government's wise investment in this lifesaving agency. 
Examples of recent clinical breakthroughs made by NIH-supported 
scientists include:
  --NIH-funded researchers have discovered a way to harness the body's 
        own immune system to fight cancer. The promising results in 
        both adults and children with leukemia lead Science Magazine to 
        name Cancer Immunotherapy as the 2013 Breakthrough of the Year 
        for all of science;
  --NIH scientists have developed new treatments for hepatitis C--the 
        leading reason for liver transplants in the U.S.--that have 
        shortened treatment times and produced cures in 85 to 95 
        percent of patients, even those with advanced disease;
  --NIH-funded researchers found that certain molecules in urine can 
        provide an early sign of kidney transplant rejection, a test 
        that allows doctors to act earlier to protect transplanted 
        kidneys;
  --An NIH-supported clinical trial demonstrated that an intensive 
        early behavioral intervention delivered before the age of 2 
        years can improve symptoms as well as normalize brain activity 
        in some children with autism; and
  --NIH-funded scientists developed an innovative method to quickly 
        identify antibiotics that can treat multidrug-resistant 
        bacteria--and reveal how these bacteria-killing medications 
        work.
    For patients and their families, NIH is the ``National Institutes 
of Hope.''
    NIH is the world's premier supporter of merit-reviewed, 
investigator-initiated basic research. This fundamental understanding 
of how disease works and insight into the cellular, molecular, and 
genetic processes underlying life itself, including the impact of 
social environment on these processes, underpin our ability to conquer 
devastating illnesses. The application of the results of basic research 
to the detection, diagnosis, treatment, and prevention of disease is 
the ultimate goal of medical research. Ensuring a steady pipeline of 
basic research discoveries while also supporting the translational 
efforts absolutely necessary to bring the promise of this knowledge to 
fruition requires a sustained investment in NIH.
    The research supported by NIH drives not only medical progress but 
also local and national economic activity, creating skilled, high-
paying jobs and fostering new products and industries. According to a 
report released by United for Medical Research, a coalition of 
scientific advocates, institutions and industries, in fiscal year 2011, 
NIH-funded research supported an estimated 432,000 jobs all across the 
United States, enabled 13 states to experience job growth of more than 
10,000 jobs, and generated more than $62 billion in new economic 
activity.
Stagnant Funding Threatens Scientific Momentum
    Despite the increase provided in the current year, over the past 
decade NIH has lost more than 22 percent of its budget after inflation, 
significantly impacting the Nation's ability to sustain the scientific 
momentum that has contributed so greatly to our Nation's health and our 
economic vitality. The leadership and staff at NIH and its Institutes 
and Centers has engaged patient groups, scientific societies, and 
research institutions to identify emerging research opportunities and 
urgent health needs, and has worked resolutely to prioritize precious 
Federal dollars to those areas demonstrating the greatest promise. But 
a continued erosion of our national commitment to medical research 
threatens our ability to support a medical research enterprise that is 
capable of taking full advantage of existing and emerging scientific 
opportunities.
    Perhaps one of the greatest concerns is the obstacle these 
continued cuts will present to the next generation of scientists, who 
will see training funds slashed and the possibility of sustaining a 
career in research diminished. NIH plays a significant role in 
supporting the next generation of innovators, the young and talented 
scientists and physicians who will be responsible for the breakthroughs 
of tomorrow.
    The challenges of maintaining a cadre of physician-scientists to 
facilitate translation of basic research to human medicine, ensuring a 
biomedical workforce that reflects the racial and gender diversity of 
our citizenry, and maximizing our Nation's human capital to solve our 
most pressing health problems will only be addressed through continued 
support of NIH.
NIH is Critical to U.S. Competitiveness
    Our country still has the most robust medical research capacity in 
the world, but that capacity simply cannot weather repeated blows such 
as persistent below-inflation funding levels and cuts of sequestration, 
which jeopardize our competitive edge in an increasingly innovation-
based global marketplace.
    Other countries have recognized the critical role that biomedical 
science plays in innovation and economic growth and have significantly 
increased their investment in biomedical science. Between 1999 and 
2009, Asia's share (including China, India, Japan, Malaysia, Singapore, 
South Korea, Taiwan, and Thailand) of worldwide research and 
development (R&D) expenditures grew from 24 percent to 32 percent, 
while U.S. R&D expenditures declined from 38 percent to 31 percent. 
While the U.S. currently leads the world in R&D spending, China's 
increasing investment in R&D is projected to close the gap and surpass 
the U.S. in total R&D spending by about 2022. The European Commission 
also has recently urged its member Nations to increase their investment 
in research substantially, recommending budgets of 80 billion Euro 
(equivalent to $108 billion) from 2014 to 2020, a 40 percent increase 
over the previous 7-year period.
    This shift in funding raises the concern that talented medical 
researchers from all over the world, who once flocked to the U.S. for 
training and stayed to contribute to our innovation-driven economy, are 
now returning to better opportunities in their home countries. We 
cannot afford to lose that intellectual capacity, much less the jobs 
and industries fueled by medical research. The U.S. has been the global 
leader in medical research because of Congress's bipartisan recognition 
of NIH's critical role. To maintain our dominance, we must reaffirm 
this commitment to provide NIH the funds needed to maintain our 
competitive edge.
NIH: An Answer to Challenging Times
    The Ad Hoc Group's members recognize the tremendous challenges 
facing our Nation's economy and acknowledge the difficult decisions 
that must be made to restore our country's fiscal health. Nevertheless, 
we believe strongly that NIH is an essential part of the solution to 
the Nation's economic restoration. Strengthening our commitment to 
medical research, through robust funding of the NIH, is a critical 
element in ensuring the health and well-being of the American people 
and our economy.
    Therefore, the Ad Hoc Group for Medical Research recommends that 
NIH receive at least $32 billion in fiscal year 2015 as the next step 
toward a multi-year increase in our Nation's investment in medical 
research.
                                 ______
                                 
 Prepared Statement of the AIDS Alliance for Women, Infants, Children, 
                            Youth & Families
    Dear Chairman Harkin Ranking Moran, and Members of the 
Subcommittee: AIDS Alliance for Women, Infants, Children, Youth & 
Families was founded in 1994 to help respond to the unique concerns of 
HIV-positive and at-risk women, infants, children, youth, and families. 
AIDS Alliance conducts policy research, education, and advocacy on a 
broad range of HIV/AIDS prevention, care, and research issues. We are 
pleased to offer written testimony for the record in opposition of the 
fiscal year 2015 budget proposal consolidating Ryan White Part D 
funding into Part C and in support of maintaining Part D of the Ryan 
White Program as part of the fiscal year 2015 Labor, Health and Human 
Services, Education, and Related Agencies appropriations measure. This 
testimony also has the support of the Elizabeth Glaser Pediatric AIDS 
Foundation.
Ryan White Part D Funding Request
    Sufficient funding of the Ryan White Program is necessary to 
provide quality care for individuals living with HIV/AIDS. We thank the 
Subcommittee for its continuous support of Ryan White Part D Programs, 
providing $75 million to the program in fiscal year 2014. While the 
AIDS Alliance for Women, Infants, Children, Youth & Families 
understands that these are difficult economic times, we are requesting 
the Subcommittee to maintain its commitment to the Ryan White Part D 
program and restore its funding eliminated in the President's fiscal 
year 2015 budget proposal and increase Ryan White Part D funding by 
$9.9 million in fiscal year 2015.
Ryan White Part D Background and History
    Over concerns with the increase in the number of pediatric AIDS 
cases, Congress first acted to address pediatric cases in 1987 by 
providing $5 million for the Pediatric AIDS Demonstration Projects in 
the fiscal year 1988 budget. Those demonstration projects became part 
of the Ryan White CARE Act of 1990 which today is known as Ryan White 
Part D and have served thousands of women, infants, children, youth and 
families. Since the program's inception in 1988, Part D programs have 
been and continue to be the entry point into medical care for women and 
youth and, in many communities or regions, Part D programs are the only 
perinatal clinical service available to serve HIV-positive pregnant 
women and youth when payments for such services are unavailable from 
other sources. Ryan White Part D programs have been extremely effective 
in bringing the most vulnerable populations into and retained in care 
and is the lifeline for women, infants, children and youth living with 
HIV/AIDS. The Part D programs are instrumental in preventing mother-to-
child transmission of HIV and for ensuring that women, including HIV- 
positive pregnant women, HIV exposed infants, children and youth have 
access to quality HIV care. The program is built on a foundation of 
combining medical care and essential support services that are 
coordinated, comprehensive, and culturally and linguistically 
competent. This model of care addresses the healthcare needs of the 
most vulnerable populations living with HIV/AIDS in order to achieve 
optimal health outcomes.
    In 2012, Part D provided funding to 114 community-based 
organizations, academic medical centers and hospitals, federally 
qualified health centers, and health departments in 39 States and 
Puerto Rico. These federally, directly-funded grantees provide HIV 
primary care, specialty and subspecialty care, oral health services, 
treatment adherence monitoring and education services pertaining to 
opportunities to participate in HIV/AIDS-related clinical research. 
These grantees also provide support services which include case 
management (medical, non-medical, and family-centered); referrals for 
inpatient hospital services; treatment for substance use, and mental 
health services. Part D grantees also receive assistance from other 
parts of the Ryan White Program that help support HIV testing and 
linkage to care services; provide access to medication; additional 
medical care, such as dental services; and key support services, such 
as case management and transportation, which all are essential 
components of the highly effective Ryan White HIV care model. This 
model has continuously provided comprehensive quality healthcare 
delivery systems that have been responsive to women, infants, children, 
youth and families for two decades.
A Response to Women, Infants, Children, and Youth
    The Ryan White Program has been enormously successful in meeting 
its mission to provide life-extending care and services. Yet, even 
though we have made significant progress in decreasing HIV-related 
morbidity and mortality, much work remains to be done. While accounting 
for less that 6 percent of Ryan White direct care dollars (minus ADAP 
and Part F), Ryan White Part D programs have been extremely effective 
in bringing our most vulnerable populations into care and developing 
medical care and support services especially designed to reach women, 
children, youth, and families. Part D funded programs played a leading 
role in reducing mother-to-child transmission of HIV-from as many as 
2,000 babies born HIV positive in 1990 to roughly 200 cases in 2010 
through aggressive efforts to reach out to pregnant women. Appropriate 
funding is critical to maintain and improve upon this success, as there 
are still approximately 8,000 HIV-positive women giving birth every 
year in the United States that need counseling, services and support to 
prevent pediatric HIV Infections. According to the CDC, youth account 
for 39 percent of all new HIV infections in the U.S. As of 2010, one in 
four new HIV infections occur among young people ages 13-24. Most new 
HIV infections in youth (about 70 percent) occur in gay and bisexual 
males, most of whom are African Americans. Of the new HIV infections 
among youth, 2,100 are among young women; two-thirds of these are among 
young African American women. Ryan White Part D programs are the entry 
point into medical care for many HIV positive youth and leads the 
Nation's effort in recruiting and retaining HIV positive youth to 
comprehensive medical care and support services. According to the 
Health Resources and Services Administration, more than 37 percent of 
women receiving medical care in Ryan White Programs do so through Part 
D. Additionally, Part D provides medical and supportive services to a 
large number of women over 50 who are heading into their senior years 
as HIV survivors which is a testament to the high standard of care 
provided to Ryan White Part D programs. Support and care through the 
Ryan White Part D program was and continues to be funding of last 
resort for the most vulnerable women and children, who often have 
fallen through the cracks of other public health safety nets. Full 
implementation of the Affordable Care Act with continuation of the Ryan 
White Program will dramatically improve health access and outcomes for 
many more women, infants, children, and youth living with HIV disease.
Proposed Consolidation
    The medical and supportive services provided by Ryan White Part D 
are unique and are not currently being provided by other parts of the 
Ryan White Program, including Ryan White Part C. These services are 
uniquely tailored to address the needs of women, including HIV positive 
pregnant women, HIV exposed infants, children and youth living with 
HIV/AIDS. The proposed consolidation of Part D funding into Part C in 
the Federal budget would eliminate a strong safety net for our most 
vulnerable populations and weaken the systems of care Part D programs 
have created and invested in for more than 25 years. Furthermore, the 
loss of Part D funds in some community areas would profoundly impact 
access to comprehensive HIV care and treatment for women, infants, 
children and youth. Many of the population served by Part D will be 
lost or never enter into care. We will not make progress in ending HIV/
AIDS in this country without supporting all of the Parts of Ryan White.
Conclusion
    These are difficult economic times, and we recognize the 
considerable fiscal constraints Congress faces in allocating limited 
Federal dollars as well as the need to reduce administrative burdens 
associated with the overall operational aspects of Ryan White programs. 
However, it is unclear how the proposed consolidation of Part D funding 
into Part C of the program will be implemented to ensure the 
continuation of the delivery of life-saving HIV/AIDS care and treatment 
to the most vulnerable populations without destabilizing existing 
models of care created to address the unique needs of these 
populations. Without the Ryan White Part D program, many of these 
medically-underserved women, infants, children and youth would not 
receive the vital primary care and support services traditionally 
provided to them.
    The AIDS Alliance for Women, Infants, Children, Youth & Families 
respectfully requests that the Subcommittee consider this written 
testimony for the record as you develop your fiscal year 2015 
appropriations bill. Thank you.

    [This statement was submitted by Dr. Ivy Turnbull, Deputy Executive 
Director, AIDS Alliance for Women, Infants, Children, Youth & 
Families.]
                                 ______
                                 
                Prepared Statement of The AIDS Institute
    Dear Chairman Harkin and Members of the Subcommittee: The AIDS 
Institute, a national public policy, research, advocacy, and education 
organization, is pleased to offer comments in support of critical HIV/
AIDS and hepatitis programs as part of the fiscal year 2015 Labor, 
Health and Human Services, Education, and Related Agencies 
appropriation measure. We thank you for supporting these programs over 
the years, and hope you will do your best to adequately fund them in 
the future in order to provide for and protect the health of many 
Americans.
    HIV/AIDS remains one of the world's worst health pandemics. 
According to the CDC, in the U.S. over 636,000 people have died of AIDS 
and there are 50,000 new infections each year. A record 1.1 million 
people in the U.S. are living with HIV. Persons of minority races and 
ethnicities are disproportionately affected. African Americans, who 
make up just 12 percent of the population, account for 44 percent of 
new infections. HIV/AIDS disproportionately affects low income people; 
nearly 90 percent of Ryan White Program clients have a household income 
of less than 200 percent of the Federal Poverty Level.
    The U.S. government has played a leading role in fighting HIV/AIDS, 
both here and abroad. The vast majority of the discretionary programs 
supporting domestic HIV/AIDS efforts are funded through this 
Subcommittee. We are keenly aware of current budget constraints and 
competing interests for limited dollars, but programs that prevent and 
treat HIV are inherently in the Federal interest as they protect the 
public health against a highly infectious virus. If not adequately 
funded, there will certainly be increased infections, more deaths, and 
higher health costs.
    With the advent of antiretroviral medicines, HIV has turned from a 
near certain death sentence to a treatable chronic disease if people 
have access to consistent and affordable healthcare and medications. 
Through prevention, care and treatment, and research we now have the 
ability to actually end AIDS. In 2011, a ground-breaking clinical trial 
(HPTN 052)--named the scientific breakthrough of the year by Science 
magazine--found that HIV treatment not only saves the lives of people 
with HIV, but also reduces HIV transmission by more than 96 percent--
proving that HIV treatment is also HIV prevention. In order to realize 
these benefits, people with HIV must be diagnosed through testing, and 
linked to and retained in care and treatment.
    We also have a National HIV/AIDS Strategy that sets clear goals and 
priorities, and brings the Federal agencies addressing HIV together to 
ensure resources are well coordinated. Over the past 30 years we have 
made great progress in the fight against HIV/AIDS and are truly at a 
tipping point. However, without stable and adequate funding that 
progress is in jeopardy, as well as the lives of millions who are or 
will be infected.
The Ryan White Program
    The Ryan White HIV/AIDS Program provides some level of medical 
care, drug treatment, and support services to approximately 554,000 
low-income, uninsured, and underinsured individuals with HIV/AIDS. With 
people living longer and continued new diagnoses, the demands on the 
program continue to grow and many needs remain unmet. According to the 
CDC, only 37 percent of people living with HIV in the U.S. are retained 
in HIV care, only 33 percent have been prescribed antiretroviral 
treatment, and only 25 percent are virally suppressed. We have a long 
way to go before we can realize the dream of an AIDS-free generation. 
With continued funding we can improve these numbers and health 
outcomes.
    The AIDS Drug Assistance Program (ADAP), one component of the Ryan 
White Program, provides States with funds to pay for medications for 
over 200,000 people. Over the last couple of years, as more infections 
were identified due to increased HIV testing and people lost their jobs 
and health insurance, demand on the program far outpaced its budget. 
This led to ADAP wait lists of 9,300 people. We are thankful that 
President Obama and Congress allocated additional funds, which when 
combined with assistance from pharmaceutical companies has virtually 
eliminated the wait list. With inadequate funding that could all 
change.
    We urge you to ensure that ADAP and the rest of the Ryan White 
Program receive adequate funding to keep up with the growing demand. 
According to NASTAD, enrollment in ADAP increased by 8 percent between 
fiscal year 2012 and fiscal year 2013, and utilization reached its 
highest level ever. With this increased demand for medications comes a 
corresponding increase in medical care and support services provided by 
all other parts of the program.
    As the Affordable Care Act (ACA) is implemented, there will be 
expanded opportunities for healthcare coverage for some Ryan White 
clients. While it will result in some cost shifting for medications and 
primary care, it will never be a substitute for the Ryan White Program. 
Over 70 percent of Ryan White Program clients today have some sort of 
insurance coverage, mostly through traditional Medicaid and Medicare. 
Their coverage will not change with health reform; the Ryan White 
Program will be needed as it is today. The Medicaid expansion is a 
State option and not all States are moving forward with it at this 
time. As ACA is implemented, benefits will differ from State to State 
and there will be many gaps that will have to be filled by the Ryan 
White Program. Plans will not offer all of the comprehensive essential 
support services that the Program does, such as case management, 
transportation, and nutritional services, that are needed to ensure 
retention in medical care and adherence to drug treatment. This 
approach of coordinated, comprehensive, and culturally competent care 
leads to better health outcomes. Therefore, the Ryan White Program, 
while it may need to change in the future, must continue and must be 
adequately funded.
    The AIDS Institute urges the Committee to reject the President's 
budget proposal to eliminate dedicated funding for Part D of the Ryan 
White Program and transfer it to Part C. Part D serves women, infants, 
children, and youth with HIV/AIDS and is a well-established system of 
care that has worked since 1988 in nearly eliminating perinatal 
infection and providing medical care and family-centered support that 
helps ensure these vulnerable populations remain in care and adherent 
to their medications. With youth, particularly black gay youth, being 
the only population experiencing an increase in HIV incidence, we 
cannot afford to dramatically alter the only Ryan White Program part 
dedicated to their care. While changes to the structure of the Ryan 
White Program might be needed in the future, it should not be done 
through the appropriations process and not without community input.
CDC HIV Prevention
    As a Nation, we must do more to prevent new infections, but we only 
allocate 3 percent of our HIV/AIDS spending towards prevention. All the 
care and treatments costs would be saved if we did not have the 
infections in the first place. Preventing just one infection would save 
$402,000 in future lifetime medical costs. Preventing all the new 
50,000 cases in just 1 year would translate into an astounding $20 
billion saved in lifetime medical costs.
    With more people living with HIV than ever before, there are 
greater chances of HIV transmission. The CDC and its grantees have been 
doing their best with limited resources to keep the number of 
infections stable, but that is not good enough. It is focusing 
resources on those populations and communities most impacted by HIV and 
investing in those programs that will prevent the most number of 
infections. This includes young black gay men, who experienced a 38 
percent increase in new infections from 2008-2010 and is a population 
which merits additional attention and resources
    With over 200,000 people living with HIV who are unaware of their 
infection, the CDC is also focused on increased testing programs. 
Testing people early and linking them to care and treatment is critical 
not only for their own health outcomes but also in preventing new 
infections.
    The CDC estimates that in 2010, 26 percent of all new HIV 
infections occurred among youth ages 13 to 24. Nearly 75 percent of 
those infections were among young gay men. Clearly, we must do a better 
job of educating the youth of our Nation, including gay youth, about 
HIV. Adequately funding the HIV Division of Adolescent and School 
Health (DASH) will help address this critical need.
CDC Viral Hepatitis Prevention
    Given that more than 5.3 million people in the U.S. are living with 
hepatitis B and/or C and 65-75 percent of them are undiagnosed, funding 
for the Hepatitis Prevention Division must be increased. With a 25 
percent mortality rate among affected baby boomers--those born between 
1945 and 1965--and with prevalence rates two times higher than whites 
for African Americans in that birth cohort, we cannot afford to 
inadequately fund this program. The current amount of only $29 million 
is far too small to conduct testing, surveillance, and other hepatitis 
prevention and educational programs for the entire country. Currently 
there is no national surveillance system to track hepatitis infections 
and testing programs are inadequate; therefore the majority of the 
millions affected will never become aware of their disease until they 
present with liver cancer or cirrhosis. Increased funding for testing 
and surveillance could bring more people into care and treatment 
allowing them the chance to receive new and more effective treatments 
that actually can result in curing their hepatitis.
HIV/AIDS Research at the National Institutes of Health (NIH)
    While we have made great strides in the area of HIV/AIDS, there is 
still a long way to go. Continued research at the NIH is necessary to 
learn more about the disease and to develop new treatments and 
prevention tools. Recent breakthroughs have provided functional cures 
in a few instances in infants and adults. Work also continues on 
vaccine research as scientists learn more about the disease, and 
combined with cure research it may be possible to see the end of AIDS 
if funding is maintained.
    Again, we thank you for your continued support of these programs 
critical to so many individuals and communities nationwide. We have 
made great progress, but we are still far from achieving our goal of an 
AIDS-free generation. We now have the tools, but we need continued 
leadership and the necessary resources to realize our goal. Thank you.

    [This statement was submitted by Carl E Schmid II, Deputy Executive 
Director, The AIDS Institute.]
                                 ______
                                 
                 Prepared Statement of The AIDS United
    I am Ronald Johnson, Vice President of Policy and Advocacy at AIDS 
United writing in reference to HIV funding at the Department of Health 
and Human Services, on behalf of the 32 organizational members of our 
Public Policy Committee and our over 90 programmatic directly funded 
organizational grantees all of whom are many of the leading AIDS 
Service Organizations across the Nation. AIDS United is a national 
organization that seeks to end the AIDS epidemic in the United States 
by combining private-sector fundraising, philanthropy, coalition 
building, public policy expertise, and advocacy--as well as a network 
of passionate local and State partners--to respond effectively and 
efficiently to the HIV/AIDS epidemic in the communities most impacted 
by the epidemic. Through its unique Public/Private Partnerships, Public 
Policy Committee and targeted special grant-making initiatives, AIDS 
United and its partners reach over 300 grassroots organizations. These 
organizations provide HIV prevention, care, treatment, and support 
services to underserved individuals and populations most impacted by 
the HIV/AIDS epidemic including communities of color, women and gay and 
bisexual men and men who have sex with men (MSM) as well as education 
and training to providers of treatment services. It is our request that 
you increase funding for the Department of Health and Human Services by 
$7.361 billion in fiscal year 2015. This request includes an increase 
of $931 million over fiscal year 2014 throughout the detailed request 
listed below.
    AIDS United understands the fiscal environment that the country is 
wrestling with right now is austere. However, we know that investment 
in prevention and retention in HIV care are critical in lowering the 
number of new infections in the domestic HIV epidemic. As competing 
budget priorities are weighed please keep in mind that HIV is 100 
percent preventable, if we as a Nation muster the political will and 
funding to address domestic HIV on level that meets the needs of the 
epidemic. The increased funding for the domestic HIV/AIDS portfolio in 
fiscal year 2015 will help reach the National HIV/AIDS Strategy (NHAS). 
We look forward to working with you and your Administration in the 
coming year on the fiscal year 2015 budget.
The Ryan White Program
    Early and reliable access to HIV care and treatment is cost 
effective and helps patients with HIV live healthy and productive 
lives. The needs of the Ryan White Program (RWP) continue to grow, even 
with the beginning of the implementation of the Affordable Care Act 
(ACA) and the integration of the RWP there may still be many needs 
unmet. In order to improve the continuum of care and progress toward an 
AIDS-free generation, continued, robust funding for all parts of the 
Ryan White Program in fiscal year 2015 will be necessary. The Ryan 
White Program works in conjunction with Medicaid, Medicare and now the 
Affordable Care Act, and as a result we believe more people living with 
HIV will be able to receive and remain in care and on treatment.
    It will take some time for enrollment to occur and assess the 
impact of the ACA on the Ryan White Program. In the meantime, we urge 
you to fund the Ryan White Program at a total of $2.44 billion in 
fiscal year 2015, an increase of $123 million over fiscal year 2014, 
distributed in the following manner: Part A: $687 million, Part B 
(Care): $428 million, Part B (ADAP): $943 million, Part C: $225 
million, Part D: $85 million, Part F/AETC: $35 million, Part F/Dental 
$15 million.
    AIDS United disagrees with the President's budget request and does 
not support the consolidation of Part D with Part C. We believe it 
should only be considered as part of a larger authorization process 
after key data questions about the value of consolidation are answered.
HIV Prevention
            CDC HIV Prevention and Surveillance
    There still are 50,000 new infections annually and about 1 in 6 
people living with HIV do not know they have the virus. Gay, bisexual, 
and other men who have sex with men (MSM) account for 66 percent of all 
new HIV infections. Between 2008 and 2010, infections among MSM 
increased by 12 percent, and among MSM aged 13-24 years by 22 percent. 
Black and Latino MSM, and especially those who are young continue to be 
disproportionately affected. While we are making progress in decreasing 
new infections among women, black women accounted for 64 percent of 
women infected in 2010. Black and Hispanic women ages 13-24 accounted 
for 82 percent of young women living with HIV in 2010 even though 
together they represent only about 30 percent of women these ages.
    Investing in HIV prevention today translates into less spending in 
the future on care and treatment. Most CDC funding is distributed to 
the primary implementers of prevention activities--State and local 
public health departments and community based organizations. Increased 
investments are critical to expand comprehensive prevention programs 
and to successfully reach individuals at highest risk for infection. 
Early detection of HIV, linkage and retention in care, and adherence to 
treatment will suppress individual and community viral loads. Adequate 
resources are necessary to carry out increased HIV testing programs, 
targeted interventions, public education campaigns, and surveillance 
activities needed to track new infections andCD4 and viral load 
reporting.
    For fiscal year 2015, we request an increase of $55 million over 
fiscal year 2014 for a total of $812.7 million for the CDC Division of 
HIV prevention and surveillance activities.
            Division of Adolescent and School Health (DASH)
    One-third of all new HIV infections are among young people under 
the age of 29, the largest share of any age group. DASH is the only 
federally funded adolescent health program in our Nation's schools, 
helping education agencies provide school districts and individual 
schools with the tools to implement high-quality, effective, and 
sustainable programs to reduce HIV and other STD infections in 
adolescents. Increased funding would help expand this vital 
infrastructure beyond the currently funded 36 State or local education 
agencies.
    We request that the CDC Division of Adolescent and School Health 
receive a total of $50 million, an increase of $21 million over fiscal 
year 2014 final funding. This request includes $3 million in evaluation 
transfer funds.
            CDC STD Prevention
    Given the strong link between HIV and other STDs, including high 
rates of co-infection among certain populations, an increased 
investment in STD programs is an essential component of HIV prevention. 
Investments in STD prevention and treatment further the National HIV/
AIDS Strategy's goal of reducing new infections.
    We request an increase of $54 million for a total of $211 million 
for the CDC's Division of STD Prevention in fiscal year 2015.
            CDC Viral Hepatitis Prevention
    CDC estimates that up to 5.3 million people are living with 
hepatitis B (HBV) and/or hepatitis C (HCV) in the U.S., and as many as 
75 percent are not aware of their infection. In 2010 alone, 35,000 
Americans were newly infected with HBV and 17,000 with HCV. It is 
estimated that 10 percent of people living with HIV are co-infected 
with hepatitis B and 25 percent are co-infected with hepatitis C.
    We request an increase of $31 million above the fiscal year 2014 
level, for a total of $60 million for the CDC's Division of Viral 
Hepatitis.
            Access to Sterile Syringes
    About 1 of 12 new infections (8.6 percent) of HIV in 2011 was 
related to injection drug use, a 28 percent decrease from 2008. One 
factor leading to this reduction has been syringe exchange programs. 
Numerous studies have shown syringe exchange programs can be an 
evidence-based and cost-effective means to lower HIV and hepatitis 
infections, reduce the use of illegal drugs and help connect people to 
medical treatment, including substance abuse treatment. In a May 2012 
letter, the President's Advisory Council on HIV/AIDS also supported 
ending the Federal ban on syringe exchange and noted that doing so is 
supported by public health, HIV/AIDS, viral hepatitis and harm 
reduction communities as well.
    We urge you to add language to end the ban on the use of Federal 
funds for syringe exchange programs and to maintain language that 
allows the use of local funds for syringe exchange programs in the 
District of Columbia.
            Abstinence-only
    We also request that you eliminate the funding for failed 
abstinence-only-until-marriage programs.
HIV/AIDS Research at the National Institutes of Health (NIH)
    Research continues until better, more effective and affordable 
prevention and treatment regimens--and eventually a cure--are developed 
and universally available. For the U.S. to maintain its position as the 
global leader in HIV/AIDS research for the 33 million people globally 
of whom 1.1 million are Americans living with HIV, we must invest 
adequate resources in the NIH. NIH AIDS research has produced startling 
advances, including the HPTN 052 study of the prevention effects of 
treatment that was named Breakthrough of the Year by Science magazine, 
improved treatment programming and the first partially effective HIV 
vaccine, continued AIDS research funding is essential.
    In line with the Trans-NIH AIDS Research By-Pass Budget Estimate 
for fiscal year 2013, please include $3.6 billion for HIV research at 
the NIH, an increase of $610 million over fiscal year 2014.
Minority HIV/AIDS Initiative
    HIV/AIDS continues to impact communities of color at an alarming 
rate. According to the CDC, African Americans, more than any other 
racial/ethnic group, continue to bear the greatest burden of HIV in the 
U.S. While blacks represent approximately 12 percent of the total 
population, they accounted for 44 percent of all new HIV infections in 
2010. Hispanics represent approximately 16 percent of the total 
population, but accounted for 21 percent of all new HIV infections. In 
the Asian Pacific Islander, and Native American communities the numbers 
of HIV infection are just as startling.
    We request that the MAI be funded at $610 million in fiscal year 
2015. We note that most of these funds are contained within the budgets 
of the programs described above.
                                 ______
                                 
           Prepared Statement of the Alzheimer's Association
    The Alzheimer's Association appreciates the opportunity to comment 
on the fiscal year 2015 appropriations for Alzheimer's disease 
research, education, outreach and support at the U.S. Department of 
Health and Human Services.
    Founded in 1980, the Alzheimer's Association is the world's leading 
voluntary health organization in Alzheimer's care, support and 
research. Our mission is to eliminate Alzheimer's disease and other 
dementias through the advancement of research; to provide and enhance 
care and support for all affected; and to reduce the risk of dementia 
through the promotion of brain health. As the world's largest nonprofit 
funder of Alzheimer's research, the Association is committed to 
accelerating progress of new treatments, preventions and, ultimately, a 
cure. Through our funded projects and partnerships, we have been part 
of every major research advancement over the past 30 years. Likewise, 
the Association works to enhance care and provide support for all those 
affected by Alzheimer's and reaches millions of people affected by 
Alzheimer's and their caregivers.
Alzheimer's Impact on the American People and the Economy
    In addition to the human suffering caused by the disease, 
Alzheimer's is creating an enormous strain on the healthcare system, 
families and the Federal budget. Alzheimer's is a progressive brain 
disorder that damages and eventually destroys brain cells, leading to a 
loss of memory, thinking and other brain functions. Ultimately, 
Alzheimer's is fatal. Currently, Alzheimer's is the sixth leading cause 
of death in the United States and the only one of the top ten without a 
means to prevent, cure or slow its progression. Over five million 
Americans are living with Alzheimer's, with 200,000 under the age of 
65.
    A Federal commitment can lower costs and improve health outcomes 
for people living with Alzheimer's today and in the future. By making 
Alzheimer's a national priority, we can create the same successes that 
we have been able to achieve in other diseases that have been 
prioritized by the Federal Government. Leadership from the Federal 
Government has helped to lower the number of deaths from other major 
diseases like heart disease, HIV/AIDS, many cancers, heart disease and 
stroke. While those deaths have declined, deaths from Alzheimer's have 
increased 68 percent between 2000 and 2010.
    Alzheimer's is the most expensive disease in America. In fact, an 
NIH-funded study in the New England Journal of Medicine confirmed that 
Alzheimer's is the most costly disease in America, with costs set to 
skyrocket at unprecedented rates. If nothing is done, as many as 16 
million Americans will have Alzheimer's disease by 2050 and costs will 
exceed $1.2 trillion (not adjusted for inflation), creating an enormous 
strain on the healthcare system, families and the Federal budget. The 
expense involved in caring for those with Alzheimer's is not just a 
long-term problem. As the current generation of baby boomers age, near-
term costs for caring for those with Alzheimer's will balloon, as 
Medicare and Medicaid will cover more than two-thirds of the costs for 
their care.
    Due to these projected increases, the graying of America threatens 
the bankrupting of America. Caring for people with Alzheimer's will 
cost all payers--Medicare, Medicaid, individuals, private insurance and 
HMOs--$20 trillion over the next 40 years, enough to pay off the 
national debt and still send a $10,000 check to every man, woman and 
child in America. In 2014, America will spend an estimated $214 billion 
in direct costs for those with Alzheimer's, including $150 billion in 
costs to Medicare and Medicaid. Average per person Medicare costs for 
those with Alzheimer's and other dementias are three times higher than 
those without these conditions. Average per senior Medicaid spending is 
19 times higher.
    A primary reason for these costs is that Alzheimer's makes treating 
other diseases more expensive, as most individuals with Alzheimer's 
have one or more co-morbidity that complicate the management of the 
condition(s) and increase costs. For example, a senior with diabetes 
and Alzheimer's costs Medicare 81 percent more than a senior who only 
has diabetes. Nearly 30 percent of people with Alzheimer's or another 
dementia who have Medicare also have Medicaid coverage, compared with 
11 percent of individuals without Alzheimer's or dementia. Alzheimer's 
disease is also extremely prevalent in nursing homes, where 64 percent 
of Medicare residents live with the disease.
    With Alzheimer's, it is not just those with the disease who 
suffer--it is also their caregivers and families. In 2013, 15.5 million 
family members and friends provided unpaid care valued at over $220 
billion. Caring for a person with Alzheimer's takes longer, lasts 
longer, is more personal and intrusive, and takes a heavy toll on the 
health of the caregivers themselves. More than 60 percent of 
Alzheimer's and dementia caregivers rate the emotional stress of 
caregiving as high or very high, with one-third reporting symptoms of 
depression. Caregiving may also have a negative impact on health, 
employment, income and family finances. Due to the physical and 
emotional toll of caregiving on their own health, Alzheimer's and 
dementia caregivers had $9.3 billion in additional health costs in 
2013.
Changing the Trajectory of Alzheimer's
    Until recently, there was no Federal Government strategy to address 
this looming crisis. In 2010, thanks to bipartisan support in Congress, 
the National Alzheimer's Project Act (NAPA) (Public Law 111-375) passed 
unanimously, requiring the creation of an annually-updated strategic 
National Alzheimer's Plan (Plan) to help those with the disease and 
their families today and to change the trajectory of the disease for 
the future. The Plan is required to include an evaluation of all 
federally-funded efforts in Alzheimer's research, care and services--
along with their outcomes. In addition, the Plan must outline priority 
actions to reduce the financial impact of Alzheimer's on Federal 
programs and on families; improve health outcomes for all Americans 
living with Alzheimer's; and improve the prevention, diagnosis, 
treatment, care, institutional-, home-, and community-based Alzheimer's 
programs for individuals with Alzheimer's and their caregivers. NAPA 
will allow Congress to assess whether the Nation is meeting the 
challenges of this disease for families, communities and the economy. 
Through its annual review process, NAPA has enabled, for the first 
time, Congress and the American people to answer this simple question: 
Did we make satisfactory progress this past year in the fight against 
Alzheimer's?
    As mandated by NAPA, the Secretary of Health and Human Services, in 
collaboration with the Advisory Council on Alzheimer's Research, Care 
and Services, has developed the first-ever National Plan to Address 
Alzheimer's Disease in May of 2012 and subsequently released the 2014 
Update to the National Plan to Address Alzheimer's Disease this past 
April. The Advisory Council, composed of both Federal members and 
expert non-Federal members, is an integral part of the planning process 
as it advises the Secretary in developing and evaluating the annual 
Plan, makes recommendations to the Secretary and Congress, and assists 
in coordinating the work of Federal agencies involved in Alzheimer's 
research, care, and services.
    Having a plan with measurable outcomes is important. But unless 
there are resources to implement the plan and the will to abide by it, 
we cannot hope to make adequate progress. If we are going to succeed in 
the fight against Alzheimer's, Congress must provide the resources the 
scientists need. Understanding this and following the recommendation of 
scientists at NIH, Congress passed the Consolidated Appropriations Act 
of 2014 (Public Law 113-76) which included a $100 million increase for 
Alzheimer's research. These funds are a critically needed down payment 
for needed research and services for Alzheimer's patients and their 
families.
    A disease-modifying or preventive therapy would not only save 
millions of lives but would save billions of dollars in healthcare 
costs. Specifically, if a treatment became available in 2015 that 
delayed onset of Alzheimer's for 5 years (a treatment similar to anti-
cholesterol drugs), savings would be seen almost immediately, with 
Medicare and Medicaid spending reduced by $42 billion in 2020.
    Today, despite the Federal investment in Alzheimer's research, we 
are only just beginning to understand what causes the disease. 
Americans are growing increasingly concerned that we still lack 
effective treatments that will slow, stop, or cure the disease, and 
that the pace of progress in developing breakthrough discoveries is 
much too slow to significantly impact on this growing crisis. For every 
$26,500 Medicare and Medicaid spends caring for individuals with 
Alzheimer's, the National Institutes of Health (NIH) spends only $100 
on Alzheimer's research. Scientists fundamentally believe that we have 
the ideas, the technology and the will to develop new Alzheimer's 
interventions, but that progress depends on a prioritized scientific 
agenda and on the resources necessary to carry out the scientific 
strategy for both discovery and translation for therapeutic 
development.
    For too many individuals with Alzheimer's and their families, the 
system has failed them, and today we are unnecessarily losing the 
battle against this devastating disease. Despite the fact that an early 
and documented formal diagnosis allows individuals to participate in 
their own care planning, manage other chronic conditions, participate 
in clinical trials, and ultimately alleviate the burden on themselves 
and their loved ones, as many as half of the more than five million 
Americans with Alzheimer's have never received a formal diagnosis. 
Unless we create an effective, dementia-capable system that finds new 
solutions to providing high quality care, provides community support 
services and programs, and addresses Alzheimer's health disparities, 
Alzheimer's will overwhelm the healthcare system in the coming years. 
For example, people with Alzheimer's and other dementias have more than 
three times as many hospital stays as other older people. Furthermore, 
one out of seven individuals with Alzheimer's or another dementia lives 
alone and up to half do not have an identifiable caregiver. These 
individuals are more likely to need emergency medical services because 
of self-neglect or injury, and are found to be placed into nursing 
homes earlier, on average, than others with dementia. Ultimately, 
supporting individuals with Alzheimer's disease and their families and 
caregivers requires giving them the tools they need to plan for the 
future and ensuring the best quality of life for individuals and 
families impacted by the disease. It is vital that we make the 
investments in Alzheimer's that will fulfill the goals of the National 
Alzheimer's Plan. The Alzheimer's Association urges Congress to support 
an additional $200 million for research activities and priorities 
included in the National Alzheimer's Plan required under Public Law 
111-375.
Additional Alzheimer's programs
    National Alzheimer's Call Center: The National Alzheimer's Call 
Center, funded by the AoA, provides 24/7, year-round telephone support, 
crisis counseling, care consultation, and information and referral 
services in 140 languages for persons with Alzheimer's, their family 
members and informal caregivers. Trained professional staff and 
master's-level mental health professionals are available at all times. 
In the 12 month period ending July 31, 2013, the Call Center handled 
over 300,000 calls through its national and local partners, and its 
online message board received over 40,000 visits a month. Additionally, 
the Association provides a two-to-one match on the Federal dollars 
received for the call center. The Alzheimer's Association urges 
Congress to support $1.3 million for the National Alzheimer's Call 
Center.
    Healthy Brain Initiative (HBI): The Centers for Disease Control and 
Prevention's (CDC) HBI program works to educate the public, the public 
health community and health professionals about Alzheimer's as a public 
health issue. Although there are currently no treatments to delay or 
stop the deterioration of brain cells caused by Alzheimer's, evidence 
suggests that preventing or controlling cardiovascular risk factors may 
benefit brain health. In light of the dramatic aging of the population, 
scientific advancements in risk behaviors, and the growing awareness of 
the significant health, social and economic burdens associated with 
cognitive decline, the Federal commitment to a public health response 
to this challenge is imperative. The fiscal year 2014 omnibus funding 
bill increased funding for HBI by $1.5 million in order to bolster 
caregiver surveillance. The Alzheimer's Association urges Congress to 
support $3.3 million for the Healthy Brain Initiative.
    Alzheimer's Disease Supportive Services Program (ADSSP): The ADSSP 
at the AoA supports family caregivers who provide countless hours of 
unpaid care, thereby enabling their family members with Alzheimer's and 
dementia to continue living in the community. The program develops 
coordinated, responsive and innovative community-based support service 
systems for individuals and families affected by Alzheimer's. The 
Alzheimer's Association urges Congress to support $13.4 million for the 
Alzheimer's Disease Supportive Services Program.
Conclusion
    The Association appreciates the steadfast support of the 
Subcommittee and its priority setting activities. We look forward to 
continuing to work with Congress in order to address the Alzheimer's 
crisis. We ask Congress to address Alzheimer's with the same bipartisan 
collaboration demonstrated in the passage of the National Alzheimer's 
Project Act (Public Law 111-375) and with a commitment equal to the 
scale of the crisis.
                                 ______
                                 
      Prepared Statement of the Alzheimer's Foundation of America
    On behalf of the Alzheimer's Foundation of America (AFA), a 
national nonprofit organization that unites more than 1,600 member 
organizations nationwide with the goal of providing optimal care and 
services to individuals confronting dementia, and to their caregivers 
and families, we are making the following appropriations requests for 
programs impacting Alzheimer's disease caregiving services and research 
in the fiscal year 2015 budget. These Federal programs and support 
services are vital to providing necessary care supports and promoting 
best practice tools to family caregivers, and advancing promising 
clinical research.
    Specifically, AFA makes the following appropriations requests for 
these specific agencies and programs:
National Institutes of Health (NIH):
    Adequate investment in scientific research that could lead to new 
treatments and cures is critical in order to reduce long-term 
healthcare costs. We appreciated Congress' efforts in the fiscal year 
2014 budget which provided an additional $80 million for clinical 
research into Alzheimer's disease. AFA urges the Committee to build on 
this modest increase and provide an additional $500 million for 
Alzheimer's disease research and enhanced investments for caregiving 
supports and services in fiscal year 2015. Additional resources will 
fund effective pharmaceutical therapies to prevent, cure or slow the 
progression of Alzheimer's disease, and provide the necessary seed 
money to implement and facilitate the ambitious and laudable goals of 
the ``National Plan to Address Alzheimer's Disease.''
    AFA also urges the Committee to include $32 billion in total 
funding for NIH, as recommended by the Ad Hoc Group for Medical 
Research and a bi-partisan group of Members of Congress including Reps. 
McKinley, Davis, Carson and King. Even if funding remains flat, NIH's 
actual budget will still be effectively cut as spending will not be 
able to keep pace with biomedical inflation.
    --National Institute on Aging (NIA): Since NIA is the primary 
agency responsible for Alzheimer's disease research, AFA urges the 
Committee to include a minimum budget appropriation of $1.7 billion, an 
increase of $500 million for NIA for fiscal year 2015.
    NIA leads the national scientific effort to understand the nature 
of aging in order to promote the health and well-being of older adults, 
whose numbers are projected to rise dramatically in the coming years 
due to increased life expectancy and the aging of the baby boom 
generation.
    This funding is essential to increase the NIA's baseline to a level 
consistent with comparable research initiatives conducted under the 
auspices of NIH, and to support additional research into Alzheimer's 
disease and related dementias. This is particularly vital, as 
Alzheimer's disease holds the infamous position of being the only one 
of the top ten leading causes of death with a rising death rate.
Administration on Community Living (ACL) programs:
    AFA would like to single out the following programs within the ACL 
that are critical to individuals with Alzheimer's disease and their 
caregivers:
    --National Family Caregiver Support Program (NFCSP): NFCSP provides 
grants to States and territories, based on their share of the 
population aged 70 and over, to fund a range of supportive services 
that assist family and informal caregivers in caring for their loved 
ones at home for as long as possible, thus providing a more person-
friendly and cost-effective approach than institutional care. Last 
year's appropriation of $146 million cannot possibly keep up with the 
need for respite care as our population ages. AFA urges that $156 
million be appropriated in fiscal year 2015 to support this important 
program.
    --Lifespan Respite Care Program (LRCP): AFA urges the Committee to 
commit $10 million to LRCP in fiscal year 2015. LRCP provides 
competitive grants to State agencies working with Aging and Disability 
Resource Centers and non-profit State respite coalitions and 
organizations to make quality respite care available and accessible to 
family caregivers regardless of age or disability by establishing State 
Lifespan Respite Systems.
    --Alzheimer's Disease Demonstration Grants (ADDG): Existing 
resources for the Alzheimer's population and their caregivers are 
already tapped out, at a time when demand is continuing to rise in line 
with the skyrocketing incidence of this disease. AFA supports funding 
of $9 million for the ADDG program which fosters the development of 
innovative models of care for persons with Alzheimer's disease and 
their caregivers and is designed to improve responsiveness of the home 
and community based care system to persons with dementia including 
underserved minority, rural and low-income persons.
    --Alzheimer's Disease Initiative (ADI): AFA supports the 
President's fiscal year 2015 budget request of $12 million for this 
program that for services such as support for caregivers in the 
community, improving healthcare provider training, and raising public 
awareness. Research shows that education, counseling and other support 
for family caregivers can delay institutionalization of loved ones and 
improve a caregiver's own physical and mental well-being--thus reducing 
costs to families and government. In addition, AFA supports an 
appropriation of $5 million for the Alzheimer's Disease Communications 
Campaign.
Food and Drug Administration (FDA):
    AFA supports FDA funding in fiscal year 2015 that fully restores 
the agency's base lost in the fiscal year 2013 sequester and provides 
for a modest additional funding above that level. Specifically, we are 
requesting budget authority appropriations of $2.78 billion for FDA, 
$223 million above fiscal year 2014 appropriated spending.
    FDA activities are necessary to ensure proper evaluation and 
testing of pharmaceutical treatments for Alzheimer's disease before 
these drugs enter the market. In addition, with the science of this 
disease becoming more complex, FDA plays an increasingly important and 
often resource-intensive role in pharmaceutical innovation. AFA's 
request is in line with the appropriations request being recommended by 
the Alliance for a Stronger FDA and the Coalition to Accelerate Cure/
Treatments for Alzheimer's Disease (ACT-AD).
    As we work toward meeting the goal of the historic ``National Plan 
to Address Alzheimer's Disease'' to prevent and effectively treat 
Alzheimer's disease by 2025, adequate resources must be committed to 
meet the pending challenge. Taken together, these programs represent a 
lifeline to families who care for a loved one with Alzheimer's disease 
and provide hope to Americans living with the disease and those who 
face it in the future that there will be funding for a cure.
    AFA thanks the Committee for the opportunity to present its 
recommendations and looks forward to working with you through the 
appropriations process. Please contact me or Eric Sokol, AFA's vice 
president of public policy, at [email protected] if you have any 
questions or require further information.

    [This statement was submitted by Hon. Charles J. Fuschillo, Jr., 
Chief Executive Officer, Alzheimer's Foundation of America.]
                                 ______
                                 
               Prepared Statement of the America Achieves
    Chairman Harkin and Ranking Member Moran: Results for America 
(RFA), an initiative of America Achieves, is pleased to present our 
recommendations for fiscal year 2015 to the Senate Appropriations 
Subcommittee on the Departments of Labor, Health and Human Services, 
and Education.
    The attached letter and table outline the evidence-based policies 
and programs RFA and our coalition partners are requesting from your 
Subcommittee for fiscal year 2015 to help improve outcomes for young 
people, their families, and communities.
    Over the last several years, all levels of government have taken 
critical steps to change the way taxpayer dollars are invested to 
ensure limited resources are driven toward high-impact solutions that 
get results. To significantly improve outcomes for young people, their 
families, and communities in the context of constrained resources and 
mounting demands, the Federal Government should identify and invest in 
``what works,'' and be a catalyst for, and funder of, effective and 
innovative solutions that produce greater social impact. While public 
debate focuses on more or less resources, it is critical to identify 
how to get better results from existing resources. This approach has a 
strong history of bipartisan support. President George W. Bush's 
Administration put a priority on improving the performance of Federal 
programs and encouraged more rigorous evaluations to assess their 
effectiveness. The Obama Administration has built on this effort by 
supporting an increasing number of evidence and evaluation-based 
policies and programs. Mayors and governors from both parties across 
the country are also increasingly using data and evidence to steer 
public dollars to more effectively address needs in their communities 
and States.
    I want to thank you for the positive steps you have taken over the 
last several years toward building a strong evidence-based, results-
driven policy agenda and look forward to working with you in the months 
and years ahead.
    On March 13, 2014, the following 72 organizations sent a letter to 
Chairwoman Mikulski, Chairman Rogers, and Ranking Members Shelby and 
Lowey requesting bill and report language to invest Federal funds in 
what works. The letter and a summary of our recommendations for fiscal 
year 2015 for the House Appropriations Subcommittee on the Departments 
of Labor, Health and Human Services, and Education follow:
                          invest in what works
    Dear Chairwoman Mikulski, Chairman Rogers, Ranking Member Shelby, 
and Ranking Member Lowey:
    We are writing to urge you to include the attached ``Invest in What 
Works'' provisions in the subcommittee appropriations bills and reports 
for the Departments of Labor, Health and Human Services, Education, and 
Related Agencies, and the Departments of Commerce, Justice, Science, 
and Related Agencies for fiscal year 2015.
    America is facing enormous social and economic shifts, budget 
constraints at all levels of government, significant demographic 
changes, and an increasingly globally competitive, changing workforce. 
While the recently-enacted fiscal year 14 omnibus appropriations law 
includes an unprecedented commitment to evidence and evaluation, we 
must continue to focus on improving the ways in which Federal taxpayer 
dollars are spent in fiscal year 15 and beyond in order to be able to 
significantly improve outcomes for young people, their families, and 
communities.
    We thank you for the positive steps you have taken over the last 
several years toward building a strong evidence-based, results-driven 
policy agenda and encourage you to reaffirm your commitment to 
improving outcomes for all Americans by incorporating the attached 
``Invest in What Works'' recommendations in the fiscal year 2015 
appropriations bills and committee reports.
    Thank you for your consideration of our requests.
            Sincerely,

AdvancEd
AIDS United
Alliance College-Ready Public Schools
Amos House (RI)
Aspire Public Schools
BELL
Breakthrough Schools
Brighton Center, Inc. (KY)
Capital Impact Partners
Center for Employment Opportunities
Center for Research and Reform in Education, Johns
Hopkins University
Champlain Housing Trust (VT)
Cincinnati Works
Citizen Schools
City First Homes and City First Enterprises (DC)
City Year, Inc.
CLUE (Comunidades Latinas Unidas En Servicio) (MN)
CommonBond Communities (MN)
Communities in Schools
Community Action Duluth
Community Training and Assistance Center (CTAC)
Congreso de Latinos Unidos Inc.
CSH
Edna Martin Christian Center (IN)
Education Northwest
Emerge Community Development (MN)
Family Resources Community Action (RI)
Focus: HOPE (MI)
Gestalt Community Schools
Greater Southwest Development Corporation (IL)
GreenLight Fund
Home Start, Inc. (CA)
Housing Leadership Council, Inc. (FL)
IDEA Public Schools
Jane Addams Resource Corporation (IL)
KIPP
Knowledge Alliance
LISC
Metropolitan Family Services (IL)
Mile High United Way
National Forum to Accelerate Middle-Grades Reform
National Fund for Workforce Solutions
New Profit Inc.
North County Lifeline (CA)
Operation ABLE (MI)
Project for Pride in Living, Inc. (MN)
Providence Housing Authority
Reading Partners
REDF
Results for America
Rocketship Education
Rubicon Programs
Safer Foundation (IL)
Santa Maria Community Services (OH)
SER-Jobs for Progress of the Texas Gulf Coast, Inc.
SER Metro Detroit, Jobs for Progress, Inc.
Southeast Community Services Inc. (IN)
Southwest Solutions (MI)
StriveTogether
Success for All Foundation
Teach For America
Teach Plus
The SEED Foundation
Turnaround For Children
United Way of Greater Cincinnati
United Way for Southeastern Michigan
Urban Alliance
U.S. Soccer Foundation
Venture Philanthropy Partners
Volunteers of America Texas Inc.
Year Up
Youth Villages

                  RECOMMENDATIONS FOR FISCAL YEAR 2015
                                                       .................
               U.S. DEPARTMENT OF LABOR
 
Workforce Innovation Fund--with up to $10,000,000 for        $60,000,000
 Pay for Success initiatives.........................
Agency-Wide Evaluation Set-Aside--1 percent of         .................
 discretionary funds to be used by the Chief
 Evaluation Office for program evaluations...........
 
     U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
 
Head Start Designation Renewal System--set-aside             $25,000,000
 within the total provided for Head Start............
Mental Health Service Block Grant Program--at least 5  .................
 percent set-aside for evidence-based programs to
 address the needs of individuals with early serious
 mental illness......................................
 
             U.S. DEPARTMENT OF EDUCATION
 
First in the World--with $20,000,000 set-aside for          $100,000,000
 minority-serving institutions.......................
Investing in Innovation (i3)--language directing the        $215,000,000
 Department to provide continuation grants to certain
 current i3 grantees that are demonstrating strong
 interim outcomes but have not had sufficient time to
 achieve their program goals.........................
Replication and Expansion of High Quality Charter            $75,000,000
 Schools--set-aside within the total provided for the
 Charter School Program..............................
Title II-A--Effective Teachers and Leaders--language   .................
 requiring the Secretary to set aside 25 percent of
 ESEA Title II-A funds for competitive grants to
 States, high need local school districts, and
 national non-profit organizations, including 10
 percent set-aside for the Supporting Effective
 Educator Development (SEED) program.................
Titles I and II--language directing States to set-     .................
 aside 1 percent of Title I and II funds, prior to
 distribution to local school districts (LSD), and to
 award these funds on a competitive basis to the 25
 percent of LSD's with the highest poverty levels
 through a tiered funding frame-work.................
IDEA Results-Driven Accountability Grants--set-aside        $100,000,000
 to implement promising evidence-based reforms.......
Agency-Wide Evaluation Set-aside--1 percent of         .................
 discretionary funds (not including Pell Grants) for
 program evaluations.................................
Title II--Whole School Reform--language allowing       .................
 local school districts to use School Improvement
 Grants to implement a whole-school reform strategy
 for a school using an evidence-based strategy that
 ensures whole-school reform is undertaken in
 partnership with a strategy developer offering a
 whole-school reform program that is based on at
 least a moderate level of evidence that the program
 will have a statistically significant effect on
 student outcomes as defined by the Department's
 General Administrative Regulations..................
 
    CORPORATION FOR NATIONAL AND COMMUNITY SERVICE
 
Social Innovation Fund--including up to 20 percent           $80,000,000
 set-aside for Pay for Success initiatives and
 language directing CNCS to (1) provide renewal
 grants to current SIF grantees that are
 demonstrating significant interim outcomes but have
 not had sufficient time to achieve their program
 goals and (2) permit current SIF grantees to be
 eligible to apply for additional SIF funds for
 projects not currently funded by SIF................
 
                  GENERAL PROVISION
 
Performance Partnership Pilot--language establishing   .................
 up to 10 Performance Partnership Pilots to improve
 outcomes for disconnected youth.....................
 


    [This statement was submitted by Michele Jolin, Managing Partner, 
America Achieves.]
                                 ______
                                 
    Prepared Statement of the American Academy of Family Physicians
    The American Academy of Family Physicians (AAFP), representing 
110,600 family physicians and medical students nationwide, urges the 
Senate Appropriations Subcommittee on Labor, Health and Human Services, 
and Education to invest in our Nation's primary care physician 
workforce in the fiscal year 2015 appropriations bill to promote the 
efficient, effective delivery of healthcare by providing these 
appropriations for the Health Resources and Services Administration and 
the Agency for Healthcare Research and Quality:
  --$71 million for Health Professions Primary Care Training and 
        Enhancement authorized under Title VII, Section 747 of the 
        Public Health Service Act (PHSA);
  --$10 million for Teaching Health Centers development grants (PHSA 
        Title VII, Sec. 749A);
  --$4 million for Rural Physician Training Grants (PHSA Title VII, 
        Sec. 749B);
  --$100 million for the National Health Service Corps (PHSA Sec. 338A, 
        B, & I);
  --$375 million for the Agency for Healthcare Research and Quality 
        (PHSA Sec. 487(d)(3), SSA Sec. 1142); and
  --$3 million for the National Health Care Workforce Commission (ACA 
        Sec. 5101).
    Founded in 1947, the AAFP is dedicated to preserving and promoting 
the science and art of family medicine and ensuring high-quality, cost-
effective healthcare for patients of all ages. The AAFP appreciates the 
opportunity to comment on the fiscal year 2015 appropriations levels 
needed to achieve those important goals.
          health resources and services administration (hrsa)
    Our Nation faces a shortage of primary care physicians. The total 
number of office visits to primary care physicians is projected to 
increase from 462 million in 2008 to 565 million in 2025 requiring 
nearly 52,000 additional primary care physicians by 2025.\1\ The Health 
Resources and Services Administration (HRSA) is the Federal agency 
charged with administering the health professions training programs 
authorized under Title VII of the Public Health Services Act and first 
enacted in 1963. We urge the Committee to restore funding for 
discretionary HRSA programs to the fiscal year 2010 level of $7.48 
billion in the fiscal year 2015 bill.
---------------------------------------------------------------------------
    \1\ Petterson, S, et al. Projecting U.S. Primary Care Physician 
Workforce Needs: 2010-2015. Ann Fam Med 2012; vol.10 no. 6:503-509.
---------------------------------------------------------------------------
    Title VII Health Professions Training Programs.--In the last 50 
years, Congress has revised the Title VII authority in order to meet 
our Nation's changing healthcare workforce needs. We now face 
burgeoning demand for family physicians and must work to increase their 
number in the United States. As the only medical specialty society 
devoted entirely to primary care, the AAFP is gravely concerned that a 
failure to provide adequate funding for the Title VII, Section 747 
Primary Care Training and Enhancement (PCTE) program, will destabilize 
education and training support for family physicians. Between 1998 and 
2008, in spite of persistent primary care physician shortages, family 
medicine lost 46 training programs and 390 residency positions, and 
general internal medicine lost nearly 900 positions.\2\ A study 
published in the Annals of Family Medicine on the impact of Title VII 
training programs found that physicians who work with the underserved 
in Community Health Centers and National Health Service Corps sites are 
more likely to have trained in Title VII-funded programs.\3\ Title VII 
primary care training grants are vital to departments of family 
medicine, general internal medicine, and general pediatrics; they 
strengthen curricula; and they offer incentives for training in 
underserved areas. In the coming years, medical services utilization is 
likely to rise given the increasing and aging population as well as the 
insured status of more people. These demographic trends will exacerbate 
family physician shortages. Although PCTE grants are important to 
family medicine, there has not been a competitive cycle for these 
grants since fiscal year 2010. The AAFP urges the Committee to increase 
the level of Federal funding for primary care training to at least $71 
million in fiscal year 2015 to allow for a robust new grant cycle to 
support family medicine education and training in the new competencies 
required to meet the needs of patients of all ages.
---------------------------------------------------------------------------
    \2\ Phillips RL and Turner, BJ. The Next Phase of Title VII Funding 
for Training Primary Care Physicians for America's Health Care Needs. 
Ann Fam Med 2012; vol.10 no. 2:163-168.
    \3\ Rittenhouse DR, et al. Impact of Title VII training programs on 
community health center staffing and national health service corps 
participation. Ann Fam Med 2008; vol. 6 no. 5:397-405.
---------------------------------------------------------------------------
    Teaching Health Centers.--The AAFP has long called for reforms to 
graduate medical education programs to encourage the training of 
primary care residents in non-hospital settings where most primary care 
is delivered. An excellent first step is the innovative Teaching Health 
Centers (THC) program authorized under Title VII, Sec. 749A to increase 
primary care physician training capacity that HRSA administers. Federal 
financing of graduate medical education has led to training mainly in 
hospital inpatient settings even though most patient care is delivered 
outside of hospitals in ambulatory settings. The THC program provides 
resources to any qualified community based ambulatory care setting that 
operates a primary care residency. We believe that this program 
requires an investment of $10 million in fiscal year 2015 for planning 
grants.
    Rural Physician Workforce Needs.--HRSA's Office of Rural Health 
focuses on rural health policy issues and administers rural grant 
programs. As the medical specialty most likely to enter rural practice, 
family physicians recognize the importance of dedicating appropriate 
resources to rural health needs. A recent study found that medical 
school rural programs have had a significant impact on rural family 
physician supply and called for wider adoption of that model to 
substantially increase access to care in rural areas compared to a 
greater reliance on international medical graduates or unfocused 
expansion of traditional medical schools.\4\ HRSA's Rural Physician 
Training Grant program will help medical schools recruit students most 
likely to practice medicine in rural communities. This program will 
help provide rural-focused experience and increase the number of 
medical school graduates who practice in underserved rural communities. 
The AAFP recommends that the Committee provide $4 million for Rural 
Physician Training Grants in fiscal year 2015 as called for in the 
President's budget request.
---------------------------------------------------------------------------
    \4\ Rabinowitz,HK, et al. Medical School Rural Programs: A 
Comparison With International Medical Graduates in Addressing State-
Level Rural Family Physician and Primary Care Supply. Academic 
Medicine, Vol. 87, No. 4/April 2012.
---------------------------------------------------------------------------
    Primary Care in Underserved Areas.--The National Health Service 
Corps (NHSC) recruits and places medical professionals in Health 
Professional Shortage Areas to meet the need for healthcare in rural 
and medically underserved areas. The NHSC offers scholarships or loan 
repayment as incentives for physicians to enter primary care and 
provide healthcare to Americans in Health Professional Shortage Areas. 
By addressing medical school debt burdens, the NHSC also helps to 
ensure wider access to medical education opportunities. The President's 
budget request includes $810 million for the NHSC, of which $710 
million is mandatory funding. If the NHSC is funded at the President's 
requested level in fiscal year 2015, underserved patients will benefit 
from an NHSC field strength of more than 15,400 primary care clinicians 
compared to the fiscal year 2013 field strength of 8,899. The AAFP 
supports the President's budget request for this important program and 
recommends that the Committee provide an appropriation of $100 million 
for the NHSC in fiscal year 2015 to supplement the authorized and 
requested mandatory funds.
           agency for heatlhcare research and quality (ahrq)
    AHRQ is the only Federal agency responsible for generating evidence 
to make healthcare safer; better; and more accessible, equitable and 
affordable. AHRQ provides the critical evidence reviews that the AAFP 
and other physician specialty societies use to produce clinical 
practice guidelines. These evidence-informed guidelines are important 
to family physicians as well as to patients and their families. AHRQ 
takes the results from the NIH whose research restricts subjects to 
limit the variables in clinical studies and brings the practical 
information to the practicing physicians who treat patients without 
those clinical restrictions. ARHQ supports critical primary care 
investigations through Practice-based Research Networks that examine 
practice transformation, patient quality and safety in non-hospital 
settings, multi-morbidity research, as well as mental and behavioral 
healthcare in communities and primary care practices. The AAFP asks 
that the Committee provide $375 million in base discretionary funding 
for AHRQ in fiscal year 2015.
               national health care workforce commission
    Appointed on September 30, 2010, the 15-member National Health Care 
Workforce Commission was intended to serve as a resource with a broad 
array of expertise. The Commission was directed to analyze current 
workforce distribution and needs; evaluate healthcare education and 
training; identify barriers to improved coordination at the Federal, 
State, and local levels and recommend ways to address them; and 
encourage innovations. There is broad consensus about the waning 
availability of primary care physicians in the United States, but 
estimates of the severity of the regional and local shortages vary. The 
AAFP supports the work of the Commission to analyze primary care 
shortages and propose innovations to help produce the physicians that 
our Nation needs and will need in the future. We request that the 
Committee provide $4 million in fiscal year 2015 so that this important 
Commission can finally begin this important work.
                                 ______
                                 
        Prepared Statement of the American Academy of Pediatrics
    The American Academy of Pediatrics (AAP), a non-profit professional 
organization of 62,000 primary care pediatricians, pediatric medical 
subspecialists, and pediatric surgical specialists dedicated to the 
health, safety, and well-being of infants, children, adolescents, and 
young adults, appreciates the opportunity to submit this statement for 
the record in support of strong Federal investments in children's 
health in fiscal year 2015 and beyond. AAP urges all Members of 
Congress to put children first when considering short and long-term 
Federal spending decisions. AAP supports robust investment in programs 
that help ensure the health, safety and well-being of children, 
including $5 million for the Pediatric Subspecialty Loan Repayment 
Program at the Health Resource Services Administration (HRSA), $21 
million for the Emergency Medical Services for Children (HRSA), $139 
million for the National Center for Birth Defects and Developmental 
Disabilities at the Centers for Disease Control and Prevention (CDC), 
and $160 million for Polio Eradication and $49 million for the Measles 
program within CDC.
    Every adult was once a child. Many adult diseases have their 
origins in childhood. Early and continued investments in our children's 
health are needed to prevent obesity, heart disease, substance use, and 
other chronic conditions that threaten America's health and fiscal 
solvency. As clinicians we not only diagnose and treat our patients, we 
also promote preventive interventions to improve overall health. 
Likewise, as policymakers, you have an integral role in ensuring the 
health of future generations through adequate and sustained funding of 
vital Federal programs.
Pediatric Subspecialty Loan Repayment Program
    The United States' supply of pediatric subspecialists is inadequate 
to meet children's health needs. Many children must wait more than 3 
months for an appointment with a pediatric subspecialist. Approximately 
1 in 3 children must travel 40 miles or more to receive care from a 
pediatrician certified in adolescent medicine, developmental behavioral 
pediatrics, neurodevelopment disabilities, pulmonology, emergency 
medicine, nephrology, rheumatology, and sports medicine. This problem 
is compounded by the fact that fewer medical residents are choosing 
careers in pediatric subspecialties, and the existing subspecialist 
workforce continues to age. There is also a significant disparity in 
the geographic distribution of pediatric subspecialists across the 
country, resulting in many underserved rural and urban areas.
    The Pediatric Subspecialty Loan Repayment Program (PSLRP) seeks to 
expand children's access to healthcare by creating a more robust 
pediatric work force. In the program, eligible participants must agree 
to practice full-time for not less than 2 years in a pediatric medical 
specialty, surgical specialty, or a child or adolescent mental and 
behavioral subspecialty in a health professional shortage area or a 
medically underserved area. In return, the program will pay up to 
$35,000 in loan repayment for each year of service, for a maximum of 3 
years.
    Fiscal year 2015 Request: $5 million; fiscal year 2014 Level: Not 
Funded.
Emergency Medical Services for Children
    Established by Congress in 1984 and last reauthorized in 2010, the 
Emergency Medical Services for Children (EMSC) Program is the only 
Federal program that focuses specifically on improving the pediatric 
components of the emergency medical services (EMS) system. Currently 
celebrating its 30th year, the EMSC program has made landmark 
improvements to the emergency care delivered to children all across the 
Nation. EMSC aims to ensure that state of the art emergency medical 
care for the ill and injured child or adolescent is well integrated 
into an EMS system. Every State has received EMSC funds, which they 
have used to ensure that hospitals and ambulances are properly equipped 
to treat pediatric emergencies, to provide pediatric training to 
paramedics and first responders, and to improve the systems that allow 
for efficient, effective pediatric emergency medical care.
    Continued support for EMSC has allowed the program to maintain its 
existing activities, improve pediatric capacity and transport of 
pediatric patients, and address emerging issues such as pediatric 
emergency care readiness and pediatric emergency medical services in 
rural and remote areas.
    Fiscal year 2015 Request: $21 million; fiscal year 2014 Level: 
$20.1 million.
National Center for Birth Defects and Developmental Disabilities
    The National Center for Birth Defects and Developmental 
Disabilities is a center within CDC that seeks to promote the health of 
babies, children, and adults and enhance the potential for full, 
productive living. According to the CDC, birth defects affect 1 in 33 
babies and are a leading cause of infant death in the United States; 
the center has done tremendous work in the way of identifying the 
causes of birth defects and developmental disabilities, helping 
children to develop and reach their full potential. The center also 
conducts important research on fetal alcohol syndrome, infant health, 
autism, congenital heart defects, and other conditions like Tourette 
Syndrome, Fragile X, Spina Bifida and Hemophilia. NCBDDD has proven to 
be an asset to children and their families and supports extramural 
research in every State.
    Fiscal year 2015 Request: $139 million; fiscal year 2014 Level: 
$122.4 million.
Global Health at CDC
    The AAP calls on Congress to support and resource Health and Human 
Services to implement the recommendations of the National Vaccine 
Advisory Committee of the Global Immunizations Working Group on 
enhancing the work of the HHS National Vaccine Program in Global 
Immunizations. This includes support for HHS' role in building 
international cooperation for the common goal of reducing the burden of 
vaccine-preventable diseases. HHS has unique and timely opportunities 
to eradicate polio, to reduce measles mortality, and to ensure that the 
routine immunization systems at the front lines of these efforts are 
maintained. The funding that Congress provides to CDC's Global 
Immunization account is also necessary to act on the Advisory 
Committee's recommendations that HHS enhance its ongoing efforts to 
strengthen global immunization systems, enhance global capacity for 
vaccine safety monitoring and post-marketing surveillance, build global 
immunization research and development capacity, and strengthen 
countries' capacity for vaccine decisionmaking.
    Since 1988 a coordinated global immunization campaign has reduced 
the number of polio cases globally by more than 99 percent, saving more 
than 10 million children from paralysis and bringing the disease close 
to eradication. Expanded immunization has reduced the global mortality 
attributed to measles by 74 percent between 2000 and 2010.
    Polio fiscal year 2015 Request: $160 million; fiscal year 2014 
Level: $146 million
    Measles fiscal year 2015 Request: $49 million; fiscal year 2014 
Level: $42.2 million
America's children deserve better
    Twenty 2 percent of children in the United States now live in 
poverty--up from 17 percent in 2007. Many children suffer from food 
insecurity, unstable housing, family dysfunction, abuse and neglect. 
Such adverse childhood experiences are linked with ``toxic stress,'' a 
biologic phenomenon associated with profound and irreversible changes 
in brain anatomy and chemistry that have been implicated in the 
development of health-threatening behaviors and medical complications 
later in life including drug use, obesity, and altered immune function. 
Adults affected by such adverse childhood experiences are more likely 
to have experienced school failure, gang membership, unemployment, 
violent crime, and incarceration.
Healthier children, healthier future
    On behalf of the 75 million American children and their families 
that we serve and treat, the Nation's pediatricians expect Congress to 
respond to mounting evidence that child health has life-long impacts 
and put children first during appropriations negotiations. Investing in 
children is not only the right thing to do for the long-term physical, 
mental, and emotional health of the population, but is imperative for 
the Nation's long-term fiscal health as well. In addition to the 
programs we have specifically mentioned in this testimony, Federal 
support for children's health programs, such as early brain and child 
development, parenting and health education, and preventive health 
services, will yield high returns for the American economy. Cuts to 
these areas in the short-term will blunt the possible long-term savings 
these programs could achieve.
    We fully recognize the Nation's fiscal challenges and respect that 
difficult budgetary decisions must be made; however, we do not support 
funding decisions made at the expense of the health and welfare of 
children and families. Rather, a focus on the long-term needs of 
children and adolescents will ensure that the United States can compete 
in the modern, highly-educated global marketplace. Strong and sustained 
financial investments in children's healthcare, research, and 
prevention programs will help keep our children healthy and pay 
dividends for years to come.
    The American Academy of Pediatrics looks forward to working with 
Members of Congress to prioritize the health of our Nation's children 
in fiscal year 2015 and beyond. If we may be of further assistance 
please contact Pat Johnson at the AAP Department of Federal Affairs at 
202-347-8600 or [email protected]. Thank you for your consideration.

    [This statement was submitted by James, Perrin, MD, FAAP, 
President, American Academy of Pediatrics.]
                                 ______
                                 
   Prepared Statement of the American Academy of Physician Assistants
    On behalf of the more than 95,000 clinically practicing physician 
assistants in the United States, the American Academy of Physician 
Assistants (AAPA) is pleased to submit comments on fiscal year 2015 
appropriations for Physician Assistant (PA) educational programs that 
are authorized through Title VII of the Public Health Service (PHS) 
Act. AAPA respectfully requests the Senate Appropriations Committee to 
approve funding at existing levels for the Title VII health professions 
education program--$280,000,000, with an allocation of 15 percent of 
the Primary Care Training and Enhancement program line for PA 
educational programs.
    Federal support for Title VII is authorized through section 747 of 
the PHS Act. It is the only continuing Federal funding available to PA 
educational programs. Unfortunately, in recent years, PA educational 
programs have received reduced support from Title VII funding, which is 
designed to educate PAs in primary care and to prepare PAs for practice 
in urban or rural medically underserved areas.
    This funding is essential to the development and training of the 
Nation's health workforce, and is critical to providing continued 
access to health services in underserved and minority communities. It 
also encourages PAs to return to these environments with the greatest 
need after they have completed their educational preparation, being one 
of the best recruitment tools to date. According to the Health 
Resources and Services Administration (HRSA), 37 percent of PAs 
practice in medically underserved counties, including medically 
underserved areas and medically underserved populations.
    Additionally, Title VII funding has helped PA Programs expand 
clinical rotations in rural and underserved areas that have been in 
critically short supply and has enhanced primary care curriculum to 
better address the needs of disadvantaged populations.
    While the purview of the Title VII programs grant funding has 
expanded to include assisting returning combat veterans, funding for PA 
educational programs has been significantly reduced. Additional 
reductions to this budget will disadvantage new PA programs that need 
these funds to help with student recruitment, faculty development, and 
establishing clinical rotation cites.
    Diverse clinical rotation sites and recruitment programs are 
critical to PA education and are paramount to the Title VII primary 
care medicine program. A review of PA graduates from 1990--2009 
demonstrated that PAs who have graduated from PA educational programs 
supported by Title VII are 67 percent more likely to be from 
underrepresented minority populations and 47 percent more likely to 
work in a rural health clinic than graduates of programs that were not 
supported by Title VII. We wish to thank the members of this 
subcommittee for your historical role in supporting funding for the 
health professions programs, and we hope that we can count on your 
support to augment funding to these important programs in fiscal year 
2015.
Overview of PA Education
    The existing 181 accredited PA educational programs are all located 
within schools of medicine or health sciences, universities, teaching 
hospitals, and the Armed Services. All PA educational programs are 
accredited by the Accreditation Review Commission on Education for the 
Physician Assistant.
    The typical PA program consists of 26 months of instruction, and 
the typical student has a bachelor's degree and about 4 years of prior 
healthcare experience. The PA curriculum includes 400 hours of basic 
sciences and nearly 1,600 hours of clinical medicine. On average, 
students devote more than 2,000 hours, or 50 to 55 weeks, to clinical 
education, divided between primary care medicine--family medicine, 
internal medicine, pediatrics, and obstetrics and gynecology--and 
various specialties, including surgery and surgical specialties, 
internal medicine subspecialties, emergency medicine, and psychiatry.
    After graduating from an accredited PA program, PAs must pass a 
national certifying examination developed by the National Commission on 
Certification of Physician Assistants and become licensed by the State 
to provide medical care.. To maintain certification, PAs must log 100 
continuing medical education hours every 2 years, and they must take a 
recertification exam every 10 years.
PA Practice
    PAs are licensed health professionals who practice medicine as 
members of a healthcare team. PAs exercise autonomy in medical 
decisionmaking and provide a broad range of medical and therapeutic 
services to diverse populations in rural and urban settings. PAs 
perform physical examinations, diagnose and treat illnesses, order and 
interpret lab tests, assist in surgery, provide patient education and 
counseling, and make rounds in nursing homes and hospitals. PAs are 
nationally certified and State licensed to practice medicine and 
prescribe medication in all fifty States, the District of Columbia, the 
Commonwealth of the Northern Mariana Islands, Guam, and the U.S. Virgin 
Islands.
PAs in Primary Care
    An estimated 30,000 PAs (32 percent of the profession) work in 
primary care across the Nation--38.2 percent work in private practice 
(multi-and single specialty and solo practices); 23.3 percent in Family 
Medicine, 3.0 percent practice in community health centers, 3.3 percent 
practice in certified rural health clinics, and 2.7 percent work in a 
federally qualified health center.
    PAs are also one of three primary care providers who provide 
medical care through the National Health Service Corps (NHSC). The NHSC 
is an important Federal program with nearly 10,000 healthcare 
providers, like PAs, who benefit from the program's loan-forgiveness 
and scholarship awards to those providers and students who commit 2 
years to provide medical, dental, and mental healthcare in medically 
underserved areas.
    Additionally, PAs provide medical care in community health centers 
(CHCs), some as CHC medical directors. CHCs provide cost-effective 
healthcare throughout the country and serve as medical homes for 
millions in medically underserved areas. CHCs offer a wide variety of 
healthcare services through team-based care, providing high quality 
healthcare to CHC patients and significantly reducing medical expenses.
Critical Role of the Title VII PHS Act Programs
    According to the Health Resources and Services Administration 
(HRSA), an additional 31,000 healthcare providers are needed to 
alleviate existing professional shortages. This existing shortage, 
combined with faculty shortages across PA education, the need to build 
greater diversity among healthcare providers, and an increasingly aging 
healthcare workforce, creates challenges in growing the primary 
healthcare workforce.
    Title VII programs are the only Federal educational programs that 
are designed to address the supply and distribution imbalances in the 
health professions. Since the establishment of Medicare, the costs of 
physician residencies, nurse training, and some allied health 
professions training have been paid through Graduate Medical Education 
(GME) funding; however, GME has not been available to support PA 
education. More importantly, GME was not intended to generate a supply 
of providers who are willing to work in the Nation's medically 
underserved communities--the purpose of Title VII.
    Furthermore, Title VII programs seek to recruit students who are 
from underserved minority and disadvantaged populations, which is a 
critical step towards reducing persistent health disparities among 
certain racial and ethnic U.S. populations. Research shows racial and 
ethnic health disparities cost the economy more than $230 billion in 
lost productivity and up to $1.24 trillion in indirect costs over 3 
years; and studies have found that health professionals from 
disadvantaged regions of the country are three to five times more 
likely to return to underserved areas to provide care which would help 
alleviate the current health disparity crisis in America.
    Support for educating PAs to practice in underserved communities is 
particularly important given the market demand for PAs. Title VII 
funding is a critical link in addressing the natural geographic mal-
distribution of healthcare providers by exposing students to 
underserved sites during their training, where they frequently choose 
to practice following graduation. Currently, 36 percent of PAs met 
their first clinical employer through their clinical rotations.
Supplementary Recommendations on fiscal year 2015 Funding
    AAPA urges members of the Appropriations Committee to consider the 
inter-dependency of all public health agencies and programs when 
determining funding for fiscal year 2015. For instance, while it is 
critical, now more than ever, to fund clinical research at the National 
Institutes of Health (NIH) and to have an infrastructure at the Centers 
for Disease Control and Prevention (CDC) that ensures a prompt response 
to an infectious disease outbreak or bioterrorist attack, the good work 
of both of these agencies will go unrealized if HRSA is inadequately 
funded.
    HRSA administers the ``people'' programs, such as Title VII, that 
bring the results of cutting edge research at NIH to patients through 
providers such as PAs who have been educated in Title VII-funded 
programs. Likewise, the CDC is heavily dependent upon an adequate 
supply of healthcare providers to be sure that disease outbreaks are 
reported, tracked, and contained.
    Thank you for the opportunity to present the AAPA's views on fiscal 
year 2015 appropriations concerning HRSA's Title VII Health Professions 
Program.

    [This statement was submitted by Sandy Harding, MSW, Senior 
Director, Federal Advocacy.]
                                 ______
                                 
         Prepared Statement of the American Alliance of Museums
    Chairman Harkin, Ranking Member Moran, and members of the 
Subcommittee, my name is Don Wildman, and for six highly rated seasons, 
I've had the extreme honor of hosting a television show, Mysteries at 
the Museum (Thursday nights on the Travel Channel), which tells the 
stories behind artifacts in museum collections. My testimony today is 
presented on behalf of the American Alliance of Museums, the largest 
organization of museums and museum professionals in the world, and we 
are respectfully asking the Subcommittee to provide $38.6 million for 
the Office of Museum Services (OMS) at the Institute of Museum and 
Library Services (IMLS), its fully-authorized amount, in fiscal year 
2015.
    Museums are among our Nation's most popular, most trusted and most 
beloved institutions. There are approximately 850 million visits to 
American museums each year, more than the attendance for all major 
league sporting events and theme parks combined. Museums also spend 
over $2 billion on educational programming, and a total of $21 billion 
in their local economies. Clearly museums are economic engines and job 
creators.
    IMLS is the primary Federal agency that supports the museum field, 
and OMS awards grants to help museums digitize, enhance and preserve 
their collections; provide teacher training; and create innovative, 
cross-cultural and multi-disciplinary programs and exhibits for schools 
and the public.
    It's no surprise that the appropriations bill that funds education 
supports this agency, because museums are indeed key education 
providers. They design exhibitions, educational programs, classroom 
kits, and online resources in coordination with State, local and common 
core curriculum standards in math, science, art, literacy, language 
arts, history, civics and government, economics and financial literacy, 
geography, and social studies. Museums also offer experiential learning 
opportunities, STEM education, mentoring, and job preparedness.
    Whatever education looks like in the future, one component will 
certainly be the development of a core set of skills: critical 
thinking; the ability to synthesize information; and the ability to 
innovate, to be creative and to collaborate. Museums are uniquely 
situated to help learners develop these core skills.
    In late 2010, legislation to reauthorize IMLS for 5 years was 
enacted (by voice vote in the House and by unanimous consent in the 
Senate). The bipartisan reauthorization included several provisions 
proposed by the museum field, including enhanced support for 
conservation and preservation, emergency preparedness and response and 
statewide capacity building. The reauthorization also specifically 
supports efforts at the State level to leverage museum resources, 
including statewide needs assessments and the development of State 
plans to improve and maximize museum services throughout the State. The 
bill (now Public Law 111-340) authorized $38.6 million for the IMLS 
Office of Museum Services to meet the growing demand for museum 
programs and services. The fiscal year 2014 appropriation of 
$30,131,000 represents a nearly 15 percent decrease from the fiscal 
year 2010 appropriation of $35,212,000.
    Grants are awarded in every State, but perhaps the best way to 
demonstrate the importance of the IMLS Office of Museum Services is to 
highlight just a few of the grants awarded in 2013 to museums in States 
represented by Subcommittee members:
    Public Programs and Energy Efficiency--Reiman Gardens, Iowa State 
University of Science and Technology (Ames, IA) was awarded $95,040 to 
develop a comprehensive landscape design, architectural, and 
engineering plan. Designs will address community programming needs, 
visitor experience, facilities and maintenance needs, and energy 
efficiency standards.
    Recognizing Excellence--The National Czech & Slovak Museum & 
Library (Cedar Rapids, IA) received $5,000 and the 2013 National Medal 
for Museum and Library Service. When the worst disaster in State 
history destroyed entire areas of Cedar Rapids in 2008, the National 
Czech & Slovak Museum & Library was instrumental in leading its 
devastated ethnic neighborhood in recovery, rebuilding, and 
revitalization.
    Youth Programs and Collections Care--The Kansas African American 
Museum (Wichita, KS) was awarded $149,950 to create a public history 
youth program in partnership with the University of Kansas Libraries, 
serving 60 youth and training 25 volunteer docents annually. The museum 
is also using the grant to upgrade its collections management system 
and to address its most critical collections care and security needs.
    Environmental Science--The Calvert Marine Museum Society (Solomons, 
MD) was awarded $142,500 to develop and install an exhibit on the 
ecosystem of the Patuxent River and Chesapeake Bay. They are partnering 
with local schools and community groups to facilitate lifelong learning 
of scientific concepts and environmental stewardship.
    Collections Care--The Birmingham Civil Rights Institute 
(Birmingham, AL) was awarded $74,277 to safeguard its collections to 
ensure that they will be available for use by current and future 
students, the general public, researchers and staff.
    STEM Education--The University of Alabama/Alabama Museum of Natural 
History (Tuscaloosa, AL) was awarded $99,998 to create the Discovery 
Learning Lab to give middle and high school-aged students access to 
``geek'' mentors who will guide them in explorations of digital 
technologies not readily available at home or school in low-income 
areas. This program exposes teens to STEM disciplines, skills, 
activities, and software at the lab and in a cyberspace environment.
    Science and Ocean Literacy--The Seattle Aquarium (Seattle, WA) was 
awarded $103,821 to design, implement, and evaluate an aquarium 
classroom program. The museum will develop the program in cooperation 
with practicing scientists, emphasizing both the scientific process and 
content based on sea otter and ocean acidification research. The 
project will also produce materials to help interpret its findings both 
in the museum and in the larger community.
    Cultural Identity--The Wing Luke Museum of the Asian Pacific 
American Experience (Seattle, WA) was awarded $150,000 to produce a 
newly designed tour program that emphasizes community storytelling and 
audience engagement. The Chinatown International District is Seattle's 
lowest-income neighborhood, and will benefit from increased museum 
attendance and enhanced community involvement.
    Recognizing Excellence--The Delta Blues Museums (Clarksdale, MS) 
was awarded $5,000 and the 2013 National Medal for Museum and Library 
Service for its work celebrating and nurturing this American art form. 
Participants young and old, from diverse economic and ethnic 
backgrounds participate in the museum's popular music classes while its 
travelling trunk exhibit inspires blues appreciation nationwide.
    3D Printing--The Art Institute of Chicago (Chicago, IL) was awarded 
$25,000 to reach audiences of all ages by using 3D printing 
technologies. The museum will evaluate the potential impact of this 
technology on engagement with museum collections, and will develop 
guidelines to be shared with other museums and educators.
    Collections Care--The Hermann-Grima and Gallier Historic Houses 
(New Orleans, LA) were awarded $22,830 to develop a plan to improve 
their interior environments to better conserve collections and the 
historical buildings.
    Professional Development--The Newport Art Museum and Art 
Association (Newport, RI) was awarded $24,028 for an initiative that 
orients high school students to cultural administration careers through 
classroom learning, site visits, and mentoring. The grant will allow 
the museum to expand the reach of this initiative and establish paid 
internships for students, helping them develop their interests and 
build valuable skills for the future.
    Mobile Science Classroom--The Discovery Center at Murfree Spring 
(Murfreesboro, TN) was awarded $103,849 to convert a school bus into a 
mobile science classroom for elementary school students.
    Digitization--The Country Music Hall of Fame (Nashville, TN) was 
awarded $150,000 for a digitization initiative to preserve and increase 
access to the museum's unparalleled collection.
    Collections Care--The University Museum, University of Arkansas 
(Fayetteville, AR) was awarded $31,464 to improve its zoology 
collection and make it more accessible to researchers.
    I am aware that this subcommittee wants to ensure that its 
investments in Federal grant programs have measurable and significant 
impact. I believe that the grants listed above demonstrate the value of 
investing in museums as a means of investing in our communities. 
Further, it should be noted that each time a Federal grant is awarded, 
additional local and private funds are also leveraged. Two-thirds of 
IMLS grantees report that their Museums for America grant positioned 
the museum to receive additional private funding.
    Even the most ardent deficit hawks view the IMLS grant-making 
process as a model for the Nation. Each grant is selected through a 
rigorous, peer-reviewed process. And due to the large number of grant 
applications and the limited funds available, many highly-rated grant 
proposals go unfunded each year.
  --Only 28 percent of Museums for America/Conservation Project Support 
        project proposals were funded;
  --Only 15 percent of National Leadership project proposals were 
        funded;
  --Only 15 percent of Sparks Ignition Grants for Museums project 
        proposals were funded;
  --Only 46 percent of Native American/Hawaiian Museum Services project 
        proposals were funded; and
  --Only 31 percent of African American History and Culture project 
        proposals were funded.
    On a final and personal note, the interviews I conduct with museum 
professionals for my television show have confirmed for me what I've 
known since I was a kid--that museums are cool, really cool. If there's 
one thing Americans young and old love, it's a good story about America 
and that's what museums have to offer.
    American museums do this job and they do it extremely well. They 
collect the stories by preserving and curating the objects--documents, 
inventions, clothing, paintings, sculptures and skeletons--which 
explain who we've been, who we are and how we survive.
    I was raised outside of Philadelphia. Without museums, I'd have 
never walked through the left ventricle of the super-sized heart in the 
Ben Franklin Institute. But for the Academy of Natural Sciences, I'd 
have never understood the difference between a stegosaurus and a 
triceratops. I wouldn't have had that first encounter with Vincent van 
Gogh at the Philadelphia Museum of Art. It's impossible to imagine my 
childhood without museums or to imagine my adulthood. They're our 
lifeline to the past--and an inspiration for the future.
    We hope you'll support our cause, and provide at least $38.6 
million in fiscal year 2015 for the Office of Museum Services (OMS) at 
the Institute of Museum and Library Services (IMLS), its fully-
authorized amount.

    [This statement was submitted by Don Wildman, Host, Travel 
Channel's Mysteries at the Museum, American Alliance of Museums.]
                                 ______
                                 
   Prepared Statement of the American Association for Dental Research
    On behalf of the 3,500 individual and 44 institutional members of 
the American Association for Dental Research (AADR), I am pleased to 
submit testimony describing AADR's fiscal year 2015 requests, which 
include $32 billion for the National Institutes of Health (NIH) and 
$425 million for the National Institute of Dental and Craniofacial 
Research (NIDCR). These funding recommendations represent the true 
needs of the research community while at the same time taking into 
consideration the continued tight budget climate dictated by the caps 
established by the Bipartisan Budget Act of 2013. I want to emphasize 
the recent Federal austerity measures--sequestration, government 
shutdown and the continued uncertainty--had a significant impact on our 
members, universities and research supported via NIDCR. In actual 
dollars, NIDCR lost $23 million in funding in fiscal year 2013 and only 
$10 million was restored in fiscal year 2014. However, when adjusted 
for inflation, the NIDCR budget is 22 percent, or $75 million, less 
than it was in 2002, resulting in the lowest number of research grants 
awarded in 13 years. This creates an atmosphere that is very 
discouraging to new scientific investigators whose research proposals 
are good enough to be funded but were not because of the budget cuts. 
We are at risk of losing them and their promising research ideas--ideas 
that might lead to significant advances in dental, oral health and 
craniofacial health.
    The downward trend in lost purchasing power is particularly 
troubling because the improvements in oral health during the last half 
century are largely credited to research supported by NIDCR. It is 
therefore reasonable to assume that these declines in funding will slow 
or limit future breakthroughs. NIDCR is the largest institution in the 
world dedicated exclusively to research to improve dental, oral and 
craniofacial health. The health of the mouth and surrounding 
craniofacial (skull and face) structures is central to a person's 
overall health and well-being. Left untreated, oral diseases and poor 
oral conditions go untreated, make it difficult to eat, drink, swallow, 
smile, talk and maintain proper nutrition. Scientists also have 
discovered important linkages between gum disease, or periodontal 
disease, and heart disease, stroke, diabetes and pancreatic cancer.
    In spite of these improvements, however, treating oral health 
conditions is costly with $110.9 billion in expenditures on dental 
services in 2012. While tooth decay and gum disease remain the most 
prevalent, complete tooth loss, oral cancer, and craniofacial 
congenital anomalies, like cleft lip and palate are also health and 
economic burdens to the American people. Moreover, oral health 
disparities exist for many racial and ethnic groups. By providing $425 
million in fiscal year 2015, NIDCR, dental, oral and craniofacial 
researchers will be able to build upon the gains of the past decades, 
creating less invasive, cost effective and more efficient ways to 
improve oral health. Below are some examples highlighting the important 
work supported by NIDCR:
  --Point of Care Diagnostics: Salivary diagnostics are measures that 
        draw and analyze saliva to test for conditions such as HIV, 
        HPV, substance abuse, caries, periodontitis and oral cancer. 
        Through the work and support of NIDCR over the last decade, 
        these diagnostics are showing great promise in screening for 
        diabetes, heart disease, lung cancer, ovarian cancer and 
        pancreatic cancer. Salivary diagnostics only require 
        withdrawing saliva, unlike traditional methods that rely on 
        withdrawing blood or on doing tissue biopsy. As a result, 
        salivary diagnostics are less invasive. In addition, they are 
        relatively inexpensive and have the potential of showing more 
        immediate results which is particularly beneficial when results 
        are urgently needed.
  --Periodontal Disease: Periodontal or gum disease is a chronic 
        inflammatory disease that affects the gum tissue and bone 
        supporting the teeth. Approximately 47.2 percent of Americans 
        have mild, moderate or severe periodontitis. If left untreated, 
        periodontal disease can lead to tooth loss. Research has shown 
        that periodontal disease is associated with other chronic 
        inflammatory diseases such as diabetes and cardiovascular 
        disease. To date, the prevention of gum disease has been 
        limited to successful oral hygiene and regular professional 
        care. Recently, however, scientists reported the discovery of 
        resolvins, a biologically active product that has the potential 
        to protect against soft tissue and bone loss associated with 
        gum disease. More research is needed to further intensify 
        efforts to apply the novel biological approach to treating 
        inflammatory diseases.
  --Dental Caries: Dental caries, or tooth decay, remains the most 
        prevalent chronic disease in both children and adults resulting 
        in a substantial economic and health burden to the American 
        people. Although caries has significantly decreased for most 
        Americans over the past four decades, disparities remain among 
        some population groups. In addition, this downward trend has 
        recently reversed for young children. More research is needed 
        to enhance efforts to address dental caries.
  --HPV-Related Oral Cancer: This type of cancer is caused by the human 
        papillomavirus (HPV). It is predicted that this cancer will be 
        the most common HPV-related cancer by 2020. HPV-induced oral 
        cancers among men are likely to exceed HPV-induced cervical 
        cancers within the next 8 years. In fact, HPV is now causing 
        more oral cancers than smoking. Identifying the presence of HPV 
        in a mouth swab or a blood draw does not definitively indicate 
        the impending presence of cancer. As a result, more research is 
        needed for the early detection of HPV-related oral cancer, and 
        for the development of therapies that would lead to the 
        prevention of cancer progression.
  --Evidenced-Based Practice: NIDCR recently awarded a seven-year grant 
        that consolidates its dental practice-based research network 
        initiative into a unified nationally coordinated effort. The 
        consolidated initiative, the National Dental Practice Based 
        Research Network (NDPBRN) is headquartered at the University of 
        Alabama at Birmingham School of Dentistry. A dental practice-
        based research network is an investigative union of practicing 
        dentists and academic scientists. The network provides 
        practitioners with an opportunity to propose or participate in 
        research studies that address daily issues in oral healthcare. 
        These studies help to expand the profession's evidence base and 
        further refine care.
  --Cleft Lip and/or Cleft Palate--Craniofacial anomalies such as cleft 
        lip and/or cleft palate (CLP) are among the most common birth 
        defects. Both genetic and environmental factors contribute to 
        oral clefts. Cleft lip is an abnormality in which the lip does 
        not completely form during fetal development and cleft palate 
        occurs when the roof of the mouth does not fully close, leaving 
        an opening that can extend into the nasal cavity. Genome-wide 
        association studies (GWAS) of cleft lip and/or cleft palate 
        supported by NIDCR are providing important new leads about the 
        role genetic factors and gene-environment interactions play in 
        the development of these conditions. In addition, a DNA 
        sequencing study is underway to identify less common genetic 
        variants that influence the risk of developing cleft lip and/or 
        cleft palate. NIDCR will continue to support the best science 
        to understand craniofacial structures and anomalies more 
        completely.
    Our members remain concerned that unless Congress fully reverses 
the erosion caused by sequestration our ability to attract the next 
generation of scientists will stall; our standing as a world leader in 
science will decline; and innovation necessary to push the boundaries 
of research will be stymied. Accordingly, I strongly urge you work in a 
bipartisan manner to prioritize funding for dental, oral and 
craniofacial research this year and undo sequestration permanently in 
fiscal year 2016 and beyond. Future advances in healthcare depend on a 
sustained investment in basic research to identify the fundamental 
causes and mechanisms of disease, accelerate technological development 
and discovery, and ensure a robust pipeline of creative and skillful 
biomedical researchers. For these reasons, I implore you to work in a 
bipartisan manner and provide funding increases for NIH and NIDCR in 
fiscal year 2015.
    In addition to the NIH, AADR members care deeply about the Title 
VII Health Resources and Services Administration (HRSA) programs 
training the dental health workforce; the Centers for Disease Control 
and Prevention (CDC) Division of Oral Health's public health prevention 
efforts; data from the National Center for Health Statistics (NCHS) and 
the Agency for Healthcare Research & Quality (AHRQ). Please support 
AADR's funding recommendations for these agencies depicted in the chart 
below.

 
                                            [In millions of dollars]
----------------------------------------------------------------------------------------------------------------
                                           Fiscal year   Fiscal year   Fiscal year    Fiscal year    Fiscal year
                 Agency                       2012          2013           2014         2015 PBR      2015 AADR
----------------------------------------------------------------------------------------------------------------
NIH.....................................      30,702        29,070        30,020         30,220         32,000
NIDCR...................................         410.3         386.8         397.10         397.13         425.0
NCATS...................................         574.8         542.1         633.3          657.5          657.5
AHRQ....................................         405.1         429.4         364            334            375
CDC, Oral Health........................          14.6          13.8          15.8           15.8           19.0
CDC, NCHS...............................         153.8         153.8         155.3          155.4          182
HRSA, Title VII Oral Health.............          32.4          30.7          32             32             32.4
----------------------------------------------------------------------------------------------------------------


    [This statement was submitted by Timothy DeRouen, PhD, President, 
American Association for Dental Research.]
                                 ______
                                 
 Prepared Statement of the American Association of Colleges of Nursing
    As the national voice for baccalaureate and graduate nursing 
education, the American Association of Colleges of Nursing (AACN) 
represents 750 schools of nursing that educate over 450,000 students 
and employ more than 17,000 full-time faculty members. Collectively, 
these institutions produce approximately half of our Nation's 
Registered Nurses (RNs) and all nurse faculty, Advanced Practice 
Registered Nurses (APRNs), and nurse scientists. AACN requests that 
nursing education, research, and practice are strongly supported in 
fiscal year 2015 through an investment of $251 million for HRSA's 
Nursing Workforce Development programs (authorized under Title VIII of 
the Public Health Service Act [42 U.S.C. 296 et seq.]), $150 million 
for the National Institute of Nursing Research (NINR) within NIH, and 
$20 million in authorized funding for the Nurse-Managed Health Clinics 
(NMHCs) (Title III of the Public Health Service Act). These levels will 
ensure that our Nation's nurses are prepared to care for the growing 
number of patients requiring a complex range of healthcare services.
                        demand for nursing care
    The Bureau of Labor Statistics' (BLS) publication Employment 
Projections for 2012-2022 anticipates significant growth in the nursing 
workforce from 2.71 million in 2012 to 3.24 million by 2022. This surge 
in demand translates to 526,800 nurses, or an increase of 19.4 percent. 
When considering the number of job openings for RNs due to the 
increasing demand for nursing care and replacements in an aging nursing 
workforce, more than one million nurses will be needed by 2022. In 
fact, according to the The U.S. Nursing Workforce: Trends in Supply and 
Education released by HRSA in 2013, over the next 10 to 15 years, the 
nearly 1 million RNs older than age 50--about one-third of the current 
workforce--will reach retirement age. The retirement decisions of these 
experienced RNs may be influenced by the pace of economic recovery and 
have the potential to create a serious deficit in the nursing pipeline.
    Moreover, the BLS projects a need for 47,600 additional Nurse 
Practitioners, Certified Registered Nurse Anesthetists, and Certified 
Nurse-Midwives (or APRNs) to meet the call for more primary and acute 
care services, particularly due to the aging baby boomer population and 
increased access to health insurance coverage. The BLS' Occupational 
Outlook Handbook reported that there will be a 31 percent increase in 
this sector of the workforce between 2012-2022. Investments are 
necessary to educate the RNs and APRNs who will provide the care that 
Americans need now and in the future.
           title viii nursing workforce development programs
    For fifty years, the Nursing Workforce Development programs, 
authorized under Title VIII of the Public Health Service Act, have 
helped build the supply and distribution of qualified nurses to meet 
our Nation's healthcare needs. Between fiscal year 2006 and 2012 alone, 
the Title VIII programs supported over 450,000 nurses and nursing 
students, as well as numerous academic nursing institutions and 
healthcare facilities. The programs bolster nursing education at all 
levels, from entry-level preparation through graduate study, and 
provide support to educate nurses for practice in rural and medically 
underserved communities. Today, the Title VIII programs are essential 
to ensuring that the demand for nursing care is met by supporting 
future practicing nurses and the faculty who educate them.
    However, faculty vacancies have repeatedly been cited as a 
fundamental obstacle to maximizing nursing school enrollment. According 
to the American Association of Colleges of Nursing's 2013-2014 
Enrollment and Graduations in Baccalaureate and Graduate Programs in 
Nursing survey, 78,089 qualified applications were turned away from 
nursing schools in 2013 alone. A primary barrier to accepting all 
qualified students at nursing colleges and universities continues to be 
a shortage of faculty. To counter this disparity, the Title VIII Nurse 
Faculty Loan Program aids in increasing nursing school enrollment 
capacity by supporting students pursuing graduate education, provided 
they serve as faculty for 4 years after graduation.
    The Title VIII programs also increase the number of practicing 
nurses entering the pipeline and the placement of these nurses into 
medically-underserved areas. AACN's Title VIII Student Recipient 
Survey, which gathers information annually about Title VIII funding and 
outcomes related to nursing education and career trajectories, provides 
evidence on the effectiveness of these programs in recruiting more 
students to the nursing profession and, more importantly, practice in 
rural and underserved areas. Results of the 2013-2014 Title VIII 
Student Recipient Survey included responses from 850 students who noted 
that these programs played a critical role in funding their nursing 
education. The survey showed that for 67 percent of respondents, Title 
VIII funding impacted their decision to enter nursing school. Moreover, 
76 percent of the students receiving Title VIII funding are able to 
attend school full-time through this Federal support. By facilitating 
full-time education, the Title VIII programs are helping to ensure that 
students enter the workforce without delay. In addition, personal 
testimony of several survey respondents revealed that many Title VIII 
recipients intend to practice in the community in which they were 
educated--a direct State investment. AACN respectfully requests $251 
million for the Nursing Workforce Development programs authorized under 
Title VIII of the Public Health Service Act in fiscal year 2015.
   national institute of nursing research: advancing nursing science
    The healthcare community is investigating methods to improve the 
delivery of high-quality care in a financially sustainable manner. As 
one of the 27 Institutes and Centers at the NIH, the NINR is dedicated 
to providing the healthcare workforce with evidence-based knowledge and 
the resources needed to accomplish this goal. Research conducted at 
NINR addresses disease prevention and health promotion efforts that 
improve quality of life and alleviate financial burden on individuals 
and the system. Specific areas targeted by NINR include chronic illness 
management, disease prevention, pain management, and care-giver 
support. Nursing research is a critical compliment to biomedical 
research as it investigates how to prevent disease and promote healthy 
living. Moreover, research funded at NINR helps to integrate biology 
and behavior as well as design new technology and tools. At a time when 
healthcare needs are changing, nursing care must be firmly grounded in 
nursing science.
    NINR also allocates a generous 6 percent of its overall budget to 
the education and training of nurse researchers, many of whom dually 
serve as nurse faculty within our Nation's nursing schools. Increased 
investments must be made in the scientists that improve healthcare 
delivery through their groundbreaking discoveries. AACN respectfully 
requests $150 million for the NINR in fiscal year 2015.
         nurse-managed health clinics: expanding access to care
    Managed by APRNs and staffed by an interdisciplinary health 
provider team, NMHCs provide necessary primary care services to 
medically-underserved communities and serve as critical access points 
to keep patients out of the emergency room, saving the healthcare 
system millions of dollars annually. NMHCs provide care to vulnerable 
populations in a host of regions of the country, including rural 
communities, Native American reservations, senior citizen centers, 
elementary schools, and urban housing developments. These communities 
are the most susceptible to developing chronic illnesses that create 
heavy financial burdens on patients and the healthcare system. NMHCs 
aim to reduce disease and create healthier communities through improved 
patient education and health practices.
    Often associated with a school, college, university, department of 
nursing, federally qualified health center, or independent nonprofit 
healthcare agency, NMHCs also serve as clinical education training 
sites for students of nursing, medicine, physical therapy, social work, 
and ancillary healthcare services. Moreover, by serving as clinical 
training sites, NMHCs help foster interprofessional education and 
practice so that patients receive individualized care from an array of 
providers. According to AACN, the lack of clinical training sites is 
often pointed to as a top reason for turning away qualified 
applications in nursing programs. AACN respectfully requests $20 
million for the Nurse-Managed Health Clinics in fiscal year 2015.
    AACN recognizes that the Subcommittee and Congress will need to 
make difficult decisions regarding appropriations for fiscal year 2015. 
AACN respectfully requests Congress to continue a strong investment in 
the health of our Nation by providing $251 million for the Title VIII 
Nursing Workforce Development programs, $150 million for the National 
Institute of Nursing Research, and $20 million for Nurse-Managed Health 
Clinics in fiscal year 2015. If you have any questions, or if AACN can 
be of assistance, please contact AACN's Director of Government Affairs 
and Health Policy, Dr. Suzanne Miyamoto, at [email protected].
                                 ______
                                 
     Prepared Statement of the American Association of Colleges of 
                          Osteopathic Medicine
    The American Association of Colleges of Osteopathic Medicine 
(AACOM) strongly supports restoring funding for discretionary Health 
Resources and Services Administration (HRSA) programs to the fiscal 
year 2010 level of $7.48 billion; funding of $520 million for HRSA's 
Title VII and VIII programs under the Public Health Service Act; $10 
million minimally for the Teaching Health Center Graduate Medical 
Education (THCGME) Development Grants; sustainment of student 
scholarship and loan repayment programs; $4 million for the Rural 
Physician Training grants; $3 million for the National Health Care 
Workforce Commission; $32 billion for the National Institutes of Health 
(NIH); and $375 million in base discretionary funding, restoring the 
base to fiscal year 2011 levels for the Agency for Healthcare Research 
and Quality (AHRQ).
    AACOM represents the 30 accredited colleges of osteopathic medicine 
in the United States. These colleges are accredited to deliver 
instruction at 42 teaching locations in 28 States. In the 2013-2014 
academic year these colleges are educating over 23,000 future 
physicians--more than 20 percent of U.S. medical students. Six of the 
colleges are publicly controlled; 24 are private institutions.
    The Title VII health professions education programs, authorized 
under the Public Health Service Act and administered through HRSA, 
support the training and education of health practitioners to enhance 
the supply, diversity, and distribution of the healthcare workforce, 
acting as an essential part of the healthcare safety net and filling 
the gaps in the supply of health professionals not met by traditional 
market forces. Title VII and Title VIII nurse education programs are 
the only Federal programs designed to train clinicians in 
interdisciplinary settings to meet the needs of special and underserved 
populations, as well as increase minority representation in the 
healthcare workforce.
    As demand for health professionals increase in the face of 
impending shortages combined with faculty shortages across health 
professions disciplines, racial and ethnic disparities in healthcare, a 
growing, aging population, and the anticipated demand for increased 
access to care, these needs strain an already fragile healthcare 
system. AACOM appreciates the investments that have been made in these 
programs, and we urge the Subcommittee to fund $520 million for the 
Title VII and VIII programs to include support for the following 
programs in order to include: the Primary Care Training and Enhancement 
(PCTE) Program, the Health Careers Opportunity Program (HCOP), the 
Centers of Excellence (COE), the Geriatric Education Centers (GECs) and 
the Area Health Education Centers (AHECs). We strongly oppose the 
Administration's proposals to eliminate funding for AHECs and the HCOP.
    AACOM has serious concerns with the Administration's budget request 
that would cut nearly $15 billion from Medicare graduate medical 
education (GME). Because GME funding is critical to addressing the 
existing physician workforce shortage and ensuring patient access to 
our Nation's healthcare, AACOM believes that current GME funding should 
not be sacrificed and simply shifted to other healthcare workforce 
programs of importance. Instead, additional investments in GME are 
critical to an already insufficiently-funded system.
    AACOM strongly supports the continuation of the THCGME Program, 
which provides funding to support primary care medical and dental 
residents training in community-based settings. THCs currently train 
more than 350 medical and dental residents and are providing more than 
700,000 primary care visits in underserved rural and urban communities. 
This program will also provide long-term benefits. According to the 
HRSA, physicians who train in THCs are three times more likely to work 
in such centers and more than twice as likely to work in underserved 
areas as physicians who train in other settings. The THCGME Program's 
5-year authorization expires in fiscal year 2015, but the recruitment 
of new residents is being impacted now. We support an investment of $10 
million in fiscal year 2015 for development grants minimally.
    Through scholarships and loan repayment, the National Health 
Service Corps (NHSC) supports the recruitment and retention of primary 
care clinicians to practice in underserved communities. Approximately 
50 million Americans live in communities with a shortage of health 
professionals, lacking adequate access to primary care. The self-
reported average medical education debt of graduates of colleges of 
osteopathic medicine who borrowed to attend medical school has 
increased by almost $85,000 in the last decade. Today, there are more 
than 23,000 students enrolled at osteopathic medical schools across the 
Nation. Recent graduates report graduating with an average medical 
education debt of $211,423.
    Today, there are nearly 8,900 NHSC members providing culturally 
competent care to more than 9.3 million people. Care is provided at 
5,100 NHSC-approved healthcare sites in urban, rural, and frontier 
areas. In addition to Corps providers currently providing care, nearly 
1,100 students, residents, and health providers receive scholarships or 
participate in the Student to Service Loan Repayment program to prepare 
to practice, which provides loan repayment assistance to medical 
students in their last year of education in return for their commitment 
to practice. AACOM appreciates the Administration's continued 
investment in the NHSC and strongly supports the preservation of 
student scholarship and loan repayment programs. Furthermore, we 
encourage congressional authorizers and appropriators to work together 
before current mandatory funding for the NHSC expires at the end of 
fiscal year 2015. This critical funding works to address the primary 
care workforce shortage and advances innovative models of service.
    HRSA's Rural Physician Training grants will help rural-focused 
training programs recruit and graduate students most likely to practice 
medicine in underserved rural communities. HRSA's Office of Rural 
Health Policy analyzes potential effects of policy on residents of 
rural communities and administers grant programs designed to build 
healthcare capacity at both the local and State levels. Health 
professions workforce shortages are exacerbated in rural areas, where 
communities struggle to attract and keep well-trained providers. 
According to HRSA, approximately 65 percent of primary care health 
professional shortage areas are rural. AACOM supports the President's 
fiscal year 2015 budget request of $4 million for the Rural Physician 
Training grants.
    The National Health Care Workforce Commission was designed to 
develop and evaluate training activities to meet demand for healthcare 
workers. Without funding, the Commission cannot identify barriers that 
may create and exacerbate workforce shortages and improve coordination 
on the Federal, State, and local levels. Having this type of 
coordinating body in place is becoming more critical as more Americans 
have insurance coverage and as the population ages, requiring access to 
care. As the United States struggles to address healthcare provider 
shortages in certain specialties and in rural and underserved areas, 
the country lacks a defined policy to address these critical. For these 
reasons, AACOM recommends that $3 million be appropriated to fund the 
Commission so it can begin its important work.
    Research funded by the NIH leads to important medical discoveries 
regarding the causes, treatments, and cures for common and rare 
diseases, as well as disease prevention. These efforts improve our 
Nation's health and save lives. To maintain a robust research agenda, 
further investment will be needed. AACOM recommends $32 billion for the 
NIH.
    In today's increasingly demanding and evolving medical curriculum, 
there is a critical need for more research geared toward evidence-based 
osteopathic medicine. AACOM believes that it is vitally important to 
maintain and increase funding for biomedical and clinical research in a 
variety of areas related to osteopathic principles and practice, 
including osteopathic manipulative medicine and comparative 
effectiveness. In this regard, AACOM encourages support for the NIH's 
National Center for Complementary and Alternative Medicine (NCCAM) to 
continue fulfilling this essential research role.
    AHRQ supports research to improve healthcare quality, reduce costs, 
advance patient safety, decrease medical errors, and broaden access to 
essential services. AHRQ plays an important role in producing the 
evidence base needed to improve our Nation's health and healthcare. The 
incremental increases for AHRQ's Patient Centered Health Research 
Program in recent years will help AHRQ generate more of this research 
and expand the infrastructure needed to increase capacity to produce 
this evidence; however, more investment is needed. AACOM recommends 
$375 million in base discretionary funding, restoring the base to 
fiscal year 2011 levels for the AHRQ. This investment will preserve 
AHRQ's current programs while helping to restore its critical 
healthcare safety, quality, and efficiency initiatives.
    AACOM is grateful for the opportunity to submit its views and looks 
forward to continuing to work with the Subcommittee on these important 
matters.
    [This statement was submitted by Stephen C. Shannon, D.O., M.P.H., 
President and Chief Executive Officer, American Association of Colleges 
of Osteopathic Medicine.]
                                 ______
                                 
    Prepared Statement of the American Association of Immunologists
    The American Association of Immunologists (AAI), the world's 
largest professional society of research scientists and physicians who 
study the immune system, respectfully submits this testimony regarding 
fiscal year 2015 appropriations for the National Institutes of Health 
(NIH). AAI recommends an appropriation of at least $32 billion for NIH 
for fiscal year 2015 to support important ongoing research, fund a 
reasonable number of outstanding new grant applications, and restore 
NIH funding to a level that can sustain a robust and dynamic biomedical 
research enterprise in the United States.
          nih's crucial role in advancing biomedical research
    NIH is essential to the advancement of biomedical research in the 
United States, where virtually all biomedical scientists rely on NIH 
leadership and funding.\1\ Academic scientists, many of whom conduct 
research while teaching the next generation of doctors and scientists, 
depend on NIH grants to support their research at universities, 
colleges and research institutions all around the country. NIH 
intramural scientists require funding to do their own research as well 
as collaborate with their private sector colleagues.\2\ And scientists 
employed by industry, who generally do not receive NIH grants or 
awards, depend on NIH-funded scientific discoveries to develop products 
that bring research to the bedside. A strong NIH budget, therefore, is 
essential to all sectors of the U.S. biomedical research enterprise, 
and has enabled NIH to remain the key international leader influencing 
biomedical research around the globe.
---------------------------------------------------------------------------
    \1\ After a highly competitive peer review process, which includes 
comprehensive review by panels of extramural scientists, NIH awards 
more than 80 percent of its $30.1 billion budget to ``more than 
300,000 researchers at more than 2,500 universities, medical schools, 
and other research institutions in every State and around the world.'' 
About 10 percent of its budget supports the work of the approximately 
6,000 scientists who work in NIH's own laboratories. (http://
www.nih.gov/about/budget.htm).
    \2\ AAI is concerned that a Federal policy limits government 
scientists' ability to attend privately sponsored scientific meetings 
and conferences. (See http://www.hhs.gov/travel/policies/
2012_policy_manual.pdf AAI believes that ``the rules have had an 
unintended and deleterious effect . . . [and] made government 
scientists feel cut off from the rest of the scientific community, 
wreaked havoc with their ability to fulfill professional commitments, 
and undermined the morale of some of the government's finest minds.'' 
Testimony (Amended) of Lauren G. Gross, J.D., on behalf of The American 
Association of Immunologists (AAI), Submitted to the Senate Homeland 
Security and Governmental Affairs Committee for the Hearing Record of 
January 14, 2014: ``Examining Conference and Travel Spending Across the 
Federal Government'' (http://aai.org/Public_Affairs/Docs/2014/
AAI_Testimony_to_Senate_HSGAC_01142014.pdf).
---------------------------------------------------------------------------
      nih budget woes slow research and threaten u.s. preeminence
    The slow growth of the NIH budget in recent years, exacerbated by 
the impact of biomedical research inflation,\3\ has significantly 
reduced NIH's purchasing power, and in turn, the purchasing power of 
its grantees. According to the Congressional Research Service (CRS), 
``[i]n constant 2003 dollars, fiscal year 2014 funding is 22 percent 
lower than the fiscal year 2003 level.'' \4\ How many avenues of 
research have not been followed because of this reduction? How many 
potential treatments and cures have been delayed or not discovered? 
These are questions that cannot be answered definitively, but we do 
know that NIH budget reductions have already caused real and lasting 
damage: the loss of grant funding, even among the most highly qualified 
scientists; the closure of labs; the termination or interruption of 
important research; and the emigration of talented scientists to other 
countries. And we do know that many scientists are spending too much 
time in a constant chase for funding, rather than conducting research 
and mentoring the Nation's future researchers, inventors and 
innovators. These budget woes threaten America's preeminence in 
advancing basic biomedical research, discovering urgently needed 
treatments and cures, and ``growing'' brilliant young scientists.
---------------------------------------------------------------------------
    \3\ The Biomedical Research and Development Price Index (BRDPI) 
``is developed each year for NIH by the Bureau of Economic Analysis of 
the Department of Commerce. It reflects the increase in prices of the 
resources needed to conduct biomedical research, including personnel, 
services, supplies, and equipment. It indicates how much the NIH budget 
must change to maintain purchasing power.'' Johnson, Judith A., ``A 
History of NIH Funding: Fact Sheet,'' Congressional Research Service, 
R43341, p. 2 (2014).
    \4\ Ibid.
---------------------------------------------------------------------------
research on the immune system: essential to our health, crucial to our 
                                 future
    The immune system is the body's primary defense against viruses, 
bacteria, and parasites that cause disease in millions of people every 
year. When the immune system is operating properly, it provides 
powerful protection against a wide variety of illnesses, including 
cancer, Alzheimer's disease, and cardiovascular disease. The immune 
system can, however, perform poorly, leaving the body vulnerable to 
infections, including influenza, HIV/AIDS, tuberculosis, malaria, and 
the common cold. It can also become overactive, damaging normal organs 
and tissues, and causing autoimmune diseases, such as allergy, asthma, 
inflammatory bowel disease, lupus, multiple sclerosis, rheumatoid 
arthritis, and type 1 diabetes. Research scientists and clinicians are 
working to harness this powerful system to protect people and animals 
from infectious diseases, cancer, and many other illnesses, and to 
protect against natural or man-made infectious organisms (including 
plague, smallpox and anthrax) that could be used for bioterrorism.\5\
---------------------------------------------------------------------------
    \5\ NIH should robustly fund and primarily rely on individual 
investigator-initiated research, in which researchers working in 
institutions across the Nation submit applications to, and following 
independent peer review, receive grants from, NIH. Biomedical 
innovation and discovery are less likely to be achieved through ``top-
down'' science, in which the government specifies the type of research 
it wishes to fund.
---------------------------------------------------------------------------
      recent immunological advances and their promise for tomorrow
1. Cancer Immunotherapies: Offering Hope of Conquering Cancer
    NIH-funded scientists recently identified inhibitory receptors 
which suppress immune cell activation. Blocking these receptors can 
allow the immune system to destroy tumor cells.\6\ Today, therapeutics 
targeted against inhibitory receptors like CTLA4 are undergoing 
rigorous clinical trials against a variety of cancers. The success 
rates for these therapies have been astounding and unprecedented: for 
example, rates of tumor regression in patients with metastatic melanoma 
have increased from 10 percent to 50 percent.\7\ With this level of 
success, immunotherapy is one of the most exciting and promising areas 
of cancer treatment.
---------------------------------------------------------------------------
    \6\ Couzin-Frankel, Jennifer. ``Cancer Immunotherapy.'' Science 
342.6165 (2013): 1432-433.
    \7\ Wolchok, J. D. et al. ``Nivolumab plus Ipilimumab in Advanced 
Melanoma.'' N Engl J Med 369.2 (2013): 122-33.
---------------------------------------------------------------------------
2. Early Antiretroviral Therapy: Eliminating HIV, Ending AIDS?
    NIH-funded researchers have discovered that early administration of 
antiviral medication, known as anti-retroviral therapy (ART), can have 
lasting effects on an HIV-infected patient's long-term prognosis. In 
one study,\8\ an infant born to an HIV-infected mother began receiving 
ART within hours of birth. The infant tested positive for HIV and 
continued treatment for 18 months. Despite the HIV diagnosis and 
subsequent discontinuation of ART, the child remained virus-free 1 year 
later. A second baby with a similar history also showed an absence of 
HIV.\9\ Together with several additional unconfirmed cases of babies 
``cured'' of HIV infection, these findings offer hope to the 250,000 
babies born each year infected with HIV.\10\
---------------------------------------------------------------------------
    \8\ Deborah, Persaud et al. ``Absence of Detectable HIV-1 Viremia 
after Treatment Cessation in an Infant.'' N Engl J Med 369 (2013): 
1828-835.
    \9\ Conference on Retroviruses and Opportunistic Infections, March 
3--6, 2014, Boston, MA (http://www. croi2014.org/) (See also http://
www.nytimes.com/2014/03/06/health/second-success-raises-hope-for-a-way-
to-rid-babies-of-hiv.html).
    \10\ A clinical trial following 60 babies born infected with HIV 
and being treated with antiretroviral medication will begin soon. (See 
http://www.nytimes.com/2014/03/06/health/second-success-raises-hope-
for-a-way-to-rid-babies-of-hiv.html) A second study found that adult 
HIV-infected patients who were treated with ART within 4 months of 
infection display significantly improved response to treatment. [See 
Le, Tuan, et al. ``Enhanced CD4+ T-Cell Recovery with Earlier HIV-1 
Antiretroviral Therapy.'' N Engl J Med 368 (2013): 218-30].
---------------------------------------------------------------------------
3. Gut (Intestinal) Bacteria: The Microbiome Role in Autoimmune Disease
    NIH-funded research has shown that gut bacteria (the intestinal 
``microbiome''), which aid in food digestion, may impact the 
development of autoimmune diseases, including rheumatoid arthritis, 
type 1 diabetes, multiple sclerosis and inflammatory bowel 
disorders.\11\ Current research is exploring changes in gut bacteria 
from diet, hormones, antibiotics, and infections, and the effect of gut 
bacteria based therapeutics [for example, the ingestion of healthy gut 
bacteria (probiotics) in yogurt]. One study involving fecal 
transplantation (which includes the transfer of intestinal bacteria 
from one person to another) has found that such transplantation in pill 
form is well tolerated and is 98-100 percent efficacious in curing 
infections with Clostridium difficile, a bacterium linked to 14,000 
diarrheal deaths in the U.S. per year.\12\
---------------------------------------------------------------------------
    \11\ Sorini, C., and M. Falcone. ``Shaping the (auto)immune 
Response in the Gut: The Role of Intestinal Immune Regulation in the 
Prevention of Type 1 Diabetes.'' Am J Clin Exp Immunol 2.2 (2013): 156-
71.
    \12\ Infectious Diseases Society of America. ``Fecal Transplant 
pill knocks out recurrent C. diff infection,'' Science Daily (2013) 
(See http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html).
---------------------------------------------------------------------------
4. RSV Vaccine: Saving Infants' Lives
    Millions of infants are hospitalized and 160,000 children die each 
year each from pneumonia and other lung diseases caused by respiratory 
syncytial virus (RSV).\13\ Until recently, however, a vaccine for RSV 
has been elusive. In an important breakthrough, scientists at the NIH 
discovered antibodies--protective molecules produced by the immune 
system--that helped identify a key protein for use in vaccine 
development.\14\ The NIH scientists were then able to engineer this 
protein and demonstrate its ability to produce a strong protective 
immune response against RSV in animals.\15\ This molecule is expected 
to be ready soon for testing in humans. Importantly, the approach 
developed in this case can be applied to vaccine design for numerous 
other viruses, such as HIV, hepatitis C, dengue, and West Nile viruses, 
that have evaded the body's protective immune responses, and will 
provide insight into how viruses evade the immune system.
---------------------------------------------------------------------------
    \13\ Couzin-Frankel, Jennifer. ``Cancer Immunotherapy.'' Science 
342.6165 (2013): 1432-433.
    \14\ McLellan, J. S. et al. ``Structure of RSV Fusion Glycoprotein 
Trimer Bound to a Pre-fusion Specific Neutralizing Antibody.'' Science 
340.6136 (2013): 1113-117.
    \15\ McLellan, J. S. et al. ``Structure-Based Design of a Fusion 
Glycoprotein Vaccine for Respiratory Syncytial Virus.'' Science 
342.6158 (2013): 592-98.
---------------------------------------------------------------------------
                               conclusion
    AAI thanks the members and staff of the subcommittee for their 
ongoing, strong bipartisan support for biomedical research, and 
recommends an appropriation of at least $32 billion for NIH for fiscal 
year 2015 to fund important ongoing research, strengthen the biomedical 
research enterprise, and ensure that the brightest scientists, 
trainees, and students are able to pursue careers in biomedical 
research in the United States.

    [This statement was submitted by Elizabeth J. Kovacs, Ph.D., 
American Association of Immunologists.]
                                 ______
                                 
  Prepared Statement of the American Association of Nurse Anesthetists

                                 FISCAL YEAR 2015 APPROPRIATIONS REQUEST SUMMARY
                                              [Dollars in millions]
----------------------------------------------------------------------------------------------------------------
                                                  Fiscal year     Fiscal year
                                                  2013 actual    2014 enacted     AANA fiscal year 2015 request
----------------------------------------------------------------------------------------------------------------
HHS/HRSA/BHPr Title 8 Advanced Education                 $2.25           $2.25  $4 million for nurse
 Nursing, Nurse Anesthetist Education Reserve.                                   anesthesia education
Total for Advanced Education Nursing, from                59.4          61.581  83.925 million for advanced
 Title 8.                                                                        education nursing
----------------------------------------------------------------------------------------------------------------
Title 8 HRSA BHPr Nursing Education Programs..           220.4         223.841  251
----------------------------------------------------------------------------------------------------------------

    About the American Association of Nurse Anesthetists (AANA) and 
Certified Registered Nurse Anesthetists (CRNAs)
    The AANA is the professional association for more than 47,000 CRNAs 
and student nurse anesthetists, representing over 90 percent of the 
nurse anesthetists in the United States. Today, CRNAs deliver 
approximately 34 million anesthetics to patients each year in the U.S. 
CRNA services include administering the anesthetic, monitoring the 
patient's vital signs, staying with the patient throughout the surgery, 
and providing acute and chronic pain management services. CRNAs provide 
anesthesia for a wide variety of surgical cases and in some States are 
the sole anesthesia providers in almost 100 percent of rural hospitals, 
affording these medical facilities obstetrical, surgical, and trauma 
stabilization, and pain management capabilities. CRNAs work in every 
setting in which anesthesia is delivered, including hospital surgical 
suites and obstetrical delivery rooms, ambulatory surgical centers 
(ASCs), pain management units and the offices of dentists, podiatrists 
and plastic surgeons.
    Nurse anesthetists are experienced and highly trained anesthesia 
professionals whose record of patient safety is underscored by 
scientific research findings. The landmark Institute of Medicine report 
To Err is Human found in 2000 that anesthesia was 50 times safer then 
than in the 1980s. (Kohn L, Corrigan J, Donaldson M, ed. To Err is 
Human. Institute of Medicine, National Academy Press, Washington DC, 
2000.) Though many studies have demonstrated the high quality of nurse 
anesthesia care, the results of a new study published in Health Affairs 
led researchers to recommend that costly and duplicative supervision 
requirements for CRNAs be eliminated. Examining Medicare records from 
1999-2005, the study compared anesthesia outcomes in 14 States that 
opted-out of the Medicare physician supervision requirement for CRNAs 
with those that did not opt out. (To date, 17 States have opted-out.) 
The researchers found that anesthesia has continued to grow more safe 
in opt-out and non-opt-out States alike. (Dulisse B, Cromwell J. No 
Harm Found When Nurse Anesthetists Work Without Supervision By 
Physicians. Health Aff. 2010;29(8):1469-1475.)
    CRNAs provide the lion's share of anesthesia care required by our 
U.S. Armed Forces through active duty and the reserves, staffing ships, 
remote U.S. military bases, and forward surgical teams without 
physician anesthesiologist support. In addition, CRNAs predominate in 
rural and medically underserved areas, and where more Medicare patients 
live (Government Accountability Office. Medicare and private payment 
differences for anesthesia services. GAO-07-463, Washington DC, Jul. 
27, 2007. http://www.gao.gov/products/GAO-07-463).
    Importance of and Request for HRSA Title 8 Nurse Anesthesia 
Education Funding
    Our profession's chief request of the Subcommittee is for $4 
million to be reserved for nurse anesthesia education and $83.925 
million for advanced education nursing from the HRSA Title 8 program, 
out of a total Title 8 budget of $251 million. We request that the 
Report accompanying the fiscal year 2014 Labor-HHS-Education 
Appropriations bill include the following language: ``Within the 
allocation, the Committee encourages HRSA to allocate funding at least 
at the fiscal year 2014 level for nurse anesthetist education.'' This 
funding request is justified by the safety and value proposition of 
nurse anesthesia, and by anticipated growth in demand for CRNA services 
as baby boomers retire, become Medicare eligible, and require more 
healthcare services. In making this request, we associate ourselves 
with the request made by The Nursing Community with respect to Title 8 
and the National Institute of Nursing Research (NINR) at the National 
Institutes of Health.
    The Title 8 program, on which we will focus our testimony, is 
strongly supported by members of this Subcommittee in the past, and is 
an effective means to help address nurse anesthesia workforce demand. 
In expectation for dramatic growth in the number of U.S. retirees and 
their healthcare needs, funding the advanced education nursing program 
at $83.925 million is necessary to meet the continuing demand for 
nursing faculty and other advanced education nursing services 
throughout the U.S.,. The program funds competitive grants that help 
enhance advanced nursing education and practice, and traineeships for 
individuals in advanced nursing education programs. It also targets 
resources toward increasing the number of providers in rural and 
underserved America and preparing providers at the master's and 
doctoral levels, thus increasing the supply of clinicians eligible to 
serve as nursing faculty, a critical need.
    Demand remains high for CRNA workforce in clinical and educational 
settings. A 2007 AANA nurse anesthesia workforce study found a 12.6 
percent CRNA vacancy rate in hospitals and a 12.5 percent faculty 
vacancy rate. The supply of clinical providers has increased in recent 
years, stimulated by increases in the number of CRNAs trained. From 
2002-2012, the annual number of nurse anesthesia educational program 
graduates increased from 1,362 to 2,469, according to the Council on 
Accreditation of Nurse Anesthesia Educational Programs (COA). The 
number of accredited nurse anesthesia educational programs grew from 85 
to 114. We anticipate increased demand for anesthesia services as the 
population ages, the number of clinical sites requiring anesthesia 
services grows, and a portion of the CRNA workforce retires.
    The capacity of our 114 nurse anesthesia educational programs to 
educate qualified applicants is limited by the number of faculty, the 
number and characteristics of clinical practice educational sites, and 
other factors--and they continue turning away hundreds of qualified 
applicants. A qualified applicant to a CRNA program is a bachelor's 
educated registered nurse who has spent at least 1 year serving in an 
acute care healthcare practice environment. They are prepared in nurse 
anesthesia educational programs located all across the country, 
including Arkansas, California, Connecticut, Georgia, Kentucky, 
Maryland, New York, Ohio, and Tennessee. To meet the nurse anesthesia 
workforce challenge, the capacity and number of CRNA schools must 
continue to grow and modernize with the latest advancements in 
simulation technology and distance learning consistent with improving 
educational quality and supplying demand for highly qualified 
providers. With the help of competitively awarded grants supported by 
Title 8 funding, the nurse anesthesia profession is making significant 
progress, but more is required.
    This progress is extremely cost-effective from the standpoint of 
Federal funding. Anesthesia can be provided by nurse anesthetists, 
physician anesthesiologists, or by CRNAs and anesthesiologists working 
together. Of these, the nurse anesthesia practice model is by far the 
most cost-effective, and ensures patient safety. (Hogan P et al. Cost 
effectiveness analysis of anesthesia providers. Nursing Economic$, Vol. 
28 No. 3, May-June 2010, p. 159 et seq.) Nurse anesthesia education 
represents a significant educational cost-benefit for competitively 
awarded Federal funding in support of CRNA educational programs.
    Support for Safe Injection Practices and the Alliance for Injection 
Safety
    As a leader in patient safety, the AANA has been playing a vigorous 
role in the development and projects of the Alliance for Injection 
Safety, intended to reduce and eventually eliminate the incidence of 
healthcare facility acquired infections. In the interest of promoting 
safe injection practice, and reducing the incidence of healthcare 
facility acquired infections, we associate ourselves with the AIS 
recommendation.
    Support Effective Implementation of Provider Non-Discrimination
    AANA applauds the Committee for including report language in its 
fiscal year 2014 bill directing the Administration to implement the 
provision in a manner consistent with its intent, to promote 
competition, quality and choice in a way that supports access and 
controls costs.
    The AANA is firmly committed to supporting competition, access and 
choice within the healthcare delivery system and has been working to 
ensure effective implementation of the Federal provider 
nondiscrimination provision in the Patient Protection and Affordable 
Care Act (ACA). This provision, which prohibits health plans from 
discriminating against qualified licensed healthcare professionals 
solely on the basis of their licensure, went into effect on January 1, 
2014.
    Proper implementation of the ACA provider nondiscrimination 
provision is crucial because health plans today may discriminate 
against whole classes of healthcare professionals based solely on their 
licensure or certification, limiting or denying patient choice and 
access to beneficial, safe and cost-efficient healthcare professionals, 
impairing competition, patient access to care, and optimal healthcare 
delivery. For example, a commercial carrier in South Carolina stated in 
its policy manual that it will not reimburse CRNAs for monitored 
anesthesia care (MAC), but that it will pay anesthesiologists for these 
same services. Not only does such a policy impair patient access to 
care provided by CRNAs; it expressly impairs competition and choice and 
contributes to unjustifiably higher healthcare costs without improving 
quality or access to care.
    The AANA urges the committee to include the following report 
language with the House Appropriation, Health and Human Services, 
Education and Related Agencies Subcommittee legislation. The Committee 
directs HHS to continue its work with the Departments of Labor and 
Treasury to implement the provider non discrimination law to reflect 
the original Congressional intent of the provision.

    [This statement was submitted by Dennis Bless, CRNA, MS, President, 
American Association of Nurse Anesthetists.]
                                 ______
                                 
 Prepared Statement of the American Association of Nurse Practitioners
    On behalf of the American Association of Nurse Practitioners 
(AANP), the largest full service professional organization representing 
the 189,000 nurse practitioners across the country, we would like to 
submit the below noted funding requests for fiscal year 2015. Nurse 
Practitioners (NPs) have been providing primary, acute, and specialty 
healthcare to patients of all ages for nearly half a century. As you 
know, in addition to treating acute and chronic illnesses of patients 
coming to them for care, they emphasize health promotion and disease 
prevention in all their undertakings. This includes assessments, 
ordering, performing, supervising and interpreting diagnostic and 
laboratory tests, making diagnoses, initiating and managing treatment 
which includes prescribing medications as well as non-pharmacologic 
treatments, counselling and educating patients, their families and 
communities. They are the healthcare providers of choice for millions 
of patients; in fact last year they conducted over 900 million patient 
visits across the Nation.
    The vast majority of nurse practitioners throughout the United 
States are primary care providers. Eighty 8 percent are prepared to be 
primary care clinicians and nearly seventy percent are currently 
practicing in a primary care setting. As clinicians that blend clinical 
expertise in diagnosing and treating health conditions with an added 
emphasis on disease prevention and health promotion, NPs bring a 
comprehensive perspective to healthcare that enhances health and well-
being among their patients. Given the demand for primary care 
providers, NPs are and will continue to fill a critical role in the 
American healthcare system. Likewise the need to create and fund more 
nurse managed clinics is critical. As the need for primary care 
services grows, funding such clinics becomes increasingly necessary. 
The need to adequately prepare nurse practitioners and facilitate the 
high quality outcomes of these clinics is clear. Equally clear is the 
need for funding assistance to nurse practitioner educational programs, 
students and nurse managed clinics. We are anxious to include among our 
ranks, students who would not be able to enter our programs without 
assistance as well as clinic sites that serve as clinical education 
sites and meet the unmet healthcare needs of a wide variety of 
populations throughout the country. Therefore we ask that at the very 
least the following funding be appropriated:
    For fiscal year 2015, AANP respectfully requests $251 million for 
the Health Resources and Services Administration's (HRSA) Nursing 
Workforce Development programs (authorized under Title VIII of the 
Public Health Service Act [42 U.S.C. 296 et seq.]), $150 million for 
the National Institute of Nursing Research (NINR) within the National 
Institutes of Health (NIH), and $20 million in authorized funding for 
the Nurse-Managed Health Clinics (Title III of the Public Health 
Service Act). These investments made through the appropriation process 
will help to ensure that our Nation's population receives high quality, 
cost effective healthcare.
    AANP would like to work closely with the committee on areas of 
common interest. We are happy to serve as a resource to the committee 
as you make decisions about these investments. We thank you for the 
opportunity to share our concerns with you and look forward to 
continuing to work with you and your staff on issues affecting our 
profession. Please contact AANP's Federal Government Affairs department 
at: [email protected] should you have any questions or need 
further information.
                                 ______
                                 
   Prepared Statement of the American Congress of Obstetricians and 
                             Gynecologists
    The American Congress of Obstetricians and Gynecologists (ACOG), 
representing 58,000 physicians and partners in women's healthcare, is 
pleased to offer this statement to the Senate Committee on 
Appropriations, Subcommittee on Labor, Health and Human Services, and 
Education. We thank Chairman Harkin, and the entire Subcommittee for 
the opportunity to provide comments on some of the most important 
programs to women's health.
    Today, the U.S. lags behind many other Nations in healthy births. 
ACOG's Making Obstetrics and Maternity Safer (MOMS) Initiative would 
help improve maternal and infant health through Federal research 
investments, including comprehensive data collection and surveillance, 
biomedical research, and translating research into evidence-based care 
for women and babies. We urge you to make funding of the following 
programs and agencies a top priority in fiscal year 2015.
Data Collection and Surveillance at the Centers for Disease Control and 
        Prevention (CDC)
    In order to conduct robust research, uniform, accurate and 
comprehensive data and surveillance are critical. The National Center 
for Health Statistics is the Nation's principal health statistics 
agency and collects State data from records like birth certificates 
that give us raw, vital statistics. Information from birth and death 
certificates is key to gathering vital information about both mother 
and baby during pregnancy and labor and delivery. Uniform, accurate 
data collection depends on all States and territories using electronic 
birth and death records based on the 2003 US-standard birth and death 
certificates, yet 4 States are still not using the electronic birth 
registries and 12 States are still not using the electronic death 
registries.
    States not using the standard records likely underreport maternal 
and infant deaths and complications from childbirth; causes of these 
deaths remain unknown. Previous appropriations have helped increase the 
number of States using electronic birth and death registries, but NCHS 
needs increased resources to help enroll the remaining States, and to 
improve the accuracy of birth and death data, including through linking 
data from Electronic Health Records to State vital records systems. For 
fiscal year 2015, ACOG requests $182 million for the National Center 
for Health Statistics, $5 million of which we urge you to designate to 
modernize the National Vitals Statistics System, helping States update 
their birth and death records systems.
    The Pregnancy Risk Assessment Monitoring System (PRAMS) at CDC 
extends beyond vital statistics and surveys new mothers on their 
experiences and attitudes during pregnancy, with questions on a range 
of topics, including what their insurance covered, whether they had 
stressful experiences during pregnancy, when they initiated prenatal 
care, and what kinds of questions their doctor covered during prenatal 
care visits. By identifying trends and patterns in maternal health, CDC 
researchers and State health departments are better able to identify 
behaviors and environmental and health conditions that may lead to 
preterm births. Only 40 States use the PRAMS surveillance system today. 
ACOG requests adequate funding to expand PRAMS to all U.S. States and 
territories.
Biomedical Research at the National Institutes of Health (NIH)
    Biomedical research is critically important to understanding the 
causes of maternal and infant mortality and morbidity, and developing 
effective interventions to lower the incidence of mortality and 
morbidity. The National Institute on Child Health and Human 
Development's (NICHD's) 2012 Scientific Vision identified the most 
promising research opportunities for the next decade. Goals include 
determining the complex causes of prematurity and developing evidence-
based measures for its prevention within the next 10 years, 
understanding the long term health implications of assisted 
reproductive technology, and understanding the role of the placenta in 
fetal health outcomes. The placenta, one of the least studied human 
organs, is essential to the viability and proper growth of the fetus. 
NICHD's Human Placenta Project will help discover the causes of 
placental failures, and ultimately ways to prevent failure and improve 
maternal and fetal birth outcomes.
    Another major issue that merits attention is that of clinical 
trials involving pregnant women. Pregnant women have historically been 
excluded from most research trials due to concern that trial 
participation could harm the fetus. Although there has been substantial 
progress in the inclusion of women in federally funded research, 
pregnant women are still excluded, even from research that would 
advance our knowledge of medical conditions and treatments in 
pregnancy. Mindful of the important considerations of clinical trials 
on pregnant women, we support establishment of a Federal work group to 
propose how clinical research might be done appropriately in this area.
    Adequate levels of research require a robust research workforce. 
The years of training combined with uncertainty in getting grant 
funding are huge disincentives for students considering a career in 
bio-medical research. This has resulted in a huge gap between the too-
few women's reproductive health researchers being trained and the 
immense need for research. We urge continued investments in the Women's 
Reproductive Health Research (WRHR) Career Development program, 
Reproductive Scientist Development Program (RSDP), and the Building 
Interdisciplinary Research Careers in Women's Health (BIRCWH) programs 
to address the shortfall of women's reproductive health researchers. 
ACOG supports a minimum of $32 billion for NIH and $1.37 billion within 
that funding request for NICHD in fiscal year 2015.
Public Health Programs at the Health Resources and Services 
        Administration (HRSA) and the Centers for Disease Control and 
        Prevention (CDC):
    Projects at HRSA and CDC are integral to translating research 
findings into evidence-based practice changes in communities. Where NIH 
conducts research to identify causes of maternal and infant mortality 
and morbidity, CDC and HRSA help ensure those research findings lead to 
improved maternal and infant health outcomes.
    Maternal Child Health Block Grant (HRSA): The Maternal Child Health 
Block Grant at HRSA is the only Federal program that exclusively 
focuses on improving the health of mothers and children. State and 
territorial health agencies and their partners use MCH Block Grant 
funds to reduce infant mortality, deliver services to children and 
youth with special healthcare needs, support comprehensive prenatal and 
postnatal care, screen newborns for genetic and hereditary health 
conditions, deliver childhood immunizations, and prevent childhood 
injuries.
    These early healthcare services help keep women and children 
healthy, eliminating the need for later costly care. Every $1 spent on 
preconception care for a woman with diabetes can save up to $5.19 by 
preventing costly complications. Over $90 million has been cut from the 
Block Grant since 2003. ACOG requests $639 million for the Block Grant 
in fiscal year 2015 to maintain its current level of services.
    Title X Family Planning Program (HRSA): Family planning and 
interconception care are essential to helping ensure healthy women and 
healthy pregnancies. The Title X Family Planning Program provides 
services to more than 5 million low income men and women who may not 
otherwise have access to these services. Title X clinics accounting for 
$3.4 billion in healthcare savings in 2008 alone. ACOG supports $327 
million for Title X in fiscal year 2015 to sustain its level of 
services.
    Fetal Infant Mortality Review (HRSA): HRSA's Healthy Start Program 
promotes community-based programs to reduce infant mortality and racial 
disparities. These programs are encouraged to use the Fetal and Infant 
Mortality Review (FIMR) which brings together ob-gyn experts and local 
health departments to address local issues contributing to infant 
mortality. Today, more than 220 local programs in 42 States find FIMR a 
powerful tool to help reduce infant mortality and address issues 
related to preterm delivery. For over 20 years, ACOG has partnered with 
the Maternal and Child Health Bureau to sponsor the National FIMR 
Program. ACOG supports $0.5 million in fiscal year 2015 for HRSA to 
increase the number of Healthy Start programs that use FIMR.
    Maternal Health Initiative (HRSA): The Maternal Child Health Bureau 
launched the Maternal Health Initiative to foster the notion of 
``healthy moms make healthy babies.'' As part of this effort, ACOG has 
convened the National Partnership on Maternal Safety to identify key 
factors to reduce maternal morbidity and mortality. ACOG requests at a 
minimum level funding for MCHB to advance this important work.
    Safe Motherhood, Maternity and Perinatal Collaboratives (CDC): The 
Safe Motherhood Initiative at CDC works with State health departments 
to collect information on pregnancy-related deaths, track preterm 
births, and improve maternal outcomes. Through Safe Motherhood, CDC 
funds State-based Maternity and Perinatal Collaboratives that improve 
birth outcomes by encouraging use of evidence-based care, including 
reducing early elective deliveries. Through the Ohio Perinatal Quality 
Collaborative, started in 2007 with funding from CDC, 21 OB teams in 25 
hospitals have significantly decreased early non-medically necessary 
deliveries, in accordance with ACOG guidelines, reducing costly and 
dangerous pre-term births. Avalere estimated that reducing early 
elective can save from $2.4 million to $9 million a year. The PREEMIE 
Reauthorization Act, enacted in 2013, authorizes funding to increase 
the number of States receiving assistance for perinatal collaboratives. 
ACOG urges you to re-instate the pre-term birth sub-line as authorized 
by PREEMIE and provide an additional $16 million to Safe Motherhood to 
implement PREEMIE and help States expand or establish maternity 
perinatal care collaboratives.
    Again, we would like to thank the Committee for commitment to 
improving women's health, and we urge you to fund programs we've 
identified in our MOMS Initiative in fiscal year 2015.
                                 ______
                                 
        Prepared Statement of the American College of Physicians
    The American College of Physicians (ACP) is pleased to submit the 
following statement for the record on its priorities, as funded under 
the U.S. Department of Health & Human Services, for fiscal year 2015. 
ACP is the largest medical specialty organization and the second-
largest physician group in the United States. ACP members include 
137,000 internal medicine physicians (internists), related 
subspecialists, and medical students. Internal medicine physicians are 
specialists who apply scientific knowledge and clinical expertise to 
the diagnosis, treatment, and compassionate care of adults across the 
spectrum from health to complex illness. As the Subcommittee begins 
deliberations on appropriations for fiscal year 2015, ACP is urging 
funding for the following proven programs to receive appropriations 
from the Subcommittee:
  --Title VII, Section 747, Primary Care Training and Enhancement, at 
        no less than $71 million;
  --National Health Service Corps, $810 million in funding, including 
        the $310 million in enhanced funding through the Community 
        Health Centers Fund;
  --National Health Care Workforce Commission, $3 million;
  --Agency for Healthcare Research and Quality, $375 million; and
  --Centers for Medicare and Medicaid Services, Program Management for 
        Marketplaces, $629 million.
    The United States is facing a growing shortage of physicians in key 
specialties, most notably in general internal medicine and family 
medicine--the specialties that provide primary care to most adult and 
adolescent patients. With enactment of the Affordable Care Act (ACA), 
we expect the demand for primary care services to increase with the 
addition of 25 million Americans receiving access to health insurance, 
including an additional 13 million under Medicaid/CHIP, once the law is 
fully implemented. With increased demand, current projections indicate 
there will be a shortage of over 45,000 primary care physicians by 
2020, growing to a shortage of over 65,000 primary care physicians by 
2025. (AAMC Center for Workforce Studies with the Lewin Group. The 
Impact of Health Care Reform on the Future Supply and Demand of 
Physicians Updated Projections Through 2025. June 2010. Accessed at: 
https://www.aamc.org/download/158076/data/updated_projections_through_
2025.pdf). Without critical funding for vital workforce programs, this 
physician shortage will only grow worse. A strong primary care 
infrastructure is an essential part of any high-functioning healthcare 
system, with over 100 studies showing primary care is associated with 
better outcomes and lower costs of care (http://www.acponline.org/
advocacy/where_we_stand/policy/primary_shortage.pdf).
    The health professions' education programs, authorized under Title 
VII of the Public Health Service Act and administered through the 
Health Resources and Services Administration (HRSA), support the 
training and education of healthcare providers to enhance the supply, 
diversity, and distribution of the healthcare workforce, filling the 
gaps in the supply of health professionals not met by traditional 
market forces, and are critical in helping institutions and programs 
respond to the current and emerging challenges of ensuring that all 
Americans have access to appropriate and timely health services. Within 
the Title VII program, we urge the Subcommittee to fund the Section 
747, Primary Care Training and Enhancement program at $71 million, in 
order to maintain and expand the pipeline for individuals training in 
primary care. The Section 747 program is the only source of Federal 
training dollars available for general internal medicine, general 
pediatrics, and family medicine. For example, general internists, who 
have long been at the frontline of patient care, have benefitted from 
Title VII training models emphasizing interdisciplinary training that 
have helped prepare them to work with other health professionals, such 
as physician assistants, patient educators, and psychologists. Without 
a substantial increase in funding, for the fourth year in a row, HRSA 
will not be able to carry out a competitive grant cycle for physician 
training; the Nation needs new initiatives supporting expanded training 
in multi-professional care, the patient-centered medical home, and 
other new competencies required in our developing health system.
    The College urges $810 million in funding for the National Health 
Service Corps (NHSC), as requested in the President's fiscal year 2015 
budget; this amount includes the $310 million in enhanced funding the 
Health and Human Services Secretary has been given the authority to 
provide to the NHSC through the Community Health Centers Fund. Since 
the enactment of the ACA, the NHSC has awarded over $1 billion in 
scholarships and loan repayment to healthcare professionals to help 
expand the country's primary care workforce and meet the healthcare 
needs of underserved communities across the country. With field 
strength of nearly 9,000 clinicians, NHSC members are providing 
culturally competent care to more than 10.4 million people at nearly 
14,000 NHSC-approved healthcare sites in urban, rural, and frontier 
areas. The increase in funds would expand NHSC field strength to 15,000 
and would serve the needs of more than 16 million patients, helping to 
address the health professionals' workforce shortage and growing 
maldistribution. The programs under NHSC have proven to make an impact 
in meeting the healthcare needs of the underserved, and with increased 
appropriations, they can do more.
    We urge the Subcommittee to fully fund the National Health Care 
Workforce Commission, as authorized by the ACA, at $3 million. The 
Commission is authorized to review current and projected healthcare 
workforce supply and demand and make recommendations to Congress and 
the Administration regarding national healthcare workforce priorities, 
goals, and polices. Members of the Commission have been appointed, but 
have not begun work due to a lack of funding. The College believes the 
Nation needs a comprehensive workforce policy founded on sound research 
to determine the Nation's current and future needs for physicians by 
specialty and geographic areas; the work of the Commission is 
imperative to ensure Congress is creating the best policies for our 
Nation's needs.
    The Agency for Healthcare Research and Quality (AHRQ) is the 
leading public health service agency focused on healthcare quality. 
AHRQ's research provides the evidence-based information needed by 
consumers, clinicians, health plans, purchasers, and policymakers to 
make informed healthcare decisions. The College is dedicated to 
ensuring AHRQ's vital role in improving the quality of our Nation's 
health and recommends a budget of $375 million. This amount will allow 
AHRQ to help providers help patients by making evidence-informed 
decisions, fund research that serves as the evidence engine for much of 
the private sector's work to keep patients safe, make the healthcare 
market place more efficient by providing quality measures to health 
professionals, and ultimately, help transform health and healthcare.
    Finally, ACP supports $629 million in funding for the Centers for 
Medicare and Medicaid Services, Program Management for Marketplaces as 
requested in the President's fiscal year 2015 budget in order to carry 
out its duties as necessary. Such funding would allow the Federal 
Government to continue to administer the insurance marketplaces as 
authorized by the ACA if a State has declined to establish an exchange 
that meets Federal requirements. CMS now manages and operates some or 
all marketplace activities in over 30 States. If the Subcommittee 
decides to deny the requested funds, it will be much more difficult for 
the Federal Government to operate and manage a federally-facilitated 
exchange in those States, raising questions about where and how their 
residents would obtain and maintain coverage. It is ACP's belief that 
all legal Americans--regardless of income level, health status, or 
geographic location--must have access to affordable health insurance.
    In conclusion, the College is keenly aware of the fiscal pressures 
facing the Subcommittee today, but strongly believes the United States 
must invest in these programs in order to achieve a high performance 
healthcare system and build capacity in our primary care workforce and 
public health system. The College greatly appreciates the support of 
the Subcommittee on these issues and looks forward to working with 
Congress as you begin to work on the fiscal year 2015 appropriations 
process.
                                 ______
                                 
   Prepared Statement of the American College of Preventive Medicine
    The American College of Preventive Medicine (ACPM) urges the Senate 
Labor, Health and Human Services, Education, and Related Agencies 
Appropriations Subcommittee to reaffirm its support for training 
preventive medicine physicians and other public health professionals by 
providing $10 million in fiscal year 2015 for preventive medicine 
residency training under the public health and preventive medicine line 
item in Title VII of the Public Health Service Act. We further 
respectfully request that funds allocated for ``public health and 
preventive medicine'' be separated into two distinct line items, with 
separation of funds for preventive medicine residency training from 
other funds allocated to the ``public health and preventive medicine'' 
line-item. In conjunction, ACPM also supports the recommendation of the 
Health Professions and Nursing Education Coalition of $520 million in 
fiscal year 2015 to support all health professions and nursing 
education and training programs authorized under Titles VII and VIII of 
the Public Health Service Act.
    In today's healthcare environment, the tools and expertise provided 
by preventive medicine physicians play an integral role in ensuring 
effective functioning of our Nation's public health system. These tools 
and skills include the ability to deliver evidence-based clinical 
preventive services, expertise in population-based health sciences, and 
knowledge of the social and behavioral determinants of health and 
disease. These are the tools employed by preventive medicine physicians 
who practice at the health system level where improving the health of 
populations, enhancing access to quality care, and reducing the costs 
of medical care are paramount. As the body of evidence supporting the 
effectiveness of clinical and population-based interventions continues 
to expand, so does the need for specialists trained in preventive 
medicine.
    Organizations across the spectrum have recognized the growing 
demand for preventive medicine professionals. The Institute of Medicine 
released a report in 2007 calling for an expansion of preventive 
medicine training programs by an ``additional 400 residents per year,'' 
and the Accreditation Council on Graduate Medical Education (ACGME) 
recommends increased funding for preventive medicine residency training 
programs. Additionally, the Association of American Medical Colleges 
released statements in 2011 that stressed the importance of 
incorporating behavioral and social sciences in medical education as 
well as announcing changes to the Medical College Admission Test that 
would test applicants on their knowledge in these areas. Such measures 
strongly indicate increasing recognition of the need to take a broader 
view of health that goes beyond just clinical care--a view that is a 
unique focus and strength of preventive medicine residency training.
    In fact, preventive medicine is the only one of the 24 medical 
specialties recognized by the American Board of Medical Specialties 
that requires and provides training in both clinical and population-
based medicine. Preventive medicine residency training programs provide 
a blueprint on how to train our future physician workforce; physicians 
trained to zoom in on individual patient care needs and zoom out to the 
community and population level to identify and treat the social 
determinants of health. Preventive medicine physicians have the 
training and expertise to advance the population health outcomes that 
public and private payers are increasingly promoting to their 
providers. These physicians have a strong focus on quality care 
improvement and are at the forefront of efforts to integrate primary 
care and public health.
    According to the Health Resources and Services Administration 
(HRSA) and health workforce experts, there are personnel shortages in 
many public health occupations, including epidemiologists, 
biostatisticians, and environmental health workers among others. 
According to the 2012 Physician Specialty Data Book released by the 
Association of American Medical Colleges, preventive medicine had one 
of the biggest decrease (-25 percent) in the number of first-year ACGME 
residents and fellows between 2005 and 2010. ACPM is deeply concerned 
about the shortage of preventive medicine-trained physicians and the 
ominous trend of even fewer training opportunities. This deficiency in 
physicians trained to carry out core public health activities will lead 
to major gaps in the expertise needed to deliver clinical prevention 
and community public health. The impact on the health of those 
populations served by HRSA may be profound.
    Despite being recognized as an underdeveloped national resource and 
in shortage for many years, physicians training in the specialty of 
Preventive Medicine are the only medical residents whose graduate 
medical education (GME) costs are not supported by Medicare, Medicaid 
or other third party insurers. Training occurs outside hospital-based 
settings and therefore is not financed by GME payments to hospitals. 
Both training programs and residency graduates are rapidly declining at 
a time of unprecedented national, State, and community need for 
properly trained physicians in public health and disaster preparedness, 
prevention-oriented practices, quality improvement, and patient safety.
    Currently, residency programs scramble to patch together funding 
packages for their residents. Limited stipend support has made it 
difficult for programs to attract and retain high-quality applicants. 
Support for faculty and tuition has been almost non-existent. Directors 
of residency programs note that they receive many inquiries about and 
applications for training in preventive medicine; however, training 
slots often are not available for those highly qualified physicians who 
are not directly sponsored by an outside agency or who do not have 
specific interests in areas for which limited stipends are available 
(such as research in cancer prevention).
    HRSA--as authorized in Title VII of the Public Health Service Act--
is a critical funding source for several preventive medicine residency 
programs, as it represents the largest Federal funding source for these 
programs. HRSA funding ($3.8 million in fiscal year 2014) currently 
supports only 55 preventive medicine residents across 8 residency 
training programs. An increase of roughly $6 million will allow HRSA to 
support nearly 120 new preventive medicine residents.
    Of note, the preventive medicine residency programs directly 
support the mission of the HRSA health professions programs by 
facilitating practice in underserved communities and promoting training 
opportunities for underrepresented minorities:
  --Thirty-five percent of HRSA-supported preventive medicine graduates 
        practice in medically underserved communities, a rate of almost 
        3.5 times the average for all health professionals. These 
        physicians are meeting a critical need in these underserved 
        communities.
  --Nearly one in five preventive medicine residents funded through 
        HRSA programs are under-represented minorities, which is almost 
        twice the average of minority representation among all health 
        professionals.
  --Fourteen percent of all preventive medicine residents are under-
        represented minorities, the largest proportion of any medical 
        specialty.
    In addition to training under-represented minorities and generating 
physicians who work in medically underserved areas, preventive medicine 
residency programs equip our society with health professionals and 
public health leaders who possess the tools and skills needed in the 
fight against the chronic disease epidemic that is threatening the 
future of our Nation's health and prosperity. Correcting the root 
causes of this critical problem of chronic diseases will require a 
multidisciplinary approach that addresses issues of access to 
healthcare; social and environmental influences; and behavioral 
choices. ACPM applauds the initiation of programs such as the Community 
Transformation Grant that take this broad view of the determinants of 
chronic disease. However, any efforts to strengthen the public health 
infrastructure and transform our communities into places that encourage 
healthy choices must include measures to strengthen the existing 
training programs that help produce public health leaders.
    Many of the leaders of our Nation's local and State health 
departments are trained in preventive medicine. Their unique 
combination of expertise in both medical knowledge and public health 
makes them ideal choices to head the fight against chronic disease as 
well as other threats to our Nation's health. Their contributions are 
invaluable. Investing in the residency programs that provide physicians 
with the training and skills to take on these leadership positions is 
an essential part of keeping Americans healthy and productive. As such, 
the American College of Preventive Medicine urges the Labor, Health and 
Human Services, Education, and Related Agencies Appropriations 
Subcommittee to reaffirm its support for training preventive medicine 
physicians and other public health professionals by providing $10 
million in fiscal year 2015 for preventive medicine residency training 
under the public health and preventive medicine line item in Title VII 
of the Public Health Service Act.
                                 ______
                                 
        Prepared Statement of the American College of Radiology
    The American College of Radiology (ACR)--a professional 
organization serving more than 35,000 radiologists, radiation 
oncologists, interventional radiologists, nuclear medicine physicians, 
and medical physicists--recommends increased funding for the National 
Institutes of Health (NIH) in fiscal year 2015 appropriations 
legislation. Specifically, the ACR endorses the position of the Ad Hoc 
Group for Medical Research--a coalition of more than 300 patient and 
voluntary health groups, medical and scientific societies, academic and 
research organizations, and industry--that NIH receive at least $32 
billion in fiscal year 2015 as the next step toward a multi-year 
increase in our Nation's investment in medical research. That 
recommended funding level is approximately $1.874 billion above the 
President's Budget request for fiscal year 2015. Additionally, the ACR 
joins the Ad Hoc Group in urging Congress and the Administration to 
work in a bipartisan manner to end sequestration and the continued cuts 
to medical research that squander invaluable scientific opportunities, 
discourage young scientists, jeopardize our economic future, and 
threaten medical progress and continued improvements in our Nation's 
health.
    The value of the NIH to American taxpayers is immeasurable, and 
there have been several recent examples of impactful science in the 
biomedical imaging domain that would not have been realized and 
translated swiftly into patient care without NIH support and 
involvement. For instance, the NIH National Cancer Institute's (NCI) 
nearly decade-long National Lung Screening Trial--conducted by the 
American College of Radiology Imaging Network (ACRIN) and Lung 
Screening Study group--found that computed tomography (CT) screening of 
high risk patients could reduce deaths from lung cancer by 20 percent 
versus chest X-ray screening. Another NCI-supported success, the 
National CT Colonography Trial--also conducted by ACRIN--found that 
virtual colonoscopy was effective as a screening method for colorectal 
cancer thanks to its accuracy, safety, cost-effectiveness, and patient 
acceptability compared to more invasive and potentially intimidating 
screening options. The Radiation Therapy Oncology Group (RTOG) now a 
member of the NRG Oncology Group in the new National Clinical Trials 
Network (NCTN), is the international leader in investigating the 
appropriateness of advanced technologies such as proton therapy and 
intensity modulated radiation therapy (IMRT) in multi-center randomized 
trials examining the safety, effectiveness, and quality of life 
implications of these treatments. Additional ACRIN (now ECOG-ACRIN in 
the NCTN) and NRG activities under NCI's purview promise to advance the 
areas of personalized early cancer detection, identify biomarkers to 
predict treatment effectiveness, reduce the rate of false-positive 
imaging examinations, and improve cancer screening outcomes. However, 
NCI's funding of cooperative groups in the evolved National Clinical 
Trials Network (NCTN) has been severely cut and the groups' planned 
budgets are considerably below expectations. We urge Congress to 
restore the full funding approved by the NCI's Board of Scientific 
Advisors for the organizations that transitioned from the cooperative 
group program into the new NCTN.
    Although smaller than NCI, the NIH National Institute of Biomedical 
Imaging and Bioengineering (NIBIB) has likewise been successful in 
advancing the science behind evolving biomedical imaging technologies 
and techniques. The ACR played a key role in NIBIB's creation through 
co-founding a coalition of likeminded organizations and working with 
Federal policymakers to successfully advance the establishing 
legislation in 2000. Since its inception, NIBIB has been particularly 
effective in supporting training initiatives, educational symposia, and 
international collaborations, as well as fostering future generations 
of biomedical imaging and bioengineering scientists via innovative 
initiatives and communications.
    Without significantly increased funding levels for NIH in fiscal 
year 2015 and beyond, America's leadership in biomedical research will 
decline, scientists will be increasingly discouraged by the lack of 
funding opportunities, and innovative technologies and techniques (such 
as those supported through NCI and NIBIB) will not be appropriately 
researched and translated into patient care. Therefore, the ACR 
endorses the Ad Hoc Group for Medical Research's recommendation that 
NIH receive at least $32 billion in fiscal year 2015 as part of a 
multi-year increase, and that Congress and the Administration work 
together to decisively end sequestration.
    Thank you for your consideration.

    [This statement was submitted by Gloria R. Romanelli, JD, Senior 
Director of Legislative and Regulatory Relations, and Michael Peters, 
Director of Legislative and Regulatory Affairs.]
                                 ______
                                 
    Prepared Statement of the American Dental Education Association
    The American Dental Education Association (ADEA), on behalf of all 
65 U.S. dental schools, 700 dental residency training programs, nearly 
600 allied dental programs, as well as more than 12,000 faculty who 
educate and train the nearly 50,000 students and residents attending 
these institutions, submits this statement for the record and for your 
consideration as you begin to prioritize fiscal year 2015 appropriation 
requests. ADEA urges you to protect the funding and fundamental 
structure of Federal programs that provide access to oral healthcare to 
millions of American, train the next generation of healthcare providers 
and fund cutting-edge dental and craniofacial research.
    At ADEA's academic dental institutions, future practitioners and 
researchers are trained and significant dental safety-net care is 
provided. Services are provided through campus and offsite dental 
clinics where students and faculty provide oral healthcare to the 
uninsured and underserved populations. And, in light of the findings 
that good oral health is inextricably linked to good systemic health, 
the need to provide access to oral healthcare is critical. However, in 
order to provide these services, there must be adequate funding.
    We are asking the committee to help ADEA's member institutions 
continue to provide care to all segments of the population by 
maintaining adequate funding for programs focused on access to oral 
healthcare, dental and craniofacial research, and training for oral 
healthcare providers. Specifically we request that you maintain and 
protect funding for Title VII of the Public Health Service Act; the 
National Institutes of Health (NIH) and the National Institute of 
Dental and Craniofacial Research (NIDCR); the Dental Health Improvement 
Act; Part F of the Ryan White HIV/AIDS Treatment and Modernization Act: 
the Dental Reimbursement Program and the Community-Based Dental 
Partnerships Program; and State-Based Oral Health Programs at the 
Centers for Disease Control and Prevention (CDC). These programs 
enhance and sustain State oral health departments, fund public health 
programs proven to prevent oral disease, fund research to eradicate 
dental disease and detect certain cancers, and fund programs to develop 
an adequate workforce of dentists with advanced training to serve 
American citizens including the underserved, the elderly, and those 
suffering from chronic immune-compromised conditions and life-
threatening diseases.
    We respectfully make the following requests:
  --$32 million for Oral Health Training Programs
    The dental programs in Title VII, Section 748 of the Public Health 
Service Act that provide training in general, pediatric, and public 
health dentistry and dental hygiene are critical. Support for these 
programs will help to ensure there will be an adequate oral healthcare 
workforce. The funding supports pre-doctoral oral health education and 
postdoctoral pediatric, general, and public health dentistry training. 
The investment that Title VII makes not only helps to educate dentists 
and dental hygienists, but also expands access to care for underserved 
communities.
    Additionally, Section 748 addresses the shortage of professors in 
dental schools with the dental faculty loan repayment program and 
faculty development courses for those who teach pediatric, general, or 
public health dentistry or dental hygiene. There are currently almost 
200 open budgeted faculty positions in dental schools. These two 
programs provide schools with assistance in recruiting and retaining 
faculty. ADEA is increasingly concerned that with projected restrained 
funding, the oral health research community will not be able to grow 
and that the pipeline of new researchers will be inadequate to the 
future need.
    Title VII Diversity and Student Aid programs play a critical role 
in helping to diversify the health profession's student body and 
thereby the healthcare workforce. For the last several years, these 
programs have not received adequate funding to sustain the progress 
that is necessary to meet the challenges of an increasingly diverse 
U.S. population. ADEA is most concerned that the Administration did not 
request any funds for the Health Careers Opportunity Program (HCOP). 
This program provides a vital source of support for oral health 
professionals serving underserved and disadvantaged patients by 
providing a pipeline for such individuals from these populations to 
learn about careers in healthcare generally and dentistry specifically 
that is not available through other workforce programs.
    For example, a collaboration between the University of 
Connecticut's Schools of Dental Medicine and Medicine have used HCOP 
grants to perform extensive outreach to colleges and Historically Black 
Colleges and Universities (HBCU); support 30 week and 6 week summer 
science enrichment programs in middle schools; support several high 
school programs, including a Bridge to the Future Science Mentoring, 
support mini dental and medical programs, and in support of a Junior 
and Senior Doctors' Academy program. And at the college level the two 
schools continue the Bridge to the Future Science Mentor program and 
conduct a 7 week Health Disparities Clinical Summer Research Fellowship 
program that explores an introduction to health disparities, cross 
cultural issues, principles of clinical medicine and skills for public 
health research and interventions, techniques for work with diverse 
populate and interventions, techniques for work with diverse 
populations.
    UCONN's program is illustrative of programs that dental schools at 
the University of Iowa, Kansas University, University of Maryland-
Baltimore, the University of South Alabama, Marquette University, the 
University of Michigan, and many others have sponsored. HRSA reports 
that the average grant is only $670,000 and reaches over 7,100 students 
from underserved and disadvantaged background.
    If policy makers are serious about reversing health disparities and 
providing opportunity for underrepresented minorities and economically 
disadvantaged individuals they will continue this program at current 
levels, if not expand it.
    Another vital program targeted at enhancing high quality culturally 
competent care in community-based interprofessional clinical training 
settings is the Area Health Education Centers (AHEC) program. Again the 
Administration's has not requested any funds. The infrastructure 
development grants and point of service maintenance and expansion 
grants ensure that patients from underserved populations receive 
quality care in a technologically current setting and that health 
professionals receive training in treating such diverse populations.
    The reason given by HRSA in not requesting any appropriations for 
next fiscal year is short-sighted and counterproductive. HRSA states 
that funding priorities is being redirected to programs that directly 
increase the number of primary care health professionals. Increasing 
the number of providers without the adequate opportunities to treat 
underrepresented populations in their communities makes little clinical 
or cultural sense. This is the case especially if the policy goals 
remain to increase the number coming from those populations and 
practicing in rural and underserved areas. Exposure to the rewards and 
professional challenges of such care is a powerful enducement to 
accomplishing the goal. ADEA encourages the Committee, in the strongest 
possible terms, to continue funding the AHEC program.
  --$18 million for Part F of the Ryan White HIV/AIDS Treatment and 
        Modernization Act: Dental Reimbursement Program (DRP) and the 
        Community-Based Dental Partnerships Program
    Patients with compromised immune systems are more prone to oral 
infections like periodontal disease and tooth decay. By providing 
reimbursement to dental schools and schools of dental hygiene, the 
Dental Reimbursement Program (DRP) provides access to quality dental 
care for people living with HIV/AIDS while simultaneously providing 
educational and training opportunities to dental residents, dental 
students, and dental hygiene students who deliver the care. DRP is a 
cost-effective Federal/institutional partnership that provides partial 
reimbursement to academic dental institutions for costs incurred in 
providing dental care to people living with HIV/AIDS. This program, in 
fiscal year 2013, only reimbursed dental schools for the unreimbursed 
costs at 23 percent of those costs, continuing the shift of the cost 
burden to the schools. This path is not sustainable to provide the 
necessary care. The increase requested would reimburse barely half of 
the dental school's incurred costs of care.
  --$425 million for the National Institute of Dental and Craniofacial 
        Research (NIDCR)
    Discoveries stemming from dental research have reduced the burden 
of oral diseases, led to better oral health for millions of Americans, 
and uncovered important associations between oral and systemic health. 
Dental researchers are poised to make breakthroughs that can result in 
dramatic progress in medicine and health, such as repairing natural 
form and function to faces destroyed by disease, accident, or war 
injuries; diagnosing systemic disease from saliva instead of blood 
samples (such as HIV, and certain types of cancer); and deciphering the 
complex interactions and causes of oral health disparities involving 
social, economic, cultural, environmental, racial, ethnic, and 
biological factors. Dental research is the underpinning of the 
profession of dentistry. With grants from NIDCR, dental researchers in 
academic dental institutions have built a base of scientific and 
clinical knowledge that has been used to enhance the quality of the 
Nation's oral health and overall health.
    Also, dental scientists are putting science to work for the benefit 
of the healthcare system through translational research, comparative 
effectiveness research, health information technology, health research 
economics, and further research on health disparities.
  --$19 million for the Division of Oral Health at the Centers for 
        Disease Control and Prevention (CDC)
    The CDC Division of Oral Health expands the coverage of effective 
prevention programs. The program increases the basic capacity of State 
oral health programs to accurately assess the needs of the State, 
organize and evaluate prevention programs, develop coalitions, address 
oral health in State health plans, and effectively allocate resources 
to the programs. This strong public health response is needed to meet 
the challenges of oral disease affecting children and vulnerable 
populations.
    The level of funds available in recent fiscal years are below the 
level needed to adequately sustain an appropriately staffed State 
dental program, provide a robust surveillance system to monitor and 
report disease, and support State efforts with other governmental, non-
profit, and corporate partners. The current path of funding will 
continue to have a negative effect upon the overall health and 
preparedness of the Nation's States and communities.
    Thank you for your consideration of these requests. ADEA looks 
forward to working with you to ensure the continuation of congressional 
support for these critical programs. Also, please feel free to use ADEA 
as a resource on any matter pertaining to academic dentistry under your 
purview.
                                 ______
                                 
   Prepared Statement of the American Dental Hygienists' Association
    On behalf of the American Dental Hygienists' Association (ADHA), 
thank you for the opportunity to submit testimony regarding fiscal year 
2015 appropriations. ADHA appreciates the Subcommittee's past support 
of programs that seek to improve the oral health of Americans and to 
bolster the oral health workforce. Oral health is a part of total 
health and authorized oral healthcare programs require appropriations 
support in order to increase the accessibility of oral health services, 
particularly for the underserved. ADHA urges that the block on funding 
for Section 340G-1 of the Public Health Service Act--a much needed 
dental workforce demonstration program--be lifted and that $1.25 
million be appropriated. Lifting the block on this dental workforce 
grants program, officially titled the Alternative Dental Health Care 
Providers Demonstration Program, would send an important signal to 
States and to HRSA that innovation in dental workforce is a meritorious 
undertaking. Importantly, the authorizing language requires that the 
grants be conducted in compliance with State law and that they must 
increase access to dental healthcare in rural and other underserved 
communities. Further, the Institute of Medicine is required to provide 
a qualitative and quantitative evaluation of the grants.
    Congress recognized the need to improve the oral healthcare 
delivery system when it authorized the Alternative Dental Health Care 
Provider Demonstration Grants, Section 340G-1 of the Public Health 
Service Act. The Alternative Dental Health Care Providers Demonstration 
Grants program is a Federal grant program that recognizes the need for 
innovations to be made in oral healthcare delivery to bring quality 
care to the underserved by pilot testing new models. The authorizing 
statute makes clear that pilots must ``increase access to dental care 
services in rural and underserved communities'' and comply with State 
licensing requirements.
    New dental providers are already authorized in Minnesota and are 
under consideration in a number of States, including Connecticut, 
Kansas, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and 
Washington State. Both the W.K. Kellogg Foundation and the PEW 
Charitable Trust Dental Campaign are investing in State efforts to 
increase oral healthcare access by adding new types of dental providers 
to the dental team. Further, the U.S. Federal Trade Commission 
supported dental workforce expansion in December 2013, noting that 
``expanding the supply of dental therapists . . . is likely to increase 
the output of basic dental services, enhance competition, reduce costs 
and expand access to dental care.'' The National Governors 
Association's January 2014 issue brief on ``The Role of Dental 
Hygienists in Providing Access to Oral Health Care'' found that 
``innovative State programs are showing that increased use of dental 
hygienists can promote access to oral healthcare, particularly for 
underserved populations, including children'' and that ``such access 
can reduce the incidence of serious tooth decay and other dental 
disease in vulnerable populations.''
    The fiscal year 2014 HHS funding bill included language designed to 
block funding for this important demonstration program. We seek your 
leadership in removing this unjustified prohibition on funding for the 
Alternative Dental Health Care Providers Demonstration Grants. Further, 
because the authorizing language required HRSA to begin the dental 
workforce grant program under Section 340G-1 within 2 years of its 2010 
enactment (i.e., by 2012) and to conclude it within 7 years of 
enactment (2017), language directing HRSA to move forward with Section 
340G-1 grants despite this timeline is needed. ADHA, along with more 
than 60 other oral healthcare organizations, advocated for funding of 
this important program. Without the appropriate supply, diversity and 
distribution of the oral health workforce, the current oral health 
access crisis will only be exacerbated. ADHA recommends funding at a 
level of $1.25 million for fiscal year 2015 to support these vital 
dental workforce demonstration projects.
    Additionally, ADHA joins the American Dental Association, the 
American Dental Education Association and others in the oral health 
community, in recommending $32 million for Title VII Program Grants to 
expand and educate the dental workforce; $19 million for oral health 
programming at CDC, and funding of $425 million for National Institute 
of Dental and Craniofacial Research.
    ADHA urges funding of all authorized oral health programs and 
describes some of the key oral health programs below:
Title VII Program Grants to Expand and Educate the Dental Workforce--
        Fund at a level of $32 million in fiscal year 2015
    A number of existing grant programs offered under Title VII support 
health professions education programs, students, and faculty. ADHA is 
pleased dental hygienists are recognized as primary care providers of 
oral health services and are included as eligible to apply for several 
of the grants offered under ``General, Pediatric, and Public Health 
Dentistry.'' With millions more Americans eligible for dental coverage 
in coming years, it is critical that the oral health workforce is 
bolstered. Dental and dental hygiene education programs currently 
struggle with significant shortages in faculty and there is a dearth of 
providers pursuing careers in public health dentistry and pediatric 
dentistry. Securing appropriations to expand the Title VII grant 
offerings to additional dental hygienists and dentists will provide 
much needed support to programs, faculty, and students in the future.
Oral Health Programming within the Centers for Disease Control--Fund at 
        a level of $19 million in fiscal year 2015
    ADHA joins with others in the dental community in urging $19 
million for oral health programming within the Centers for Disease 
Control. This funding level will enable CDC to continue its vital work 
to control and prevent oral disease, including vital work in community 
water fluoridation. Federal grants will serve to facilitate improved 
oral health leadership at the State level, support the collection and 
synthesis of data regarding oral health coverage and access, promote 
the integrated delivery of oral health and other medical services, 
enable States to be innovative, and promote a data-driven approach to 
oral health programming.
    National Institute of Dental and Craniofacial Research--Fund at a 
level of $425 million in fiscal year 2015
    The National Institute of Dental and Craniofacial Research (NIDCR) 
cultivates oral health research that has led to a greater understanding 
of oral diseases and their treatments and the link between oral health 
and overall health. Research spurs innovation and efficiency, both of 
which are vital to improving access to oral healthcare services and 
improved oral status of Americans in the future. ADHA joins with others 
in the oral health community to support NIDCR funding at a level of 
$425 million in fiscal year 2015.
    ADHA is the largest national organization representing the 
professional interests of more than 150,000 licensed dental hygienists 
across the country. In order to become licensed as a dental hygienist, 
an individual must graduate from one of the Nation's 335 accredited 
dental hygiene education programs and successfully complete a national 
written and a State or regional clinical examination. Dental hygienists 
are primary care providers of oral health services and are licensed in 
each of the 50 States. Hygienists are committed to improving the 
Nation's oral health, a fundamental part of overall health and general 
well-being. In the past decade, the link between oral health and total 
health has become more apparent and the significant disparities in 
access to oral healthcare services have been well documented. At this 
time, when 130 million Americans struggle to obtain the oral healthcare 
required to remain healthy, Congress has a great opportunity to support 
oral health prevention, infrastructure and workforce efforts that will 
make care more accessible and cost-effective.
Conclusion
    ADHA appreciates the difficult task appropriators face in 
prioritizing and funding the many meritorious programs and grants 
offered by the Federal Government. ADHA urges the Committee to lift the 
block on funding for Section 340G-1 of the PHSA, dental workforce 
demonstration grants. Lifting the block on funding for these dental 
workforce grants would be an important signal to States and to 
healthcare stakeholders that exploring new ways of bringing oral health 
services to the underserved is a meritorious expenditure of resources. 
In addition to the items listed, ADHA also supports full funding for 
community health centers, and urges HRSA be directed to further bolster 
the delivery of oral health services at community health centers, 
including the use of new types of dental providers. ADHA remains a 
committed partner in advocating for meaningful oral health programming 
that makes efficient use of the existing oral health workforce and 
delivers high quality, cost-effective care.

    [This statement was submitted by Denise Bowers, RDH, PHD, 
President, American Dental Hygienists' Association.]
                                 ______
                                 
  Prepared Statement of the American Foundation for Suicide Prevention
    Dear Chairman Harkin and Ranking Moran: As you begin work on the 
fiscal year 2015 Labor, Health and Human Services, and Education 
Appropriations bill, the American Foundation for Suicide Prevention 
(AFSP) respectfully urges you to support investments in public health 
research by including $40 million for the National Institute of Mental 
Health to conduct suicide prevention and brain research including 
studies designed to reduce the risk of self-harm, suicide, and 
interpersonal violence; $25 million for the National Violent Death 
Reporting System (NVRDS) at the Centers for Disease Control and 
Prevention (CDC); $60.15 million for suicide prevention programs under 
the Garrett Lee Smith Memorial Act (GLSMA) through the Substance Abuse 
Mental Health Services Administration (SAMHSA); and $20 million for the 
Mental Health First Aid Program (MHFA).
$40 Million in Funding for Suicide Prevention Research
    Suicide, already the 10th leading cause of death overall in the 
U.S., the 3rd leading cause of death among 15-24 year olds, and the 2nd 
leading cause of death among 24-34 year olds; continues to take more 
and more lives each year. In 2010 (latest available data), suicide took 
the lives of more than 38,000 Americans, up 31 percent from 2000.
    AFSP supports at a minimum a $40 million investment in suicide 
prevention research as recommended by Representative Ron Barber in H.R. 
4075 (the Suicide Prevention Research Innovation Act or SPRINT Act) so 
we can obtain similar reductions in suicide mortality that have 
resulted from strategic investments in other major public health 
concerns.
Full Funding of $25 Million for the National Violent Death Reporting 
        System (NVDRS)
    The NVDRS collects in-depth information on the details of and 
circumstances surrounding each suicide, which goes beyond the basic 
information collected through the CDC's National Vital Statistics 
Reports/Fatal Injury Report and implementing the NVDRS nationwide is 
essential to developing, informing and evaluating suicide prevention 
programs.
    Currently, the National Violent Death Reporting System collects 
surveillance data in only 18 States (Alaska, Colorado, Georgia, 
Kentucky, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, 
North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, 
Utah, Virginia and Wisconsin). The data collected helps inform policy 
makers on trends and characteristics of violent deaths within specific 
communities so they can design appropriate prevention measures and 
evaluate ongoing efforts to curb violence.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Included in the fiscal year 2014 omnibus appropriations bill was an 
additional $7.7 million (bringing the program total to $11.2 million) 
in funding to expand the program; however, AFSP requests the full $25 
million be provided so the CDC would have the resources to scale up 
this effort to include all 50 States. Today, there exists no other data 
surveillance system that offers this benefit for such a modest 
investment. No other data collection or centralization effort carries 
the inherent value associated with NVDRS and, in fact, no other effort 
has the ability to directly inform and impact State and Federal suicide 
prevention activities.
Funding of $60.15 Million for GLSMA Suicide Prevention Programs
    Since its creation in 2004, GLSMA has provided resources to 
communities and college campuses all across the country, and supported 
needed technical assistance to develop and disseminate effective 
strategies and promising practices related to youth suicide prevention. 
To date, the GLSMA has supported youth suicide prevention grants in 49 
States, the District of Columbia and Guam, 48 Tribes or Tribal 
organizations, and 138 institutions of higher education.
    AFSP requests that the Committee approve $60.15 million for GLSMA 
programs in fiscal year 2015 to ensure a continuation of these 
critically important youth and college suicide prevention programs.
Funding of $20 Million for Mental Health First Aid (MHFA)
    Sometimes, first aid isn't a bandage, or CPR, or the Heimlich, or 
calling 911. Sometimes, first aid is you. While many Americans know how 
to administer first aid and seek medical help should they come across a 
person having a heart attack, few are trained to provide similar help 
to someone experiencing a mental health or substance abuse crisis.
    Mental Health First Aid is a public education program that helps 
people identify, understand, and respond to signs of mental illnesses 
and substance abuse. The course teaches participants a 5-step action 
plan to reach out to a person in crisis and connect them with 
professional, peer, or other help.
    AFSP requests that $20 million be approved for MHFA training 
programs around the country that would train participants in 
recognizing the symptoms of common mental illnesses and addiction 
disorders, de-escalating crisis situations safely, and initiating 
timely referral to mental health and substance abuse resources 
available in the community.
    Thank you for your time and consideration of these requests by the 
American Foundation for Suicide Prevention. Should you have any 
questions I can be reached at [email protected].

    [This statement was submitted by John Madigan, Vice President, 
Public Policy.]
                                 ______
                                 
         Prepared Statement of the American Geriatrics Society
    Mr. Chairman and Members of the Subcommittee: We submit this 
testimony on behalf of the American Geriatrics Society (AGS), a non-
profit organization of over 6,000 geriatrics healthcare professionals 
dedicated to improving the health, independence and quality of life of 
all older Americans. As the Subcommittee works on its fiscal year 2015 
Labor-HHS-Education Appropriations bill, we ask that you prioritize 
funding for the geriatrics education and training programs under Title 
VII and Title VIII of the Public Health Service Act and for research 
funding within the National Institutes of Health/National Institute on 
Aging.
    We ask that the subcommittee consider the following recommended 
funding levels for these programs in fiscal year 2015:
  --$39.7 million for Title VII Geriatrics Health Professions Programs
  --$5.0 million for Title VIII Comprehensive Geriatric Education 
        Nursing Program
  --An increase of $500 million for aging research within the National 
        Institutes of Health
    While we recognize the fiscal challenges facing our Nation, 
sustained and enhanced Federal investments in these initiatives are 
essential to delivering higher quality, better coordinated and more 
cost effective care to our Nation's seniors. We request that Congress 
provide the additional investments necessary to expand and enhance the 
geriatrics workforce, which is an integral component of the primary 
care workforce, and to foster groundbreaking medical research so that 
our Nation is prepared to meet the unique healthcare needs of the 
rapidly growing population of seniors.
         programs to train geriatrics health care professionals
    Our Nation is facing a critical shortage of geriatrics faculty and 
healthcare professionals across disciplines. This trend must be 
reversed if we are to provide our seniors with the quality care they 
need and deserve. Care provided by geriatric healthcare professionals, 
who are trained to care for individuals who are the most complex and 
frail and who account for 80 percent of our Medicare expenditures, has 
been shown to reduce common and costly conditions that are often 
preventable with appropriate care, such as falls, polypharmacy, and 
delirium.
Title VII Geriatrics Health Professions Programs ($39.7 million)
    These programs support three initiatives: the Geriatric Academic 
Career Awards (GACAs), the Geriatric Education Center (GEC) program, 
and geriatric faculty fellowships. These are the only programs 
specifically designed to address the well-documented shortage of 
geriatrics healthcare professionals in the U.S. We ask the subcommittee 
to provide a fiscal year 2015 appropriation of $39.7 million for Title 
VII Geriatrics Health Professions Programs.
    Our funding request breaks down as follows:
  --Geriatric Academic Career Awards (GACAs) ($5.5 million)
    GACAs support the development of newly trained geriatric clinicians 
in academic medicine who are committed to teaching geriatrics in 
medical schools across the country. GACA recipients are required to 
provide training in clinical geriatrics, including the training of 
interdisciplinary teams of healthcare professionals. HRSA, through the 
Affordable Care Act, expanded the awards to other disciplines--a change 
long supported by AGS--and requests adequate funding to reflect this. 
In addition, new awardees are only selected every 5 years and we 
believe that these awards should be available annually in order to 
ensure that we have an adequate number of faculty available to provide 
training in the principles of geriatric medicine. Our budget request of 
$5.5 million would support GACA program awardees in their development 
as clinician educators.
    Program Accomplishments.--In Academic Year 2012-2013, the GACA 
program funded 62 full-time junior faculty. These awardees delivered 
over 1,100 different courses, workshops and other types of training 
activities to over 53,000 trainees across the health professions--the 
most common of which included medical school students, residents in 
internal medicine and residents in geriatrics. In addition, GACA 
awardees are highly encouraged to engage in professional development 
and scholarly activities during each academic year as a way of 
advancing the field of geriatrics. Results showed that the awardees 
conducted presentations about their own research and other related 
topics at over 215 conferences at the local, State or national level 
and published a total of 108 peer-reviewed publications.
  --Geriatric Education Centers (GECs) ($20.0 million)
    GECs provide grants to support collaborative arrangements involving 
several health professions, schools and healthcare facilities to 
provide multidisciplinary training in geriatrics, including assessment, 
chronic disease syndromes, care planning, emergency preparedness, and 
cultural competence unique to older Americans. Our funding request of 
$20.0 million includes continued support for the core work of 45 GECs 
($20.0).
    Program Accomplishments.--In Academic Year 2012-2013, the GECs 
supported various types of geriatrics-specific training for health 
professions students and faculty, as well as for current community-
based providers--delivering over 1,650 different continuing education 
courses to over 94,000 trainees. This exceeded the program's 
performance target by 58.5 percent. GEC grantees also partnered with 
over 650 healthcare delivery sites across the country to provide 
clinical and experiential training, in areas such as nursing homes and 
chronic and acute disease hospitals, to over 25,000 trainees. It is 
estimated that 2 out of every 5 sites used by GEC grantees for the 
purposes of offering these types of training were primary care settings 
and/or were located in a medically underserved community.
    --Alzheimer 's Disease Prevention, Education, and Outreach 
            Program.--Funding for this program was included in the 
            President's fiscal year 2015 budget request and allows HRSA 
            to expand efforts to provide interprofessional continuing 
            education to healthcare practitioners on Alzheimer's 
            disease and related dementias through the already existing 
            GECs. We are requesting $5.3 million to support this 
            program.
  --Geriatric Training for Physicians, Dentists, Behavioral/Mental 
        Health Professions ($8.9 million)
    This program is designed to train physicians, dentists, and 
behavioral and mental health professionals who choose to teach 
geriatric medicine, dentistry or psychiatry. The program provides 
fellows with exposure to older adult patients in various levels of 
wellness and functioning, and from a range of socioeconomic and racial/
ethnic backgrounds. Our funding request of $8.9 million will support 
this important faculty development program.
    Program Accomplishments.--In Academic Year 2012-2013, a total of 64 
physicians, psychiatrists, dentists, and psychologists, were supported 
through this program. These fellows received clinical training in over 
200 different healthcare delivery sites across the country; the most 
common types of sites where fellows trained included Veteran's Affairs 
hospitals and clinics, private hospitals, and academic centers. It is 
estimated that nearly half of the sites (49 percent) where GTPD fellows 
received clinical training were located in a medically underserved 
community. Additionally, results showed that GTPD fellows delivered 
over 275 courses, workshops and other training activities focused on 
topics including oral health, chronic disease management and geriatric 
medicine, among others. It is estimated that over 5,600 trainees were 
trained as a result of these activities--the most common of which 
included medical school students, dental school students, residents in 
geriatrics and residents in geriatric psychiatry.
Title VIII Comprehensive Geriatric Education Nursing Program ($5.0 
        million)
    The American healthcare delivery system for older adults will be 
further strengthened by Federal investments in Title VIII Nursing 
Workforce Development Programs, specifically the comprehensive 
geriatric education grants, as nurses provide cost-effective, quality 
care. This program supports additional training for nurses who care for 
the elderly, development and dissemination of curricula relating to 
geriatric care, and training of faculty in geriatrics. It also provides 
continuing education for nurses practicing in geriatrics. Our funding 
request of $5.0 million includes funds to continue the training of 
nurses caring for older Americans.
    Program Accomplishments.--In Academic Year 2012-2013, the 
Comprehensive Geriatric Education Program (CGEP) supported numerous 
types of geriatric-related training programs and activities for health 
professions students and their faculty, as well as for community-based 
healthcare providers across the country. CGEP grantees offered over 150 
different continuing education (CE) courses to over 11,600 trainees 
across the health professions. In addition, 74 students received 
traineeships--the majority of which (81 percent) are pursuing a Masters 
Degree in Nursing to become Nurse Practitioners in the fields of Adult 
Gerontology or Acute Care in Adult Gerontology.
    Grantees of the CGEP also developed and implemented over 120 
different geriatric-focused training activities to include new 
continuing education courses for current providers, as well as new 
academic courses and clinical rotations for health professions 
students, residents and fellows across the country focused on these 
issues. It is estimated that a total of 4,500 trainees were reached as 
a result of these activities. Lastly, CGEP grantees supported over 40 
different faculty development activities and programs. It is estimated 
that over 300 faculty-level trainees were trained on emerging issues in 
the field of geriatrics (e.g., pain management among the elderly, 
advances in patient engagement, among others) as a result of these 
activities.
 research funding initiatives--national institutes of health/national 
                           institute on aging
    The institutes that make up the NIH, and in particular the NIA, 
lead a broad scientific effort to understand the nature of aging and to 
extend the healthy, active years of life. As a member of the Friends of 
the NIA, a broad-based coalition of aging, disease, research, and 
patient groups committed to the advancement of medical research that 
affects millions of older Americans, AGS urges an increase in NIH 
funding of $500 million to support aging research across all 
institutes.
    Considering what the Federal Government spends on the healthcare 
costs associated with age-related diseases, it makes sound economic 
sense to increase Federal resources for aging research. Chronic 
diseases associated with aging afflict 80 percent of the age 65+ 
population and account for more than 75 percent of Medicare and other 
Federal health expenditures. Continued Federal investments in 
scientific research, including comparative effectiveness initiatives, 
will ensure that the NIH has the resources to succeed in its mission to 
establish research networks, assess clinical interventions and 
disseminate credible research findings to patients, providers and 
payers of healthcare.
    In closing, geriatrics is at a critical juncture, with our Nation 
facing an unprecedented increase in the number of older patients with 
complex health needs. Strong support such as yours will help ensure 
that every older American is able to receive high-quality healthcare.
    Thank you for your consideration.
                                 ______
                                 
          Prepared Statement of the American Heart Association
    Although great progress has been made in prevention and treatment 
of cardiovascular disease, including stroke, there is no cure and CVD 
remains America's No. 1 killer, costing a projected $315 billion in 
medical expenses and lost productivity each year. Stroke, alone, is our 
No. 4 killer, costing an estimated $37 billion a year. Both remain 
major causes of disability.
    Nearly 84 million U.S. adults suffer from some form of CVD. It is 
projected that by the year 2030, more than 44 percent of U.S. adults 
will live with CVD at a cost exceeding $1 trillion annually. So, it is 
disturbing that CVD research, prevention and treatment remain 
disproportionately underfunded with no sustained and stable funding 
from the National Institutes of Health. NIH is key for the U.S. to 
mount an ongoing and effective crusade against these devastating 
diseases.
    We appreciate Congress' and the Administration's partial stay of 
sequestration. These cuts jeopardize the health of tens of millions of 
CVD sufferers and weaken our fragile economy and erode our global 
leadership in medical research. We challenge Congress to appropriate 
stable and sustained funding for CVD research, prevention and 
treatment. NIH funding is not only important for the health of our 
Nation, but also supports our economy through research-related 
employment opportunities it provides.
     funding recommendations: investing in the health of our nation
    Research that could move us closer to a cure for heart disease and 
stroke goes unfunded. Congress must capitalize on 50 years of progress 
or our Nation will pay more in lives lost and healthcare costs. Our 
recommendations tackle the topics in a fiscally responsible way.
Capitalize on Investment for the National Institutes of Health (NIH)
    AHA is disappointed Congress did not fully restore sequester cuts 
for NIH in Public Law 113-76. NIH funded studies help prevent and cure 
disease, revolutionize patient care, drive economic growth, advance 
innovation, and sustain U.S. leadership in pharmaceuticals and 
biotechnology. NIH is the world's leader of basic research--the 
starting point for all medical progress and an indispensable Federal 
Government role that the private sector cannot fill. The U.S. is in 
jeopardy of losing our competitive edge in scientific research.
    In addition to improving health, NIH creates a solid return on 
investment. In fiscal year 2012, NIH supported 400,000 U.S. jobs and 
produced nearly $60 billion in new economic activity. Every $1 in NIH 
funding produced $2 in economic activity in 2007. Yet, for the past 
decade, the NIH's budget has not kept pace with medical research 
inflation, resulting in more than a 20 percent loss in purchasing 
power. Such reductions, along with only a 50 percent restoration of 
sequester cuts, have occurred during a time of remarkable heightened 
scientific opportunity and when other countries have been increasing 
investment in science--some by double digits. These cutbacks have also 
demoralized early career investigators who, sadly, may leave and never 
return to research. We cannot afford to lose one of our Nation's most 
valuable resources--an innovative biomedical research workforce.
    American Heart Association Advocates: We ask Congress to 
appropriate $32 billion for NIH to restore sequester cuts, provide for 
modest growth, and advance CVD research.
Enhance Funding for NIH Heart and Stroke Research: A Proven and Wise 
        Investment
    Declining death rates from CVD is directly related to NIH research, 
with scientists on the verge of discoveries that could lead to 
groundbreaking treatments and even cures. In addition to saving lives, 
NIH research is cost-effective. For example, the first NIH tPA drug 
trial resulted in a 10-year net $6.47 billion drop reduction in stroke 
healthcare costs.
Cardiovascular Disease Research: National Heart, Lung, and Blood 
        Institute (NHLBI)
    CVD death rates have greatly declined, with much of the reduction 
traced to research emanating from the NHLBI. Stable and sustained NHLBI 
funding is key to capitalize on investments that have led to major 
discoveries. For example, 10 percent of genetic changes leading to 
severe congenital heart disease are new and not passed down by a 
parent; people who maintained ideal health had better brain function in 
mid-life; digestive system bacteria may cause red meat to raise two 
chemicals linked to CVD; and post-traumatic stress disorder may be a 
heart disease risk factor. Sustained funding will allow robust 
implementation of priority CVD strategic plan initiatives.
Stroke Research: National Institute of Neurological Disorders and 
        Stroke (NINDS)
    An estimated 795,000 Americans will suffer a stroke this year and 
more than 129,000 will die. Many of the 7 million survivors face grave 
physical and mental disabilities and emotional trauma. In addition to 
the physical and emotional toll, stroke costs an estimated $37 billion 
in medical expenses and lost productivity each year. Moreover, the 
future looks grim. A study projects that direct costs of stroke will 
triple between 2010 and 2030.
    Stable and sustained NINDS funding is needed to capitalize on 
investments, including one showing aggressive medical treatment is 
better than stents in preventing a second stroke, and to advance the 
BRAIN Initiative. More resources are required to facilitate the NIH 
Stroke Trials Network and other priorities in stroke prevention, 
treatment and recovery research. They include: hastening translation of 
preclinical animal models into clinical studies; preventing vascular 
cognitive damage; expediting comparative effectiveness research trials; 
developing imaging biomarkers; refining clot-busting treatments; 
achieving robust brain protection; targeting early stroke recovery; and 
using neural interface devices.
    American Heart Association Advocates: We recommend that NHLBI be 
funded at $3.2 billion and NINDS at $1.7 billion for fiscal year 2015.
Increase Funding for the Centers for Disease Control and Prevention 
        (CDC)
    Prevention is the best way to promote good health and reduce the 
costs of heart disease and stroke. Yet, proven prevention approaches 
are not implemented due to limited funds. We applaud Congress for 
providing in Public Law 113-76 the Division for Heart Disease and 
Stroke Research with a much needed boost. In addition to supporting 
research and evaluation and developing a surveillance system, the DHDSP 
administers Sodium Reduction Communities and the Paul Coverdell 
National Acute Stroke Registry. DHDSP, with the Centers for Medicare 
and Medicaid Services, implements Million HeartsTM to 
prevent 1 million heart attacks and strokes by 2017.
    DHDSP runs WISEWOMAN, serving uninsured and under-insured, low-
income women ages 40 to 64. It helps them from becoming heart disease 
and stroke statistics by offering preventive health services, referrals 
to local healthcare, and tailored lifestyle programs to promote lasting 
behavioral change.
    American Heart Association Advocates: We join with the CDC 
Coalition in asking for $7.8 billion for CDC's program level. AHA 
requests $130.188 million for the DHDSP to sustain its participation in 
the State Public Health Actions to Prevent and Control Diabetes, Heart 
Disease, Obesity and Associated Risk Factors and Promote School Health 
and $37 million for WISEWOMAN. We ask for $3 million for Million 
HeartsTM to better control blood pressure.
Restore Funding for Rural and Community Access to Emergency Devices 
        (AED) Program
    About 90 percent of cardiac arrest victims die outside of a 
hospital. Yet, early CPR and use of an automated external defibrillator 
can more than double survival. Communities with full AED programs have 
survival rates near 40 percent. HRSA's Rural and Community AED Program 
awards competitive grants to States to buy AEDs, tactically place them, 
and train lay rescuers and first responders in their use. Nearly 800 
patients were saved from August 1, 2009 to July 31, 2010. But scarce 
resources let only 22 percent of approved applicants in 6 States 
receive funds in fiscal year 2013.
    American Heart Association Advocates: We ask for a fiscal year 2015 
appropriation of $8.927 million to return this life-saving AED program 
to fiscal year 2005 levels when 47 States were funded.
                               conclusion
    Cardiovascular disease, including stroke, still wreak a deadly, 
disabling and costly toll on Americans. Our recommendations for NIH, 
CDC and HRSA will save lives and slash escalating healthcare costs. We 
challenge Congress to carefully study our requests that signify a wise 
investment for our country and for the health and well-being of this 
and future generations.

    [This statement was submitted by Mariell Jessup, M.D., President, 
American Heart Association.]
                                 ______
                                 
 Prepared Statement of the American Indian Higher Education Consortium
    This statement includes the fiscal year 2015 recommendations of the 
Nation's Tribal Colleges and Universities (TCUs), in two areas of the 
Department of Education: Office of Postsecondary Education and Office 
of Vocational Education.
                     higher education act programs
    Strengthening Developing Institutions.--Titles III and V of the 
Higher Education Act support institutions that enroll large proportions 
of financially disadvantaged students and have low per-student 
expenditures. The TCUs, which by any definition are truly developing 
institutions, funded under Title III-A Sec. 316 are providing quality 
higher education opportunities to some of the most rural/isolated, 
impoverished, and historically underserved areas of the country. The 
goal of HEA-Titles III/V programs is ``to improve the academic quality, 
institutional management and fiscal stability of eligible institutions, 
in order to increase their self-sufficiency and strengthen their 
capacity to make a substantial contribution to the higher education 
resources of the Nation.'' The TCU Title III-A program is specifically 
designed to address the critical, unmet needs of their American Indian 
students and communities, in order to effectively prepare them to 
succeed in a globally competitive workforce. Yet, in fiscal year 2011 
this critical program was cut by over 11 percent, by another 4 percent 
in fiscal year 2012, and hit by sequestration--on the lowered 
baseline--in fiscal year 2013. Although sequestration was not imposed 
in fiscal year 2014, the TCUs have not recovered from the earlier cuts 
to this vitally important program. The TCUs urge the Subcommittee to 
restore the discretionary funding for HEA Title III-A, Sec. 316 to 
$30,000,000 in fiscal year 2015.
    TRIO.--Retention and support services are vital to achieving the 
national goal of having the highest proportion of college graduates in 
the world by 2020. TRIO programs, such as Student Support Services and 
Upward Bound, were created out of recognition that college access is 
not enough to ensure advancement and that multiple factors work to 
prevent the successful completion of postsecondary programs for many 
low-income and first-generation students and students with 
disabilities. Therefore, in addition to providing the maximum Pell 
Grant award level, it is critical that Congress also sustain student 
assistance programs, such as Student Support Services and Upward Bound 
so that low-income and minority students have the Federal support 
necessary to allow them to remain enrolled in and ultimately complete 
their higher education degrees.
    Pell Grants.--The importance of Pell Grants to TCU students cannot 
be overstated. Approximately, 80 percent of TCU students receive Pell 
Grants, primarily because student income levels are so low and they 
have far less access to other sources of financial aid than students at 
State-funded and other mainstream institutions. Within the TCU system, 
Pell Grants are doing exactly what they were intended to do--they are 
serving the needs of the lowest income students by helping them gain 
access to quality higher education, an essential step toward becoming 
active, productive members of the workforce. However, the U.S. 
Department of Education has changed its regulations to limit Pell 
eligibility from 18 to 12 full-time semesters, without any 
consideration of those already in the process of earning a 
postsecondary degree. This change in policy has impeded some TCU 
students from completing a postsecondary degree, which is widely 
recognized as being critical for access to, and advancement in, today's 
highly technical workforce.
    TCUs are open enrollment institutions. Recent placement tests 
administered at TCUs to first-time entering students indicated that 74 
percent required remedial math, 54 percent required remedial reading, 
and 57 percent needed remedial writing. These results clearly 
illustrate just how serious this new Pell Grant eligibility limit is to 
the success of TCU students in completing a postsecondary degree. 
Students requiring remediation can use as much as a full year of 
eligibility enhancing their math, and or reading/writing skills, 
thereby hampering their future postsecondary degree plans. A prior 
national goal was to provide access to quality higher education 
opportunities for all students regardless of economic means, at which 
TCUs have been extremely successful. While the new national goal 
intends to produce graduates with postsecondary degrees by 2020, this 
change in policy does not advance that objective. On the contrary, the 
new regulations will cause many low-income students to once again 
abandon their dream of a postsecondary degree, as they will simply not 
have the means to continue to pursue it. The goal of a well-trained 
technically savvy workforce will be greatly compromised. This new 
policy evokes the adage ``penny wise--pound foolish.'' The TCUs urge 
the Subcommittee to continue to fund this essential program at the 
highest possible level, and to direct the Secretary of Education to 
implement a process to waive the very restrictive 12 semester Pell 
Grant eligibility for TCU students.
            perkins career and technical education programs
    Tribally-Controlled Postsecondary Career and Technical 
Institutions.--Section 117 of the Carl D. Perkins Career and Technical 
Education Act provides a competitively awarded grant opportunity for 
tribally chartered and controlled career and technical institutions. 
AIHEC requests $8,200,000 to fund grants under Sec. 117 of the Perkins 
Act.
    Native American Career and Technical Education Program (NACTEP).--
NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding to 
support American Indian career and technical programs. The TCUs 
strongly urge the Subcommittee to continue to support NACTEP, which is 
vital to the continuation of career and technical education programs 
offered at TCUs that provide job training and certifications to remote 
reservation communities.
  american indian adult and basic education (office of vocational and 
                            adult education)
    This program supports adult basic education programs for American 
Indians offered by State and local education agencies, Indian tribes, 
agencies, and TCUs. Despite the absence of dedicated funding, TCUs must 
find a way, often using already insufficient institutional operating 
funds, to continue to provide adult basic education classes for those 
American Indians that the present K-12 Indian education system has 
failed. Before many individuals can even begin the course work needed 
to learn a productive skill, they first must earn a GED or, in some 
cases, even learn to read. The new GED exam, which was instituted in 
January 2014, has a much stronger focus on mathematics. As noted 
earlier, placement tests for TCU entering students reveal a tremendous 
need for math remediation. Additionally, the new GED test is fully 
computerized. While younger GED seekers may be well versed and 
comfortable with computer-based testing, older and poorer citizens may 
not be. These factors indicate a further and growing need for adult 
basic educational programs and GED preparation on Indian reservations. 
TCUs must have sufficient and stable funding to continue to provide 
these essential activities and to ensure their communities residents 
have the same chances to succeed as others throughout the country have. 
TCUs request that the Subcommittee direct that $8,000,000 of the funds 
appropriated annually for the Adult Education State Grants be made 
available to make competitive awards to TCUs to help meet the growing 
demand for adult basic education and remediation program services on 
their respective Reservations.
further justifications for fiscal year 2015 appropriations requests for 
                                  tcus
    Tribal colleges and our students are already being 
disproportionately impacted by ongoing efforts to reduce the Federal 
budget deficit and control Federal spending. The fiscal year 2011 
Continuing Resolution eliminated all of the Department of Housing and 
Urban Development's Minority Serving Institutions (MSIs) community-
based programs, including a critically needed TCU-HUD facilities 
program. TCUs were able to maximize leveraging potential, often 
securing even greater non-Federal funding to construct and equip Head 
Start and early childhood centers; student and community computer 
laboratories and public libraries; and student and faculty housing in 
rural and remote communities where few and sometimes none of these 
facilities existed. Important STEM programs, administered by the 
National Science Foundation and NASA were cut, and for the first time 
since the NSF program was established in fiscal year 2001, no new TCU-
STEM awards were made in fiscal year 2011. While NSF-TCUP grants 
resumed in fiscal year 2012, a year of grant opportunity was lost. TCUs 
Additionally, TCUs and their students suffer the realities of cuts to 
programs such as GEAR-UP, TRIO, SEOG, and as noted earlier, are 
seriously impacted by the new highly restrictive Pell Grant eligibility 
criteria more profoundly than mainstream institutions of higher 
education, which can realize economies of scale due to large 
endowments, alternative funding sources, including the ability to 
charge higher tuition rates and enroll more financially stable 
students, and access to affluent alumni. The loss of opportunities that 
cuts to DoEd, HUD, NSF, and NASA programs represent to TCUs, and to 
other MSIs, is magnified by cuts to workforce development programs 
within the Department of Labor, nursing and allied health professions 
tuition forgiveness and scholarship programs operated by the Department 
of Health and Human Services, and an important TCU-based nutrition 
education program planned by USDA. Combined, these cuts strike at the 
most economically disadvantaged and health-challenged Americans.
    We respectfully request that the Members of the Subcommittee 
continue the Federal investment in the Nation's Tribal Colleges and 
Universities and full consideration of our fiscal year 2015 
appropriations needs and recommendations.
                                 ______
                                 
        Prepared Statement of the American Physiological Society
    The American Physiological Society (APS) thanks the subcommittee 
for its ongoing support of the National Institutes of Health (NIH). 
Research carried out by the NIH contributes to our understanding of 
health and disease, which allows all Americans to look forward to a 
healthier future. The APS urges you to make every effort to provide the 
NIH with a net funding level of $32 billion in fiscal year 2015. This 
is necessary to prevent further erosion of research capacity.
    Federal investment in research is critically important because 
breakthroughs in basic and translational research are the foundation 
for new drugs and therapies that help patients, fuel our economy, and 
provide jobs. The Federal Government is the primary funding source for 
discovery research through competitive grants awarded by the NIH. 
Although the private sector partners with academic researchers to 
develop research findings into new treatments, industry relies upon 
federally funded research to identify where innovation opportunities 
can be found. This system of public-private partnership has been 
critical to U.S. leadership in the biomedical sciences. However, this 
position of leadership is at risk as other nations, including China, 
increase their investments in research and development while the United 
States investment has lagged in recent years.
    Federal research dollars also have a significant impact at the 
local level: Approximately 85 percent of the NIH budget is awarded 
throughout the country to researchers who use grant funds to pay 
research and administrative staff, purchase supplies and equipment, and 
cover other costs associated with their research.
NIH funds outstanding science
    As a result of improved healthcare, Americans in the 21st century 
are living longer and healthier lives than ever before. However, 
chronic conditions such as cardiovascular disease, diabetes, 
respiratory illnesses, Alzheimer's and cancer continue to inflict a 
heavy burden in the United States and around the world. As the U.S. 
population ages, the prevalence and cost of these diseases will 
increase exponentially. The NIH invests heavily in basic research to 
understand the physiological mechanisms at work in health and disease. 
This knowledge is crucial to the development of safe and effective 
interventions and prevention strategies.
    Exciting new initiatives are underway at the NIH to advance 
science, including the Brain Research through Advancing Innovative 
Neurotechnologies (``BRAIN'') initiative and the Big Data 2 Knowledge 
project (BD2K). The BRAIN initiative will bring together researchers 
from diverse disciplines to tackle major gaps in current knowledge 
about the brain and brain diseases. BD2K will explore ways to 
capitalize on the immense volume of data being created by biomedical 
scientists, ultimately enhancing the work of the entire community by 
providing new tools and resources to make better use of that data. 
These important projects require significant resources, and at a time 
of constrained budgets, that will further diminish funding for 
investigator-initiated grants. The NIH system of allowing investigators 
to develop and propose ideas which are then evaluated by their peers 
and selected for funding based on their merit has fostered a research 
enterprise that is second to none. Increasing the NIH budget to $32 
billion would provide funding for large projects as described above, 
while also providing resources for individual scientists to pursue 
creative new avenues of research.
NIH nurtures the biomedical research enterprise
    In addition to supporting research, the NIH must also address 
workforce issues to ensure that our Nation's researchers are ready to 
meet the challenges they will face in the future. The pressures placed 
on the biomedical research enterprise after years of sub-inflationary 
budget increases were severely compounded by sequestration cuts in 
fiscal year 2013. One analysis showed that NIH supported approximately 
1000 fewer investigators in fiscal year 2013 as a result of its 
declining budget.\1\ Researchers who lose their funding face an 
uncertain future as there are few options to sustain their research 
without Federal grants. Losing Federal support puts at risk the 
investment that it took to build those programs over many years. It 
also means that talented individuals working in those labs will have to 
look elsewhere for increasingly scarce jobs. As a result of stagnant 
funding for NIH, scientists at all stages of their careers struggle to 
maintain their research programs.
---------------------------------------------------------------------------
    \1\ http://www.asbmb.org/asbmbtoday/201403/PresidentsMessage/
---------------------------------------------------------------------------
    Scientists in the early stages of their careers face a particular 
set of challenges as they work to establish themselves during a time of 
dwindling resources. To address some of these problems, the NIH is 
continuing its commitment to fund new investigators at approximately 
the same rate as established investigators. The NIH is also developing 
three new efforts to ensure a diverse and sustainable future biomedical 
workforce. The National Research Mentoring Network (NRMN) and the 
Building Infrastructure Leading to Diversity (BUILD) initiative are 
complementary programs that will develop innovative new mentorship 
programs to engage individuals from diverse backgrounds and help them 
prepare to succeed in biomedical research careers. The Coordination and 
Evaluation Center (CEC) will play a role in coordinating and assessing 
NRMN and BUILD, providing program-wide goals and tools to assess 
progress. These efforts are critical to helping young scientists launch 
their careers. However, to sustain a talented workforce the NIH needs 
predictable and sustainable budget growth. If the current funding 
crisis is not resolved, the continued loss of senior researchers will 
begin to erode the pool of experienced mentors for early career 
scientists on which the BUILD and NRMN programs rely.
    The NIH also uses the Institutional Development Award (IDeA) 
Program to broaden the geographic distribution of NIH funds by 
providing support to researchers and institutions in areas that have 
not previously received significant NIH funding. IDeA builds research 
capacity and improves competitiveness in those States by developing 
shared resources, infrastructure and expertise. Networks established 
through this program expand research opportunities for students and 
faculty at predominantly undergraduate institutions and enhance the 
level of science and technology knowledge of the workforce in IDeA 
States. The program currently serves institutions and researchers in 23 
States and Puerto Rico. The APS believes this program is an important 
way to broaden participation in the scientific workforce.
    The APS appreciates the support of the committee in continuing the 
Science Education Partnership Awards (SEPA) program at the NIH. This 
program was slated for elimination last year under the proposed 
consolidation of science education programs across Federal agencies. 
The SEPA program fosters important connections between biomedical 
researchers and K-12 students and teachers, providing an opportunity 
for students at the earliest levels to learn about STEM careers. No 
other Federal STEM program addresses biomedicine or provides this kind 
of outreach concerning what NIH does to promote the health of our 
citizens. Thus, SEPA programs promote health literacy among young 
individuals, who will increasingly be expected to manage their own 
healthcare. Many of the programs sponsored by SEPA, including those at 
the APS, disproportionately reach underrepresented and disadvantaged 
students. The APS believes that the SEPA program helps establish the 
groundwork to address issues of workforce diversity and health 
literacy.
    The APS is a professional society dedicated to fostering research 
and education as well as the dissemination of scientific knowledge 
concerning how the organs and systems of the body work. The Society was 
founded in 1887 and now has more than 10,000 member physiologists. APS 
members conduct NIH-supported research at colleges, universities, 
medical schools, and other public and private research institutions 
across the U.S.
    The APS joins the Federation of American Societies for Experimental 
Biology (FASEB) in urging that NIH be provided with no less than $32 
billion in fiscal year 2014.\2\
---------------------------------------------------------------------------
    \2\ www.faseb.org/fundingreport

    [This statement was submitted by Kim E. Barrett, Ph.D., President, 
American Physiological Society.]
                                 ______
                                 
      Prepared Statement of the American Psychological Association
    The American Psychological Association (APA) is the largest 
scientific and professional organization representing psychology in the 
U.S.: its membership includes nearly 130,000 researchers, educators, 
clinicians, consultants and students. APA works to advance the 
creation, communication and application of psychological knowledge to 
benefit society and improve people's lives. Many programs in the Labor-
HHS-Education bill impact science, education, and the populations 
served by clinical psychologists.
    National Institutes of Health.--The Consolidated Appropriations Act 
of 2014 increase for NIH did not give back all of the funds cut by 
sequestration in fiscal year 2013 nor did it restore the purchasing 
power lost over the past decade. As a member of the Ad Hoc Group for 
Medical Research, APA recommends that NIH receive at least $32 billion 
in fiscal year 2015 as the next step toward a multi-year increase in 
our Nation's investment in health research. APA also urges Congress and 
the Administration to work in a bipartisan manner to end sequestration 
and the continued cuts to health research that squander invaluable 
scientific opportunities, discourage young scientists, threaten or slow 
improvements in our Nation's health, and jeopardize our economic 
future.
    Psychological scientists are supported by research grants or 
training programs in almost all of NIH's 27 institutes and centers. 
They are working with animal models or human participants to improve 
diagnosis and treatment of Alzheimer's disease and autism, to 
understand the mechanisms underlying adoption of healthy behaviors, and 
to help prevent transmission of HIV and unhealthy behaviors such as 
substance abuse. Behavioral research is critical to NIH's mission: 
approximately 40 percent of premature mortality in the U.S. is due to 
behaviors such as smoking, sedentary lifestyle, and alcohol and other 
drug consumption. APA encourages continued support for OppNet, the 
trans-institute initiative funded through the Office of Behavioral and 
Social Sciences Research that has led to some $90 million in funding of 
basic research through fiscal year 2013 on critical issues such as 
sleep, stress, and multisensory perception. As NICHD develops 
initiatives to understand and prevent harmful and costly preterm 
births, APA encourages that institute to enhance research on 
psychological factors that may contribute.
    There remains a disturbing paucity of scientific evidence about the 
effects of sporadic vs. regular use of marijuana, alcohol, nicotine and 
other substances on the developing brain. A large-scale, prospective 
study that (a) includes brain imaging and (b) begins in late childhood 
(prior to substance exposure) and continues into early adulthood is 
urgently needed. Now is the time to begin an in-depth and definitive 
longitudinal study to document the short- and long-term effects of 
substance use and, in particular, the impact on young brains to inform 
future drug policy decisions. By tracking brain development and various 
life outcomes alongside behavioral data on substance use, the study 
would also illuminate the developmental effects of individual 
substances as well as substance interactions, as well as better 
establish the relationship between substance use and other mental 
disorders (e.g., does substance use predispose adolescent users to 
mental illness; do subclinical or premorbid symptoms of mental illness 
lead to substance use; or are associations due to a shared 
vulnerability?). APA urges the NIH to conduct such a study as part of 
the Collaborative Research on Addictions at NIH (CRAN initiative) to 
comprehensively document the biological and behavioral effects of 
substance use on the developing brain by conducting a longitudinal 
naturalistic study monitoring a nationally representative sample of 
10,000 healthy 10-year-old children over the course of 10 years.
    Centers for Disease Control and Prevention.--As a member of the CDC 
Coalition, APA supports at least $7.8 billion for core programs in 
fiscal year 2015. Rather than relying on the Prevention Fund and other 
transfers, APA urges the committee to restore CDC's budget authority. 
As a member of the Friends of NCHS, APA recommends a program level of 
$182 million for the National Center on Health Statistics. APA strongly 
supports the President's request for increased funding for the National 
Injury Prevention and Control Center, including $10 million research 
into the causes and prevention of gun violence, to allow the CDC to 
carry out the critical research agenda developed last year by the 
Institute of Medicine and the National Research Council, and for $23.57 
million for the National Violent Death Reporting System, to allow for 
its expansion to all 50 States and DC. APA is pleased that the 
Committee provided an increase in funding for the Prevention Research 
Centers program in fiscal year 2014, and urges that funding be restored 
for the program to at least $28 million in fiscal year 2015, consistent 
with the fiscal year 2011 funding level, to support research essential 
to the focus on prevention. APA supports the President's request of 
$360.7 million for surveillance, research and programs to support HIV 
prevention in the Division of HIV/AIDS Prevention, an increase of $4.3 
million above fiscal year 2014. Additional resources should be directed 
toward behavioral and social science research that optimizes outcomes 
along the HIV care continuum; implementation science to enhance linkage 
and retention in care; research on adherence to treatment; developing 
and scaling up interventions for most the impacted persons living with 
HIV/AIDS; development, adaptation and implementation of innovative 
strategies to address stigma and discrimination; and research into 
structural and environmental factors that drive the HIV epidemic.
    Substance Abuse and Mental Health Services Administration.--APA 
strongly supports:
  --The National Child Traumatic Stress Network (NCTSN) program. APA 
        recommends increased support for the Network's efforts on 
        behalf of the recovery of children, families, and communities 
        affected by physical and sexual abuse, school and community 
        violence, natural disasters, sudden death of a loved one, war's 
        impact on military families, and other trauma.
  --Garrett Lee Smith Memorial Act programs--Campus Suicide Prevention, 
        State and Tribal Youth Suicide Prevention and the Suicide 
        Prevention Resource Center. These effective national programs 
        help meet the mental and behavioral health needs of youth and 
        young adults through access to prevention, education, and 
        outreach services to reduce suicide risk in these populations. 
        First authorized in 2004, the Garrett Lee Smith Memorial Act 
        has supported youth suicide prevention grants in 49 States, 48 
        Tribes or Tribal organizations, and 138 institutions of higher 
        education.
  --Minority Fellowship Program. APA remains concerned that while 
        minorities represent 30 percent of the population and are 
        projected to increase to 40 percent by 2025, only 23 percent of 
        recent doctorates in psychology, social work and nursing were 
        awarded to minorities. We encourage the Committee to support 
        the Administration's $5 million increase for the MFP as 
        requested in the fiscal year 2015 budget proposal. The increase 
        reflects the need to continually grow the pool of culturally 
        competent mental health professionals.
  --Mental Health Care Provider Education in HIV/AIDS Program, in CMHS. 
        Continuing education for mental health providers in these 
        crucial clinical issues remains a high priority. APA urges 
        Congress to maintain level funding in CMHS for the training of 
        psychologists, social workers, and psychiatrists in mental 
        health and psychosocial issues related to HIV/AIDS.
  --SAMHSA-funded programs providing vital substance abuse and mental 
        health services to people with HIV/AIDS.
  --SAMHSA's Safe Schools/Healthy Students program that expands access 
        to mental and behavioral health services in schools and reduces 
        violence through prevention and early intervention supports.
    Health Resources and Services Administration.--APA recommends 
funding SSA Section 512 regarding services to individuals with a 
postpartum condition. Postpartum Depression (PPD) is one of the most 
common and frequently undiagnosed conditions associated with 
childbirth. In the U.S. approximately one in five women suffers from 
PPD each year. While PPD is a widespread problem, under the current 
USPSTF guidelines, depression screening is available as an Essential 
Health Benefit to all non-pregnant adults, yet excludes the vulnerable 
population of pregnant women. APA supports funding for this as-yet 
unfunded provision that supports PPD research and treatment and the 
incorporation of screening and linkages to behavioral health treatment 
for families affected by this condition. APA encourages the Committee 
to support incorporation of PPD screening into the Title V programs 
administered by HRSA as well as Healthy Start. APA also encourages the 
Committee to urge the Secretary to prioritize the issue of PPD by 
raising awareness, expanding research, and establishing grants for the 
operation and coordination of cost-effective services to afflicted 
women and their families.
    APA recommends continued investments in the mental and behavioral 
health workforce, including $6.9 million for the Graduate Psychology 
Education program to increase the number of health service 
psychologists trained to provide services to high-need and high-demand 
underserved populations in both urban and rural communities. This 
program supports the training of doctoral psychology students, interns 
and postdoctoral residents with other health professionals while they 
provide supervised mental and behavioral health services to underserved 
and vulnerable populations, including: children, older adults, veterans 
and their families, individuals with chronic illnesses, and victims of 
abuse and trauma. In 2010-2011 alone, the GPE program supported the 
training of 620 graduate psychology students and provided mental and 
behavioral health services to over 46,000 underserved persons. APA 
encourages HRSA to maintain a strong emphasis on serving rural veteran 
populations and their families. There is a growing need for highly 
trained mental and behavioral health professionals to deliver evidence-
based services to the rapidly aging population. APA encourages HRSA to 
reinstate the geropsychology component, and help integrate health 
service psychology trainees at federally Qualified Health Centers.
    HHS programs on aging.--Given that approximately 20-25 percent of 
older adults have a mental or behavioral health problem, and older 
white males (age 85 and over) currently have the highest rates of 
suicide of any group in the U.S. APA supports an expanded effort to 
address the mental and behavioral health needs of older adults 
including implementation of the mental and behavioral health provisions 
in the Older Americans Act Amendments of 2006, grants to States for the 
delivery of mental health screening, and treatment services for older 
individuals and programs to increase public awareness and reduce the 
stigma associated with mental disorders in older individuals.
    APA also recommends continued support of the HHS's Lifespan Respite 
Program. Respite care can provide family caregivers with relief 
necessary to maintain their own health, bolster family stability and 
well-being, and avoid or delay more costly nursing home or foster care 
placements.
    Department of Education.--APA supports strengthening our Federal 
investment in gifted and talented education and encourages Congress to 
fund the Javits Gifted and Talented Education Program in fiscal year 
2015, funded last year at $5 million. And, as a member of the Friends 
of the Institute of Education Sciences (IES), APA supports $202.3 
million for IES's research, development and dissemination portfolio, 
consistent with the Administration's 2013 and 2014 requests. This would 
support critical investments to provide evidence-based information on 
effective educational practices to parents, teachers and schools, and 
new research to fill gaps in knowledge.
    Thank you for the opportunity to submit testimony for the record in 
support of critical program areas funded by the Labor-Health and Human 
Services-Education appropriations bill.
                                 ______
                                 
      Prepared Statement of the American Public Health Association
    The American Public Health Association is a diverse community of 
public health professionals who champion the health of all people and 
communities. We are pleased to submit our request to fund the Centers 
for Disease Control and Prevention at $7.8 billion and the Health 
Resources and Services Administration at $7.48 billion in fiscal year 
2015. We urge you to take our recommendations to restore funding to at 
least fiscal year 2010 levels into consideration as you move forward 
with writing the fiscal year 2015 Labor-HHS-Education Appropriations 
bill.
Centers for Disease Control and Prevention
    APHA believes Congress should support CDC as an agency, not just 
the individual programs that it funds. Given the challenges and burdens 
of chronic disease and disability, public health emergencies, new and 
reemerging infectious diseases and other unmet public health needs, we 
urge a funding level of $7.8 billion for CDC's programs in fiscal year 
2015. We appreciate some of the important new investments in President 
Obama's fiscal year 2015 budget proposal; however, under the 
president's proposal, CDC's total budget would be cut by nearly $243 
million compared to fiscal year 2014. CDC's budget authority under the 
president's budget is lower than fiscal year 2003 levels. State and 
local health departments continue to operate on tight budgets and with 
a smaller workforce, losing more than 50,000 public health jobs since 
2008. These cuts will reduce the ability of CDC and its State and local 
grantees to investigate and respond to public health emergencies, 
ensure adequate immunization rates and track environmental hazards.
    By translating research findings into effective intervention 
efforts, CDC is a critical source of funding for many of our State and 
local programs that aim to improve the health of communities. Perhaps 
more importantly, Federal funding through CDC provides the foundation 
for our State and local public health departments, supporting a trained 
workforce, laboratory capacity and public health education 
communications systems. It is notable that more than 70 percent of 
CDC's budget supports public health and prevention activities by State 
and local health organizations and agencies, national public health 
partners and academic institutions.
    CDC also serves as the command center for our Nation's public 
health defense system against emerging and reemerging infectious 
diseases. With the potential onset of a worldwide influenza pandemic 
and the many other natural and man-made threats that exist in the 
modern world, CDC has become the Nation's--and the world's--expert 
resource and response center, coordinating communications and action 
and serving as the laboratory reference center. States and communities 
rely on CDC for accurate information and direction in a crisis or 
outbreak.
    CDC serves as the lead agency for bioterrorism and other public 
health emergency preparedness and response programs and must receive 
sustained support for its preparedness programs in order for our Nation 
to meet future challenges. Given the challenges of terrorism and 
disaster preparedness, and our many unmet public health needs and 
missed prevention opportunities we urge you to provide adequate funding 
for State and local capacity grants. Unfortunately, this is not a 
threat that is going away.
    CDC plays a significant role in addressing chronic diseases such as 
heart disease, stroke, cancer, diabetes and arthritis that continue to 
be the leading causes of death and disability in the United States. 
These diseases, many of which are preventable, are also among the most 
costly to our health system. CDC's National Center for Chronic Disease 
Prevention and Health Promotion provides critical funding for State 
programs to prevent chronic disease, conducts surveillance to collect 
data on disease prevalence and monitor intervention efforts and 
translates scientific findings into public health practice in our 
communities.
    CDC's National Center for Environmental Health is essential to 
protecting the health and well being of the public by helping to 
control asthma, protect from threats associated with climate change and 
reduce exposure to lead and other hazards. We urge the subcommittee to 
provide adequate funding for NCEH which has been significantly cut in 
recent years.
Health Resources and Services Administration
    HRSA operates programs in every State and U.S. territory and is a 
national leader in improving the health of Americans through the 
delivery of quality health services and supporting a well prepared 
workforce. The agency serves the health needs of people who are 
medically vulnerable, low-income and geographically isolated. The 
Nation faces a shortage of health professionals and continues to 
experience an ever growing, aging and increasingly diverse population, 
alongside health professionals that are nearing retirement age. We are 
deeply concerned that since fiscal year 2010, HRSA's discretionary 
budget authority has been cut by 19 percent in nominal dollars and 25 
percent when adjusted for inflation. Funding for HRSA is far too low 
and keeping austerity measures in place will threaten the agency's 
ability to address the present and growing health needs of the U.S. To 
respond to the needs of our Nation, APHA recommends restoring funding 
to the fiscal year 2010 level of $7.48 billion for discretionary HRSA 
programs in fiscal year 2015.
    HRSA programs have a strong history of providing quality care to 
keep people healthy and improve health equity for those living outside 
of the economic and medical mainstream. HRSA has contributed to the 
decrease in infant mortality rate, a widely used indicator of the 
Nation's health, which is now at an all-time low. Most recently, 
preliminary data indicates that the infant mortality rate for black 
infants has decreased, resulting in a narrowing of the gap that exists 
between racial groups. HIV/AIDS programs administered by HRSA provide 
access to regular care and ensure adherence to antiretroviral treatment 
for people living with HIV, which reduces HIV transmission by 96 
percent and greatly contributes to the prevention of new HIV 
infections. A committed investment from Congress is required to 
continue achieving the health improvements HRSA has made and to pave 
the way for new achievements.
    Our recommendation is based on the need to continue improving the 
health of Americans by supporting critical HRSA programs, including:
  --Health Professions supports the education and training of a broad 
        range of health professionals. With a focus on primary care and 
        training in interdisciplinary, community-based settings, these 
        are the only Federal programs focused on filling the gaps in 
        the supply of health professionals, as well as improving the 
        distribution and diversity of the workforce so health 
        professionals are well-equipped to care for the growing and 
        changing population.
  --Primary Care supports 9,200 health sites in every State and U.S. 
        territory, improving access to care for more than 21 million 
        patients in geographically isolated and economically distressed 
        communities. Close to half of these health centers serve rural 
        populations. In addition, health centers target populations 
        with special needs, including migrant and seasonal farm 
        workers, homeless individuals and families and those living in 
        public housing.
  --Maternal and Child Health including the Title V Maternal and Child 
        Health Block Grant, Healthy Start and others support 
        initiatives designed to promote optimal health, reduce 
        disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality healthcare for more 
        than 43 million women and children, including children with 
        special healthcare needs.
  --HIV/AIDS provides assistance to States and communities most 
        severely affected by HIV/AIDS. The programs deliver 
        comprehensive care, prescription drug assistance and support 
        services for about half of the total population--1.1 million 
        people--living with HIV/AIDS in the U.S. Additionally, the 
        programs provide education and training for health 
        professionals treating people with HIV/AIDS and work toward 
        addressing the disproportionate impact of HIV/AIDS on racial 
        and ethnic minorities.
  --Family Planning Title X services ensure access to a broad range of 
        reproductive, sexual and related preventive healthcare for over 
        5 million poor and low-income women, men and adolescents at 
        nearly 4,400 health centers nationwide. This program helps 
        improve maternal and child health outcomes and promotes healthy 
        families.
  --Rural Health improves access to care for the nearly 50 million 
        people living in rural areas that experience a persistent 
        shortage of healthcare services. These programs are designed to 
        support community-based disease prevention and health promotion 
        projects, help rural hospitals and clinics implement new 
        technologies and strategies and build health system capacity in 
        rural and frontier areas.
Conclusion
    In closing, we emphasize that the public health system requires 
stronger financial investments at every stage. This funding makes up 
less than 1 percent of Federal spending and continued austerity 
measures that cut funding for public health and prevention programs 
will not balance our budget and will only lead to increased costs to 
our healthcare system. Successes in biomedical research must be 
translated into tangible prevention opportunities, screening programs, 
lifestyle and behavior changes and other population-based interventions 
that are effective and available for everyone. Without a robust and 
sustained investment in our public health agencies, we will fail to 
meet the mounting health challenges facing our Nation.

    [This statement was submitted by Georges Benjamin, MD, Executive 
Director American Public Health Association.]
                                 ______
                                 
      Prepared Statement of the American Society for Microbiology
    The American Society for Microbiology (ASM), the largest single 
life science Society with over 39,000 members, wishes to submit a 
statement in support of increased funding in the fiscal year 2015 
budget for the Centers for Disease Control and Prevention (CDC). As the 
Nation's health protection Agency, the CDC's programs are critical to 
preventing disease and injury. The CDC conducts scientific 
investigations, develops public health guidelines and provides 
information and expertise in response to threats against public health 
in the United States and worldwide.
    The ASM urges Congress to approve the requested budget of $445.3 
million for the National Center for Emerging and Zoonotic Infectious 
Diseases (EZID), an overall increase of $54.9 million over fiscal year 
2104. The EZID budget includes an increase of $31 million for Core 
Infectious Diseases. A funding level of $30 million is included for 
Advanced Molecular Detection (AMD), year 2 of the 5 year initiative to 
enhance CDC's microbiology and bioinformatics capabilities to detect 
and respond to infectious disease outbreaks. The AMD initiative will 
improve pathogen identification and detection; adapt new diagnostics to 
meet evolving public health needs; help States meet future reference 
testing needs in a coordinated manner; implement enhanced, sustainable 
and integrated laboratory information systems; and develop prediction 
modeling and early recognition tools. Advances in biotechnology and 
computing must be part of CDC efforts against the threat of infectious 
diseases. Because of the need for better molecular sequencing tools and 
bioinformatics, last year CDC proposed the AMD initiative, integrating 
cutting edge laboratory and computer tools to enhance infectious 
disease prevention and control. A 2013 pilot study tracking a Listeria 
outbreak demonstrated that AMD technologies and methods could detect 
outbreaks sooner, halting disease faster. The study used whole genome 
sequencing with diagnostic testing for the first time to help clarify 
which patients' illnesses were related to a listeriosis outbreak linked 
to contaminated cheese. Listeria ranks third as a cause of death from 
foodborne pathogens in the United States and sickens about 1,600 people 
each year.
    The EZID budget includes a $10 million increase for CDC's Food 
Safety program. This increase is essential to enhance national 
surveillance outbreak detection and response and food safety prevention 
efforts. It will help modernize PulseNet and apply advanced DNA 
technology and expand sites for FoodCORE to improve outbreak detection 
and response. It will improve foodborne disease tracking, detection and 
response through the Integrated Food Safety Center of Excellence. Food 
safety is one of CDC's foremost strategic goals and heavily reliant 
upon state of the art surveillance. Last year, the CDC published first 
ever estimates of which food types were causing foodborne illnesses in 
the United States. These attribution estimates guide regulators, 
industry and consumers toward more precise and effective measures to 
prevent food contamination. In June, a new CDC report identified the 
key demographic groups most affected by Listeria bacteria infections. 
During 2009--2011, twelve Listeria outbreaks sickened people in 38 
States. CDC partnerships with other public health agencies clearly 
extend the CDC's ability to prevent disease. For example, data from the 
Foodborne Diseases Active Surveillance Network (FoodNet) are the source 
for CDC's most recent annual food safety report, which showed that 2012 
rates of infection for two foodborne pathogens (Campylobacter and 
Vibrio) had increased significantly when compared to 2006--2008, while 
rates of most others have not changed during the same period. FoodNet 
involves CDC, ten State health departments, the Department of 
Agriculture and the Food and Drug Administration.
    The ASM strongly supports the fiscal year 2015 EZID budget request 
of $30 million for the Antibiotic Resistance (AR) Strategy, which will 
speed up outbreak detection through regional labs, support development 
of new antibiotics and diagnostics and improve infection prevention and 
antibiotic prescribing. With a $30 million annual funding for 5 years, 
the AR initiative could achieve reductions in many infections, 
including C. difficile, carbapenem resistant Enterobacteriaceae (CRE), 
Multidrug Resistant (MDR) Pseudomosas, Invasive Methicillin-resistant 
Staphylococcus aureus (MRSA) and MDR Salmonella.
    CDC efforts have intensified against microbial pathogens that have 
evolved resistance against known drug therapies. In September, a 
landmark CDC report warned that antimicrobial resistant infections 
infect more than two million people in the United States every year, 
causing at least 23,000 deaths. CDC ranked AR threats into three 
categories: urgent, serious and concerning. Infections classified as 
urgent include CRE, drug resistant gonorrhea and Clostridium difficile, 
a diarrheal infection that causes about 250,000 U.S. hospitalizations 
and at least 14,000 deaths annually. Last year, CDC data showed more 
patients at hospitals and long term care facilities are being diagnosed 
with CRE infections; other AR reports are equally alarming.
    In November, CDC joined with the American Academy of Pediatrics to 
slow AR expansion with new guidelines, ``Principles of Judicious 
Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections 
in Pediatrics.'' Every year, up to 10 million children in the United 
States risk side effects from antibiotic prescriptions unlikely to help 
their respiratory symptoms. Many of these infections are caused by 
viruses not treatable by antibiotics. Antibiotic use is the single most 
important factor in antibiotic resistance, with up to 50 percent of 
prescriptions unnecessary or prescribed inappropriately. Studies 
estimate that AR adds $20 billion in excess direct health costs, with 
additional costs to Society for lost productivity as high as $35 
billion a year.
    CDC guidelines that include science based prevention protocols can 
be very effective, for example, the ongoing battle against healthcare 
acquired infections (HAIs). About 1 in every 20 hospitalized patients 
develops an infection caused by receiving medical care. Many of these 
are drug resistant (e.g., three quarters of Staphylococcus aureus 
infections in hospital ICUs are methicillin resistant MRSA). CDC 
aggressively promotes use of prevention protocols in all facilities in 
the United States. In 2013, CDC found that bloodstream infections in 
patients with central IV lines had decreased by over 40 percent and 
surgical site infections by 20 percent since 2008 and that following 
CDC protocols could cut dialysis related bloodstream infections in 
half. Another CDC coauthored report last fall concluded that there were 
an estimated 30,800 fewer invasive MRSA infections in 2011 compared 
with 2005. More than 12,000 healthcare facilities now track HAI 
infections using CDC's National Healthcare Safety Network (NHSN).
Surveillance and Response
    CDC depends upon extensive surveillance networks and unique rapid 
response mobilization. Sustaining these CDC capabilities is critical to 
detect health threats, halt outbreaks and prevent illness and injury. 
Familiar threats like hepatitis and HIV/AIDS continue to affect lives. 
Public health institutions also are repeatedly challenged by emerging 
infectious diseases (EIDs), unexpected and often dangerous. CDC 
regularly confronts new threats, including the following EIDs in the 
past year:
  --CDC scientists traced the newly discovered Heartland virus that 
        infected two men from Missouri to lone star ticks in the 
        region, adding another tick borne disease to those the CDC 
        monitors.
  --NCEZID helped identify a novel poxvirus (the same genus as 
        smallpox) afflicting shepherds in the Republic of Georgia and 
        is developing new diagnostic tests.
  --International travel advisories released by CDC address threats 
        posed by the new coronavirus MERS-CoV, first reported by Saudi 
        Arabia in 2012. CDC is working with health departments, 
        hospitals and other partners to prepare for possible cases in 
        the United States.
  --CDC is monitoring new reports of the mosquito borne chikungunya 
        virus among residents of St. Martin in the Caribbean, the first 
        time the disease has been detected among non-travelers in the 
        Western Hemisphere.
    In 2013, CDC updated new surveillance results on several infectious 
diseases with serious healthcare and economic consequences in the 
United States:
  --Each year there are about 19 to 21 million cases of norovirus 
        illness, about 570 to 800 people die, and many thousands more 
        are hospitalized or visit emergency rooms and outpatient 
        clinics. Another CDC study found that the contagious stomach 
        virus is now the leading cause of acute gastroenteritis among 
        children less than 5 years of age who seek medical care. It 
        caused nearly one million U.S. pediatric visits in 2009--2010.
  --About 300,000 people are diagnosed with Lyme disease each year in 
        the United States, making it the most commonly reported tick 
        borne illness. The early estimate is based on findings from 
        three ongoing CDC studies. It suggests that the total number is 
        roughly 10 times higher than the number reported to CDC by 
        healthcare providers.
  --Valley Fever, a fungal respiratory infection, dramatically 
        increased in several southwestern States, from 2,265 in 1998 to 
        more than 22,000 in 2011. CDC is investigating whether the 
        increase is related to changes in weather, rising populations 
        or changes in the way the disease is detected and reported to 
        the States or CDC.
    Each year, CDC gives financial support to all 50 State health 
departments, six local departments, and eight territories or 
affiliates. Since 2010, CDC has provided funds to 57 State, local and 
territorial health departments to increase the use of electronic lab 
reporting (ELR). About 10,400 labs send reportable data to health 
agencies but many do not report electronically.
Global Health
    With globalization of our food supply and frequent travel to and 
from the United States, health security threats can come from anywhere. 
CDC's Center for Global Health and Office of Infectious Diseases 
oversee Agency efforts to prevent, detect and respond to outbreaks in 
other countries. There are more than 1,600 CDC employees located in 
over 60 countries. At present, only 1 in 5 countries can rapidly 
detect, respond to or prevent global health threats caused by emerging 
infections. Improvements overseas, such as strengthening surveillance 
and lab systems or training investigators, make both the United States 
and the rest of the world more secure against infectious disease.
    In January, CDC reported results from pilot projects in Uganda and 
Vietnam to improve disease detection and response capabilities. Work in 
Uganda modernized diagnostic testing, developed real time information 
systems for faster outbreak response and improved emergency operations 
procedures. It focused on three priority diseases, drug resistant 
tuberculosis, cholera and viral hemorrhagic fever caused by Ebola 
virus. The Vietnam project trained Vietnamese health officials in 
advanced PCR techniques to detect H7N9 influenza, enterovirus 71 and 
respiratory viruses.
    The ASM strongly urges Congress to increase CDC's budget in fiscal 
year 2015 to the highest level possible and approve funding increases 
for infectious diseases.
                                 ______
                                 
      Prepared Statement of the American Society for Microbiology
    The American Society for Microbiology (ASM), the largest single 
life science Society with over 39,000 members, wishes to submit the 
following comments and recommendations for the record on the fiscal 
year 2015 budget for the National Institutes of Health (NIH). The ASM 
commends Congress for passage of the fiscal year 2014 Omnibus 
Appropriations Bill which represents a step in the right direction 
although funding for NIH remains too low in view of the gaps in our 
knowledge of disease and the abundance of scientific opportunities that 
cannot be pursued because of lack of funding. The ASM recommends that 
NIH receive at least $32 billion in fiscal year 2015 as the next step 
toward a multi-year increase in the Nation's investment in medical 
research.
    The ASM is very concerned about the future of biomedical research 
in the United States. NIH support for basic research is critical to 
health and security, job creation and growing the U.S. economy. In 
fiscal year 2013, the success rate for NIH research grant applicants 
fell to an historic low 16.8 percent. The average size of research 
project grants (RPGs) decreased to the lowest ever since 1999. During 
last year's sequestration, there were reports of delayed research 
projects, enforced layoffs of technical staff and waning innovation. 
Such stagnation undercuts biomedical research progress in the United 
States at a time when the opportunities are great and other Nations are 
growing their investment in basic and translational biomedical 
research.
    NIH is the primary supporter of biomedical research in the Nation. 
In 2012 alone, NIH funding supported more than 402,000 jobs and $57.8 
billion in new economic activity nationwide. Among NIH's investments 
are those in the rapidly advancing field of genomics. A recent report 
from the nonprofit United for Medical Research (UMR) spotlighted the 
economics of Federal investment in the human genome project, which has 
generated $965 billion in economic impact, more than 53,000 direct 
genomics related jobs and $293 billion in personal income.
    Current trends in the Nation's R&D investments clearly do not bode 
well for future innovation and global competition. Federal R&D 
expenditures declined by 16.3 percent between fiscal years 2010 and 
2013, while China's investment jumped more than 400 percent over the 
past decade. Since 2001, the U.S. share of global R&D performed has 
decreased from 37 percent to 30 percent. The Science Coalition Report 
in 2013 highlighted the importance of federally funded university 
research in creating new companies and R&D jobs. The report profiles 
R&D companies launched by relatively small Federal investment in 
university research, including NIH grants funding rapid pathogen 
detection technologies, vaccine development and advances in food and 
water safety.
    Several UMR reports from last year underscore how NIH supported 
research can propel private sector growth and innovation. U.S. biotech 
companies catalyzed by NIH funding illustrate the productive 
collaborations among NIH, university research scientists and the 
private sector. These companies are reshaping lucrative R&D sectors 
like gene sequencing and therapeutics for human disease, taking basic 
research to the marketplace. NIH support is responsible for several of 
Science magazine's top ten 2013 discoveries, all expected to return 
huge dividends, including the ``breakthrough of the year'' cancer 
immunotherapy, the new gene editing CRISPR technique and the 
astoundingly important human microbiome project.
    Also included was the first use of structural biology techniques to 
custom design a powerful immunogen with vaccine potential, in this case 
against respiratory syncytial virus (RSV). Worldwide, about 64 million 
cases of RSV infection occur each year, responsible for 160,000 deaths, 
making it the most common cause of severe respiratory illness in 
infants and young children. There is no approved vaccine, but the team 
led by NIAID Vaccine Research Center identified 3-D structures of 
attachment sites on the virus surface and potent antibodies against 
those sites, offering new tools to develop new or improved vaccines.
    NIH investments build the scientific foundation for the Nation's 
valuable biomedical R&D sector, which employs 7 million and exports $90 
billion in goods and services. In 2013, all three recipients of the 
Nobel Prize in Physiology or Medicine and all three winners of the 
Nobel Prize in Chemistry had at some point received NIH funding (for a 
total of 144 NIH supported Nobel laureates). Four NIH funded scientists 
also won prestigious 2013 Lasker Foundation awards.
    As the Nation's largest funder of biomedical research, NIH leads 
the Nation's efforts to discover new cures, preventions and therapies 
for difficult disease challenges by funding intramural and extramural 
projects to combat infectious diseases that kill millions of people 
worldwide. The National Institute of Allergy and Infectious Diseases 
(NIAID) and the National Institute of General Medical Sciences (NIGMS) 
contribute to new, paradigm shifting technologies like high throughput 
genomic sequencing, as well as new multidisciplinary research 
approaches like systems biology.
    NIAID funded scientists have discovered therapies, vaccines, 
diagnostic tests and other biomedical tools that improve human health. 
Lifesaving examples are vaccines for rabies, meningitis, whooping 
cough, hepatitis A and B, chickenpox and pneumococcal pneumonia. 
Developing new influenza vaccines is a high priority for NIAID, which 
has supported a health provider consortium for clinical trials since 
the 1960s. The NIAID Vaccine Research Center's influenza research has 
produced multiple promising advances like a DNA vaccine against H5N1 
avian influenza and it helped establish the Southeast Asia Influenza 
Clinical Research Network to address global influenza threats. Ongoing 
NIAID research is making progress toward the highly significant goal of 
a universal influenza vaccine that would confer decades long protection 
from any flu virus strain.
    In February, NIAID reported on its latest contributions in the 
battle to halt antimicrobial resistance (AR) spreading among pathogens, 
which is creating ever more dangerous diseases like multidrug resistant 
gonorrhea and extensively drug resistant tuberculosis. Each year, there 
are 2 million drug resistant infections and 23,000 deaths in the United 
States. Annual costs are an estimated $20 billion in added healthcare 
and $35 billion in lost productivity. NIAID leads U.S. research against 
drug resistant pathogens, making major investments in basic, 
translational and clinical research. Results include advances in 
prevention, diagnosis and treatment of AR infections, as well as 
greater support for new drug discovery. The agency has helped support 
R&D of at least 25 percent of the antibiotics currently in clinical 
testing. Basic AR research funded by NIAID is detailing the ways that 
pathogens evade host defenses, to identify new therapeutic and 
diagnostic targets. Using the latest in technological tools, NIAID 
supported researchers are developing novel diagnostics platforms for 
more rapid and accurate detection of emerging AR infections. NIAID's 
expansive AR portfolio also includes vaccine development against 
increasingly common AR threats like drug resistant staph and gonorrhea 
bacteria.
    One of NIAID's greatest challenges for the 21st century is 
developing defenses against familiar enemies, the world's three 
greatest microbial killers, HIV/AIDS, malaria and tuberculosis. Recent 
research advances include the following:
  --A novel compound, from a new class of potential antimalarial drugs, 
        appears effective against multiple life stages of the malaria 
        causing Plasmodium parasite. Most antimalarials only target the 
        parasite as it grows in the host's bloodstream, giving the 
        parasite more chances to spread and acquire drug resistance.
  --After designing nanoparticles loaded with copies of mutated HIV 
        selected via computerized screening, scientists have activated 
        host immune cells to produce VRC01 neutralizing antibodies. The 
        approach offers a new tool to potentially reverse engineer 
        neutralizing antibodies against HIV and other viruses.
  --Using a systems biology approach, scientists have identified 
        interactions among genetic regulators in Mycobacterium 
        tuberculosis (Mtb), the bacterium that causes tuberculosis 
        (TB). The results help explain how Mtb lies latent for long 
        periods in otherwise healthy people, then becomes active and 
        transmissible TB. About one third of the world's population is 
        infected, making Mtb switches between different stages crucial 
        to public health.
    Research strategies clearly rely upon previous scientific 
successes. Ever shifting influenza viruses and steady evolution of AR 
pathogens illustrate how any effort must build upon the past, respond 
to the present and plan for the future. New microbial threats emerge as 
old threats persist, the recent spread of dengue fever, detection of 
influenza H7N9 last year and the newly emerging coronavirus caused 
Middle East respiratory syndrome (MERS). First identified in 2012, 
MERS-CoV infection has been implicated in 181 cases (as of February 4) 
and 79 deaths. With high mortality and no treatments, the disease's 
spread from the Middle East to Europe has health officials concerned. 
NIAID funded researchers now have reported some laboratory success 
using potential MERS-CoV therapy that combines two licensed antiviral 
drugs routinely used to treat diseases such as hepatitis C.
    At NIGMS, microbial genetics and cell/molecular biology are 
principal research emphases, recognition that microbiology not only 
provides insights to human health and biology in general, but also 
stimulates innovation in U.S. biotechnology. Each year, NIGMS awards 
more than 4,500 research grants and supports one fourth (4,000) of the 
NIH supported technical trainees.
    NIGMS funded research has generated high value technologies like 
PCR, high throughput DNA sequencing, and the human genome project. The 
latest exciting biotech tool to emerge is CRISPR technology (Clustered 
Regularly Interspaced Short Palindromic Repeats, DNA loci in bacterial 
genomes), innovation that evolved from basic research in both phage 
biology and advanced computing genomics. With huge potential for 
improved genome editing essential to the biotech industry, today the 
CRISPR system is increasingly used in gene cutting and other customized 
gene targeting.
    Without sustained NIH funding in diverse fields like microbiology, 
ASM strongly believes there will be fewer new discoveries and 
innovation in the United States. We urge Congress to build on 
bipartisan efforts to replace the random cuts of sequestration that 
have been devastating to basic research in the United States and to 
increase funding for the National Institutes of Health. Increased 
investment will enable the scientific progress that is needed to 
improve the health, security and economic growth of the country.
                                 ______
                                 
        Prepared Statement of the American Society for Nutrition
    Dear Chairwoman Mikulski and Ranking Member Shelby: Thank you for 
the opportunity to provide testimony regarding fiscal year 2015 
appropriations. The American Society for Nutrition (ASN) respectfully 
requests $32 billion dollars for the National Institutes of Health 
(NIH) and $182 million dollars for the Centers for Disease Control and 
Prevention/National Center for Health Statistics (CDC/ NCHS) in Fiscal 
Year 2015. ASN is dedicated to bringing together the world's top 
researchers to advance our knowledge and application of nutrition, and 
has more than 5,000 members working throughout academia, clinical 
practice, government, and industry.
National Institutes of Health (NIH)
    The NIH is the Nation's premier sponsor of biomedical research and 
is the agency responsible for conducting and supporting 86 percent of 
federally-funded basic and clinical nutrition research. Although 
nutrition and obesity research makes up less than eight percent of the 
NIH budget, some of the most promising nutrition-related research 
discoveries have been made possible by NIH support. NIH nutrition-
related discoveries have impacted the way clinicians prevent and treat 
heart disease, cancer, diabetes and other chronic diseases. For 
example, U.S. death rates from heart disease and stroke have decreased 
by more than 60 percent, and the proportion of older adults with 
chronic disabilities has dropped by one-third. With additional support 
for NIH, additional breakthroughs and discoveries to improve the health 
of all Americans will be made possible.
    Investment in biomedical research generates new knowledge, improved 
health, and leads to innovation and long-term economic growth. A decade 
of flat-funding, followed by sequestration cuts, has taken a 
significant toll on NIH's ability to support research. Such economic 
stagnation is disruptive to training, careers, long-range projects and 
ultimately to progress. Increasing the NIH budget to $32 billion 
dollars would fully restore the funding that was lost to sequestration 
and support at least 600 additional competing research project grants. 
As a first step toward sustainable growth, ASN recommends a minimum of 
$32 billion dollars for NIH in fiscal year 2015. NIH needs sustainable 
and predictable budget growth in order to fulfill the full potential of 
biomedical research, including nutrition research, and to improve the 
health of all Americans.
Centers for Disease Control and Prevention National Center for Health 
        Statistics (CDC NCHS)
    The National Center for Health Statistics, housed within the 
Centers for Disease Control and Prevention, is the Nation's principal 
health statistics agency. ASN recommends a fiscal year 2015 funding 
level of $182 million dollars for NCHS, consistent with the President's 
budget request, to help ensure uninterrupted collection of vital health 
and nutrition statistics, and help cover the costs needed for 
technology and information security maintenance and upgrades that are 
necessary to replace aging survey infrastructure. More than half of 
NCHS's budget is supported through the evaluation tap. Therefore, ASN 
does not support efforts to eliminate the evaluation tap--in part or in 
full--unless a viable alternative funding mechanism is put in place to 
continue these important functions.
    The NCHS provides critical data on all aspects of our health care 
system, and it is responsible for monitoring the Nation's health and 
nutrition status through surveys such as the National Health and 
Nutrition Examination Survey (NHANES), that serve as a gold standard 
for data collection around the world. Nutrition and health data, 
largely collected through NHANES, are essential for tracking the 
nutrition, health and well-being of the American population, and are 
especially important for observing nutritional and health trends in our 
Nation's children.
    Nutrition monitoring conducted by the Department of Health and 
Human Services in partnership with the U.S. Department of Agriculture/
Agricultural Research Service is a unique and critically important 
surveillance function in which dietary intake, nutritional status, and 
health status are evaluated in a rigorous and standardized manner. 
Nutrition monitoring is an inherently governmental function and 
findings are essential for multiple government agencies, as well as the 
public and private sector. Nutrition monitoring is essential to track 
what Americans are eating, inform nutrition and dietary guidance 
policy, evaluate the effectiveness and efficiency of nutrition 
assistance programs, and study nutrition-related disease outcomes. 
Funds are needed to ensure the continuation of this critical 
surveillance of the Nation's nutritional status and the many benefits 
it provides.
    Through learning both what Americans eat and how their diets 
directly affect their health, the NCHS is able to monitor the 
prevalence of obesity and other chronic diseases in the U.S. and track 
the performance of preventive interventions, as well as assess 
`nutrients of concern' such as calcium, which are consumed in 
inadequate amounts by many subsets of our population. Data such as 
these are critical to guide policy development in the area of health 
and nutrition, including food safety, food labeling, food assistance, 
military rations and dietary guidance. For example, NHANES data are 
used to determine funding levels for programs such as the Supplemental 
Nutrition Assistance Program (SNAP) and the Women, Infants, and 
Children (WIC) clinics, which provide nourishment to low-income women 
and children.
    To continue support for the agency and its important mission, ASN 
recommends an FY 2015 funding level of $162 million for NCHS. Sustained 
funding for NCHS can help to ensure uninterrupted collection of vital 
health and nutrition statistics, and will help to cover the costs 
needed for technology and information security upgrades that are 
necessary to replace aging survey infrastructure.
    Thank you for the opportunity to submit testimony regarding fiscal 
year 2015 appropriations for the National Institutes of Health and the 
CDC/National Center for Health Statistics. Please contact John E. 
Courtney, Ph.D., Executive Officer, if ASN may provide further 
assistance.

    [This statement was submitted by Gordon M. Jensen, M.D., Ph.D., 
2013-2014 ident, American Society for Nutrition.]
                                 ______
                                 
     Prepared Statement of the American Society for Pharmacology & 
                       Experimental Therapeutics
    The American Society for Pharmacology and Experimental Therapeutics 
(ASPET) is pleased to submit written testimony in support of the 
National Institutes of Health (NIH) fiscal year 2015 budget. ASPET 
recommends a fiscal year 2015 NIH budget of at least $32 billion.
    Sustained growth for the NIH should be an urgent national priority. 
Congress showed bipartisan support for the agency in fiscal year 2014 
as evidenced by the $1 billion increase above the fiscal year 2013 
sequestered level. While this 3.5 percent increase helps put NIH on the 
path to more sustainable funding levels, it does not begin to make up 
for a lost decade of funding. Adjusting for inflation, the fiscal year 
2013 budget for the NIH is less than it was in 2003. For NIH to meet 
its vital role in improving public health, stimulating our economy, and 
improving global competitiveness it is critical that the agency 
continue to receive steady and sustainable increases.
    Additionally, if funding for the next 10 years is similar to that 
of the past decade, the Nation will lose a generation of young 
scientists. Increasingly, these individuals, seeing no prospects for 
careers in biomedical research, will leave the research enterprise or 
look for employment in foreign countries. Not only are jobs 
increasingly limited in the academic sector, but industry too is under 
stress. The ``brain drain'' of young scientific talent jeopardizes the 
Nation's leadership in biomedical research. A survey of ASPET's own 
graduate students and post-doctoral researchers indicates that 45 
percent of post-doctoral trainees and 25 percent of graduate students 
say they are no longer considering a career in biomedical research due 
to the restrictive funding environment; 50 percent of graduate students 
and 29 percent of post-doctoral trainees say they are willing to 
consider leaving the United States to pursue a career in biomedical 
research.
    A $32 billion budget for the NIH in fiscal year 2015 is a start to 
help restore NIH's biomedical research capacity. Currently, the NIH 
only can fund one in six grant applications, the lowest rate in the 
agency's history. Furthermore, the number of research project grants 
funded by NIH has declined every year since 2004.
    A budget of at least $32 billion in fiscal year 2015 will help the 
agency manage its research portfolio more effectively without having to 
withhold funding for existing grants to researchers throughout the 
country. Only through steady, sustained and predictable funding 
increases can NIH continue to fund the highest quality biomedical 
research to help improve the health of all Americans and continue to 
make significant economic impact in many communities across the 
country.
    There is no substitute for a steady, sustained Federal investment 
in biomedical research. Industry, venture capital, and private 
philanthropy can supplement research but cannot replace the investment 
in basic, fundamental biomedical research provided by NIH. Neither the 
private sector nor industry will be able to fill a void for NIH funded 
basic biomedical research. Much of industry support is applied research 
that builds upon the discoveries generated from NIH-funded projects. 
The majority of the investment in basic biomedical research that NIH 
provides is broad and long-term providing a continuous development 
platform for industry, which would not typically invest in research 
that may be of higher risk and require several years to fully mature. 
In addition to this long term view, NIH also has mechanisms in place to 
rapidly build upon key technologies and discoveries that have the 
ability to have significant impact on the health and well being of our 
citizens.
    Many of the basic science initiatives supported by NIH have led to 
totally unexpected discoveries and insight that have transformed our 
mechanistic understanding of and our ability to treat a wide range of 
diseases
Diminished Support for NIH will Negatively Impact Human Health
    Continued diminishment of funding and loss of purchasing power will 
mean a loss of scientific opportunities to discover new therapeutic 
targets. Without a steady, sustained Federal investment in fundamental 
biomedical research, scientific progress will be slower and potentially 
helpful therapies or cures will not be developed. For example, more 
research is needed on Parkinson's disease to help identify the causes 
of the disease and help develop better therapies; discovery of gene 
variations in age-related macular degeneration could result in new 
screening tests and preventive therapies; more basic research is needed 
to focus on new molecular targets to improve treatment for Alzheimer's 
disease; and diminished support for NIH will prevent new and ongoing 
investigations into rare diseases that the Food and Drug Administration 
estimates almost 90 percent are serious or life-threatening.
    Historically, our past investment in basic biological research has 
led to many innovative medicines. The National Research Council 
reported that of the 21 drugs with the highest therapeutic impact, only 
five were developed without input from the public sector. The 
significant past investment in the NIH has provided major gains in our 
knowledge of the human genome, resulting in the promise of 
pharmacogenomics and a reduction in adverse drug reactions that 
currently represent a major worldwide health concern. Several completed 
human genome sequence analyses have pinpointed disease-causing variants 
that have led to improved therapy and cures but further advances and 
improvements in technology will be delayed or obstructed with 
diminished NIH funding.
Investing in NIH Helps America Compete Economically
    A $32 billion budget in fiscal year 2015 will also help the NIH 
train the next generation of scientists and provide a platform for 
broader workforce development that is so critical to our Nation's 
growth. Many individuals trained in the sciences through NIH support 
become educators in high schools and colleges. These individuals also 
enter into other aspects of technology development and evaluation in 
public and private sectors to further enrich the community and 
accelerate economic development.
    This investment will help to create jobs and promote economic 
growth. A stagnating NIH budget will mean forfeiting future discoveries 
and jobs to other countries.
    The U.S. share of global research and development investment from 
1999-2009 is now only 31 percent, a decline of 18 percent. In contrast, 
other nations continue to invest aggressively in science. China has 
grown its science portfolio with annual increases to the research and 
development budget averaging over 23 percent annually since 2000, 
including a 26 percent increase in 2012. Russia plans to increase 
support for research by 65 percent over the next 5 years. The European 
Union, despite great economic distress among its member nations, has 
proposed to increase spending on research and innovation by 45 percent 
between 2014 and 2020.
    NIH research funding catalyzes private sector growth. More than 83 
percent of NIH funding is awarded to over 3,000 universities, medical 
schools, teaching hospitals and other research institutions in every 
State. One national study by an economic consulting firm found that 
Federal (and State) funded research at the Nation's medical schools and 
hospitals supported almost 300,000 jobs and added nearly $45 billion to 
the U.S. economy. NIH funding also provides the most significant 
scientific innovations of the pharmaceutical and biotechnology 
industries.
Conclusion
    ASPET appreciates the many competing and important spending 
decisions the Subcommittee must make. However, the NIH's contribution 
to the Nation's economic and physical well being should make it one of 
the Nation's top priorities. With enhanced and sustained funding, NIH 
can begin to reverse its decline and help meet its potential to address 
many of the more promising scientific opportunities that currently 
challenge medicine. A budget of at least $32 billion in fiscal year 
2015 will allow the agency to begin moving forward to full program 
capacity, exploiting more scientific opportunities for investigation, 
and increasing investigator's chances of discoveries that prevent, 
diagnose and treat disease. NIH should be restored to its role as a 
national treasure, one that attracts and retains the best and brightest 
to biomedical research and provides hope to millions of individuals 
afflicted with illness and disease.
    ASPET is a 5,100 member professional society whose members conduct 
basic, translational, and clinical pharmacological research within the 
academic, industrial and government sectors. Our members discover and 
develop new medicines and therapeutic agents that fight existing and 
emerging diseases, as well as increase our knowledge regarding how 
therapeutics affects humans.

    [This statement was submitted by James S. Bernstein, Director, 
Government and Public Affairs, American Society for Pharmacology & 
Experimental Therapeutics.]
                                 ______
                                 
    Prepared Statement of the American Society of Clinical Oncology
    The American Society of Clinical Oncology (ASCO), the world's 
leading professional organization representing nearly 35,000 physicians 
and other professionals who treat people with cancer, appreciates this 
opportunity to provide the following recommendations for fiscal year 
2015 (fiscal year 2015) funding:
  --National Institutes of Health (NIH): $32 billion
  --National Cancer Institute (NCI): $5.26 billion
    ASCO's members set the standard for cancer care world-wide and lead 
the way in carrying out translational and clinical research aimed at 
improving the screening, prevention, diagnosis and treatment of cancer. 
ASCO advocates for policies that provide access to high-quality care 
for all patients with cancer. ASCO's efforts are also directed toward 
supporting oncology clinical and translational research that is 
critical to improving the lives of our citizens and that can inform 
cancer services for people worldwide.
Cancer's Growing Footprint and the Importance of Federal Cancer 
        Research
    According to ASCO's State of Cancer Care in America report (http://
www.asco.org/practice-research/cancer-care-america) released earlier 
this year, cancer will surpass heart disease as the leading cause of 
death in the United States (US) over the next 16 years. While cancer 
deaths in the US are declining for all populations, the number of new 
cancer cases is expected to increase nearly 45 percent by 2030, from 
1.6 million cases to 2.3 million cases annually. The leading overall 
risk factor for cancer is aging and these numbers reflect overall 
progress in healthcare, enabling more Americans to live longer.
    While we have made great strides in cancer treatment, now is not 
the time to cut back as cancer impacts more and more Americans. We now 
have more cancer survivors alive today than at any point in our history 
and understand more about the diseases that make up cancer than ever 
before. This is largely because of Federal investment in cancer 
research, but we will not be able to harness the opportunities this new 
knowledge provides without further investment. Adjusting for inflation, 
funding for the NIH is down 23 percent since 2003. In addition, the NCI 
has become a smaller share of NIH's total budget. If NCI was funded as 
the same percentage of overall NIH spending that it was in 2003, it 
would mean an additional $350 million for cancer research.
    ASCO thanks the subcommittee for its past commitment to cancer 
research through the appropriations process and appreciates the unique 
effort made by the subcommittee in this challenging budget environment. 
We recognize the challenging environment, but caution that the current 
path of investment in cancer research will be devastating to attempts 
to find future cures. ASCO calls on this subcommittee to renew the 
commitment to clinical cancer research--without which our basic science 
findings would never help improve the lives of patients.
    While we appreciate the bipartisan efforts that led to a brief 
reprieve from sequester in fiscal year 2015, the lasting effects of 
these draconian cuts, exacerbated by years of stagnant funding, will be 
felt for decades to come if the trend is not reversed. ASCO released a 
survey (http://www.asco.org/press-center/asco-survey-underscores-
%E2%80%9Cdevastating%E2%80%9D-impact-stagnant-funding-cancer-research) 
of its members in September 2013 that showed the profound impact of 
sequester on the U.S. cancer research enterprise.
    A large majority, 75 percent, of survey respondents, reported that 
the current Federal funding situation is having a direct impact on 
their ability to conduct cancer research, in many cases triggering 
``devastating'' changes. Delayed clinical trials, the elimination of 
research staff positions, and the halting or slowing of promising 
research that could lead to new therapies for cancer were cited as 
specific results of stagnant funding.
    In order to stop these devastating trends and capitalize on forward 
progress, the NIH and the NCI must have sustained and predictable 
increases in funding. While private industry is a strong partner in 
cancer research, they do not conduct the broad scope of clinical 
research that is important to cancer patients. In contrast, the NCI 
conducts the high risk, high reward research that leads to practice-
changing advancements that industry is often unwilling to undertake--
such as pediatric applications, direct comparisons of approved drugs, 
and providing drugs in combination with or prior to radiation or 
surgical treatments. Progress in fighting cancer would be faster, more 
efficient, and more sustainable if funding were steady and sustained.
    Our prior investments established the global leadership of American 
cancer research and care. Without maintenance of those investments, our 
global leadership and the benefits it offers everyday Americans in both 
health and economically are profoundly threatened.
Clinical Trials and Translational Research
    NIH-funded translational research and clinical trials have 
significantly improved the standard of care in many diseases. At the 
same time, they also have demonstrated more cost-effective treatment 
options for many common cancers. Unfortunately, these trials are at 
risk, due to funding concerns that slow the launch and completion of 
trials. Of great concern is the deterioration of NCI support for 
federally funded trials that take place in virtually every community in 
which cancer providers treat patients. On March 1, 2014, the NCI 
launched the reorganized National Clinical Trials Network (NCTN). The 
program currently involves over 3,000 institutions and community-based 
investigators in the US and provides approximately 17,000 patients with 
access to promising new treatments each year, at a $243 million annual 
cost to taxpayers. Due to funding constraints, the number of patients 
enrolled in clinical trials has fallen from a peak of almost 30,000 
patients in 2009 to a planned enrollment of only 12,000 adults in the 
current fiscal year and some trials may be forced to close early 
potentially depriving patients of access to life-prolonging treatments. 
Please note that without patient accrual to clinical trials, there can 
be no changes in routine care, practice, and outcomes. This is where 
science becomes practice changing for patients in America.
    We understand that March 1 also marked the end of funding for the 
NCI Community Clinical Oncology Program (CCOP). NCI is transforming 
this program into the NCI Community Oncology Research Program (NCORP). 
NCI is currently reviewing NCORP applications and does not expect to 
issue notices of award until September 2014. In the meantime, CCOP 
sites have ongoing ethical obligations to active trial participants to 
continue clinical trial procedures and required follow-up. At present, 
community practice sites are expected to do so without any transition 
in funding. These community sites are crucial to making cutting edge 
cancer care available to patients in the communities where they live. 
Without any assurance of sustained funding, some community sites will 
no longer be able to offer clinical trials to patients.
    Clinical trials supported by Federal funding have led to important 
breakthroughs in cancer care that touch every American family and often 
these are in areas that industry has no incentive to pursue. Typically, 
the trial concepts are proposed directly by clinician investigators who 
hypothesize ways to improve treatments for their patients and want to 
test those hypotheses through rigorously designed prospective clinical 
trials. Just as the NIH RO1 and R21 grant mechanisms inspire researcher 
creativity and innovation, the NCTN and NCORP programs are important in 
fostering research initiatives directly from clinician investigators 
who see firsthand the importance of answering questions vital to their 
patients. Publicly funded clinical trials involve establishing 
comparative effectiveness, examining promising regimens, optimizing 
multimodality treatments, developing therapies for rare cancers, and 
studying prevention and survivorship strategies. These research goals 
may run parallel to those of commercial sponsors, but publicly funded 
trials are designed to benefit patients--not intended to achieve 
regulatory approval or shareholder interest. Many of these trials are 
at risk due to funding constraints and the pace of further progress, 
especially against the most common cancers in America, will slow. For 
example, at the present time there is no publically funded breast 
cancer adjuvant treatment trial available in the US.
    ASCO's Clinical Cancer Advances report (http://
www.cancerprogress.net/clinical-cancer-advances-2013) provides annual 
recognition of the major advances in patient treatments and care. The 
2013 report details 76 research advances, 27 of which received NIH 
funding, in diseases impacting an estimated 1.6 million patients last 
year alone. Its top areas of progress include: using genomics to make 
treatment decisions for individual patients, discovering new cancer 
subtypes specifically associated with potential new therapies, tackling 
treatment resistant forms of cancer through precision medicine 
approaches, enhancing the ability of patients' own immune systems to 
fight cancer, and implementing new cancer screening paradigms to reduce 
disparities.
    To maintain global American scientific leadership, ASCO urges a 
substantial increase in funding for the National Clinical Trials 
Network and NCI Community Oncology Research Program, as well as 
transition funding for CCOP sites until NCORP launches. ASCO is very 
concerned that the Federal funding situation is causing NCI to propose 
capping patient participation in clinical trials in order to stretch an 
ever-shrinking funding pot. NCI acknowledges that current payments are 
inadequate to cover the costs of conducting trials because they have 
not increased over nearly a decade. Making the needed increases at the 
expense of new scientific opportunities, however, is short-sighted and 
has long-term negative implications. The Institute of Medicine (IOM) 
recognized this in its 2010 report, A National Cancer Clinical Trials 
System for the 21st Century: Reinvigorating the NCI Cooperative Group 
Program. The IOM pointed to the notable achievements of Cooperative 
Group trials that have dramatically improved the outcomes of today's 
cancer patients and recognized that increases in funding should 
accompany the changes that the NCI and Cooperative Groups have already 
implemented to increase the efficiency of their operations and to keep 
pace with scientific opportunity. An increase in NCI funding would 
enable the Institute to maintain or increase the number of accruals to 
trials at the same time as it increases payments to cover the cost of 
conducting the research.
Threat to America's Global Leadership
    While the United States is slowing its investment in medical 
research, countries around the globe are making significant increases 
to theirs. Russia is increasing basic research funding by 65 percent, 
European investments are increasing by 40 percent over 7 years, South 
Korea has pledged a 50 percent increase, and China announced a 26 
percent boost in basic research funding in 2012. These investments 
result not only in additional research in these countries, but are 
attracting the best and brightest American-trained scientists to work 
abroad. The long-term consequences are easy to predict. If scientific 
progress is achieved elsewhere, Americans will be asked to import new 
treatments including drugs, intellectual property, and products.
    The previously referenced ASCO survey also revealed the disturbing 
finding that many young investigators are leaving the field altogether 
due to lack of funding. This too is a predictable effect of funding 
limits. With more than 35 percent of survey participants reporting 
having to lay off skilled staff, many appear to be questioning the 
viability of a career in research and raising serious concerns about 
the ultimate impact of budget cuts on patient care and outcomes.
    Declining Federal funding for clinical trials, coupled with the 
rising costs of increasingly complex studies, will severely harm the 
nation's clinical research enterprise by limiting opportunities for 
innovation and demoralizing young clinical investigators. As 
opportunities to develop and lead trials diminish and institutional 
pressures to generate research funding and clinical revenue continue to 
grow, young investigators may leave the field of research, or choose to 
pursue research opportunities in other countries. Not only does this 
threaten our progress against cancer, but it also diminishes the 
overall scientific workforce in America.
    In addition, clinical trials are increasingly being conducted 
overseas, due to the costs and regulatory complexities of conducting 
trials in the US. This denies your constituents the opportunity to 
participate, either as a patient receiving the most promising potential 
treatment or as a physician or research nurse conducting the clinical 
trial. Congress should demonstrate a continued commitment to ensure 
biomedical research is federally funded.
    Because of the incredible scientific opportunities facing us and 
the current threats to this opportunity, ASCO urges the NIH and NCI to 
focus more of its resources in the area of clinical trials and 
translational research.
    ASCO again thanks the Subcommittee for its continued support of 
cancer patients in the US through funding for the NIH and the NCI. We 
look forward to working with all members of the subcommittee to advance 
US cancer research.

    [This statement was submitted by Clifford A. Hudis, MD, FACP, 
President, American Society of Clinical Oncology.]
                                 ______
                                 
        Prepared Statement of the American Society of Hematology
    The American Society of Hematology (ASH) thanks the Subcommittee 
for the opportunity to submit written testimony on the fiscal year 2015 
Departments of Labor, Health and Human Services, and Education 
Appropriations bill.
    ASH represents more than 15,000 clinicians and scientists committed 
to the study and treatment of blood and blood-related diseases. These 
diseases encompass malignant disorders such as leukemia, lymphoma, and 
myeloma; life-threatening conditions, including thrombosis and bleeding 
disorders; and congenital diseases such as sickle cell anemia, 
thalassemia, and hemophilia. In addition, hematologists have been 
pioneers in the fields of bone marrow transplantation, stem cell 
biology and regenerative medicine, gene- and immunotherapy, and the 
development of many drugs for the prevention and treatment of heart 
attacks and strokes.
Funding for Hematology Research: An Investment in the Nation's Health
    Over the past 60 years, American biomedical research has led the 
world in probing the nature of human disease. This research has led to 
new medical treatments, saved innumerable lives, reduced human 
suffering, and spawned entire new industries. This research would not 
have been possible without support from the National Institutes of 
Health (NIH).
    Funding for hematology research has been an important component of 
this investment in the Nation's health. Most of the research that 
produced cures and treatments for hematologic diseases has been funded 
by the NIH. The study of blood and its disorders is a trans-NIH issue 
involving many institutes at the NIH, including the National Heart, 
Lung and Blood Institute (NHLBI), the National Cancer Institute (NCI), 
the National Institute of Diabetes, Digestive and Kidney Diseases 
(NIDDK), and the National Institute on Aging (NIA).
    With the advances gained through an increasingly sophisticated 
understanding of how the blood system functions, hematologists have 
changed the face of medicine through their dedication to improving the 
lives of patients. As a result, children are routinely cured of acute 
lymphoblastic leukemia (ALL); more than 90 percent of patients with 
acute promyelocytic leukemia (APL) are cured with a drug derived from 
vitamin A; older patients suffering from previously lethal chronic 
myeloid leukemia (CML) are now effectively treated with well-tolerated 
pills; and patients with multiple myeloma are treated with new classes 
of drugs.
    Additionally, as NIH Director Francis Collins recently noted in his 
testimony to the Subcommittee, researchers are ``aiming to harness the 
body's own immune system to fight cancer.'' One such method, known as 
chimeric antigen receptor (CAR) cell engineering, extracts T cells 
(naturally occurring immune cells) from the blood of a cancer patients 
and modifies the cells to produce special proteins on their surface. 
With these new engineered features, the T cells are injected back into 
the patient, now primed to seek and destroy cancer cells. Preliminary 
studies have found that this process may generate responses in as many 
as two-thirds of cases in which all other treatment options have 
failed. Further, because the cells are derived from the patient, there 
is an inherently lower risk of toxicity because the cells are less 
likely to attack the host tissue than cells introduced from a foreign 
body. Promising results in patients with leukemia prompted Science 
magazine to name this its 2013 ``Breakthrough of the Year.''
    Hematology advances also help patients with other types of cancers, 
heart disease, and stroke. Even modest investments in hematology 
research have yielded large dividends for other disciplines. Basic 
research on blood has aided physicians who treat patients with heart 
disease, strokes, end-stage renal disease, cancer, and AIDS. Blood 
thinners effectively treat or prevent blood clots, pulmonary embolism, 
and strokes. Death rates from heart attacks are reduced by new forms of 
anticoagulation drugs.
Sequestration Threatens Scientific Momentum
    ASH is particularly concerned about the impact of continued cuts on 
biomedical research supported by the NIH. NIH's ability to continue 
current research capacity and encourage promising new areas of science 
is, and will be, significantly limited. At a time when we should be 
investing more in research to save lives, research funding remains in 
serious jeopardy. Trials to find new therapies and cures for millions 
of Americans with blood cancers, bleeding disorders, clotting problems, 
and genetic diseases are just a few of the important projects that 
could be delayed unless NIH continues to receive predictable and 
sustained funding.
    Additionally, perhaps one of the greatest concerns is the obstacle 
these continued cuts will present to the next generation of scientists, 
who will see training funds slashed and the possibility of sustaining a 
career in research diminished. The Society is especially concerned 
about the number of scientists who have abandoned research careers; 
continued cuts will exacerbate this exodus, forcing researchers to 
abandon potentially life-enhancing research.
Fiscal year 2015 NIH Funding Request
    ASH appreciates the welcome and much needed funding increase for 
the NIH that Congress provided in the Consolidated Appropriations Act 
of 2014. However, this increase did not give back all of the funds cut 
by sequestration in fiscal year 2013 nor did it restore the purchasing 
power lost over the past decade. ASH supports the Ad Hoc Group for 
Medical Research recommendation that NIH receive at least $32 billion 
in fiscal year 2015 as the next step toward a multi-year increase in 
our Nation's investment in medical research. ASH also urges Congress 
and the Administration to work in a bipartisan manner to end 
sequestration and the continued cuts to medical research that squander 
invaluable scientific opportunities, discourage young scientists, 
threaten medical progress and continued improvements in our Nation's 
health, and jeopardize our economic future.
Centers for Disease Control and Prevention (CDC) Public Health Response 
        for Blood Disorders
    The Society also recognizes the important role of the Centers for 
Disease Control and Prevention (CDC) in preventing and controlling 
clotting, bleeding, and other hematologic disorders. Blood disorders--
such as sickle cell disease, anemia, blood clots, and hemophilia--are a 
serious public health problem and affect millions of people each year 
in the United States, cutting across the boundaries of age, race, sex, 
and socioeconomic status. Men, women, and children of all backgrounds 
live with the complications associated with these conditions, many of 
which are painful and potentially life-threatening.
    CDC is uniquely positioned to reduce the public health burden 
resulting from blood disorders by contributing to a better 
understanding of these conditions and their complications; ensuring 
that prevention programs are developed, implemented, and evaluated; 
ensuring that information is accessible to consumers and healthcare 
providers; and encouraging action to improve the quality of life for 
people living with or affected by these conditions. The Society is 
concerned that the Division of Blood Disorders was cut by nearly $6 
million in the Consolidated Appropriations Act of 2014 and the 
President's Budget for fiscal year 2015 did not restore this funding. 
ASH respectfully requests that the Division of Blood Disorders be 
funded in fiscal year 2015 at $19 million to assure that the programs 
funded by the Division for Hemophilia, Thalassemia, Sickle Cell 
Disease, and DVT/PE can be maintained. This funding will allow CDC to 
improve health outcomes and limit complications to those who are risk 
or currently have blood disorders, by promoting a comprehensive care 
model; identifying and evaluating effective prevention strategies; and 
increasing public and healthcare provider awareness of bleeding and 
clotting disorders such as such as hemophilia and thrombosis, and 
hemoglobinopathies, including sickle cell disease and thalassemia.
    Thank you again for the opportunity to submit testimony. Please 
contact Tracy Roades, ASH Legislative Advocacy Manager, at 
[email protected], if you have any questions or need further 
information concerning hematology research or ASH's fiscal year 2015 
funding request.
                                 ______
                                 
        Prepared Statement of the American Society of Nephrology
    The American Society of Nephrology (ASN) is the world's largest 
kidney health professional organization in the world, representing 
15,000 physicians, other healthcare providers, and scientists, and 
committed to advancing research, prevention, and treatment options for 
the more than 20 million adults, children, and adolescents with kidney 
disease in the United States today. The society requests at least 
$2.066 billion for the National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK) at the National Institutes of Health (NIH). The 
society also requests an additional $150 million/year over 10 years for 
kidney research above current funding for NIDDK.
    ASN believes these are crucial and necessary investments for 
preventing illness and maintaining fiscal responsibility. Investing in 
research to slow the progression of kidney disease and identify new 
therapies will save Medicare spending for the End-Stage Renal Disease 
(ESRD) Program in the long run.
    In 1972, Congress made a commitment to treat all Americans with 
kidney failure through the Medicare ESRD Program--the only health 
entitlement program that provides coverage regardless of age or 
disability. Today, ESRD patients account for less than 1 percent of the 
Medicare population but 7 percent of the Medicare budget. Meanwhile, at 
approximately $650 million per year, total Federal funding for kidney 
research is equivalent to less than 1 percent of the nearly $77 billion 
Medicare spends annually for the care of patients with kidney disease.
    Given that the Medicare ESRD Program is unique in that it covers 
treatment for all patients with kidney failure regardless of age or 
disability, preventing kidney disease and improving therapy--starting 
with innovative research at NIDDK--would yield significant savings to 
the Centers for Medicare and Medicaid Services.
    The vast majority of Federal research leading to advances in the 
care and treatment of patients with kidney disease is funded by NIDDK. 
Examples of critical discoveries arising from NIDDK-funded research are 
numerous.
    For instance, investigative studies supported by NIDDK led to a 
groundbreaking discovery that helps explain racial and ethnic 
disparities that increase risks for kidney disease, which can lead to 
earlier detection and treatment. The finding that African Americans 
with two variants of the APOL1 gene are likely to progress to kidney 
failure faster than other ethnicities paves the way for future research 
to unlock better preventive therapies and gene-based cures.
    Recent findings from NIDDK's Chronic Renal Insufficiency Cohort 
(CRIC) Study led to the discovery that the progression of kidney 
disease is associated with less efficient pumping of blood by the 
heart. Further research exploring the mechanisms for this development 
could lead to new interventions that could slow down the progression of 
kidney disease.
    Scientists supported by NIDDK have pursued cutting-edge basic, 
clinical, and translational research. While ASN fully understands the 
difficult economic environment, the society firmly believes that 
funding NIDDK is a sound investment to create jobs, support the next 
generation of investigators, and ultimately provide quality care that 
is less expensive in order to improve the public health of Americans.
    Medical research is a major force in the economic health of 
communities nationwide: every dollar invested in medical research 
generates $2.60 in economic activity. America must continue to 
capitalize on previous investments to drive research progress, train 
the next generation of scientists, create new jobs, promote economic 
growth, and maintain leadership in the global innovation economy--
particularly as other countries increase their investments in 
scientific research. Most important, a failure to maintain and 
strengthen NIDDK's ability to support the groundbreaking work of 
researchers across the country carries a palpable human toll, denying 
hope to the millions of patients awaiting the possibility of a 
healthier tomorrow.
    ASN urges Congress to uphold its longstanding legacy of bipartisan 
support for biomedical research. Should you have any questions or wish 
to discuss NIDDK or kidney research in more detail, please contact ASN 
Manager of Policy and Government Affairs Rachel Meyer at (202) 640-4659 
or [email protected].
                               about asn
    The American Society of Nephrology (ASN) is a 501(c)(3) non-profit, 
tax-exempt organization that leads the fight against kidney disease by 
educating the society's 15,000 physicians, scientists, and other 
healthcare professionals, sharing new knowledge, advancing research, 
and advocating the highest quality care for patients. For more 
information, visit ASN's website at www.asn-online.org.
                                 ______
                                 
     Prepared Statement of the American Society of Plant Biologists
    On behalf of the American Society of Plant Biologists (ASPB), we 
would like to thank the Subcommittee for its support of the National 
Institutes of Health (NIH). ASPB and its members strongly believe that 
sustained investments in scientific research will be a critical step 
toward economic recovery and job creation in our Nation. ASPB supports 
the maximum fiscal year 2015 appropriation for NIH and asks that the 
Subcommittee Members encourage increased support for plant-related 
research within the agency; 25 percent of our medicines originate from 
discoveries related to plant natural products, and such research has 
contributed in innumerable ways to improving the lives and health of 
Americans and people throughout the world.
    ASPB is an organization of some 4,500 professional plant biology 
researchers, educators, students, and postdoctoral scientists with 
members across the Nation and throughout the world. A strong voice for 
the global plant science community, our mission--achieved through work 
in the realms of research, education, and public policy--is to promote 
the growth and development of plant biology, to encourage and 
communicate research in plant biology, and to promote the interests and 
growth of plant scientists in general.
Plant Biology Research and America's Future
    Among many other functions, plants form much of the base of the 
food chain upon which all life depends. Importantly, plant research is 
also helping make many fundamental contributions in the area of human 
health, including that of a sustainable supply and discovery of plant-
derived pharmaceuticals, nutriceuticals, and alternative medicines. 
Plant research also contributes to the continued, sustainable, 
development of better and more nutritious foods and the understanding 
of basic biological principles that underpin improvements in the health 
and nutrition of all Americans.
Plant Biology and the National Institutes of Health
    Plant science and many of our ASPB member research activities have 
enormous positive impacts on the NIH mission to pursue ``fundamental 
knowledge about the nature and behavior of living systems and the 
application of that knowledge to extend healthy life and reduce the 
burdens of illness and disability.'' In general, plant research aims to 
improve the overall human condition--be it food, nutrition, medicine or 
agriculture--and the benefits of plant science research readily extend 
across disciplines. In fact, plants are often the ideal model systems 
to advance our ``fundamental knowledge about the nature and behavior of 
living systems'' as they provide the context of multi-cellularity while 
affording ease of genetic manipulation, a lesser regulatory burden, and 
maintenance requirements that are less expensive than those required 
for the use of animal systems.
    Many fundamental biological components and mechanisms (e.g., cell 
division, viral and bacterial invasion, polar growth, DNA methylation 
and repair, innate immunity signaling and circadian rhythms) are shared 
by both plants and animals. For example, a process known as RNA 
interference, which has potential application in the treatment of human 
disease, was first discovered in plants. Subsequent research eventually 
led to two American scientists, Andrew Fire and Craig Mello, earning 
the 2006 Nobel Prize in Physiology or Medicine. More recently 
scientists engineered a class of proteins called TALENs capable of 
precisely editing genomes to potentially correct mutations that lead to 
disease. That these therapeutic proteins are derived from others 
initially discovered in a plant pathogen exemplifies the application of 
plant biology research to improving human health. These important 
discoveries again reflect the fact that some of the most important 
biological discoveries applicable to human physiology and medicine can 
find their origins in plant-related research endeavors.
    Health and Nutrition--Plant biology research is also central to the 
application of basic knowledge to ``extend healthy life and reduce the 
burdens of illness and disability.'' Without good nutrition, there 
cannot be good health. Indeed, a World Health Organization study on 
childhood nutrition in developing countries concluded that over 50 
percent of child deaths under the age of five could be attributed to 
malnutrition's effects in weakening the immune system and exacerbating 
common illnesses such as respiratory infections and diarrhea. 
Strikingly, most of these deaths were not linked to severe 
malnutrition, but chronic nutritional deficiencies brought about by 
overreliance on single crops for primary staples. Plant researchers are 
working today to address the root cause of this problem by balancing 
the nutritional content of major crop plants to provide the full range 
of essential micronutrients in plant-based diets.
    By contrast to developing countries, obesity, cardiac disease, and 
cancer take a striking toll in the developed world. Research to improve 
and optimize concentrations of plant compounds known to have, for 
example, anti-carcinogenic properties, will hopefully help in reducing 
disease incidence rates. Ongoing development of crop varieties with 
tailored nutraceutical content is an important contribution that plant 
biologists can and are making toward realizing the long-awaited goal of 
personalized medicine, especially for preventative medicine.
    Drug Discovery--Plants are also fundamentally important as sources 
of both extant drugs and drug discovery leads. In fact, 60 percent of 
anti-cancer drugs in use within the last decade are of natural product 
origin--plants being a significant source. An excellent example of the 
importance of plant-based pharmaceuticals is the anti-cancer drug 
taxol, which was discovered as an anti-carcinogenic compound from the 
bark of the Pacific yew tree through collaborative work involving 
scientists at the NIH National Cancer Institute and plant natural 
product chemists. Taxol is just one example of the many plant compounds 
that will continue to provide a fruitful source of new drug leads.
    While the pharmaceutical industry has largely neglected natural 
products-based drug discovery in recent years, research support from 
NIH offers yet another paradigm. Multidisciplinary teams of plant 
biologists, bioinformaticians, and synthetic biologists are being 
assembled to develop new tools and methods for natural products 
discovery and creation of new pharmaceuticals. We appreciate NIH's 
current investment into understanding the biosynthesis of natural 
products through transcriptomics and metabolomics of medicinal plants. 
The recently released ``Genomes to Natural Products'' funding 
opportunity is also to be applauded as a potential avenue for new 
plant-related medicinal research, and we strongly encourage the 
continuation of these types of investments and other plant-related 
initiatives which can help further achievement of the NIH mission.
Conclusion
    Although NIH does recognize that plants serve many important roles, 
the boundaries of plant-related research are expansive and integrate 
seamlessly and synergistically with many different disciplines that are 
also highly relevant to NIH. As such, ASPB asks the Subcommittee to 
provide the maximum appropriation and direction to NIH to support 
additional plant research in order to continue to pioneer new 
discoveries and new methods with applicability and relevance in 
biomedical research.
    Thank you for your consideration of ASPB's testimony. For more 
information about ASPB, please see www.aspb.org.

    [This statement was submitted by Tyrone C. Spady, Ph.D., Director 
of Legislative and Public Affairs American Society of Plant 
Biologists.]
                                 ______
                                 
          Prepared Statement of the American Thoracic Society

                    SUMMARY: FUNDING RECOMMENDATIONS
                        [In millions of dollars]
------------------------------------------------------------------------
                                                                 Amount
------------------------------------------------------------------------
National Institutes of Health................................     32,000
    National Heart, Lung & Blood Institute...................      3,214
    National Institute of Allergy & Infectious Disease.......      4,701
    National Institute of Environmental Health Sciences......      717.7
    Fogarty International Center.............................       72.7
    National Institute of Nursing Research...................        151
Centers for Disease Control and Prevention...................      7,800
    National Institute for Occupational Safety & Health......      292.3
    Asthma Programs..........................................         28
    Div. of Tuberculosis Elimination.........................        243
    Office on Smoking and Health.............................        250
    National Sleep Awareness Roundtable (NSART)..............          1
------------------------------------------------------------------------

    The ATS's 15,000 members help prevent and fight respiratory disease 
through research, education, patient care and advocacy.
                        lung disease in america
    Diseases of breathing constitute the third leading cause of death 
in the U.S., responsible for one of every seven deaths. Diseases 
affecting the respiratory (breathing) system include chronic 
obstructive pulmonary disease (COPD), lung cancer, tuberculosis, 
influenza, sleep disordered breathing, pediatric lung disorders, 
occupational lung disease, asthma, and critical illness.
National Institutes of Health
    The NIH is the world's leader in groundbreaking biomedical health 
research into the prevention, treatment and cure of diseases such as 
lung cancer, COPD and tuberculosis. But due to eroded funding, the 
success rate for NIH research grants has plummeted to below 13 percent, 
which means that more than 85 percent of meritorious research is not 
being funded. The implementation of budget sequestration in fiscal year 
2013 cut NIH by an additional $1.5 billion, which resulted in the 
elimination of at least 1,000 grant opportunities and cuts of up to 10 
percent for continuing grants. These cuts will result in the halting of 
vital research into diseases affecting millions around the world. We 
ask the subcommittee to provide $32 billion in funding for the NIH in 
fiscal year 2015.
    Despite the rising lung disease burden, lung disease research is 
underfunded. In fiscal year 2012, lung disease research represented 
just 23.2 percent of the National Heart Lung and Blood Institute's 
(NHLBI) budget. Although lung disease is the third leading cause of 
death in the U.S., research funding for the disease is a small fraction 
of the money invested for the other three leading causes of death. In 
order to stem the devastating effects of lung disease, research funding 
must continue to grow.
Centers for Disease Control and Prevention
    In order to ensure that health promotion and chronic disease 
prevention are given top priority in Federal funding, the ATS supports 
a funding level for the Centers for Disease Control and Prevention 
(CDC) that enables it to carry out its prevention mission, and ensure a 
translation of new research into effective State and local public 
health programs. We ask that the CDC budget be adjusted to reflect 
increased needs in chronic disease prevention, infectious disease 
control, including TB control and occupational safety and health 
research and training. The ATS recommends a funding level of $7.8 
billion for the CDC in fiscal year 2015.
                  chronic obstuctive pulmonary disease
    COPD is the third leading cause of death in the United States and 
the third leading cause of death worldwide, yet the disease remains 
relatively unknown to most Americans. CDC estimates that 12 million 
patients have COPD; an additional 12 million Americans are unaware that 
they have this life threatening disease. In 2010, the estimated 
economic cost of lung disease in the U.S. was $186 billion, including 
$117 billion in direct health expenditures and $69 billion in indirect 
morbidity and mortality costs.
    The NHLBI is developing a national action plan on COPD, in 
coordination with the Centers for Disease Control and Prevention (CDC) 
to expand COPD surveillance, development of public health interventions 
and research on the disease and increase public awareness of the 
disease and we urge Congress to support it. We also urge CDC to include 
COPD-based questions to future CDC health surveys, including the 
National Health and Nutrition Evaluation Survey (NHANES) and the 
National Health Information Survey (NHIS).
                            tobacco control
    Cigarette smoking is the leading preventable cause of death in the 
U.S., responsible for one in five deaths annually. The ATS is pleased 
that the Department of Health and Human Services has made tobacco use 
prevention a key priority. The CDC's Office of Smoking and Health 
coordinates public health efforts to reduce tobacco use. In order to 
significantly reduce tobacco use within 5 years, as recommended by the 
subcommittee in fiscal year 2010, the ATS recommends a total funding 
level of $250 million for the Office of Smoking and Health in fiscal 
year 2015.
                                 asthma
    Asthma is a significant public health problem in the United States. 
Approximately 25 million Americans currently have asthma. In 2010, 
3,388 Americans died as a result of asthma exacerbations. Asthma is the 
third leading cause of hospitalization among children under the age of 
15 and is a leading cause of school absences from chronic disease. The 
disease costs our healthcare system over $50.1 billion per year. 
African Americans have the highest asthma prevalence of any racial/
ethnic group and the age-adjusted death rate for asthma in this 
population is three times the rate in whites. A study published in the 
American Journal of Respiratory Critical Care in 2012 found that for 
every dollar invested in asthma interventions, there was a $36 benefit. 
We ask that the subcommittee's appropriations request for fiscal year 
2015 that funding for CDC's National Asthma Control Program be 
maintained at a funding level of at least $28 million.
                                 sleep
    Several research studies demonstrate that sleep-disordered 
breathing and sleep-related illnesses affect an estimated 50-70 million 
Americans. The public health impact of sleep illnesses and sleep 
disordered breathing is still being determined, but is known to include 
increased mortality, traffic accidents, cardiovascular disease, 
obesity, mental health disorders, and other sleep-related 
comorbidities. The ATS recommends a funding level of $1 million in 
fiscal year 15 to support activities related to sleep and sleep 
disorders at the CDC, including for the National Sleep Awareness 
Roundtable (NSART), surveillance activities, and public educational 
activities. The ATS also recommends an increase of funding for research 
on sleep disorders at the Nation Center for Sleep Disordered Research 
(NCSDR) at the NHLBI.
                              tuberculosis
    Tuberculosis (TB) is the second leading global infectious disease 
killer, claiming 1.3 million lives each year. In the U.S., every State 
reports cases of TB annually. Drug-resistant TB poses a particular 
challenge to domestic TB control due to the high costs of treatment and 
intensive healthcare resources required. Treatment costs for multidrug-
resistant (MDR) TB range from $100,000 to $300,000. The global TB 
pandemic and spread of drug resistant TB present a persistent public 
health threat to the U.S.
    The Comprehensive Tuberculosis Elimination Act (CTEA, Public Law 
110-392), enacted in 2008, reauthorized programs at CDC with the goal 
of putting the U.S. back on the path to eliminating TB. The ATS, 
recommends a funding level of $243 million in fiscal year 2015 for 
CDC's Division of TB Elimination, as authorized under the CTEA, and 
encourages the NIH to expand efforts to develop new tools to reduce the 
rising global TB burden.
                         pediatric lung disease
    The ATS is pleased to report that infant death rates for various 
lung diseases have declined for the past 10 years. In 2009, of the 10 
leading causes of infant mortality, 4 were lung diseases or had a lung 
disease component. Many of the precursors of adult respiratory disease 
start in childhood. Many children with respiratory illness grow into 
adults with COPD. It is estimated that 7.1 million children suffer from 
asthma. While some children appear to outgrow their asthma when they 
reach adulthood, 75 percent will require life-long treatment and 
monitoring of their condition. The ATS encourages the NHLBI to continue 
with its research efforts to study lung development and pediatric lung 
diseases.
                            critical illness
    The burden associated with the provision of care to critically ill 
patients is enormous, and is anticipated to increase significantly as 
the population ages. Approximately 200,000 people in the United States 
require hospitalization in an intensive care unit because they develop 
a form of pulmonary disease called Acute Lung Injury. Despite the best 
available treatments, 75,000 of these individuals die each year from 
this disease. This is the approximately the same number of deaths each 
year due to breast cancer, colon cancer, and prostate cancer combined. 
Investigation into diagnosis, treatment and outcomes in critically ill 
patients should be a priority, and the NIH should be encouraged and 
funded to coordinate investigation in this area in order to meet this 
growing national imperative.
                      fogarty international center
    The Fogarty International Center (FIC) provides training grants to 
U.S. universities to teach AIDS treatment and research techniques to 
international physicians and researchers. Because of the link between 
AIDS and TB infection, FIC has created supplemental TB training grants 
for these institutions to train international health professionals in 
TB treatment and research. The ATS recommends Congress provide $72.8 
million for FIC in fiscal year 2015, to allow expansion of the TB 
training grant program from a supplemental grant to an open competition 
grant.
          researching and preventing occupational lung disease
    As Congress considers funding priorities for fiscal year 2015, the 
ATS urges the subcommittee to provide at least level funding for the 
National Institute for Occupational Safety and Health (NIOSH). NIOSH, 
within the Centers for Disease Control and Prevention (CDC), is the 
primary Federal agency responsible for conducting research and making 
recommendations for the prevention of work-related illness and injury.
    The ATS appreciates the opportunity to submit this statement to the 
subcommittee.

    [This statement was submitted by Thomas Ferkol, MD, President, 
American Thoracic Society.]
                                 ______
                                 
    Prepared Statement of the Americans for Nursing Shortage Relief
    The organizations of the ANSR Alliance greatly appreciate the 
opportunity to submit written testimony recommending $251 million in 
fiscal year 2015 for the Title VIII Nursing Workforce Development 
Programs at the Health Resources and Services Administration (HRSA) and 
$20 million for the Nurse Managed Health Clinics as authorized under 
Title III of the Public Health Service Act. We represent a diverse 
cross-section of healthcare and other related organizations, healthcare 
providers, and supporters of nursing issues (http://
www.ansralliance.org/Members.html) that have united to address the 
national nursing shortage. ANSR stands ready to work with Congress to 
advance programs and policy that will ensure our Nation has a 
sufficient and adequately prepared nursing workforce to provide quality 
care to all well into the 21st century.
The Nursing Shortage
    Nursing is the largest healthcare profession in the United States 
and work in a variety of settings, including primary care, public 
health, long-term care, surgical care facilities, schools, and 
hospitals. In the Bureau of Labor Statistics (BLS) Employment 
Projections for 2012-2022, the total employment of registered nurses 
(RNs) and advanced practice registered nurses (APRNs) will increase by 
574,400 jobs. With upcoming RN retirements in the mix, the Nation will 
need to produce 1.13 million new RNs by 2022 to fill those jobs. 
Because of the retirements, the projected number of RNs needed to fully 
staff healthcare facilities is virtually double the number of increased 
jobs due to expanded demand from new patients coupled with the aging 
baby boomer population wanting healthcare services. More new RNs are 
graduating from nursing programs than had been observed in the early 
2000's but not sufficient numbers to make up the difference over the 
long-term. The Title VIII Nursing Workforce Education Programs will 
help fill these vacancies by supporting training programs designed to 
meet these healthcare needs.
    The Title VIII Nursing Workforce and Education programs provide 
training for entry-level and advanced degree nurses to improve the 
access to, and the quality of, healthcare in underserved areas. These 
programs provide the largest source of Federal funding for nursing 
education, providing loans, scholarships, traineeships, and 
programmatic support that, between fiscal year 2005 and 2010, supported 
over 400,000 nurses and nursing students as well as numerous academic 
nursing institutions and healthcare facilities.
The Desperate Need for Nurse Faculty
    Nursing vacancies exist throughout the entire healthcare system, 
including long-term care, home care and public health. Government 
estimates indicate that this situation only promises to worsen due to 
an insufficient supply of individuals matriculating in nursing schools, 
an aging existing workforce, and the inadequate availability of nursing 
faculty to educate and train the next generation of nurses. At the 
exact same time that the nursing shortage is expected to worsen, the 
baby boom generation is aging and the number of individuals with 
serious, life-threatening, and chronic conditions requiring nursing 
care will increase.
    Each year, nursing schools turn away tens of thousands of qualified 
applications at all degree levels due to an insufficient number of 
faculty, clinical sites, classroom space, clinical preceptors, and 
budget constraints. Securing and retaining adequate numbers of faculty 
is essential to ensure that all individuals interested in--and 
qualified for--nursing school can matriculate in the year that they are 
accepted.
    ANSR supports the need for sustained attention on the efficacy and 
performance of existing and proposed programs to improve nursing 
practices and strengthen the nursing workforce. The support of research 
and evaluation studies that test models of nursing practice and 
workforce development is integral to advancing healthcare for all in 
America. Investments in research and evaluation studies have a direct 
effect on the caliber of nursing care. Our collective goal of improving 
the quality of patient care, reducing costs, and efficiently delivering 
appropriate healthcare to those in need is served best by aggressive 
nursing research and performance and impact evaluation at the program 
level.
The Nursing Supply Impacts the Nation's Health and Economic Safety
    The demand for primary care services in the US is expected to 
increase over the next few years, particularly with the aging and 
growth of the population. One study projects that by the year 2019, the 
demand for primary care in the United States will increase by between 
15 million and 25 million visits per year. HRSA estimates that more 
than 35.2 million people living within the 5,870 Health Professional 
Shortage Areas nationwide do not currently receive adequate primary 
care services. Research suggests that nurses and other health 
professionals are trained to and already do deliver many primary care 
services and may therefore be able to help increase access to primary 
care, particularly in underserved areas.
    ANSR applauds the subcommittee's bipartisan efforts to recognize 
that a strong nursing workforce is essential to a health policy that 
provides high-value care for every dollar invested in capacity building 
for a 21st century nurse workforce. For 50 years, the Title VIII 
Nursing Workforce Development Programs have responded to the Nation's 
evolving workforce needs by providing education and training 
opportunities to nurses. These programs are the only Federal programs 
focused on filling gaps in the supply of nurses not met by traditional 
market forces, as well as producing a workforce prepared to care for 
the Nation's increasingly diverse and aging population. Numerous 
studies have demonstrated that the Title VIII programs graduate more 
minority and disadvantaged students more likely to serve in community 
health centers as well as rural and underserved areas. In a difficult 
economy, the Title VIII Nursing Workforce Education Programs help 
schools offer scholarships and affordable loans to nursing students, 
making such educational opportunities available to aspiring nurses of 
all backgrounds. By guiding job seekers to high-demand nursing jobs, 
the programs fulfill both their individual career goals and a 
community's health needs.
Summary
    HRSA's Title VIII Nursing Workforce Education programs contribute 
to a sufficient nursing workforce to meet the demands of a highly 
diverse and aging population is an essential component to improving the 
health status of the Nation and reducing healthcare costs. While the 
ANSR Alliance understands the immense fiscal pressures facing the 
Nation, we respectfully urge support for $251 million in funding for 
Nursing Workforce Development Programs under Title VIII of the Public 
Health Service Act at HRSA and $20 million for the Nurse Managed Health 
Clinics under Title III of the Public Health Service Act in fiscal year 
2015. We look forward to working with the Subcommittee to prioritize 
the Title VIII programs in fiscal year 2015 and the future.
                        ansr alliance co-chairs
Christine Murphy, ANSR Alliance Co-Chair
Senior Public Policy Specialist
National League for Nursing
  
Wade Delk, ANSR Alliance Co-Chair
Government Affairs Director
American Society for Pain Management Nursing & International Nurses 
Society on Addictions
                   list of ansr member organizations:
Academy of Medical-Surgical Nurses
American Academy of Ambulatory Care Nursing
American Academy of Nurse Practitioners
American Academy of Nursing
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordination
American Association of Occupational Health Nurses
American College of Nurse-Midwives
American Organization of Nurse Executives
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
American Society of Plastic Surgical Nurses
Association for Radiologic & Imaging Nursing
Association of Pediatric Hematology/Oncology Nurses
Association of State and Territorial Directors of Nursing
Association of Women's Health, Obstetric & Neonatal Nurses
Citizen Advocacy Center
Dermatology Nurses' Association
Developmental Disabilities Nurses Association
Emergency Nurses Association
Infusion Nurses Society
International Association of Forensic Nurses
International Nurses Society on Addictions
International Society of Nurses in Genetics, Inc.
Legislative Coalition of Virginia Nurses
National Association of Clinical Nurse Specialists
National Association of Hispanic Nurses
National Association of Neonatal Nurses
National Association of Neonatal Nurse Practitioners
National Association of Nurse Massage Therapists
National Association of Nurse Practitioners in Women's Health
National Association of Orthopedic Nurses
National Association of Registered Nurse First Assistants
National Association of School Nurses
National Black Nurses Association
National Council of State Boards of Nursing
National Council of Women's Organizations
National Gerontological Nursing Association
National League for Nursing
National Nursing Centers Consortium
National Nursing Staff Development Organization
National Organization for Associate Degree Nursing
National Student Nurses' Association, Inc.
Nurses Organization of Veterans Affairs
Pediatric Endocrinology Nursing Society
Preventive Cardiovascular Nurses Association
RN First Assistants Policy & Advocacy Coalition
Society of Gastroenterology Nurses and Associates, Inc.
Society of Pediatric Nurses
Society of Trauma Nurses
Women's Research & Education Institute
Wound, Ostomy and Continence Nurses Society
                      
                                 ______
                                 
 Prepared Statement of the Animal Protection of New Mexico and Animal 
                           Protection Voters
    On behalf of the board, staff, members and supporters of Animal 
Protection of New Mexico (APNM) and Animal Protection Voters (APV), we 
sincerely appreciate the opportunity to provide testimony on our top 
NIH funding priority for the House Labor, Health and Human Services, 
Education and Related Agencies Appropriations Subcommittee in fiscal 
year 2015.
   capacity for federally-owned chimpanzees retired by the national 
                          institutes of health
    APNM and APV request NIH be given authority to use $5 million of 
funds appropriated in this and subsequent appropriations bills for 
extramural construction and renovation within the National Chimpanzee 
Sanctuary System.
    In 2013, NIH announced their plan to retire hundreds of government 
owned chimpanzees to sanctuary. This decision followed years of 
scientific review that determined chimpanzees are not necessary for 
research to advance human health along with broad public outcry over 
the ethics of holding chimpanzees in labs. Additional sanctuary 
construction is needed to enable NIH to move forward with their plan to 
retire the vast majority of government owned chimpanzees. Even taking 
into account upfront construction expenditures, the sooner the 
construction is completed and the chimpanzees are moved to sanctuary, 
the more the government will save over the lifetimes of the 
chimpanzees--which can be 60 years or more.
    Detailed information on the request follows.
Background information
    In June of 2010, the National Institutes of Health proposed a plan 
to move 202 aging, sick chimpanzees from a facility New Mexico where 
they had not been used for invasive research for years to a laboratory 
in Texas for further research. Intense public scrutiny over the animal 
cruelty issues and taxpayer waste of this plan was bolstered by 
involvement from New Mexico Governor Bill Richardson, Dr. Jane Goodall, 
and many more. In December 2010 U.S. Senators Tom Udall, Tom Harkin, 
and Jeff Bingaman requested an independent study from the National 
Academy of Sciences on whether chimpanzees are necessary as invasive 
research subjects.
    The December 2011 Institute of Medicine study found that 
chimpanzees are not necessary for the vast majority of research and 
noted the serious ethical objections raised by keeping chimps in 
research labs. Immediately following the announcement of the IOM study 
results, NIH accepted the findings and assembled a panel of experts to 
advise them on the best way to implement the IOM findings. NIH accepted 
nearly all of the expert panel's recommendations in their final 
decision. In June of 2013, the National Institutes of Health announced 
their plan to retire all but 50 government-owned chimpanzees to 
sanctuary, significantly curtail the use of chimps in NIH funded 
studies and not to revitalize breeding of chimpanzees for research.
    NIH had already begun the transfer of the 110 government owned 
chimpanzees at the New Iberia Research Center in Louisiana to Chimp 
Haven (the National Chimpanzee Sanctuary), also located in Louisiana. 
This transfer is on schedule to be completed by the end of fiscal year 
2014. At that point, approximately 350 government-owned chimpanzees 
will remain in laboratories--300 of whom are slated for retirement to 
sanctuary per NIH's plan.
    In late November of 2013, the President signed into law amendments 
to the Chimpanzee Health Improvement Maintenance and Protection (CHIMP 
Act) which continued funding for the care, maintenance and 
transportation of federally owned chimpanzees over the next 5 years. 
These amendments have enabled NIH to provide funds for basic care for 
chimpanzees the agency already approved into sanctuary and also set the 
stage for NIH to move forward with their plan to retire hundreds more 
chimpanzees.
Costs in laboratories vs. sanctuary
    Accredited sanctuaries provide the highest welfare standards for 
chimps at a lower cost to taxpayers than housing chimpanzees in 
research laboratories (see attached chart). It is estimated that 
transferring the 300 government-owned chimpanzees who are slated for 
retirement from the laboratories where they are currently housed to the 
national sanctuary will save taxpayers $1.7 million to $2.7 million per 
year in care and maintenance costs.
    Construction to house more chimpanzees in sanctuary will require an 
upfront expenditure. However, due to the lower per diem cost in 
sanctuary, retiring chimpanzees to sanctuary will still yield a 
significant savings to taxpayers. The sooner construction is completed 
and the chimpanzees are moved to sanctuary, the more the taxpayers will 
save.
We respectfully request the subcommittee to consider the following 
        language for inclusion in the appropriations bill:
    Of the funds appropriated to NIH, $5,000,000 shall be for grants or 
contracts for construction, renovation, or repair of the sanctuary 
system established by Section 404K of the Public Health Service Act.
    Estimated Costs Related to Care and Maintenance of Government Owned 
Chimpanzees:

               Government Owned Chimpanzees in Research Facilities and Research Reserve Facilities
----------------------------------------------------------------------------------------------------------------
                                                          Number of                              NIH cost,  $/
                      Facility                           chimpanzees       NIH cost, $M/year     chimpanzee/day
----------------------------------------------------------------------------------------------------------------
New Iberia Research Center..........................           \1,2\ 59              \3\ 1.01           \4\ 46.7
Keeling Center for Comparative Medicine and Research             \2\147              \3\ 2.44               45.4
Keeling Center for Comparative Medicine and                      \2\ 16              \2\ 0.4                68.8
 Research, DVR grant................................
Southwest National Primate Research Center, U42                  \2\ 22              \3\ 0.65               80.9
 grant \5\..........................................
Alamogordo Primate Facility.........................            \2\ 162              \2\ 3.60               61.3
    Totals..........................................                406                  8.10      Average: 54.7
----------------------------------------------------------------------------------------------------------------


                                    Government Owned Chimpanzees in Sanctuary
----------------------------------------------------------------------------------------------------------------
                                                             Number of                            NIH cost, $/
                        Facility                            chimpanzees     NIH cost, $M/year     animal/day,
----------------------------------------------------------------------------------------------------------------
Chimp Haven............................................        \6\ 118-153            \7\ 1.7              30-39
----------------------------------------------------------------------------------------------------------------
\1\ The remaining 59 chimpanzees at New Iberia Research Center are scheduled to be moved to Chimp Haven by the
  end of fiscal year 2014
\2\ Based on information available on NIH website regarding chimpanzee maintenance costs for fiscal year 2014
\3\ Based on data available in NIH Research Portfolio Online Reporting Tools (RePORT) for fiscal year 2014
\4\ Figure expected to increase significantly as chimpanzees move to Chimp Haven and funds are spread over fewer
  chimpanzees
\5\ In addition to this grant, NIH also supports an additional 91 chimpanzees at the facility. These chimpanzees
  are owned by the laboratory and are not under the control of NIH.
\6\ Fifty chimpanzees from New Iberia Research Center were transferred to Chimp Haven during this contract year.
\7\ Unlike the other facilities, Chimp Haven has a cost reimbursement contract in which they are reimbursed for
  costs incurred. This number represents actual costs billed to NIH over the most recently completed contract
  year (06/30/2012--06/29/2013)

    We appreciate the opportunity to share this testimony with the 
Labor, Health and Human Services, Education and Related Agencies 
Appropriations Act for fiscal year 2015. We hope the Committee will be 
able to accommodate this request. Thank you for your consideration.
                                 ______
                                 
  Prepared Statement of the Association of American Cancer Institutes
    The Association of American Cancer Institutes (AACI), representing 
93 of the Nation's premier academic and free-standing cancer centers, 
appreciates the opportunity to submit this statement for consideration 
by the subcommittee. AACI submits this request for the Department of 
Health and Human Services budget for the National Institutes of Health 
(NIH) in the amount of $32 billion for fiscal year 2015.
    AACI thanks Congress for its long-standing commitment to ensuring 
quality care for cancer patients, as well as for providing researchers 
with the resources that they need to develop better cancer treatments 
and, ultimately, to find cures for this deadly disease. The partnership 
between the Federal Government and our Nation's cancer centers is 
mutually beneficial, and cancer centers continue to make strides in 
biomedical research thanks to a partnership with the Federal 
Government. Without such support, research projects with the potential 
to discover breakthrough therapies would not be possible.
    The President's fiscal year 2015 budget proposes $30.2 billion for 
the NIH, an increase of $200 million (0.7 percent) over the fiscal year 
2014 level. This amount includes $4.931 billion for the National Cancer 
Institute (NCI), a $7.5 million increase over fiscal year 2014 (0.2 
percent). Though we appreciate the president's support, NIH and NCI 
continue to endure a lag in funding. The fiscal year 2015 proposal 
falls far short of the inflation rate of 2.9 percent, a figure that NIH 
projected last year for the Biomedical Research and Development Price 
Index (BRDPI) for fiscal year 2015. AACI joins with our colleagues in 
the biomedical research community in recommending that the subcommittee 
recognize NIH as a critical national priority by providing at least $32 
billion in funding in the fiscal year 2015 Labor-HHS-Education 
Appropriations bill, including an equivalent percentage increase in 
funding for NCI. This funding level represents the minimum investment 
necessary to avoid further loss of promising research.
   cancer centers must be supported in order to move research forward
    America's standing in research and scientific discovery is 
threatened with each dollar slashed from the NIH budget. The budgetary 
pain in fiscal year 2014 has been less intense than in recent years but 
still remains for cancer centers striving both to keep gifted 
scientists at their institutions and to resume halted research projects 
due to sequestration. For some labs, recovery is nowhere in sight. Many 
have closed their doors, while some scientists have taken early 
retirement or simply left the field. Even some well-established labs 
claim they will never recover from the damage caused by sequestration.
    With cancer centers challenged to provide infrastructure resources 
necessary to support researchers, the failure to keep pace with the 
biomedical inflation rate will limit AACI members' ability to provide 
well-functioning shared resources to investigators who depend on them 
to complete their research. For most academic cancer centers, the 
majority of NCI grant funds are used to sustain shared resources that 
are essential to basic, translational, clinical and population cancer 
research, or to provide matching dollars which allow departments to 
recruit new cancer researchers to a university and support them until 
they receive their first grants. Center infrastructure is expensive and 
it is not clear where cancer centers would acquire alternative funding 
if NCI grants for these efforts continue to dwindle.
    AACI cancer centers are at the forefront of the national effort to 
eradicate cancer. The cancer centers that AACI represents house more 
than 20,000 scientific, clinical and public health investigators who 
work collaboratively to translate promising research findings into new 
approaches to prevent and treat cancer. Making progress against cancer 
is complex and time-intensive. However, the pace of discovery and 
translation of novel basic research to new therapies could be quickened 
if researchers could count on an appropriate and predictable investment 
in Federal cancer funding. As research costs and patient need increase, 
cancer centers continue to be highly dependent on Federal cancer center 
grants.
                cancer centers are pioneers in research
    The negative effects of diminished biomedical research funding 
reach beyond the lab as AACI cancer center directors have vocalized 
their concerns. The impact of flat funding to the NIH continues to 
disturb advances in biomedical research and is of paramount concern to 
cancer center leaders.
    While AACI President Michelle M. Le Beau, PhD, director of the 
University of Chicago Comprehensive Cancer Center, applauded the 
president's budget proposal, she asked that Congress build upon that 
budget. Dr. Le Beau has said that at a time when cancer centers 
continue to address the losses sustained due to budget sequestration, 
research institutions rely on robust aid from their partnership with 
the Federal Government. She said, ``Cancer centers have served as 
pioneers in biomedical research, improving patient care and gaining a 
deeper understanding of the molecular basis of cancer through research. 
Advances in science are within reach, but without sufficient funding at 
the NIH and ultimately, the NCI, such progress in research will move at 
a slower pace.''
    Speaking at a meeting of the AACI Government Relations Forum in 
Houston, TX, University of Texas MD Anderson Cancer Center president 
Ronald DePinho, MD, echoed Dr. Le Beau's concerns. Dr. DePinho 
underscored the need for increased Federal funding for cancer research, 
noting that cancer incidence in the U.S. is projected to increase 45 
percent between today and 2030. Dr. DePinho has acknowledged that the 
major solutions for patients will come from scientific innovations that 
will lead to transformation in cancer prevention, early detection and 
definitive cures. He said that academic medical centers are the engines 
for such discoveries. Dr. DePinho stressed that it is ``critical that 
we vigorously support these national treasures to deal with the 
onslaught of people who will need cancer services.''
    University of New Mexico Cancer Center researchers, physicians, and 
staff work tirelessly to provide vital patient care and breakthrough 
cancer technology to a richly diverse and widely dispersed population. 
Cancer center director and CEO Cheryl Lynn Willman, MD is dedicated to 
ensuring all patients who enter UNM Cancer Center receive unsurpassed 
care, yet she is troubled by worries that not everyone in New Mexico 
has the ability and means to seek care at the NCI-designated center. 
While Willman and her team at UNM Cancer Center devote their time, 
effort, and hard work to bringing the most advanced cancer treatments 
available to the public, providing all potential patients with access 
to care is not achieved without high costs. Without sustained and 
stable NIH funding UNM Cancer Center and other centers across the 
country will struggle to uphold their devoted mission in cancer care 
and research to the people of New Mexico.
    Robert S. DiPaola, MD, director of Rutgers Cancer Institute of New 
Jersey, knows the strides that can be made within cancer research due 
to increased NIH funding. Recently, Rutgers was awarded a competitive 
grant by the NCI to support their precision experimental therapeutics 
endeavor. Dr. DiPaola was proud to announce their collaboration with 
investigators from the University of Wisconsin Carbone Cancer Center as 
well as with a network of cancer centers. Though Dr. DiPaola and his 
team are grateful for the NCI funding that has made this work possible, 
they are increasingly aware that without adequate increases to NIH 
funding, the future of cancer research collaboration could suffer. He 
asserted that, ``Ensuring that NIH acquires an increase at least 
relative to the inflation rate of 2.9 percent will help to keep the 
progress we are making in cancer research nationwide moving in the 
right direction.''
    Samir N. Khleif, MD, director of GRU Cancer Center at Georgia 
Regents University, testified before the appropriations subcommittee on 
March 25, noting that decades of sustained strong investment in NIH and 
NCI have sparked remarkable progress in cancer research and treatment. 
Dr. Khleif asked for increased funding at the NIH and the NCI in order 
to ``keep our best and brightest minds focused on developing the 
biomedical research breakthroughs that save lives.'' He requested that 
support for NIH not falter in order for the U.S. to maintain its global 
edge in scientific discovery and innovation and maintain its progress 
in reducing the burden of cancer and other diseases.
    AACI President-Elect George Weiner, MD, director of the Holden 
Comprehensive Cancer Center at the University of Iowa, agreed with Dr. 
Khleif's testimony. Dr. Weiner's greatest concern stems from the 
decrease in funding for the NIH and the NCI and the impact reduced 
Federal funding will have on young scientists and he has blogged about 
scientific and budgetary concerns. Dr. Weiner fears young scientists 
might not chose to conduct their research in the U.S. in the future, 
instead opting to go overseas as U.S. support for innovation has been 
flat or dropped and other countries begin to make progress. Dr. Weiner 
knows that the U.S. remains the world leader in biomedical research, 
but feels that ``ongoing success will be dependent on outstanding 
physicians and scientists, born here and abroad, having the 
collaborative culture, resources and infrastructure needed to 
accelerate progress toward our shared mission of reducing the burden of 
cancer.'' Dr. Weiner stated that providing these tools will have a 
positive impact on our Nation's ability to care for patients, our 
ability to conduct research, and our economy. Dr. Weiner stressed the 
need to continue to emphasize the importance of investing in innovation 
through education and research. He maintained that a commitment to 
investing in the NIH and the NCI is vital to the successes achieved 
through science.
             cancer research is improving america's health
    The broad portfolio of research supported by NIH and NCI is 
essential for improving our basic understanding of diseases and has 
paid off considerably in terms of improving Americans' health. The 5-
year relative survival rate for all cancers diagnosed between 2002 and 
2008 is 68 percent, up from 49 percent in 1975-1977. In addition, 
cancer death rates have dropped 11.4 percent among women and 19.2 
percent among men over the past 15 years.\1\ The improvement in 
survival reflects both progress in diagnosing certain cancers at an 
earlier stage and better treatment.
---------------------------------------------------------------------------
    \1\ American Cancer Society. Facts and Figures, 2014. http://
www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2014/.
---------------------------------------------------------------------------
    Despite that success, cancer remains the second leading cause of 
death in the U.S., with almost 1,600 deaths per day. More than 1.6 
million new cancer cases will be discovered in 2014 and over 580,000 
cancer deaths are expected.\2\ NCI estimates that 41 percent of 
individuals born today will receive a cancer diagnosis at some point in 
their lifetime.\3\
---------------------------------------------------------------------------
    \2\ American Cancer Society. Facts and Figures.
    \3\ Cancer Trends Progress Report--2011/2012 Update, National 
Cancer Institute, NIH, DHHS, Bethesda, MD, August 2012, http://
progressreport.cancer.gov.
---------------------------------------------------------------------------
                               conclusion
    NIH estimates that the overall costs of cancer in 2008 were $201.5 
billion: $77.4 billion for direct medical costs (total of all health 
expenditures) and $124 billion for indirect mortality costs (cost of 
lost productivity due to premature death).\4\ The cost of cancer 
continues to rise, but the investment in cancer research will one day 
eliminate such economic burdens on Americans and the cancer center 
researchers who work tirelessly to find a cure for this deadly disease. 
Failure to keep pace with the biomedical rate of inflation will only 
hinder our Nation's cancer center researchers from grasping future 
knowledge that will aid in the prevention, detection and treatment of 
cancer.
---------------------------------------------------------------------------
    \4\ American Cancer Society. Facts and Figures.
---------------------------------------------------------------------------
    As Congress makes difficult appropriations decisions for fiscal 
year 2015 and beyond, AACI asks that it recall that the Nation's 
financial support of NIH and NCI has paid dividends by introducing 
innovative therapies for cancers that years ago cut short far too many 
American lives. The future of scientific discovery in cancer research 
is in the hands of the scientists whose research is conducted in labs 
across the country. NIH's full support of NCI-designated centers and 
their programs remains a top priority for our Nation's research 
institutions and we ask that Congress aid our Nation's cancer centers 
in their goal to eradicate cancer.

    [This statement was submitted by Barbara Duffy Stewart, MPH, 
Executive Director, Association of American Cancer Institutes.]
                                 ______
                                 
   Prepared Statement of the Association of American Medical Colleges
    The Association of American Medical Colleges (AAMC) is a not-for-
profit association representing all 141 accredited U.S. and 17 
accredited Canadian medical schools; nearly 400 major teaching 
hospitals and health systems; and nearly 90 academic and scientific 
societies. Through these institutions and organizations, the AAMC 
represents 128,000 faculty members, 75,000 medical students, and 
110,000 resident physicians. The AAMC requests the following for 
Federal priorities essential in assisting medical schools and teaching 
hospitals to fulfill their missions of education, research, and patient 
care: at least $32 billion for the National Institutes of Health (NIH); 
$375 million for the Agency for Healthcare Research and Quality (AHRQ); 
$520 million for the Title VII and VIII health professions workforce 
programs the Health Resources and Services Administration (HRSA)'s 
Bureau of Health Professions; and student aid through the Department of 
Education and HRSA's National Health Service Corps. The AAMC 
appreciates the Subcommittee's longstanding, bipartisan efforts to 
strengthen these programs.
    National Institutes of Health--Congress's long-standing bipartisan 
support for medical research through the NIH has created a scientific 
enterprise that is the envy of the world and has contributed greatly to 
improving the health and well-being of all Americans. The foundation of 
scientific knowledge built through NIH-funded research drives medical 
innovation that improves health through new and better diagnostics, 
improved prevention strategies, and more effective treatments.
    Nearly 84 percent of NIH research funding is awarded to more than 
2,500 research institutions in every state. At least half of this 
funding supports life-saving research at America's medical schools and 
teaching hospitals, where scientists, clinicians, fellows, residents, 
medical students, and trainees work side-by-side to improve the lives 
of Americans through research. This successful partnership between the 
Federal Government and academic medicine not only lays the foundation 
for improved health and quality of life, it also strengthens the 
Nation's long-term economy.
    The Consolidated Appropriations Act of 2014 included a welcome and 
much needed increase for NIH. However, this increase did not restore 
the funding cut from sequestration in fiscal year 2013 or the 
purchasing power lost over the past decade. The AAMC hopes fiscal year 
2014 represents a first step toward restoring our Nation's preeminence 
in medical research. The AAMC supports the Ad Hoc Group for Medical 
Research recommendation that NIH receive at least $32 billion in fiscal 
year 2015 as the next step toward a multi-year increase in our Nation's 
investment in medical research. The AAMC also urges Congress and the 
Administration to work in a bipartisan manner to end sequestration and 
the continued cuts to medical research that squander invaluable 
scientific opportunities, discourage young scientists, threaten medical 
progress and continued improvements in our Nation's health, and 
jeopardize our economic future.
    The AAMC thanks the Subcommittee for its efforts to retain the 
limit on salaries that can be drawn from NIH extramural awards at 
Executive Level II of the Federal Executive Pay Scale. Medical schools' 
and teaching hospitals' discretionary funds from clinical revenues and 
other sources have become increasingly constrained and less available 
to invest in research. If institutions and departments divert funds to 
compensate for a reduction in the salary limit, they have less funding 
for critical activities such as bridge funding to investigators between 
grants and start-up packages to young investigators to launch their 
research programs. A lower salary cap also will disproportionately 
affect physician investigators, who will be forced to make up salaries 
from clinical revenues, thus leaving less time for research. This may 
serve as a deterrent to their recruitment into research careers. The 
AAMC urges the Subcommittee to continue its efforts to retain the limit 
at Executive Level II.
    Agency for Healthcare Research and Quality--Complementing the 
medical research supported by NIH, AHRQ sponsors health services 
research designed to improve the quality of healthcare, decrease 
healthcare costs, and provide access to essential healthcare services 
by translating research into measurable improvements in the healthcare 
system. The AAMC firmly believes in the value of health services 
research as the Nation continues to strive to provide high-quality, 
evidence-based, efficient, and cost-effective healthcare to all of its 
citizens. The AAMC joins the Friends of AHRQ in recommending $375 
million in base discretionary funding for the agency in fiscal year 
2015.
    As the only Federal agency with the sole purpose of generating 
evidence to make healthcare safer; higher quality; and more accessible, 
equitable, and affordable, AHRQ also works to ensure such evidence is 
available across the continuum of healthcare stakeholders, from 
patients to payers to providers. These research findings will better 
guide and enhance consumer and clinical decisionmaking, provide 
improved healthcare services, and promote efficiency in the 
organization of public and private systems of healthcare delivery.
    Health Professions Funding--HRSA's Title VII health professions and 
Title VIII nursing education programs are the only Federal programs 
designed to improve the supply, distribution, and diversity of the 
Nation's primary care workforce. Through loans, loan guarantees, and 
scholarships to students, and grants and contracts to academic 
institutions and non-profit organizations, the Title VII and Title VIII 
programs fill the gaps in the supply of health professionals not met by 
traditional market forces.
    Titles VII and VIII are structured to allow grantees to test 
educational innovations, respond to changing delivery systems and 
models of care, and address timely topics in their communities. By 
assessing the needs of the communities they serve and emphasizing 
interprofessional education and training, Title VII and VIII programs 
bring together knowledge and skills across disciplines to provide 
effective, efficient and coordinated care. Further, numerous studies 
demonstrate that the programs graduate more minority and disadvantaged 
students and prepare providers that are more likely to serve in 
Community Health Centers (CHC) and the National Health Service Corps 
(NHSC).
    The AAMC joins the Health Professions and Nursing Education 
Coalition (HPNEC) in recommending $520 million for these important 
workforce programs in fiscal year 2015. This funding level is necessary 
to ensure continuation of all Title VII and Title VIII programs while 
also supporting promising initiatives such as the Pediatric 
Subspecialty Loan Repayment program, the Clinical Training in 
Interprofessional Practice program, the Rural Physician Training 
Grants, and other efforts to bolster the workforce.
    The AAMC strongly objects to the Administration's proposal to 
eliminate the Area Health Education Centers (AHEC), which, in 2012 
alone, trained more than 20,000 health professions students in 
community-based settings, and the Health Careers Opportunity Program 
(HCOP), which research shows has helped students from disadvantaged 
backgrounds achieve higher grade point averages and matriculate into 
health professions programs. Continued support for these and the full 
spectrum of Title VII and programs is essential to prepare our next 
generation of medical professionals to adapt to the evolving healthcare 
needs of the changing population.
    In addition to funding for Title VII and Title VIII, HRSA's Bureau 
of Health Professions also supports the Children's Hospitals Graduate 
Medical Education (CHGME) program. This program provides critical 
Federal graduate medical education support for children's hospitals to 
prepare the future primary care and specialty care workforce for our 
Nation's children. At a time when the Nation faces a critical physician 
shortage, the AAMC has serious concerns about the proposed elimination 
of the CHGME program in the president's budget. We strongly support 
full funding for the Children's Hospitals Graduate Medical Education 
program at $300 million in fiscal year 2015.
    Student Aid and the National Health Service Corps (NHSC)--The AAMC 
urges the committee to sustain student loan and repayment programs for 
graduate and professional students at the Department of Education. The 
average graduating debt of medical students is currently $175,000, and 
typical repayment can range from $326,000 to $492,000.
    The AAMC urges Congress to reauthorize the National Health Service 
Corps (NHSC) Fund, created under the Affordable Care Act (ACA, Public 
Law 111-142 and Public Law 111-152) and set to expire at the end of 
fiscal year 2015. In the absence of continued mandatory funding, the 
committee must address the NHSC funding shortfall in the already 
strained Labor-HHS spending bill. To date, the steady, sustained, and 
certain growth established by this mandatory funding for the NHSC has 
resulted in program expansion and innovative pilots such as the Student 
to Service (S2S) Loan Repayment Program that incentivizes fourth-year 
medical students to practice primary care in underserved areas after 
residency training.
    Once again, the AAMC appreciates the opportunity to submit this 
statement for the record and looks forward to working with the 
Subcommittee as it prepares its fiscal year 2015 spending bill.
                                 ______
                                 
     Prepared Statement of the Association of Independent Research 
                               Institutes
    The Association of Independent Research Institutes (AIRI) thanks 
the Subcommittee for its long-standing and bipartisan leadership in 
support of the National Institutes of Health (NIH). We continue to 
believe that science and innovation are essential if we are to continue 
to improve our Nation's health, sustain our leadership in medical 
research, and remain competitive in today's global information and 
innovation-based economy. The Consolidated Appropriations Act of 2014 
included a welcome and much needed increase for NIH. However, this 
increase did not give back all of the funds cut by sequestration in 
fiscal year 2013 nor did it restore the purchasing power NIH has lost 
over the past decade. We hope fiscal year 2014 represents a first step 
toward restoring our Nation's preeminence in medical research. AIRI 
recommends that NIH receive at least $32 billion in fiscal year 2015 as 
the next step toward a multi-year increase in our Nation's investment 
in medical research.
    AIRI is a national organization of more than 80 independent, non-
profit research institutes that perform basic and clinical research in 
the biological and behavioral sciences. AIRI institutes vary in size, 
with budgets ranging from a few million to hundreds of millions of 
dollars. In addition, each AIRI member institution is governed by its 
own independent Board of Directors, which allows our members to focus 
on discovery-based research while remaining structurally nimble and 
capable of adjusting their research programs to emerging areas of 
inquiry. Researchers at independent research institutes consistently 
exceed the success rates of the overall NIH grantee pool, and they 
receive about 10 percent of NIH's peer-reviewed, competitively-awarded 
extramural grants.
    The partnership between NIH and America's scientists, research 
institutions, universities, and medical schools is a unique and highly-
productive relationship, leveraging the full strength of our Nation's 
research enterprise to foster discovery, improve our understanding of 
the underlying cause of disease, and develop the next generation of 
medical advancements that deliver more treatments and cures to 
patients. Not only is NIH research essential to advancing health, it 
also plays a key economic role in communities nationwide. Approximately 
84 percent of the NIH's budget goes to more than 300,000 research 
positions at over 2,500 universities and research institutions located 
in every State.
    The Federal Government has an irreplaceable role in supporting 
medical research. No other public, corporate or charitable entity is 
willing or able to provide the broad and sustained funding for the 
cutting edge research necessary to yield new innovations and 
technologies of the future. NIH supports long-term competitiveness for 
American workers, forming one of the key foundations for U.S. 
industries like biotechnology, medical device and pharmaceutical 
development, and more. Unfortunately, continued erosion of the national 
commitment to medical research threatens our ability to support a 
medical research enterprise that is capable of taking full advantage of 
existing and emerging scientific opportunities.
    The NIH model for conducting biomedical research, which involves 
supporting scientists at universities, medical centers, and independent 
research institutes, provides an effective approach to making 
fundamental discoveries in the laboratory that can be translated into 
medical advances that save lives. AIRI member institutions are private, 
stand-alone research centers that set their sights on the vast 
frontiers of medical science. AIRI institutes are specifically focused 
on pursuing knowledge around the biology and behavior of living systems 
and applying that knowledge to improve human health and reduce the 
burdens of illness and disability. Additionally, AIRI member institutes 
have championed (and very frequently are called upon to lead) 
technologies and research centers to collaborate on biological research 
for all diseases. Using shared resources--specifically, advanced 
technology platforms or ``cores,''--as well as genomics, next-
generation sequencing, electron and light microscopy, high-throughput 
compound screening, bioinformatics, imaging, and other technologies, 
AIRI researchers advance therapeutics development and drug discovery.
    AIRI member institutes are especially vulnerable to reductions in 
the NIH budget, as they do not have other reliable sources of revenue 
to make up the shortfall. In addition to concerns over funding, AIRI 
member institutes oppose legislative provisions--such as directives to 
reduce the salary limit for extramural researchers--which would harm 
the integrity of the research enterprise and disproportionately affect 
independent research institutes. Such prescriptive policies hinder AIRI 
members' research missions and their ability to recruit and retain 
talented researchers. AIRI also does not support legislative language 
limiting the flexibility of NIH to determine how to most effectively 
manage its resources while funding the best scientific ideas.
    AIRI member institutes' flexibility and research-only missions 
provide an environment particularly conducive to creativity and 
innovation. Independent research institutes possess a unique 
versatility and culture that encourages them to share expertise, 
information, and equipment across research institutions, as well as 
neighboring universities. These collaborative activities help minimize 
bureaucracy and increase efficiency, allowing for fruitful partnerships 
in a variety of disciplines and industries. Also, unlike institutes of 
higher education, AIRI member institutes focus primarily on scientific 
inquiry and discovery, allowing them to respond quickly to the research 
needs of the country.
    AIRI members are located in 25 States, including many smaller or 
less-populated States that do not have major academic research 
institutions. In many of these regions, independent research institutes 
are major employers and local economic engines, and they exemplify the 
positive impact of investing in research and science.
    The biomedical research community depends upon a knowledgeable, 
skilled, and diverse workforce to address current and future critical 
health research questions. While the primary function of AIRI member 
institutions is research, most are highly involved in training the next 
generation of biomedical researchers, ensuring that a pipeline of 
promising scientists is prepared to make significant and potentially 
transformative discoveries in a variety of areas. AIRI supports 
policies that promote the ability of the United States to maintain a 
competitive edge in biomedical science. The NIH initiatives focusing on 
career development and recruitment of a diverse scientific workforce 
are important to innovation in biomedical research and public health.
    AIRI thanks the Subcommittee for its important work dedicated to 
ensuring the health of the Nation, and we appreciate this opportunity 
to urge the Subcommittee to provide $32 billion for NIH in the fiscal 
year 2015 appropriations bill. AIRI also urges Congress and the 
Administration to work in a bipartisan manner to end sequestration and 
the continued cuts to medical research that squander valuable 
scientific opportunities, discourage young scientists, threaten medical 
progress and continued improvements in our Nation's health, and 
jeopardize our economic future.
                                 ______
                                 
    Prepared Statement of the Association of University Programs in 
                     Occupational Health and Safety
    On behalf of the Association of University Programs in Occupational 
Health and Safety (AUPOHS), an organization representing the 18 
multidisciplinary, university-based Education and Research Centers 
(ERCs) and the ten Agricultural Centers for Disease and Injury 
Research, Education, and Prevention funded by the National Institute 
for Occupational Safety and Health (NIOSH), we respectfully request 
that the fiscal year 2015 Labor, Health and Human Services 
Appropriations bill include level funding of $27 million for the 
Education and Research Centers and $24 million for the Agriculture, 
Forestry and Fishing (AFF) Program within the NIOSH budget.
    NIOSH is the Federal agency responsible for supporting education, 
training, and research for the prevention of work-related injuries and 
illnesses in the United States. The ERCs are regional resources for 
parties involved with occupational health and safety--industry, labor, 
government, academia, and the public. Collectively, the ERCs provide 
training and research resources to every Public Health Region in the 
United States. ERCs contribute to national efforts to reduce losses 
associated with work-related illnesses and injuries by offering:
  --Prevention Research: Developing the basic knowledge and associated 
        technologies to prevent work-related illnesses and injuries.
  --Professional Training: ERCs support 86 graduate degree programs in 
        Occupational Medicine, Occupational Health Nursing, Safety 
        Engineering, Industrial Hygiene, and other related fields to 
        provide qualified professionals in essential disciplines.
  --Research Training: Preparing doctoral-trained scientists who will 
        respond to future research challenges and who will prepare the 
        next generation of occupational health and safety 
        professionals.
  --Continuing Education: Short courses designed to enhance 
        professional skills and maintain professional certification for 
        those who are currently practicing in occupational health and 
        safety disciplines. These courses are delivered throughout the 
        regions of the 18 ERCs, as well as through distance learning 
        technologies.
  --Regional Outreach: Responding to specific requests from local 
        employers and workers on issues related to occupational health 
        and safety.
    Occupational injury and illness represent a striking burden on 
America's health and well-being. Despite significant improvements in 
workplace safety and health over the last several decades, each year 
nearly 1.2 million workers are injured seriously enough to require time 
off work and, daily, an average of 11,000 U.S. workers sustain 
disabling injuries on the job, 13 workers die from an injury suffered 
at work, and 146 workers die from work-related diseases. This burden 
costs industry and citizens an estimated $4 billion per week--$250 
billion dollars per year. This is an especially tragic situation 
because work-related fatalities, injuries and illnesses are preventable 
with effective, professionally directed, health and safety programs.
    The rapidly changing workplace continues to present new health 
risks to American workers that need to be addressed through 
occupational safety and health research. For example, between 2000 and 
2015, the number of workers 55 years and older will increase 72 percent 
to over 31 million. Work related injury and fatality rates increase at 
age 45, with rates for workers 65 years and older nearly three times 
greater than younger workers. In addition to changing demographics, the 
rapid development of new technologies (e.g., nanotechnology) poses many 
unanswered questions with regard to workplace health and safety that 
require urgent attention.
    The heightened awareness of terrorist threats, and the increased 
responsibilities of first responders and other homeland security 
professionals, illustrates the need for strengthened workplace health 
and safety in the ongoing war on terror. The NIOSH ERCs play a crucial 
role in preparing occupational safety and health professionals to 
identify and mitigate vulnerabilities to terrorist attacks and to 
increase readiness to respond to biological, chemical, or radiological 
attacks. In addition, occupational health and safety professionals have 
worked for several years with emergency response teams to minimize 
disaster losses. For example, NIOSH took a lead role in protecting the 
safety of 9/11 emergency responders in New York City and Virginia, with 
ERC-trained professionals applying their technical expertise to meet 
immediate protective needs and to implement evidence-based programs to 
safeguard the health of clean-up workers.
    Additionally, NIOSH is now administering grants to provide health 
screening of World Trade Center responders. We need manpower to address 
these challenges and it is the NIOSH ERCs that train the professionals 
who fill key positions in health and safety programs, regionally and 
around the Nation. And because ERCs provide multi-disciplinary 
training, ERC graduates protect workers in virtually every walk of 
life. Despite the success of the ERCs in training such qualified 
professionals, the country continues to have ongoing manpower 
shortages.
    The Agricultural Safety and Health Centers program was established 
by Congress in 1990 (Public Law 101-517) in response to evidence that 
agricultural workers were suffering substantially higher rates of 
occupational injury and illness than other U.S. workers.
    Today the NIOSH Agriculture, Forestry, and Fishing (AFF) Initiative 
includes nine regional Centers for Agricultural Disease and Injury 
Research, Education, and Prevention and one national center to address 
children's farm safety and health. The AFF program is the only 
substantive Federal effort to meet the obligation to ensure safe 
working conditions for workers in this most vital production sector. 
While agriculture, forestry, and fishing constitute one of the largest 
industry sectors in the U.S. (DOL 2011), most AFF operations are 
themselves small: nearly 78 percent employ fewer than 10 workers, and 
most rely on family members and/or immigrants, part-time, contract and 
seasonal labor. Thus, many AFF workers are excluded from labor 
protections, including many of those enforced by OSHA.
    In 2012 the AFF sector had a work-related fatality rate of 22 per 
100,000 workers, the highest of any sector in the Nation. More than 1 
in 100 AFF workers incur nonfatal injuries resulting in lost work days 
each year. These reported figures do not even include men, women, and 
youths on farms with fewer than 11 full-time employees. In addition to 
the harm to individual men, women, and families, these deaths and 
injuries inflict serious economic losses including medical costs and 
lost capital, productivity, and earnings. The life-saving, cost-
effective work of the NIOSH AFF program is not replicated by any other 
agency:
  --State and Federal OSHA personnel rely on NIOSH research in the 
        development of evidence-based standards for protecting 
        agricultural workers and would not be able to fulfill their 
        mission without the NIOSH AFF program.
  --While committed to the well-being of farmers, the USDA has little 
        expertise in the medical or public health sciences. USDA no 
        longer funds, as it did historically, land grant university-
        based farm safety specialists.
  --Staff members of USDA's National Institute of Food and Agriculture 
        interact with NIOSH occupational safety and health research 
        experts to keep abreast of cutting-edge research and new 
        directions in this area.
    NIOSH Agricultural Center activities include:
  --AFF research has shown that the use of rollover protective 
        structures (ROPS or rollbars) and seatbelts on tractors can 
        prevent 99 percent of overturn-related deaths. A New York 
        program has increased the installation of ROPS by 10-fold and 
        recorded over 140 close calls with no injuries among farmers 
        who had installed ROPS. 99 percent of program participants said 
        they would recommend the program to other farmers.
  --Working in partnership with producers and farm owners, the NIOSH 
        AFF Centers have developed evidence-based solutions for 
        reducing exposure to pesticides and other farm chemicals among 
        farmers, farm workers and their children.
  --Commercial Fishing had a reported annual fatality rate 58 times 
        higher than the rate for all U.S. workers in 2009. Research has 
        shown that knowledge of maritime navigation rules and emergency 
        preparedness means survival. A NIOSH AFF-funded team produced 
        an interactive navigation training CD in three languages, 
        demonstrated the effectiveness of refresher survival drill 
        instruction, and assisted the US Coast Guard's revision of 
        regulations requiring commercial fishing vessel captains 
        complete navigation training.
  --The Centers have partnered with producers, employers, the Federal 
        migrant health program, physicians, nurses, and Internet 
        Technology specialists to educate farmers, employers, and 
        healthcare providers about the best way to treat and prevent 
        agricultural injury and illness.
  --In 2010, the logging industry had a reported fatality rate of 91.9 
        deaths per 100,000 workers (preliminary data), a rate more than 
        25 times higher than that of all US workers. NIOSH AFF Centers, 
        including the Southeast and the Northwest, are uniquely 
        positioned to ensure the safety of our Nation's 86,000 workers 
        in forestry & logging.
    Thank you for the opportunity to present testimony on behalf of the 
many individuals committed to working to improve the safety and well 
being of others in our communities.
                                 ______
                                 
      Prepared Statement of the Association of Zoos and Aquariums
    Thank you Chairman Harkin and Ranking Member Moran for allowing me 
to submit testimony on behalf of the Nation's 213 U.S. accredited zoos 
and aquariums. Specifically, I want to express my support for the 
inclusion of $38.6 million for the Institute of Museum and Library 
Services' (IMLS) Office of Museum Services in the fiscal year 2015 
Labor, Health and Human Services, Education, and Related Agencies 
appropriations bill.
    Founded in 1924, the Association of Zoos and Aquariums (AZA) is a 
nonprofit 501c(3) organization dedicated to the advancement of zoos and 
aquariums in the areas of conservation, education, science, and 
recreation. Accredited zoos and aquariums annually see more than 182 
million visitors, collectively generate more than $21 billion in annual 
economic activity, and support more than 204,000 jobs across the 
country. Over the last 5 years, AZA-accredited institutions supported 
more than 4,000 field conservation and research projects with 
$160,000,000 annually in more than 100 countries. In the last 10 years, 
accredited zoos and aquariums formally trained more than 400,000 
teachers, supporting science curricula with effective teaching 
materials and hands-on opportunities. School field trips annually 
connect more than 12,000,000 students with the natural world.
    Aquariums and zoological parks are defined by the ``Museum and 
Library Services Act of 2003'' (Public Law 108-81) as museums. The 
Office of Museum Services awards grants to museums to support them as 
institutions of learning and exploration, and keepers of cultural, 
historical, and scientific heritages. Grants are awarded in several 
areas including educational programming, professional development, and 
collections management, among others.
    The Nation's accredited zoos and aquariums, even while facing 
budget limitations, are thriving during these uncertain economic times. 
As valued members of local communities, zoos and aquariums offer a 
variety of programs ranging from unique educational opportunities for 
schoolchildren to conservation initiatives that benefit both local and 
global species. The competitive grants offered by the IMLS Office of 
Museum Services ensure that many of these programs, which otherwise may 
not exist because of insufficient funds, positively impact local 
communities and many varieties of species.
    For example, with a 2013 Museums for America--Collections 
Stewardship grant the Toledo Zoo will obtain new life support systems 
for an interactive visitor touch tank containing invertebrates and 
another holding sharks and stingrays. The exhibits provide multi-
sensory experiences that connect people with animals, while the systems 
ensure the animals are properly cared for. Through its 2012 Museums for 
American grant, the Birmingham Zoo supported its Africa Zoo School 
program, which is serving 1,200 students over 2 years. Partnering with 
Birmingham City School, seventh-grade students from low-performing 
schools attend a week-long ``Zoo School'' session, where they learn 
about the crisis of the elephant species' survival in Africa, the 
cultures of people in Africa, and the scientific and engineering 
research involved in sustaining these populations. Finally, a 2011 
Museums for America grant enabled The National Aquarium in Baltimore to 
create a more robust volunteer program by developing and testing new 
techniques to attract, train, engage, and retain a new generation of 
more diverse volunteers.
    Unfortunately, current funding has allowed IMLS to fund only a 
small fraction of all highly-rated grant applications. Despite this 
funding shortfall, zoo and aquarium attendance has increased and the 
educational services zoos and aquariums provide to schools and 
communities are in greater demand than ever. Zoos and aquariums are 
essential partners at the Federal, State, and local levels in providing 
education and cultural opportunities that adults and children may 
otherwise never enjoy.
    As museums, zoos and aquariums share the same mission of preserving 
the world's great treasures, educating the public about them, and 
contributing to the Nation's economic and cultural vitality. Therefore, 
I strongly encourage you to include $38.6 million for the Institute of 
Museum and Library Services' Office of Museum Services in the fiscal 
year 2015 Labor, Health and Human Services, Education, and Related 
Agencies appropriations bill.
    Thank you.
    [This statement was submitted by Jim Maddy, President and CEO, 
Association of Zoos and Aquariums.]
                                 ______
                                 
     Prepared Statement of the Brain Injury Association of America
    Chairman Harkin and Ranking Member Moran, thank you for the 
opportunity to submit this written testimony with regard to the fiscal 
year 2015 Labor-HHS-Education appropriations bill. This testimony is on 
behalf of the Brain Injury Association of America (BIAA), our network 
of State affiliates, and hundreds of local chapters and support groups 
from across the country.
    In the civilian population alone every year, more than 2.5 million 
people sustain brain injuries from falls, car crashes, assaults and 
contact sports. Males are more likely than females to sustain brain 
injuries. Children, teens and seniors are at greatest risk.
    Increasing numbers of service members returning from the conflicts 
in Iraq and Afghanistan with TBI and their families are seeking 
resources for information to better understand TBI and to obtain vital 
support services to facilitate successful reintegration into their 
communities.
    Since 1997, Congress has provided minimal funding through the 
Health Resources and Services Administration (HRSA) Federal TBI Program 
to assist States in developing services and systems to help individuals 
with brain injuries and their families who have a broad range of 
service and support needs. . Similarly, Congress has appropriated funds 
to HRSA for grants to State Protection and Advocacy Systems to assist 
individuals with TBI in accessing services through education, legal and 
advocacy remedies, but the program is woefully underfunded. 
Rehabilitation, community support and long-term care systems are still 
developing in many States, while stretched to capacity in others. 
Additional numbers of individuals with TBI as the result of war-related 
injuries only adds more stress to these inadequately funded systems.
    BIAA respectfully urges you to provide States with the resources 
they need to address both the civilian and military populations that 
look to them for much needed support in order to live and work in their 
communities.
    With broader regard to all of the programs authorized through the 
TBI Act, BIAA specifically requests:
  --$10 million (+ $4 million) for the Centers for Disease Control and 
        Prevention TBI Registries and Surveillance, Brain Injury Acute 
        Care Guidelines, Prevention and National Public Education/
        Awareness
  --$12 million (+ $1 million) for the Health Resources and Services 
        Administration (HRSA) Federal TBI State Grant Program
  --$4 million (+ $1 million) for the HRSA Federal TBI Protection & 
        Advocacy (P&A) Systems Grant Program
    CDC--National Injury Center--The Centers for Disease Control and 
Prevention's National Injury Center is responsible for assessing the 
incidence and prevalence of TBI in the United States. The CDC estimates 
that 2.5 million TBIs occur each year and 5.3 million Americans live 
with a life-long disability as a result of TBI. The TBI Act as amended 
in 2008 requires the CDC to coordinate with the Departments of Defense 
and Veterans Affairs to include the number of TBIs occurring in the 
military. This coordination will likely increase CDC's estimate of the 
number of Americans sustaining TBI and living with the consequences.
    CDC also funds States for TBI registries, creates and disseminates 
public and professional educational materials, for families, caregivers 
and medical personnel, and has recently collaborated with the National 
Football League and National Hockey League to improve awareness of the 
incidence of concussion in sports. CDC plays a leading role in helping 
standardize evidence based guidelines for the management of TBI and $1 
million of this request would go to fund CDC's work in this area.
    HRSA TBI State Grant Program--The TBI Act authorizes HRSA to award 
grants to (1) States, American Indian Consortia and territories to 
improve access to service delivery and to (2) State Protection and 
Advocacy (P&A) Systems to expand advocacy services to include 
individuals with traumatic brain injury. Since 1997, the HRSA Federal 
TBI State Grant Program has supported State efforts to address the 
needs of persons with brain injury and their families and to expand and 
improve services to underserved and unserved populations including 
children and youth; veterans and returning troops; and individuals with 
co-occurring conditions
    In fiscal year 2009, HRSA reduced the number of State grant awards 
to 21, in order to increase each monetary award from $118,000 to 
$250,000. This means that many States that had participated in the 
program in prior years have now been forced to close down their 
operations, leaving many individuals with brain injury and their 
families unable to access needed care and supports.
    Increasing the program to $8 million will provide funding necessary 
to sustain the grants for the 21 States currently receiving funding 
along with the three additional States added this year and to ensure 
funding for four additional States. Steady increases over 5 years for 
this program will provide for each State including the District of 
Columbia and the American Indian Consortium and territories to sustain 
and expand State service delivery; and to expand the use of the grant 
funds to pay for such services as Information & Referral (I&R), systems 
coordination and other necessary services and supports identified by 
the State.
    HRSA TBI P&A Program--Similarly, the HRSA TBI P&A Program currently 
provides funding to all State P&A systems for purposes of protecting 
the legal and human rights of individuals with TBI. State P&As provide 
a wide range of activities including training in self-advocacy, 
outreach, information & referral and legal assistance to people 
residing in nursing homes, to returning military seeking veterans 
benefits, and students who need educational services.
    Effective Protection and Advocacy services for people with 
traumatic brain injury is needed to help reduce government expenditures 
and increase productivity, independence and community integration. 
However, advocates must possess specialized skills, and their work is 
often time-intensive. A $4 million appropriation would ensure that each 
P&A can move towards providing a significant PATBI program with 
appropriate staff time and expertise.
    NIDRR TBI Model Systems of Care--Funding for the TBI Model Systems 
in the Department of Education is urgently needed to ensure that the 
Nation's valuable TBI research capacity is not diminished, and to 
maintain and build upon the 16 TBI Model Systems research centers 
around the country.
    The TBI Model Systems of Care program represents an already 
existing vital national network of expertise and research in the field 
of TBI, and weakening this program would have resounding effects on 
both military and civilian populations. The TBI Model Systems are the 
only source of non-proprietary longitudinal data on what happens to 
people with brain injury. They are a key source of evidence-based 
medicine, and serve as a ``proving ground'' for future researchers.
    In order to make this program more comprehensive, Congress should 
provide $13 million (+ $1.5 million) in fiscal year 2015 for NIDRR's 
TBI Model Systems of Care program, in order to add two new 
Collaborative Research Projects. In addition, given the national 
importance of this research program, the TBI Model Systems of Care 
should receive ``line-item'' status within the broader NIDRR budget.
    We ask that you consider favorably these requests for the CDC, the 
HRSA Federal TBI Program, and the NIDRR TBI Model Systems Program to 
further data collection, increase public awareness, improve medical 
care, assist States in coordinating services, protect the rights of 
persons with TBI, and bolster vital research.
                                 ______
                                 
    Prepared Statement of the California Association of Psychiatric 
                              Technicians
                              introduction
    On behalf of approximately 14,000 California Licensed Psychiatric 
Technicians representing the Nation's ``gold standard'' in direct-care 
nursing services for people with developmental disabilities and mental 
illnesses, I am writing to respectfully request that the Subcommittee, 
Committee and Congress as a whole end the practice of using Federal 
funds to downsize and close federally regulated and accredited homes 
for Americans with developmental disabilities.
      individuals and families caught in a federal web of ironies
    In recent years, the national demand for developmental centers' 
closure has come perhaps most strongly--and, perhaps, most 
surprisingly--from the Federal Government: the very Federal Government 
which requires developmental centers to meet its own regulatory 
standards.
    To be federally certified through the U.S. Centers for Medicare and 
Medicaid Services, State developmental centers must meet eight major 
criteria on management, client protections, facility staffing, active 
treatment, client behavior and facility practices, healthcare services, 
physical environment and dietetic services. To meet all of these major 
criteria, developmental centers must comply with 378 specific Federal 
standards and elements. Failure to comply with any one of these 
hundreds of requirements or to swiftly correct any deficiencies means 
the loss of Federal certification as well as Federal Medicaid funding.
    But in an interesting twist, other Federal funds go to support the 
efforts of the Protection and Advocacy system. Created by Congress, 
this federally mandated system acts as a legally based advocacy 
provider for people with developmental disabilities and other mental 
and physical disabilities throughout the Nation. Each State has a P&A 
branch to investigate allegations of discrimination, abuse or other 
concerns affecting Americans with disabilities, wherever they reside.
    The P&A system and other Federal laws arose as responses to 
widespread concerns of neglect and abuse at an unlicensed New York 
developmental center called Willowbrook State School more than 40 years 
ago. The system and laws are the bases for the regulations that today's 
developmental centers must follow to achieve and continue Federal 
accreditation. However, nothing in this system or laws require the 
closure of developmental centers. In the case of the Federal law which 
creates P&As--the Developmental Disabilities Assistance and Bill of 
Rights Act (often called the ``DD Act'')--P&As' board charge is to 
``protect and advocate'' for people with disabilities regardless of 
where they reside. In the DD Act's legislative history, Congress 
expressly cautioned against interpreting the act as mandating closures: 
``The goals expressed in this act to promote the greatest possible 
integration and independence for some individuals with developmental 
disabilities may not be read as a Federal policy supporting the closure 
of residential institutions... .'' This Congressional intent is 
reinforced in the act itself, where individuals and their families, and 
no one else, are named as the ``primary decisionmakers'' regarding 
services (including residential supports) and policies.
             u.s. supreme court supports residential choice
    To add to the paradox, another Federal group--none other than the 
U.S. Supreme Court--made key points in its touchstone 1999 Olmstead 
ruling:
    ``We emphasize that nothing in the [Americans with Disabilities 
Act] or its implementing regulations condone termination of 
institutional settings for persons unable to handle or benefit from 
community settings...Nor is there any Federal requirement that 
community-based treatment be imposed on patients who do not desire 
it.''
    The overall tragic irony of this Kafkaesque situation is not lost 
on those advocating for loved ones to have the choice of living in 
federally regulated and certified facilities. Adding to the personal 
and emotional toll of advocating to keep their loved ones' 
developmental-center homes open, family members must use their own 
personal funds to fight the deep pockets of federally funded P&A and 
DOJ attorneys seeking center closures that families and residents often 
do not wish. Federal funds are being used by one Federal agency to sue 
another Federal agency for the purpose of evicting our Nation's most 
vulnerable people from their homes. In addition to wasting taxpayer 
dollars, it defies common sense and human decency.
                   what does `most integrated' mean?
    Those taking aim at developmental centers, in the Federal 
Government or elsewhere, feel that the centers are not the most 
integrated settings possible for those with developmental disabilities. 
But the ADA defines ``most integrated setting'' to be ``a setting that 
enables individuals with disabilities to interact with non-disabled 
persons to the fullest extent possible [emphasis added].''
    Families with loved ones in developmental centers who wish to 
continue their services strongly disagree with any interpretation that 
their family members are, in any way, restricted. They feel that the 
many on-site services offered at a developmental center provide the 
most integrated environments possible, allowing their loved ones live 
securely and to meet their fullest potentials.
    Professional developmental-center staff also echo families' 
concerns about how many group homes and placements with less safety and 
oversight and fewer programs can be less ``restrictive.'' Developmental 
centers are required by Federal and State regulations to have dozens 
and dozens of federally regulated state-of-the-art therapeutic and 
rehabilitative programs in place, right there on grounds as well as in 
the broader community; but somehow a developmental center is always 
painted as ``less integrated'' and ``more restrictive'' than a house on 
a busy street with a postage-stamp yard, occasional visits by licensed 
staff, few or no programs and infrequent and pre-announced visits by 
State regulators.
    California's Licensed Psychiatric Technicians are not ```anti-
``community'''--in fact, we actively advocate for group-home placements 
when it is in the clients' best interests and is what they and their 
families wish. However, when taken as a whole, how is having more 
space, more programs both on and off the center campus, higher 
regulatory standards and a whole community of professionals there to 
help Americans enjoy the healthiest, happiest and most active life 
possible necessarily ``more restrictive?''
     end the paradox: stop funding restrictions on federal choices
    On behalf of CAPT and its dedicated professional membership, I wish 
to respectfully request that the Subcommittee and Congress as a whole 
end the use of Federal appropriations to discourage, downsize and close 
federally regulated developmental centers (``ICF/DDs and ICF/MRs'') 
throughout the country. It is the legal and moral choice and right for 
people with developmental disabilities and their loved ones to make 
decisions on their individual residential, service and support needs, 
and the choice of federally regulated developmental centers and related 
congregate settings should remain an option for them. Our Federal 
Government should not play a role in restricting or eliminating any 
viable, recognized and desired option for Americans with developmental 
disabilities.

    [This statement was submitted by Juan Nolasco, PT, State President, 
California Association of Psychiatric Technicians.]
                                 ______
                                 
  Prepared Statement of the California Association of State Hospital 
                    Parent Councils for the Retarded
    Dear Chairman Harkin and Members of the Subcommittee: The 
California Association of State Hospital Parent Councils for the 
Retarded (CASHPCR) represents the families, friends, and advocates of 
loved ones living at Porterville Developmental Center and Fairview 
Developmental Center.
    As President of CASHPCR, a healthcare professional, and the sister 
of someone with a developmental disability, I am writing to urge the 
Senate Appropriations Labor, Health and Human Services (HHS), Education 
and Related Agencies to prohibit the use of Federal HHS appropriations 
in support of deinstitutionalization activities which evict, without 
regard to individual choice, eligible individuals with intellectual and 
developmental disabilities (I/DD) from their HHS-licensed and funded 
homes.
    The ability of our family members and others with developmental 
disabilities to achieve their full potential is greatly dependent upon 
the services and supports that they receive, including housing, medical 
care, and developmental programs. The homes licensed and funded by HHS 
are an important option for many individuals--in some cases, the only 
option.
    VOR, a national nonprofit organization advocating for high quality 
care and human rights for all people with I/DD, has submitted written 
testimony for the record with this same request.
    I support VOR's testimony and request.

    [This statement was submitted by Theresa DeBell, R.N., California 
Association of State Hospital Parent Councils for the Retarded.]
                                 ______
                                 
 Prepared Statement of the Centers for Disease Control and Prevention 
                               Coalition
    The Centers for Disease Control and Prevention (CDC) Coalition is a 
nonpartisan coalition of more than 140 organizations committed to 
strengthening our Nation's prevention programs. We represent millions 
of public health workers, clinicians, researchers, educators and 
citizens served by CDC programs.
    We believe Congress should support CDC as an agency, not just the 
individual programs that it funds. Given the challenges and burdens of 
chronic disease and disability, public health emergencies, new and 
reemerging infectious diseases and other unmet public health needs, we 
urge a funding level of $7.8 billion for CDC's programs in fiscal year 
2015. We appreciate some of the important new investments in President 
Obama's fiscal year 2015 budget proposal including those for 
prescription drug overdose prevention, antimicrobial resistance and 
global health security; however, under the president's proposal, CDC's 
budget would be cut by nearly $243 million compared to fiscal year 
2014. CDC's budget authority under the president's budget is lower than 
fiscal year 2003 levels. State and local health departments continue to 
operate on tight budgets and with a smaller workforce, losing more than 
50,000 public health jobs since 2008. These cuts will reduce the 
ability of CDC and its State and local grantees to investigate and 
respond to public health emergencies, ensure adequate immunization 
rates and track environmental hazards.
    CDC is a key source of funding and technical assistance for State 
and local programs that aim to improve the health of communities. CDC 
funding provides the foundation for State and local public health 
departments, supporting a trained workforce, laboratory capacity and 
public health education communications systems. CDC serves as the 
command center for our Nation's public health defense system, 
conducting surveillance and detection of emerging and reemerging 
infectious diseases. With the potential onset of a worldwide influenza 
pandemic, in addition to the many other natural and man-made threats 
that exist in the modern world, CDC is the Nation's expert resource and 
response center, coordinating communications and action and serving as 
the laboratory reference center for identifying, testing and 
characterizing potential agents of biological, chemical and 
radiological terrorism, emerging infectious diseases and other public 
health emergencies. CDC serves as the lead agency for bioterrorism and 
public health emergency preparedness and must receive sustained support 
for its preparedness programs to meet future challenges. We urge you to 
provide adequate funding for CDC's emergency preparedness and response 
activities.
    Heart disease is the Nation's No. 1 killer. In 2010, over 597,000 
people in the U.S. died from heart disease, accounting for nearly 25 
percent of all U.S. deaths. More males than females died of heart 
disease in 2010, while more females than males died of stroke that 
year. Stroke is the fourth leading cause of death and is a leading 
cause of disability. In 2010, more than 129,000 people died of stroke, 
accounting for about one of every 19 deaths. CDC's Heart Disease and 
Stroke Prevention Program, WISEWOMAN, and the Million Hearts program 
work to improve cardiovascular health.
    Cancer is the second most common cause of death in the U.S. More 
than1.6 million new cancer cases and 585,720 deaths from cancer are 
expected in 2014. In 2009 the overall cost for cancer in the U.S. was 
more than $216.6 billion: $86.6 billion for direct medical costs, $130 
billion for indirect mortality costs. CDC's National Breast and 
Cervical Cancer Early Detection Program helps millions of low-income, 
uninsured and medically underserved women gain access to lifesaving 
breast and cervical cancer screenings and provides a gateway to 
treatment upon diagnosis. CDC also funds grants to all 50 States to 
develop comprehensive cancer control plans, bringing together a broad 
partnership of public and private stakeholders to set joint priorities 
and implement specific cancer prevention and control activities 
customized to address each State's particular needs.
    An estimated 443,000 people die prematurely every year due to 
tobacco use. CDC's Office of Smoking and Health funds important 
programs and campaigns to prevent tobacco addiction and to help those 
who want to quit. We must continue to support these vital programs to 
reduce the enormous health and economic costs of tobacco use in the 
U.S.
    Of the 25.8 million Americans who have diabetes, nearly 7 million 
cases are undiagnosed. In 2010, about 1.9 million people aged 20 years 
or older were newly diagnosed with diabetes. Diabetes is the leading 
cause of kidney failure, nontraumatic lower-limb amputations, and new 
cases of blindness among adults in the U.S. The total direct and 
indirect costs associated with diabetes were $245 billion in 2012. The 
Division of Diabetes Translation funds critical diabetes prevention, 
surveillance and control programs.
    Obesity prevalence in the U.S. remains high. While the obesity 
rates among children between the ages of 2-5 have significantly 
decreased over the past decade, more than one-third of adults are obese 
and 17 percent of children are obese. Obesity, diet and inactivity are 
cross-cutting risk factors that contribute significantly to heart 
disease, cancer, stroke and diabetes. CDC funds programs to encourage 
the consumption of fruits and vegetables, encourage sufficient exercise 
and develop other habits of healthy nutrition and physical activity.
    Arthritis is the most common cause of disability in the U.S., 
striking more than 52 million Americans of all ages, races and 
ethnicities. CDC's Arthritis Program plays a critical role in 
addressing this growing public health crisis and working to improve the 
quality of life for individuals affected by arthritis.
    CDC provides national leadership in helping control the HIV 
epidemic by working with community, State, national, and international 
partners in surveillance, research, prevention and evaluation 
activities. CDC estimates that about 1.1 million Americans are living 
with HIV, 16 percent of who are undiagnosed. The number of people 
living with HIV is increasing as new drug therapies are keeping HIV-
infected persons healthy longer and dramatically reducing the death 
rate. Prevention of HIV transmission is the best defense against the 
AIDS epidemic that has already killed more than 636,000 in the U.S. and 
is devastating populations around the globe.
    The U.S. has the highest rates of sexually transmitted diseases in 
the industrialized world. Nearly 20 million new infections occur each 
year. CDC estimates that STDs, including HIV, cost the U.S. healthcare 
system almost $16 billion annually. An adequate investment in CDC's STD 
prevention programs could save millions in annual healthcare costs in 
the future.
    The National Center for Health Statistics collects data on chronic 
disease prevalence, health disparities, emergency room use, teen 
pregnancy, infant mortality and causes of death. The health data 
collected through the Behavioral Risk Factor Surveillance System, Youth 
Risk Behavior Survey, Youth Tobacco Survey, National Vital Statistics 
System, and National Health and Nutrition Examination Survey are an 
essential part of the Nation's statistical and public health 
infrastructure and must be adequately funded.
    CDC oversees immunization programs for children, adolescents and 
adults, and is a global partner in the ongoing effort to eradicate 
polio worldwide. Influenza vaccination levels remain low for adults. 
Levels are substantially lower for pneumococcal vaccination among 
adults as well, with significant racial and ethnic disparities in 
vaccination levels persisting among the elderly. Childhood 
immunizations provide one of the best returns on investment of any 
public health program. For every dollar spent on childhood vaccines to 
prevent thirteen diseases, $10.20 is saved in direct and indirect 
costs. An estimated 20 million cases of disease and 42,000 deaths are 
prevented each year through timely immunization.
    Injuries are the leading causes of death for people ages 1-44. 
Unintentional injuries and violence, such as older adult falls, 
prescription drug overdose, child maltreatment and sexual violence, 
account for approximately 29 percent of emergency department visits 
each year. Annually, injury and violence cost the U.S. approximately 
$406 billion in direct and indirect medical costs. The National Center 
for Injury Prevention and Control works to prevent injuries and 
minimize their consequences by researching the problem, identifying the 
risk and protective factors, developing and testing interventions and 
ensuring widespread adoption of proven prevention strategies.
    Birth defects affect one in 33 babies and are a leading cause of 
infant death in the U.S. Children with birth defects who survive often 
experience lifelong physical and mental disabilities. Over 500,000 
children are diagnosed with a developmental disability and more than 50 
million people in the U.S. currently live with a disability. The 
National Center on Birth Defects and Developmental Disabilities 
conducts important programs to prevent birth defects and developmental 
disabilities and promote the health of people living with disabilities 
and blood disorders.
    The National Center for Environmental Health works to protect 
public health by helping to control asthma, protecting from threats 
associated with natural disasters and climate change and reducing 
exposure to lead and other environmental hazards. To ensure it can 
carry out these vital programs, we ask you to support and restore 
adequate funding for NCEH.
    In order to meet the many ongoing public health challenges outlined 
above, we urge you to support our fiscal year 2015 request of $7.8 
billion for CDC's programs.

    [This statement was submitted by Donald Hoppert, Director, 
Government Relations, American Public Health Association.]
                                 ______
                                 
   Prepared Statement of the Children's Environmental Health Network
    The Children's Environmental Health Network (CEHN or the Network) 
is pleased to have this opportunity to submit testimony on fiscal year 
2015 appropriations for the following programs and activities that 
safeguard the health and future of all of our children:
  --Centers for Disease Control and Prevention ($7.8 billion), 
        especially the National Center for Environmental Health ($181.1 
        million) and its programs, including:
    --Healthy Homes and Lead Poisoning Prevention Program ($29 million)
    --National Asthma Control Program ($28 million)
    --National Environmental Public Health Tracking Program ($40 
            million)
  --National Institute of Environmental Health Sciences (NIEHS) ($717.7 
        million), especially the Children's Environmental Health 
        Research Centers ($33 million)
  --Pediatric Environmental Health Specialty Units (PEHSUs) ($2 
        million)
    The Children's Environmental Health Network (CEHN) was created more 
than 20 years ago by concerned pediatricians and researchers with a 
goal of protecting the developing child from environmental health 
hazards and to promote a healthy environment.
    Today's children are facing the distressing possibility that they 
may be the first generation to see a shorter life expectancy than their 
parents due to poor health. Key contributors to this trend are the 
modern pediatric epidemics of obesity, asthma, learning disabilities, 
and autism. For all of these conditions, the child's environment plays 
a role in causing, contributing to or mitigating these chronic 
conditions. The estimated costs of environmental disease in children 
(such as lead poisoning, childhood cancer, and asthma) were $76.6 
billion in 2008.\1\
---------------------------------------------------------------------------
    \1\ Trasande, Liu Y. ``Reducing The Staggering Costs Of 
Environmental Disease In Children, Estimated At $76.6 Billion In 2008, 
Health Affairs. No. (2011): doi: 10.1377/hlthaff.2010.1239.
---------------------------------------------------------------------------
    Investments in programs that protect and promote children's health 
will be repaid by healthier children with brighter futures.
    Additionally, protecting our children--those born as well as those 
yet to be born--from environmental hazards is truly a national security 
issue. When we protect children from harmful chemicals in their 
environment, we help to assure that they will reach their full 
potential. We have a responsibility to our Nation's children, and to 
the Nation that they will someday lead, to provide them with a healthy 
environment. American competitiveness depends on having healthy, 
educated children who grow up to be healthy productive adults. Thus it 
is vital that the Federal programs and activities that protect children 
from environmental hazards receive adequate resources. We strongly urge 
the Committee to support and expand children's environmental health 
programs. Key programs in your jurisdiction deserving your support 
include:
Centers for Disease Control and Prevention (CDC)
    As the Nation's leader in public health promotion and disease 
prevention, the CDC should receive top priority in Federal funding. CDC 
continues to be faced with unprecedented challenges and 
responsibilities. CEHN applauds your support for CDC in past years and 
urges you to support a funding level of $7.8 billion for CDC's core 
programs in fiscal year 2015.
    The National Center for Environmental Health (NCEH) is particularly 
important in protecting the environmental health of young children. 
Current research is uncovering the extensive role that environment 
plays in human health and development. As a result, NCEH partners with 
public health agencies and a wide range of other organizations to bring 
their expertise and support to an expanding scope of environmental-
human health challenges. NCEH's programs are key national assets. Yet 
in recent years, NCEH funding has been drastically cut. We urge the 
Subcommittee to at least restore NCEH to its fiscal year 2010 funding 
level of $181.1 million.
    We were deeply concerned with the fiscal year 2012 gutting of the 
Healthy Homes and Lead Poisoning Prevention Program and we commend you 
for the substantial increase the program received in fiscal year 2014. 
This program helps to prevent lead poisoning and helps children who 
have already been exposed to lead. Much more needs to be done just to 
return it to fiscal year 2011 levels. Millions of American children 
remain at risk of lead poisoning and need this program, which supports 
effective local and State efforts. As evidence increasingly 
demonstrates no safe level of lead exposure for children, this funding 
is all the more essential. We join with the National Safe and Healthy 
Housing Coalition to urge a funding level of $29 million in fiscal year 
2015.
    NCEH's National Asthma Control Program not only has greatly 
increased data collection about this rampant epidemic but it also 
encourages States to use evidence-based approaches to reduce costs and 
improve outcomes for people living with asthma. Asthma is an epidemic 
in the U.S., affecting 10 percent of our Nation's children. We urge the 
Committee to fund this vital program at $28 million in fiscal year 
2015.
    Public health officials need integrated health and environmental 
data so that they can protect the public's health. The CDC's National 
Environmental Public Health Tracking Program helps to track 
environmental hazards and the diseases they may cause and to coordinate 
and integrate local, State and Federal health agencies' collection of 
critical health and environmental data. Participation in the tracking 
network development will decline under further cuts and erase the 
progress we have made across the country to better link data with 
public health action.
National Institute of Environmental Health Science (NIEHS)
    NIEHS is the leading institute conducting research to understand 
how the environment influences human health. Unlike other NIH 
Institutes focused on one disease or one body system, NIEHS is charged 
with all diseases, all human health and body systems, as they are 
affected by the environment--a vital and monumental charge. NIEHS plays 
a critical role in our efforts to understand how to protect children, 
whether it is identifying and understanding the immediate impact of 
chemical substances or understanding childhood exposures that may not 
affect health until decades later. CEHN recommends that $717.7 million 
be provided for NIEHS' fiscal year 2015 budget.
Children's Environmental Health Research Centers of Excellence
    The Children's Environmental Health & Disease Prevention Research 
Centers, jointly funded by the NIEHS and the U.S. Environmental 
Protection Agency (EPA) and located at research institutions across the 
Nation, play a vital role in providing the scientific basis for 
protecting children from environmental hazards. With their modest 
budgets, these centers are generating invaluable research. For example, 
these centers conducted the recent research that found links between 
prenatal exposures to either a common air pollutant or a common 
pesticide to lower IQs and poorer working memory at age 7.
    Several Centers have established longitudinal cohorts, which in 
some cases are more than 10 years old. The ability to look for linkages 
between exposures and health outcomes in infants, toddlers, and, now, 
adolescents, is vital. If these cohorts are disbanded due to funding 
cuts, at best it will take years and untold resources before it is 
possible to replicate them. Few if any longitudinal cohort studies on 
adolescents, puberty and environmental exposures exist. The Network is 
concerned that inadequate funding may result in the loss of these 
valuable cohorts. We urge the Subcommittee to support these centers at 
$33 million in fiscal year 2015.
Pediatric Environmental Health Specialty Units
    Pediatric Environmental Health Specialty Units (PEHSUs) form a 
valuable resource network for parents and clinicians around the Nation. 
They are funded jointly by the Agency for Toxic Substances and Disease 
Registry (ATSDR) and the EPA with a very modest budget. PEHSU 
professionals provide medical consultation to healthcare professionals 
from individual cases of exposure to advice regarding large-scale 
community issues. PEHSUs also provide information and resources to 
school, child care, health and medical, and community groups and help 
inform policymakers by providing data and background on local or 
regional environmental health issues and implications for specific 
populations or areas. We urge the Subcommittee to fully fund ATSDR's 
portion of this program in fiscal year 2015.
    In conclusion, our Nation's future will depend upon its future 
leaders. Protecting children from harmful chemicals in their 
environment will result in healthier children with brighter futures, an 
outcome we can all support. Thank you for the opportunity to testify.
                                 ______
                                 
       Prepared Statement of the Children's Hospital Association
    The Children's Hospital Association advances child health through 
innovation in the quality, cost and delivery of care. Representing more 
than 220 children's hospitals, the Association is the voice of 
children's hospitals nationally. As institutions dedicated to 
protecting and advancing the health of America's children, we thank the 
Subcommittee for its longstanding bipartisan support of the Children's 
Hospital Graduate Medical Education program (CHGME).
    CHGME is an essential investment in our children's healthcare--in 
promoting prevention and primary care, expanding healthcare for 
vulnerable and underserved children, and ensuring access to care for 
all children. The Children's Hospitals Association urges the 
Subcommittee to protect this important program and provide $300 million 
in funding for CHGME in fiscal year 2015.
    The CHGME program protects children's access to high-quality 
medical care by providing independent children's hospitals with funding 
to support the training of pediatric providers, much as Medicare 
supports training in adult teaching hospitals. CHGME funding has had a 
tremendous impact, enabling children's hospitals to increase their 
overall training by more than 45 percent since the program began in 
1999. In addition, the CHGME program has accounted for more than 74 
percent of the growth in the number of new pediatric subspecialists 
being trained nationwide.
    Today, the 55 hospitals that receive CHGME, less than 1 percent of 
all hospitals, train over 6,000 residents annually, and 49 percent of 
all pediatric residents in the country, including 45 percent of general 
pediatricians and 51 percent of pediatric specialists. CHGME benefits 
all children, supporting the training of doctors who go on to care for 
children living in every State--in cities, rural communities, suburbs 
and everywhere in between. Furthermore, CHGME is an example of a well-
functioning public-private partnership; each of the participating 
children's hospitals invests significant resources into the success of 
their training programs along with the Federal dollars they receive.
    Since the program's beginning, CHGME has enjoyed strong, bipartisan 
support in Congress, under both Republican and Democratic leadership. 
Congress created CHGME because it recognized that the absence of 
dedicated GME support for independent children's teaching hospitals 
created gaps in the training of pediatric providers, which potentially 
threatened access to care for children. At that time, independent 
children's hospitals were effectively left out of Federal GME support 
provided through Medicare because children's hospitals treat children 
and not the elderly, and received less than 0.5 percent of the GME 
support of other teaching hospitals.
    CHGME has helped close the gap, but support for training of 
pediatric providers in children's hospitals still lags significantly 
behind Medicare support for graduate medical education. Analysis 
commissioned by the Children's Hospitals Association shows that in 2014 
CHGME provides children's hospitals, on a per-resident basis, about 45 
percent of the support Medicare provides to adult teaching hospitals.
    Continued funding is essential to maintaining the gains that have 
been achieved under CHGME and strengthening the pediatric workforce 
pipeline. While much has been achieved, much remains to be done, as 
serious shortages persist in many pediatric specialties. The shortages 
affect children and their families' ability to receive timely, 
appropriate care, including surgery. Children's hospital clinics use a 
two-week benchmark when scheduling non-emergency appointments, but 
certain pediatric specialties experiencing physician shortages have 
wait times of 14.5 weeks or more, far exceeding the two-week standard.
    Unfortunately, funding for the CHGME program has been significantly 
reduced in recent years, from $317.5 million in fiscal year 2010 to 
$265 million in 2014, a 17 percent reduction. These cuts hurt the 
ability of children's hospitals to train enough pediatricians and 
pediatric specialists to keep up with growing demand at local, State 
and national levels.
    Furthermore, there are no adequate substitutes for CHGME. Other 
potential sources of support, such as Medicaid GME or competitive 
grants, are not available to many children's hospitals and cannot come 
close to supporting training on the scale necessary to meet workforce 
needs. Failing to adequately support CHGME would take us back to the 
same flawed system that was not meeting the needs of America's 
children.
    The White House's fiscal year 2015 budget proposes eliminating 
funding for CHGME and incorporating support for training at children's 
hospitals into a new competitive grant program under the Health 
Resources and Services Administration (the program would have to be 
created by Congress), funded from Medicare trust fund dollars, with 
$100 million set aside specifically for children's hospitals in fiscal 
year 2015 and fiscal year 2016. While we recognize that the White House 
includes funding for training in children's hospitals in the budget, 
the administration's proposal continues to underfund pediatric 
training. Furthermore, children's hospitals have strong concerns that 
replacing the current system with competitive grants that are limited 
in duration puts at risk the gains that have been made for children's 
health under CHGME. Children's hospitals welcome the idea of engaging 
with the administration and Congress on ways to strengthen the 
pediatric workforce for the future. In the present, however, financial 
support for GME in children's hospitals needs to be uninterrupted and 
undiminished.
    We recognize that the current budget climate is extraordinarily 
challenging and that Congress has a responsibility to carefully 
consider the Nation's spending priorities. However, now is not the time 
to take a step backwards in pediatric medicine. The CHGME program is 
critical to protecting gains in pediatric health and ensuring access to 
care for children nationwide.
    We respectfully request that the Subcommittee continue its history 
of bipartisan support for the CHGME program and include $300 million in 
funding in the fiscal year 2015 Labor-HHS appropriations bill for this 
vital program.
    The Children's Hospital Association, and the children and families 
we serve, thank you for your past support for this critical program and 
your leadership in protecting children's health.
    The Children's Hospital Association advances child health through 
innovation in the quality, cost and delivery of care. Representing more 
than 220 children's hospitals, the Association is the voice of 
children's hospitals nationally. The Association champions public 
policies that enable hospitals to better serve children and is the 
premier resource for pediatric data and analytics, driving improved 
clinical and operational performance of member hospitals. Formed in 
2011, Children's Hospital Association brings together the strengths and 
talents of three organizations: Child Health Corporation of America 
(CHCA), National Association of Children's Hospitals and Related 
Institutions (NACHRI) and National Association of Children's Hospitals 
(N.A.C.H.). The Children's Hospital Association has offices in 
Washington, DC, and Overland Park, KS.
                                 ______
                                 
  Prepared Statement of the Coalition for Clinical and Translational 
                                Science
    Chairman Harkin and distinguished members of the Subcommittee, 
thank you for your time and your consideration of the priorities of the 
clinical and translational research community as you work to craft the 
fiscal year 2015 Labor, Health and Human Services Appropriations Bill. 
The community would like to thank you for your past support of the full 
spectrum of medical research.
       about the coalition for clinical and translational science
    Coalition for Clinical and Translational Science (CCTS) is the 
unified voice of the clinical and translational science research 
community. CCTS is a nationwide, grassroots network of dedicated 
individuals who work together to educate Congress and the 
Administration about the value and importance of Federal clinical and 
translational research and research training and career development 
activities. CCTS's goals are to ensure that the full spectrum of 
medical research is adequately funded, the next generation of 
researchers is well-prepared, and the regulatory and public policy 
environment facilitates ongoing expansion and advancement of the field 
of clinical and translational science.
Association for Clinical and Translational Science (ACTS)
    ACTS supports investigations that continually improve team science, 
integrating multiple disciplines across the full translational science 
spectrum: from population based and policy research, through patient 
oriented and human subject clinical research, to basic discovery. Our 
goal is to improve the efficiency with which health needs inform 
research and new therapies reach the public.
    ACTS is the academic home for the disciplines of research 
education, training, and career development for the full spectrum of 
translational scientists. Through meetings, publications, and 
collaborative efforts, ACTS will provide a forum for members to 
develop, implement, and evaluate the impact of research education 
programs.
    ACTS provides a strong voice to advocate for translational science, 
clinical research, patient oriented research, and research education 
support. We will engage at the local, State, and Federal levels and 
coordinate efforts with other professional organizations.
    ACTS will promote investigations and dissemination of effective 
models for mentoring future generations of translational scientists. 
Through collaborative efforts, ACTS will provide a forum for members to 
share studies, promote best practices, and optimize professional 
relationships among trainees and mentors.
The Clinical Research Forum (CRF)
    CRF was formed in 1996 to discuss unique and complex challenges to 
clinical research in academic health centers. Over the past decade, it 
has convened leaders in clinical research annually and has provided a 
forum for discussing common issues and interests in the full spectrum 
of research. Through its activities, the Forum has enabled sharing of 
best clinical practices and increasingly has played a national advocacy 
role in support of the boarder interests and needs of clinical 
research.
    Governed by a Board of Directors constituted of clinical 
researchers from thirteen member institutions, CRF has grown to sixty 
members from academia, industry, and volunteer health organizations. 
CRF engages leaders in the clinical research enterprise including 
leaders from government, foundations, other not-for-profit 
organizations, and industry in addressing the challenges and 
opportunities facing the clinical research enterprise.
    Parallel with our widening focus upon the broad needs of the entire 
national clinical research enterprise, CRF is committed to working in 
those areas where it is uniquely positioned to have a significant 
impact. Collaboration with other organizations with similar goals and 
synergizing with their efforts strengthens all approaches to the issues 
facing clinical research.
                             sequestration
    Thank you for providing sequestration relief in fiscal year 2014 
and fiscal year 2015.
    Federal medical research programs form the cornerstone of our 
Nation's biotech sector. In addition to undermining active and emerging 
research projects, across the board funding cuts create widespread 
disruption. Due to a number of factors, this disruption compounds 
significant challenges facing the clinical and translational research 
training and career development pipeline.
    Recent years of near-level funding have curtailed NIH's ability to 
issue funding opportunities. As a result, the pay line at NIH has 
decreased substantially while the average age of an investigator 
receiving their first award has increased significantly. This dynamic 
creates a strong disincentive for young people to pursue a career in 
this field. Prior to sequestration, NIH would often discuss the decline 
in young investigators entering the research training and career 
development pipeline.
    Beyond public health, our country needs to ensure that we are 
adequately preparing the next generation of medical investigators for 
reasons related to both the economy and national security. Last year, 
China announced a $300 billion 5-year investment in medical research; 
this amount is double the current NIH budget over the same period of 
time. With strong competition from foreign countries, we run the risk 
of a researcher brain-drain from the U.S. to other Nations. Scientific 
breakthroughs and innovation will continue, but our loss in this area 
will mean gains for other Nations. Foreign economies will benefit from 
the significant return-on-investment that occurs through robust support 
of research.
    Sequestration has the potential to severely exacerbate an already 
difficult task of recruiting and training the next generation of 
scientific investigators. In order to ensure that the U.S. maintains a 
strong research training and career development pipeline, please 
eliminate the threat of sequestration and further support key 
activities.
                     national institutes of health
    This Nation has a proud history as a global leader in medical 
research and biotechnology. This leadership has provided our country 
with cutting-edge patient care, high-quality jobs, and meaningful 
economic growth. The Milliken Institute recently calculated that every 
dollar invested in NIH returns about a $1.70 in economic output in the 
short term and as much as $3.20 long-term. Crucially, through a robust 
external research program, NIH resources flow out to the States where 
the benefit of the funding infusion is felt on the local level.
    NIH's impact on public health has been profound. Conditions once 
considered a death-sentence can now be managed, survival rates for 
patients with life-threatening diseases have increased dramatically, 
and additional innovative therapies and diagnostic tools come to market 
each year. NIH has been successful, but much more can be done. Please 
provide NIH with at least $32 billion in fiscal year 2015 so ongoing 
research projects can be adequately supported and new research 
activities can be initiated.
Clinical and Translational Science Awards (CTSA)
    NIH's CTSA Program, which is housed within the National Center for 
Advancing Translational Sciences (NCATS), is transforming the 
efficiency and effectiveness of clinical and translational research. 
Since its establishment with 13 centers, the CTSA program has expanded 
to 62 medical research institutions located across the country. These 
centers are linked together and work in concert to improve human health 
by energizing the research and training environment to innovate and 
enhance the quality of clinical and translational research.
    Last year, the Institute of Medicine (IOM) released a review of the 
CTSA program. The report entitled, The CTSA Program at NIH: 
Opportunities for Advancing Clinical and Translational Research, spoke 
favorably of the CTSA effort and made the following recommendations to 
improve the program:
    (1) Strengthen NCATS leadership of the CTSA program, (2) 
reconfigure and streamline the CTSA Consortium, (3) build on the 
strengths of individual CTSAs across the spectrum of clinical and 
translational research, (4) formalize and standardize evaluation 
processes for individual CTSAs and the CTSA Program, (5) advance 
innovation in education and training programs, (6) ensure community 
engagement in all phases of research, (7) strengthen clinical and 
translational research relevant to child health.
    CCTS supports the recommendations of the IOM report and the 
organization is hopeful these changes will be implemented quickly. 
Further, when the CTSA program was authorized, Congress indicated that 
the consortium would be considered fully-funded when it received an 
annual appropriation of $750 million. For fiscal year 2015, as part of 
an overall funding increase for NIH, please provide CTSAs with at least 
$500 million to ensure the program can continue to grow and advance. 
Additionally, we hope you will continue working over the coming years 
to provide CTSAs with $750 million to fully fund the program and 
establish a robust home for clinical and translational research.
Additional Programs
    In recent years, Congress and NIH have made important investments 
to support the full spectrum of medical research. Key clinical and 
translational research programs at NIH include Research Centers at 
Minority Institutions (RCMI), Institutional Development Awards (IDeA), 
and the new Accelerating Medicine Partnership (AMP). Supporting the 
full spectrum of medical research encourages outcomes-oriented 
investigation where breakthroughs in basic science are translated to 
new diagnostic tools and treatments that improve health and lower 
healthcare expenses. In recognition of the future of the overall field 
of medical research, most individual NIH Institutes and Centers now 
provide some level of support for translational and clinical research 
activities.
    In order to ensure that clinical and translational research 
programs at NIH have adequate support to facilitate ongoing growth, 
please provide $32 billion for NIH in fiscal year 2015 with 
proportional increases for individual Institutes, Centers, and Offices.
       federal research training and career development programs
    As we discussed previously, the future of our Nation's biomedical 
research enterprise relies heavily on the maintenance and continued 
recruitment of promising young investigators. The ``T'' and ``K'' 
series awards at NIH and AHRQ provide much-needed support for the 
career development of young investigators. As clinical and 
translational medicine takes on increasing importance, there is a great 
need to grow these programs. Career development grants are crucial to 
the recruitment of promising young investigators, as well as to the 
continuing education of established investigators. Reduced commitment 
to the K and T awards would have a devastating impact on our pool of 
highly trained clinical researchers. CCTS urges you to support the 
ongoing commitment to research training through adequate funding for T 
and K series awards and a meaningful fiscal year 2015 funding increase 
for AHRQ.
    Thank you for the opportunity to present the views and 
recommendations of the clinical and translational research and research 
training and career development community.
                                 ______
                                 
    Prepared Statement of the Coalition for Usher Syndrome Research
    My name is Mark Dunning from the State of Massachusetts. As 
Chairman of the Coalition for Usher Syndrome Research, I am here on 
behalf of the Usher syndrome community to respectfully request this 
committee encourage NIH to prioritize research that will eventually 
expand treatment options for individuals suffering from the severe 
hearing and vision loss related to Usher syndrome. We also respectfully 
request that the committee direct NIH to move expeditiously to direct 
additional resources to respond to any deficiencies in the funding 
level or the manner in which various ICs coordinate on common goals and 
objectives related to Usher syndrome.
    Usher syndrome is the leading cause of deaf-blindness. In the 
United States, it is estimated that about 45,000 people have this rare 
genetic disorder. My fifteen year old daughter Bella is one of them. 
She has Usher syndrome type 1b. She was born profoundly deaf and now 
she is losing her vision to retinitis pigmentosa. She also suffers from 
the severe balance issues common in her type of Usher syndrome.
    Imagine yourself as a fifteen year old girl. Adulthood stands 
before you. You dream of getting your driver's license, of the freedom 
it provides, of the limits it removes. We live in a small town. There 
is no public transportation. A car is the only way to get to work, to 
visit friends, to shop for food. But Bella's vision is too poor for 
driving. How will she survive?
    Or imagine yourself as a sophomore in high school. You dream of 
college, of the freedom it provides, of the limitless career 
opportunities. Only hard work and desire stand between you and your 
dreams. Unless, like Bella, you have Usher syndrome. Then you also face 
the barriers of access to information. You cannot hear the professor or 
see the board as well as your peers. You work many times harder to get 
the same grades. And some trades are closed to you before you start. 
Can you be an architect if you are losing your vision? Can you be a 
salesperson if you have no hearing? Can you dare to dream of an 
unfettered future? Is the American dream available to you if you have 
Usher syndrome?
    My daughter is an asset to this country. She is kind and 
empathetic. She puts all others before herself. She is hard working and 
fearless. She has been honored with a John F. Kennedy award for 
leadership and a StayClassy award for philanthropy. She is the type of 
fifteen year old we should be grooming as a future leader in the 
country.
    But Bella has Usher syndrome. She was born profoundly deaf and she 
is going blind. She will fight it every step of the way, but without 
increased Federal funding, she will eventually lose. And when Bella 
loses, we all lose. Kids like Bella are our future. Unless they have 
Usher syndrome. Then they are not, and we are all the worse for it.
    People with Usher syndrome share the same range of intelligence and 
work ethic as any other slice of America. Yet they suffer from an 82 
percent unemployment rate. People with Usher syndrome are born with the 
same emotional strength as any other American. Yet they have a suicide 
rate that is 2\1/2\ times greater than the general population. People 
with Usher syndrome not only have the capacity to contribute to 
America's future, they thirst for it. They want to be active members of 
society. Yet our country spends an estimated $139 billion annually in 
direct and indirect costs for people with eye disorders and vision 
loss.\1\ That doesn't even include the costs associated with hearing 
impairment.
---------------------------------------------------------------------------
    \1\ Wittenborn, John S. & Rein, David B. ``Cost of Vision Problems: 
The Economic Burden of Vision Loss and Eye Disorders in the United 
States.'' NORC at the University of Chicago. Prepared for Prevent 
Blindness America, Chicago, IL. June 11, 2013. 
http://costofvision.preventblindness.org.
---------------------------------------------------------------------------
    In my role as the Chairman of the Coalition for Usher Syndrome 
Research, I have spoken with or met hundreds of people who are 
determined, focused, and working everyday to help themselves, their 
loved one, or in some cases complete strangers, figure out how to treat 
this syndrome. Usher genes are complex, long protein cells which 
require significant investment in research if we are ever to find a 
cure or treatment. We can't do it alone.
    Through the Coalition, we have brought the Usher community and 
researchers together by:
  --Establishing a registry of individuals with Usher syndrome which is 
        available for research or clinical trials at no cost. Our 
        registry currently has families from each of the 50 States and 
        29 countries.
  --Sponsoring an International Symposium on Usher Syndrome at the 
        Harvard Medical School in July 2014 to develop a roadmap for 
        future research projects to bring us closer to viable clinical 
        trials.
  --Sponsoring annual family conferences, webinars and monthly 
        conferences that provide information and support to all of 
        those living with Usher.
    With this in place, we have begun bringing brilliant researchers 
together who are working on developing treatments every day. 
Researchers like those in Oregon and Pennsylvania who are working on 
gene therapy treatments, one of which began clinical trials last year. 
Researchers in Louisiana, who have been able to rescue the hearing in 
mice with Usher syndrome using a drug therapy that holds promise for 
rescuing vision as well. Researchers in Iowa, California, Nebraska, 
Massachusetts, Florida, Texas, and many other States, who are 
collaborating with each other and with families through the Coalition 
to advance all kinds of Usher syndrome research.
    But still this is not enough. We cannot help any of the tens of 
thousands who have Usher, or countless others that will be born in the 
future with this devastating genetic disorder without Federal support. 
There are dozens of different mutations that cause Usher syndrome, and 
the pace of research is slowed dramatically by the lack of researchers 
and funding. The infrastructure is there to find treatments, but the 
significant financial support is not. We are asking you to supply this 
last critical resource to help us find a cure.
    When you review the report on categorical spending by the NIH, 
Usher syndrome is not even listed. Rare diseases with similar incident 
rates average around $50 million annually. These investments have 
resulted in significant discoveries for these diseases and there is 
reason to believe that we can see these same results or better for 
Usher syndrome. We do not ask that the committee throw dollars at the 
problem. Only that they ensure the appropriate funding is available. 
The researchers are there, waiting to discover what now is just a 
dream. All we are asking for is a chance; a chance for deaf children 
and adults who are going blind, a chance to see. With your help, my 
daughter and others like her can once again dare to dream.
    I will leave you with the words of America's most famous deaf-blind 
person, Helen Keller. ``Alone we can do so little; together we can do 
so much.'' Only together can we find a way to end deaf-blindness. I 
thank you on behalf of all those with Usher syndrome, their families, 
and most importantly to me, my daughter Bella.

    [This statement was submitted by Mark Dunning, Chairman, Coalition 
for Usher Syndrome Research.]
                                 ______
                                 
     Prepared Statement of the Coalition of Northeastern Governors
    The Coalition of Northeastern Governors (CONEG) is pleased to share 
with the Subcommittee on Labor, Health and Human Services, Education, 
and Related Agencies its views regarding the fiscal year 2015 
appropriations for the Low-Income Home Energy Assistance Program 
(LIHEAP).
    The CONEG Governors appreciate the Subcommittee's long-standing 
support for this vital program, and recognize the difficult fiscal 
decisions that face the Subcommittee. In recognition of the on-going 
challenges that the most vulnerable low-income households in our region 
face in heating their homes, the Governors urge the Subcommittee to 
fund the LIHEAP core block program in fiscal year 2015 at the 
authorized level of $5.1 billion but not less than $4.7 billion. In 
addition, the Governors request sufficient contingency funds to address 
unforeseen energy emergencies such as prolonged severe weather or price 
spikes in home heating fuels. Adequate, predictable and timely Federal 
funding is essential for LIHEAP to provide a vital lifeline to those 
households struggling to afford the basic necessity of home energy. The 
Governors urge the Subcommittee to provide these funds in a manner 
consistent with the LIHEAP statutory objective: ``to assist low-income 
households, particularly those with the lowest incomes that pay a high 
proportion of household income for home energy, primarily in meeting 
their immediate home energy needs.''
    LIHEAP funds are targeted to those households with the greatest 
energy burden. Most LIHEAP assistance is targeted to households whose 
income is less than 150 percent of the Federal poverty level, which for 
a two-person household is $23,595 in 2014. However the majority of 
LIHEAP recipients have incomes far below that level. Many of these 
households live on fixed incomes and are not likely to benefit from 
improvements in the job market and the national economy. More than 
ninety percent of LIHEAP households have at least one vulnerable 
member--the elderly or disabled and young children--for whom 
temperature extremes could have serious health and safety consequences. 
Approximately 20 percent of LIHEAP households contain at least one 
member who is a military veteran.
    Low-income households across the Nation spend a disproportionate 
amount of their income on home energy, often over three times more than 
non-low-income households. The AARP estimates low-income senior 
households (age 65 and older) heating with fuel oil will spend almost 
20 percent of household income on heating costs, while all other 
households heating with fuel oil will spend roughly 5 percent of their 
income to heat their homes. In the colder climates of the Northeast, 
the average household typically uses 800 gallons of heating oil per 
winter. At EIA's projected average cost of $3.83 per gallon, an elderly 
LIHEAP recipient whose primary income is a Social Security check would 
need to spend almost 3 months of income to heat her home this winter. 
Many seniors will spend more than one-third of their monthly income 
just to get the minimum 100-gallon delivery of heating oil.
    The energy burden faced by low-income households is particularly 
acute in the Northeast. This region experiences some of the Nation's 
highest home heating bills due to a combination of the extended winter 
heating season and heating fuel expenditures that typically exceed 
national averages. According to the Energy Information Administration 
(EIA), the average consumer expenditures for heating fuels in the 
Northeast have consistently and significantly exceeded similar 
expenditures in all other regions regardless of the type of fuel used--
natural gas, heating oil, propane, or electricity.
    Low-income households in the Northeast experience another aspect of 
``energy burden''. More than any other region of the country, Northeast 
households are dependent upon delivered fuels--heating oil, propane and 
kerosene. The 30 percent of Northeast households that rely upon 
delivered fuels account for approximately 80 percent of the homes 
nationwide that use home heating oil. These heating fuels are also the 
most expensive and volatile in price. The EIA estimates that households 
using heating oil can expect to pay $2,243 to keep warm this winter. 
The EIA also finds that households using delivered fuels see any change 
in wholesale prices reflected in their energy bills almost immediately, 
unlike natural gas and electricity retail customers. These ``delivered 
fuel'' households experience another vulnerability compared to natural 
gas and electricity customers. Low-income households that use delivered 
fuels are less likely to have the option of payment plans, access to 
utility assistance programs, and the protection of utility service 
shut-off moratoria during the heating season. If LIHEAP funds are not 
available to these households, the fuel delivery truck simply does not 
come.
    The Northeast has some of the country's oldest homes and coldest 
climates. Reducing home energy costs presents unique challenges to 
northeast states. State LIHEAP programs, often working with their 
Weatherization Assistance Programs, help low-income households take 
steps to reduce their energy use and lower their energy bills. Unlike 
the Federal weatherization program, LIHEAP funds can be used to provide 
repair or replace inefficient, unsafe and non-working home heating 
systems--improvements that enhance the safety and reduce the energy use 
of low-income households.
    Even with these programs to reduce energy use, many of the lowest 
income families that benefit from LIHEAP have limited options to reduce 
their energy bills. Some older homes, especially older manufactured 
homes, have structural issues that make them ineligible for 
weatherization assistance. Throughout the region, many LIHEAP 
households have limited ability to switch to more energy efficient 
heating systems due to the lack of adequate resources for the upfront 
costs and the lack of access to less expensive heating fuels. For 
example, natural gas may provide a less expensive energy source to heat 
homes, but conversion is neither simple nor affordable for low-income 
households. The New England Fuel Institute estimates that converting a 
complete home heating system from oil to natural gas can cost as much 
as $10,000. In addition, homes in rural and metropolitan areas 
throughout the Northeast are not served by natural gas infrastructure.
    State LIHEAP programs continue to seek innovative and efficient 
ways to ``do more with less'' and stretch scarce LIHEAP dollars to 
ensure that meaningful assistance can be provided to those households 
with the greatest needs. For example, LIHEAP funds are frequently 
leveraged by utility assistance programs for low-income households. 
States in the Northeast have worked with utilities to develop payment 
plans to reduce arrearages and lessen the prospect of utility shut-offs 
after the heating season ends. They have negotiated with fuel dealers 
to receive discounts on deliverable fuels, and have entered into 
agreements to purchase fuel in the summer when prices are lowest. 
LIHEAP is one of the most efficiently run programs with low overhead 
costs. Even after taking significant cost-cutting steps, States have 
had to take actions such as tightening program eligibility, closing the 
program early, and reducing benefit levels.
    In summary, the CONEG Governors appreciate the Subcommittee's 
continued support for LIHEAP, and urge you to fund the core block grant 
at the authorized level of $5.1 billion, but not less than $4.7 
billion, and sufficient contingency funds to address unforeseen energy 
emergencies.
                                 ______
                                 
    Prepared Statement of the College on Problems of Drug Dependence
    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to submit testimony to the Subcommittee in support of the 
National Institute on Drug Abuse. The College on Problems of Drug 
Dependence (CPDD), a membership organization with over 1000 members, 
has been in existence since 1929. It is the longest standing group in 
the United States addressing problems of drug dependence and abuse. The 
organization serves as an interface among governmental, industrial and 
academic communities maintaining liaisons with regulatory and research 
agencies as well as educational, treatment, and prevention facilities 
in the drug abuse field. CPDD also often works in collaboration with 
the World Health Organization.
    Recognizing that so many health research issues are inter-related, 
we request that the subcommittee provide at least $32 billion for the 
National Institutes of Health (NIH) and within that amount a 
proportionate increase for the National Institute on Drug Abuse, in 
your Fiscal 2015 Labor, Health and Human Services, Education and 
Related Agencies Appropriations bill. We also respectfully request the 
inclusion of the following NIDA specific report language.
    Marijuana Research. Efforts to legalize or ``medicalize'' marijuana 
continue across the United States. The Committee understands that 
research from different areas of science is converging on the fact that 
regular marijuana use by young people can have a long-lasting negative 
impact on the structure and function of their brains, resulting in 
lower educational achievement, reduced IQ, etc. Research clearly 
demonstrates that marijuana has the potential to cause problems in 
daily life or make a person's existing problems worse. NIDA is 
encouraged to continue to fund research on preventing and treating 
marijuana abuse and addiction, and the possible health and policy 
implications of proposals to implement ``medical marijuana'' or 
marijuana legalization programs across the U.S.
    Opiate Abuse and Addiction. The Committee is concerned about the 
continued crisis of prescription drug abuse in the U.S. In particular, 
the June 2011 IOM report on pain indicates that abuse and misuse of 
prescription opioid drugs resulted in an annual estimated cost to the 
Nation of $72,500,000,000. Further, the Committee is very concerned 
with the potential rise in heroin abuse and addiction as a result of 
successful efforts to combat the prescription drug side of this issue. 
The Committee urges NIDA to 1) continue funding research on medications 
to alleviate pain, including the development of pain medications with 
reduced abuse liability; 2) as appropriate, work with private companies 
to fund innovative research into such medications; and 3) report on 
what we know regarding the transition from opiate analgesics to heroin 
abuse and addiction within affected populations.
    Medications Development. The Committee recognizes that next-
generation pharmaceuticals will surely take advantage of new 
technologies. In the context of NIDA funding, chief among these are 
NIDA's current approaches to develop viable immunotherapeutic or 
biologic (e.g., bioengineered enzymes) approaches for treating 
addiction. The goal of this active area of research is the development 
of safe and effective vaccines or antibodies that target specific 
drugs, like nicotine, cocaine, and heroin, or drug combinations. The 
Committee is excited by this approach--if successful, immunotherapies, 
alone or in combination with other medications, behavioral treatments, 
or enzymatic approaches, stand to revolutionize how we treat, and, 
maybe even someday, prevent addiction. The Committee looks forward to 
hearing more about work in this area.
    Nurturing Talent and Innovation in Research. The Committee commends 
NIDA for its continued support of innovative research on drug addiction 
and related health problems such as pain and HIV/AIDS, and the 
Institute's effort to be at the forefront of training the next 
generation of innovative researchers. The 6 year-old Avant-Garde award 
is a good example of a program that stimulates high-impact research 
that could lead to groundbreaking opportunities for the prevention and 
treatment of HIV/AIDS in drug abusers. The Committee understands that 
NIDA is now crafting a new kind of award, which would blend NIH's 
Pioneer and New Innovator award mechanisms. This new opportunity, 
called ``AVENIR'' awards, is designed to attract creative young 
investigators into HIV/drug abuse public health research. The Committee 
strongly supports this effort, and asks the Institute to report on its 
progress in future appropriations and related requests.
    Research to Assist Military Personnel, Veterans, and Their 
Families. The Committee recognizes the significant health challenges, 
including substance abuse and addiction, faced by military personnel, 
veterans, and their families. Many of these individuals need help 
confronting war-related problems including traumatic brain injury, 
PTSD, depression, anxiety, sleep disturbances, and substance abuse and 
addiction. The Committee commends NIDA for its successful efforts to 
coordinate and support research with the Department of Veterans 
Affairs, Department of Defense, and other NIH Institutes focusing on 
these populations, and strongly urges NIDA to continue work in this 
area.
    Raising Awareness and Engaging the Medical Community in Drug Abuse 
and Addiction Prevention and Treatment. The Committee is very pleased 
with NIDAMed, an initiative designed to reach out to physicians, 
physicians in training, and other healthcare professionals. The 
Committee urges the Institute to continue its focus on activities to 
provide physicians and other medical professionals with the tools and 
skills needed to incorporate drug abuse screening and treatment into 
their clinical practices.
    Drug abuse is costly to Americans; it ruins lives, while tearing at 
the fabric of our society and taking a huge financial toll on our 
resources. Beyond the unacceptably high rates of morbidity and 
mortality, drug abuse is often implicated in family disintegration, 
loss of employment, failure in school, domestic violence, child abuse, 
and other crimes. Placing dollar figures on the problem; smoking, 
alcohol and illegal drug use results in an exorbitant economic cost on 
our Nation, estimated at over $600 billion annually. We know that many 
of these problems can be prevented entirely, and that the longer we can 
delay initiation of any use, the more successfully we mitigate future 
morbidity, mortality and economic burdens.
    Over the past three decades, NIDA-supported research has 
revolutionized our understanding of addiction as a chronic, often-
relapsing brain disease --this new knowledge has helped to correctly 
situate drug addiction as a serious public health issue that demands 
strategic solutions. By supporting research that reveals how drugs 
affect the brain and behavior and how multiple factors influence drug 
abuse and its consequences, scholars supported by NIDA continue to 
advance effective strategies to prevent people from ever using drugs 
and to treat them when they cannot stop.
    NIDA supports a comprehensive research portfolio that spans the 
continuum of basic neuroscience, behavior and genetics research through 
medications development and applied health services research and 
epidemiology. While supporting research on the positive effects of 
evidence-based prevention and treatment approaches, NIDA also 
recognizes the need to keep pace with emerging problems. We have seen 
encouraging trends--significant declines in a wide array of youth drug 
use--over the past several years that we think are due, at least in 
part, to NIDA's public education and awareness efforts. However, areas 
of significant concern include the recent increase in lethalities due 
to heroine, as well as the continued abuse of prescription opioids and 
the recent increase in designer drugs availability and their 
deleterious effects. The need to increase our knowledge about the 
effects of marijuana is most important now that decisions are being 
made about its approval for medical use and/or its legalization. We 
support NIDA in its efforts to find successful approaches to these 
difficult problems.
    The Nation's previous investment in scientific research to further 
understand the effects of abused drugs on the body has increased our 
ability to prevent and treat addiction. As with other diseases, much 
more needs be done to improve prevention and treatment of these 
dangerous and costly diseases. Our knowledge of how drugs work in the 
brain, their health consequences, how to treat people already addicted, 
and what constitutes effective prevention strategies has increased 
dramatically due to support of this research. However, since the number 
of individuals continuing to be affected is still rising, we need to 
continue the work until this disease is both prevented and eliminated 
from society.
    We understand that the fiscal year 2015 budget cycle will involve 
setting priorities and accepting compromise, however, in the current 
climate we believe a focus on substance abuse and addiction, which 
according to the World Health Organization account for nearly 20 
percent of disabilities among 15-44 year olds, deserves to be 
prioritized accordingly. We look forward to working with you to make 
this a reality. Thank you for your support for the National Institute 
on Drug Abuse.
                                 ______
                                 
  Prepared Statement of the Consortium of Social Science Associations
    Mr. Chairman and Members of the Subcommittee, the Consortium of 
Social Science Associations (COSSA) appreciates and welcomes the 
opportunity to comment on the fiscal year 2015 appropriations for the 
National Institutes of Health (NIH), Centers for Disease Control and 
Prevention (CDC) and the Agency for Healthcare Research and Quality 
(AHRQ). COSSA joins the Ad Hoc Group for Medical Research in 
recommending that NIH receive at least $32 billion in fiscal year 2015 
as the next step toward a multi-year increase in our Nation's 
investment in medical research. As a member of the CDC Coalition, COSSA 
requests $7.8 billion in funding for the CDC in fiscal year 2015. We 
join the Friends of AHRQ in requesting a funding level of $375 million 
for AHRQ in fiscal year 2015.
    COSSA is an advocacy group for the social and behavioral sciences 
supported by more than 100 professional associations, scientific 
societies, universities and research centers. It serves as a bridge 
between the academic research and Washington policy-making community. 
Our organizations are appreciative of the Subcommittee's and the 
Congress' continued support of NIH, CDC, and AHRQ. Strong, sustained 
funding for these agencies is essential to the national priorities of 
better health and economic revitalization.
              nih behavioral and social sciences research
    As this Committee knows, the NIH mission is to support 
scientifically rigorous, peer/merit-reviewed, investigator-initiated 
research, including basic and applied behavioral and social science 
research in fulfilling its mission: ``Science in pursuit of fundamental 
knowledge about the nature and behavior of living systems and the 
application of that knowledge to enhance health, lengthen life and 
reduce illness and disability.''
    The fundamental understanding of how disease works, including the 
impact of social environment on these disease processes, underpins our 
ability to conquer devastating illnesses. Perhaps the grandest 
challenge we face is to understand the brain, behavior, and society-- 
from responding to short-term pleasures to self-destructive behavior, 
such as addiction, to lifestyle factors that determine the quality of 
life, infant mortality rate and longevity. And while Americans have 
achieved very high levels of health over the past century and are 
healthier than people in many other Nations, according to the 2013 
National Academies' (NAS) report, U.S. Health in International 
Perspective: Shorter Lives, Poorer Health, ``a growing body of research 
suggests that the health of the U.S. population is not keeping pace 
with the health of people in other economically advanced, high-income 
countries.''
    Nearly 125 million Americans are living with one or more chronic 
conditions, including heart disease, cancer, diabetes, kidney disease, 
arthritis, asthma, mental illness and Alzheimer's disease. At the same 
time, healthcare spending in the United States is being driven up by 
the aging of the U.S. population and the rapid rise in chronic 
diseases, many of which are caused or exacerbated by behavioral 
factors--including, obesity, caused by sedentary behavior and poor 
diet, and addictions resulting from health problems caused by tobacco 
and other drug use. As the NAS report notes, ``the United States is 
losing ground in the control of diseases, injuries, and other sources 
of morbidity.''
    The behavioral and social sciences regularly make important 
contributions to the well-being of this Nation. Due in large part to 
the behavioral and social science research sponsored by the NIH, we are 
now aware of the enormous role behavior plays in our health. At a time 
when genetic control over disease is tantalizingly close but not yet 
possible, knowledge of the behavioral influences on health is a crucial 
component in the Nation's battles against the leading causes of 
morbidity and mortality: obesity, heart disease, cancer, AIDS, 
diabetes, age-related illnesses, accidents, substance abuse, and mental 
illness.
    As a result of the strong Congressional commitment to the NIH in 
years past, our knowledge of the social and behavioral factors 
surrounding chronic disease health outcomes is steadily increasing. The 
NIH's behavioral and social science portfolio has emphasized the 
development of effective and sustainable interventions and prevention 
programs targeting those very illnesses that are the greatest threats 
to our health, but the work is just beginning. This includes NIH's 
support of economic research, specifically, research on the linkages 
between socioeconomic status and health outcomes in the elderly and 
achievement and health outcomes in children. This research has been an 
integral part of the interdisciplinary science NIH has historically 
supported. Accordingly, the agency's investment has yielded key data, 
methodologies and substantive insights on some of the most important 
and pressing issues facing the U.S. For example, NIH-funded surveys 
such as the Health and Retirement Survey, the Panel Study of Income 
Dynamics (PSID), parts of the National Longitudinal Survey of Labor 
Market Experiences, and surveys on international aging and retirement 
provide data necessary to monitor and detect changes in important 
socioeconomic trends in health. This in turn allows NIH to support 
research that will provide the greatest return on its investment when 
it comes to the health of our citizens.
               cdc behavioral and social science research
    As the country's leading health protection and surveillance agency, 
the Centers for Disease Control and Prevention (CDC) works with State, 
local, and international partners to protect Americans from infectious 
diseases; prevent the leading causes of disease, disability, and death; 
protect Americans from natural and bioterrorism threats; monitor health 
and ensure laboratory excellence; keep Americans safe from 
environmental and work-related hazard; and ensure global disease 
protection.
    Social and behavioral science research plays a crucial role in 
helping the CDC carry out its mission. Scientists in fields ranging 
from psychology, sociology, anthropology, and geography to health 
communications, social work, and demography work in every CDC Center to 
design, analyze, and evaluate behavioral surveillance systems, public 
health interventions, and health promotion and communication programs 
using a variety of both quantitative and qualitative methods. These 
scientists play a key role in the CDC's surveillance and monitoring 
efforts, which collect and analyze data to better target public health 
prevention efforts. Another vital contribution of the social and 
behavioral sciences to CDC activities is in identifying and 
understanding health disparities. Finally, the social and behavioral 
sciences play an important role in the evaluation of CDC programs, 
helping policymakers make informed, evidence-based decisions on how to 
prioritize in a resource-scarce environment.
    The CDC is also the home of the Nation's principal health 
statistics agency, the National Center for Health Statistics (NCHS). 
NCHS collects data on chronic disease prevalence, healthcare 
disparities, emergency room use, teen pregnancy, infant mortality, 
causes of death and rates of insurance, to name a few. It provides 
critical data on all aspects of our healthcare system through data 
cooperatives and surveys that serve as the gold standard for data 
collection around the world. Data from NCHS surveys like the National 
Health Interview Survey (NHIS), the National Health and Nutrition 
Examination Survey (NHANES) and the National Vital Statistics System 
(NVSS) are used by agencies across the Federal Government, State and 
local governments, public health officials, Federal policymakers, and 
demographers, epidemiologists, health services researchers, and other 
scientists.
                     ahrq health services research
    AHRQ's sole purpose is to improve healthcare in America. Just as 
biomedical research helps us find cures for disease, the health 
services research AHRQ supports helps find ways to cure our healthcare 
system--improving its quality, safety, and efficiency for the benefit 
of patients. AHRQ's research identifies what works and what doesn't in 
healthcare to improve patient care and provide policymakers and other 
healthcare leaders with the information needed to make critical 
healthcare decisions.
    AHRQ helps providers help patients. AHRQ's research generates 
valuable evidence to help providers help patients make the right 
healthcare decisions for themselves and their loved ones. The science 
funded by AHRQ ensures patients receive high quality, appropriate care 
every time they walk through the hospital, clinic, and medical office 
doors. AHRQ's research provides the basis for protocols that prevent 
medical errors and reduce healthcare-associated infections (HAIs), and 
improve patient experiences and outcomes. AHRQ helps healthcare 
providers--from private practice physicians to large hospital systems--
understand how to deliver the best care most efficiently. The breadth 
of evidence available from AHRQ empowers healthcare providers to 
understand not just how they compare to their peers, but also how to 
improve their performance to be more competitive.
    COSSA expects this testimony to be only the beginning of an ongoing 
conversation between the Subcommittee and stakeholders on the fiscal 
year 2015 funding needs of these agencies.
    We would be pleased to provide any additional information.
                                 ______
                                 
     Prepared Statement of the Corporation for Public Broadcasting
    Chairman Harkin and distinguished members of the subcommittee, 
thank you for allowing me to submit this testimony on behalf of 
America's public media service--public television and public radio--on-
air, online and in the community. The Corporation for Public 
Broadcasting (CPB) requests level funding of $445 million for fiscal 
year 2017 and $27.3 million for the Department of Education's Ready To 
Learn program in fiscal year 2015.
    Forty-six years after passage of the Public Broadcasting Act, this 
uniquely American public-private partnership is keeping its promise to 
the American people by providing a safe place where children can learn 
on-air and online; providing high-quality educational content for 
teachers in the classroom and children schooled at home; providing 
reliable and trusted news and information; and providing emergency 
alert services. Either by looking at each station individually or 
public media as a whole, this public-private partnership is making a 
big difference in the lives of individuals and communities.
    Today we are a system that comprises more than 1,400 locally owned 
and locally operated public radio and television stations serving rural 
and urban communities throughout the country. More than 98 percent of 
the American people turn to American public media for high quality 
content that educates, informs, inspires and entertains. Public media's 
commitment to early and lifelong learning, available to all citizens, 
helps strengthen our civil society and our democracy. Our trusted, 
noncommercial services available for free to all Americans is 
especially important to those living in rural communities where the 
local public media station is sometimes the only source of broadcast 
news, information and educational programming.
    I understand that this committee is faced with the challenging task 
of allocating scarce Federal resources to a number of organizations, 
all doing worthy and important work. The financial support for the 
public broadcasting system that is derived from the Federal 
appropriation is the essential investment keeping public media free and 
commercial free for all Americans. Former President Ronald Reagan said, 
``Government should provide the spark and the private sector should do 
the rest.'' And what stations do, with the spark of Federal dollars 
that amounts to approximately 10 to 15 percent of a stations' budget, 
results in a uniquely entrepreneurial and American public media system 
with a track record of proven benefits delivered through stations to 
the American people.
    The Federal investment through CPB is the foundation on which the 
entire system is built. These critical funds leverage vital investments 
from other sources. Undermining this foundation would put the entire 
structure in jeopardy. While private donations and existing funding 
sources can help defray considerable costs for the much-honored 
programs of public television and radio--nonFederal funding represents 
five of every six dollars invested annually in public broadcasting--the 
Federal investment is indispensable to sustaining the operations of 
public broadcasting stations, the public service mission they pursue, 
local community-based accountability, and the universal service to 
which the Public Broadcasting Act aspires.
    Further, it is this initial investment in public media that keeps 
it commercial free and available to all Americans for free. However, 
smaller stations serving rural, minority and other underserved 
communities are hard pressed to raise six times the Federal 
appropriation, which can represent as much as 40 percent of their 
budget.
    Public media's contribution to education--from early childhood 
through adult learning--is well documented. We are America's largest 
classroom, with proven content available to all children, including 
those who cannot afford preschool. Our content is repeatedly regarded 
as ``most trusted'' by parents, caregivers and teachers.
    CPB's work with the Department of Education's Ready To Learn 
program is an excellent example of how public media brings together 
high-quality educational content with on-the-ground work in local 
communities. We also invest in research that demonstrates and promotes 
the effectiveness of this content in formal and informal educational 
settings.
    We talk a lot about content that matters and engagement that 
counts, further defining public media from commercial media. An example 
of this is CPB's ``American Graduate: Let's Make it Happen'' 
Initiative, which tells the story behind the statistic of one million 
American young people failing to graduate every year from high school. 
Our stations told the stories and communities throughout the country 
responded. More than 75 public media stations located in 33 States with 
at-risk communities are working with more than 1000 national and 
community-based partners to bring together diverse stakeholders and 
community organizations; filling gaps in information, resources and 
solutions; sharing best practices for teacher training and student 
engagement; creating local programming around the dropout issue unique 
to their communities, and leveraging digital media and technology to 
engage students in an effort to keep them on the path to graduation. 
Those numbers are now declining because what our stations do, counts. 
But American Graduate is just one example of how public media stations 
are using their spectrum for the public good.
    Building on our education commitment, CPB recently announced that 
it will expand on these successful models to bring meaningful impact 
and change to more communities at risk. Through the recently created 
$20 million American Graduate/PBS KIDS Fund, CPB and PBS will invest in 
the development of new tools to help parents better prepare their 
children ages 2-8 for educational success, to support teacher 
development, and to engage middle and high school youth to improve 
learning.
    Public media is utilizing today's technology to provide content of 
value to millions of citizens who trust us to deliver content that 
matters and is relevant to their lives today. CPB strategically focuses 
investments through the lens of what we refer to as the ``Three D's'' 
--Digital, Diversity and Dialogue. This refers to support for 
innovation on digital platforms, extending public media's reach and 
service over multiple platforms; content that is for, by and about 
Americans of all backgrounds; and services that foster dialogue between 
the American people and the public service media organizations that 
serve them.CPB funding enables stations to provide content of 
consequence and to keep faith with the visions of political, 
educational, philanthropic and community leaders who have seen in 
public broadcasting the potential to strengthen our nation by promoting 
lifelong learning and an informed citizenry.
    As the steward of these important taxpayer dollars, CPB ensures 
that 95 cents of every dollar received goes to support local stations 
and the programs and services they offer to their communities; no more 
than five cents of every dollar goes to the administration of funding 
programs and overhead.
    The Public Broadcasting Act ensures diversity in this programming 
by requiring CPB to fund independent and minority producers. CPB 
fulfills this obligation, in part, by funding the Independent 
Television Service, the five Minority Consortia entities in television 
(African American, Latino, Asian American, Native American and Pacific 
Islander), several public radio consortia (Latino Public Radio 
Consortia, African American Public Radio Stations, and Native Public 
Media) and numerous minority public radio stations. In addition, CPB, 
through its Diversity and Innovation fund, makes direct investments in 
the development of diverse primetime and children's broadcast programs 
as well as innovative digital content.
    As newspapers across the country have scaled back their operations, 
public media has stepped into the void. Local stations have been 
working to fill the gap with creative ventures and partnerships, such 
as our seven multimedia local journalism centers (LJCs) that are 
providing their communities with much-needed local, regional and 
statewide coverage.
    For an investment of approximately $1.35 per American per year, 
public media stations are able to train teachers and help educate 
America's children; provide in-depth journalism that informs citizens 
about issues in their neighborhoods, their country, and around the 
globe; make the arts accessible to all Americans; and provide emergency 
alert services for their communities.
    CPB's fiscal year 2017 request of $445 million balances the fiscal 
reality facing our nation with our statutory mandate to provide a 
valuable and trusted service to all Americans. Today, the challenges we 
face are more complex than ever and require new levels of thinking, 
innovation, and collaboration. Community organizations often work in 
isolation, shouldering the burden of solving societal problems. But 
public media is the essential link, uniquely poised to add real value. 
CPB's fiscal year 2017 request will allow stations to enhance their 
role as a trusted source of information and as a convener, help 
communities understand issues, and mobilize them toward positive, 
sustainable outcomes.
    Mr. Chairman and members of the subcommittee, this is only part of 
the story of our public media system in America. Public media is a 
national treasure that is available and accessible to all Americans. 
Every day public media works to strengthen and advance our civil 
society. I thank you for allowing me to submit this testimony and urge 
you to consider our request for funding.

    [This statement was submitted by Patricia Harrison, President and 
CEO, Corporation for Public Broadcasting.]
                                 ______
                                 
       Prepared Statement of Council of Academic Family Medicine
    We urge the Committee to appropriate at least $71 million for the 
health professions program, Primary Care Training and Enhancement, 
authorized under Title VII, Section 747 of the Public Health Service 
Act, under the jurisdiction of the Health Resources and Services 
Administration (HRSA.) In addition, we recommend the Committee fund the 
Agency for Healthcare Research and Quality (AHRQ) at no less than $375 
million in base discretionary funding to support research vital to 
primary care.
    The member organizations of the Council of Academic Family Medicine 
(CAFM) are pleased to submit testimony on behalf of programs under the 
jurisdiction of the Health Resources and Services Administration (HRSA) 
and the Agency for Healthcare Research and Quality (AHRQ). The programs 
we support in our testimony are ones that deliver an investment in our 
Nation's workforce and health infrastructure. They are a down payment 
on a U.S. healthcare system with a foundation of primary care that will 
produce better health outcomes and reduce the ever rising costs of 
healthcare. We understand that hard decisions must be made in these 
difficult fiscal times, but even in this climate, we hope the Committee 
will recognize that the production of a robust primary care workforce 
for the future is a necessary investment that cannot wait and will 
ultimately produce long term savings.
Primary Care Training and Enhancement
    The Primary Care Training and Enhancement Program (Title VII, 
Section 747 of the Public Health Service Act) has a long history of 
providing indispensable funding for the training of primary care 
physicians. With each successive reauthorization, Congress has modified 
the Title VII health professions programs to address relevant workforce 
needs. The most recent authorization directs the Health Resources and 
Services Administration (HRSA) to prioritize training in the new 
competencies relevant to providing care in the patient-centered medical 
home model. It also calls for the development of infrastructure within 
primary care departments for the improvement of clinical care and 
research critical to primary care delivery, as well as innovations in 
team management of chronic disease, integrated models of care, and 
transitioning between healthcare settings. Departments of family 
medicine and family medicine residency programs often rely on Title 
VII, Section 747, grants to help develop curricula and research 
training methods for transforming practice delivery.
    There has not been a competitive cycle for these grants since 
fiscal year 2010. There are currently over 200 grants, completing their 
cycle in fiscal year 2014 who will be eligible to apply in fiscal year 
2015, as well as numerous other potential applicants who did not 
receive funding in fiscal year 2010. The current funding level 
(approximately $36.9 million) is not enough to allow for the pent up 
demand. More importantly, the vital work of these grants to help reform 
primary care education and the health delivery system needs to be 
prioritized.
    As implementation of the Affordable Care Act proceeds with 
increasing numbers of insured persons, the Nation will need new 
initiatives relating to increased training in inter-professional care, 
the patient-centered medical home, and other new competencies required 
in our developing health system. Such initiatives will be impossible to 
implement without a competitive grant cycle with enough funding to 
allow for a robust result of new grants. Now is the time to ensure that 
critical funding for the Primary Care Training and Enhancement program 
takes place. Title VII has a profound impact on States across the 
country and is vital to the continued development of a workforce 
designed to care for the most vulnerable populations and meet the needs 
of the 21st century. We cannot allow the primary care pipeline to dry 
up.
    Below are some examples of how these grants have made lasting 
contributions:

    ``With funding from a Title VII Medical Student Education grant, we 
were able to expand our existing medical student family medicine 
clerkship clinic to include students from pharmacy, nursing, 
occupational and physical therapy, and law, who see patients together 
under the supervision of faculty from all disciplines. This has allowed 
us to create one of the few truly interprofessional clinical 
experiences.'' Joshua Freeman, MD, Chair, Department of Family 
Medicine, University of Kansas School of Medicine
    ``Our AAU HRSA Title VII Grant has allowed us to transform the 
education of medical students and residents at Brown University around 
the patient centered medical home, including new curricula and 
rotations, as well as the facilitation work to transform 10 family 
medicine teaching practices. In addition, we have run 3 national 
``think tanks'' to discuss practical and theoretical issues related to 
models for practice transformation, PCMH evaluation, and the Adolescent 
PCMH. This grant has had huge impact and the work could not have been 
done without it. Jeffrey Borkan, MD, PhD, Chair, Department of Family 
Medicine, Brown University
    ``Previous grants included starting a resident continuity clinic at 
an FQHC, and preparation for rural training (rural continuity clinic, 
curriculum, rural mentoring program, rural medicine interest group). 
More distant grants help set up rural training sites for medical 
students and residents in 1975 and 1980, both of which are still 
providing that important function. Steven C. Zweig, MD, MSPH, Chair, 
Department of Family Medicine, University of Missouri''
    ``We have used HRSA funding to transform our curriculum and our 
Family Medicine Center using the principles of PCMH. We have partnered 
with a local income based elderly housing complex to provide clinical 
services on-site. We have partnered with a community senior center to 
provide on-site instruction to elderly community dwelling individuals. 
We have added instruction in quality and safety throughout the 
residency and using the PDSA cycle we improve care in asthma, asthma, 
and hypertension as well as our preventive care. As a consequence we 
have put ourselves in a position to become NCQA Level 3 certified by 
December 31.'' In addition, we were able to partner with the local 
FQHCs and create a longitudinal patient care track in the first 2 years 
of medical school. Beginning October of the first year, the students 
are placed in a primary care (and most in an underserved) site on an 
ongoing, monthly basis. They are given the skills to be a member of the 
care team and participate in all aspects of patient care.'' Allen 
Perkins, MD, Professor and Chair, Department of Family Medicine, 
University of South Alabama College of Medicine
    ``Title VII funding has allowed our residency site to implement an 
interprofessional team-based care curriculum as part of our patient-
centered medical home transformation. Residents work with nurses, 
social workers, nurse midwives, community health workers, nutritionists 
and certified diabetes educators and learn about optimal team 
communication and care for their patients through participation in 
several group visit programs (centering pregnancy, well baby visits and 
diabetes group visits). Their learning is also supplemented by a 
longitudinal video feedback to improve doctor-patient communication, 
which includes 360 degree feedback and preceptor training.'' Michelle 
Roett, MD, MPH, FAAFP, Residency Program Director, Georgetown 
University-Providence Hospital FMR, in Colmar Manor, MD

Agency for Health Care Research and Quality (AHRQ)
    Two years ago, we were disappointed to see the subcommittee 
eliminate funding for AHRQ in its draft bill. We understand that in our 
current budgetary climate it is important to leverage research funding 
in the most effective ways possible. However, the majority of research 
funding supports research of one specific disease, organ system, 
cellular, or chemical process--not for primary care. This is in spite 
of the fact that the overall health of a population is directly linked 
to the strength of its primary healthcare system. Primary care research 
includes: translating science into the practice of medicine and caring 
for patients, understanding how to better organize healthcare to meet 
patient and population needs, evaluating innovations to provide the 
best healthcare to patients, and engaging patients, communities, and 
practices to improve health. AHRQ is uniquely positioned to support 
this sort of best practice research and to help advance its 
dissemination to improve primary care nationwide.
    There are six areas that we believe AHRQ excels at--and that are 
not available elsewhere in the biomedical research infrastructure: 
primary care research through Practice-based Research Networks (PBRNs), 
practice transformation, patient quality and safety in non-hospital 
settings, multi-morbidity research, mental and behavioral health 
provision in communities and primary care practices, and training 
future primary care investigators. Critical to the successful 
engagement and development of primary care research is the constraint 
of not having an adequate cadre of well-trained researchers. We believe 
there is a need to deliberately promote this training as a way to aid 
in the development of all the areas we have emphasized. AHRQ has 
researcher training mechanisms in place, which we believe are 
important, and need to be expanded.
    Some examples from the field regarding the utility of AHRQ-funded 
grants:

    ``Three AHRQ grants supported the development of patient centered 
personal health records in 2007, 2009, and 2010, and studied whether 
these tools increased prevention. In our studies we found increases in 
important tests like colon and breast cancer screening as well as 
immunizations, blood pressure and cholesterol control. In addition, we 
were able to leave the functionality in place--permanently--for 191 
doctors and now 60,000 patients. One result is that the practices are 
now using the AHRQ created portal as their sole patient portal and 
abandoned the commercial portal that did not work as well.'' Alex 
Krist, M.D., M.P.H., Virginia Commonwealth University
    ``The AHRQ-sponsored series of grants on Multiple Chronic Condition 
research were transformative for that field. They also sponsored 
regular meetings among grantees and established the Multiple Chronic 
Conditions Research Network, which has fostered many collaborations 
between researchers with shared expertise.'' Elizabeth A. Bayliss, MD, 
MSPH, Kaiser Permanente Colorado
    ``Our AHRQ grant to study the transformation of medical practices 
into patient-centered medical homes allowed us to develop a good 
partnership with the Minnesota Dept. of Health and Dept. of Human 
Services to evaluate a State experiment certifying primary care 
practices as medical homes. That partnership facilitated access to 
information and practices and helped us learn many lessons about this 
transformation and its impacts. These lessons were then provided to 
those MN departments and to the practices that were becoming medical 
homes, with the purpose of improving quality, cost, and access.'' Leif 
I. Solberg, MD, Director for Care Improvement Research, HealthPartners 
Institute for Education and Research, Bloomington, MN

    Research related to the most common acute, chronic, and comorbid 
conditions that primary care clinicians treat is lacking. AHRQ supports 
research to improve healthcare quality, reduce costs, advance patient 
safety, decrease medical errors, and broaden access to essential 
services. This research is essential to create a robust primary care 
system for our Nation--one that delivers higher quality of care and 
better health while reducing the rising cost of care. Despite this 
need, little is known about how patients can best decide how and when 
to seek care, how to introduce and disseminate new discoveries into 
real life practice, and how to maximize appropriate care. This type of 
research requires sufficient funding for AHRQ, so it can help 
researchers address the problems confronting our health system today.
    We recommend the Committee fund AHRQ at a base, discretionary level 
of at least $375 million for fiscal year 2015.

    [This statement was submitted by Grant Hoekzema, MD, Chair, Council 
of Academic Family Medicine.]
                                 ______
                                 
       Prepared Statement of the Council on Social Work Education
    On behalf of the Council on Social Work Education (CSWE), I am 
pleased to offer this written testimony to the Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies for inclusion in the official Committee record. I will 
focus my testimony on the importance of fostering a skilled, 
sustainable, and diverse social work workforce to meet the healthcare 
needs of the nation through professional education, training, and 
financial support programs for social workers at the Department of 
Health and Human Services (HHS) and the Department of Education (ED).
    CSWE is a nonprofit national association representing more than 
2,500 individual members and more than 700 master's and baccalaureate 
programs of professional social work education. Founded in 1952, this 
partnership of educational and professional institutions, social 
welfare agencies, and private citizens houses the sole accrediting body 
for social work education in the United States. Social work education 
prepares students for leadership and professional interdisciplinary 
practice with individuals, families, groups, and communities in a wide 
array of service sectors, including health, mental health, adult and 
juvenile justice, PK-12 education, child welfare, aging, and others. 
Social work practice is facilitated by a longstanding tradition of 
collaborative relationships working with health professions colleagues 
including direct care workers, families, doctors, nurses, pharmacists 
and others yielding a result that empowers individuals to be healthy, 
productive, contributing members of their communities. Social workers 
recognize that social determinants of health are a critical component 
in meeting the health needs of certain populations, and social work 
education and practice follow this framework. As Federal agencies look 
to reduce cost and improve quality, social workers can help lead in 
this area.
    Recruitment and retention in social work continues to be a serious 
challenge that threatens the workforce's ability to meet societal 
needs. The U.S. Bureau of Labor Statistics estimates that employment 
for social workers is expected to grow faster than the average for all 
occupations through 2022, particularly for social workers specializing 
in the aging population and working in rural areas. In addition, the 
need for social workers specializing in mental health and substance use 
is expected to grow by 23 percent over the 2012-2022 decade.\1\
---------------------------------------------------------------------------
    \1\ U.S. Bureau of Labor Statistics. 2012. Occupational Outlook 
Handbook: Social Workers, http://data.bls.gov/cgi-bin/print.pl/oco/
ocos060.htm. Retrieved March 21, 2014.
---------------------------------------------------------------------------
    CSWE understands the difficult funding decisions Congress is faced 
with. In these challenging times, it is my hope that the Committee will 
prioritize funding for health professions training in fiscal year (FY) 
2015 to help to ensure that the nation continues to foster a 
sustainable, skilled, and culturally competent workforce that will be 
able to keep up with the increasing demand for social work services and 
meet the unique healthcare needs of diverse communities.
          health resources and services administration (hrsa)
          title vii and title viii health professions programs
    CSWE urges the Committee to provide $520 million in fiscal year 
2015 for the health professions education programs authorized under 
Titles VII and VIII of the Public Health Service Act and administered 
through HRSA, which is equal to the fiscal year 2012 enacted level. 
HRSA's Title VII and Title VIII health professions programs represent 
Federal programs designed to train healthcare providers in an 
interdisciplinary way to meet the healthcare needs of all Americans, 
including the underserved and those with special needs. These programs 
also serve to increase minority representation in the healthcare 
workforce through targeted programs that improve the quality, 
diversity, and geographic distribution of the health professions 
workforce. The Title VII and Title VIII programs provide loans, loan 
guarantees and scholarships to students, and grants to institutions of 
higher education and non-profit organizations to help build and 
maintain a robust healthcare workforce. Social workers and social work 
students are eligible for funding from the suite of Title VII health 
professions programs.
    The Title VII and Title VIII programs were reauthorized in 2010, 
which helped to improve the efficiency of the programs as well as 
enhance efforts to recruit and retain health professionals in 
underserved communities. Recognizing the severe shortages of mental and 
behavioral health providers within the healthcare workforce, a new 
Title VII program was authorized in the Patient Protection and 
Affordable Care Act (Public Law 111-148). The Mental and Behavioral 
Health Education and Training Grants program provides grants to 
institutions of higher education (schools of social work and other 
mental health professions) for faculty and student recruitment and 
professional education and training. The program received first-time 
funding of $10 million in the final fiscal year 2012 appropriations 
bill. The President's fiscal year 2015 budget request would continue to 
support the program at HRSA and also through a partnership with the 
Substance Abuse and Mental Health Services Administration (SAMHSA) to 
expand the mental health workforce by almost 3,500 professionals 
focused on transition-age youth (16-25). CSWE urges the Committee to 
maintain funding at HRSA for this critically important program at the 
highest level possible in fiscal year 2015 and include schools of 
social work as eligible entities. CSWE supports the proposed expansion 
of the program but encourages the committee to be inclusive of non-
youth populations needing mental and behavioral health services and not 
to reduce the scope of the original intent of the program through the 
expansion.
   substance abuse and mental health services administration (samhsa)
                      minority fellowship program
    CSWE urges the Committee to appropriate the highest level possible 
for the Minority Fellowship Program (MFP) in fiscal year 2015. The goal 
of the SAMHSA Minority Fellowship Program (MFP) is to achieve greater 
numbers of minority doctoral students preparing for leadership roles in 
the mental health and substance use fields.\2\ CSWE is one of six 
grantees of this critical program and administers funds to exceptional 
minority doctoral social work students. Other grantees include national 
organizations representing nursing, psychology, psychiatry, marriage 
and family therapy, and professional counselors. SAMHSA makes grants to 
these six organizations, who in turn recruit minority doctoral students 
into the program from the six distinct professions. CSWE administers 
the funds to qualified doctoral students and helps facilitate mentoring 
and networking throughout the duration of the fellowship as well as 
facilitates an alumni group to help continue to engage former fellows 
long after their formal fellowship has ended.
---------------------------------------------------------------------------
    \2\ According to SAMHSA, minorities make up over one-fourth of the 
population, but less than 20 percent of behavioral health providers 
come from ethnic minority communities. Retrieved from SAMHSA Minority 
Fellowship Program, http://www.samhsa.gov/minorityfellowship/.
---------------------------------------------------------------------------
    Since its inception in 1974, the MFP has helped support doctoral-
level professional education for over 1,000 ethnic minority social 
workers, psychiatrists, psychologists, psychiatric nurses, and family 
and marriage therapists. Still, the program continues to struggle to 
keep up with the demands facing these health professions. Severe 
shortages of mental health professionals often arise in underserved 
areas due to the difficulty of recruitment and retention in the public 
sector. Nowhere are these shortages more prevalent than within Tribal 
communities, where mental illness and substance use go largely 
untreated and incidences of suicide continue to increase. Studies have 
shown that ethnic minority mental health professionals practice in 
underserved areas at a higher rate than non-minorities. Furthermore, a 
direct positive relationship exists between the numbers of ethnic 
minority mental health professionals and the utilization of needed 
services by ethnic minorities.\3\ The President's fiscal year 2015 
budget request includes $10 million for MFP activities. CSWE urges the 
committee to support this request, including at least $5.4 million for 
MFP core activities.
---------------------------------------------------------------------------
    \3\ U.S. Department of Health and Human Services, Substance Abuse 
and Mental Health Services Administration, Center for Mental Health 
Services. (2001). Mental Health: Culture, Race, and Ethnicity--A 
Supplement to Mental Health: A Report of the Surgeon General. Retrieved 
from http://www.surgeongeneral.gov/library/mentalhealth/cre/sma-01-
3613.pdf.
---------------------------------------------------------------------------
                        department of education
                          student aid programs
    CSWE supports full funding to keep the maximum Pell Grant at $5,830 
in fiscal year 2015. While Congress is understandably focused on 
identifying a solution that will place the Pell Grant program on solid 
ground in regards to its fiscal future, we urge you to remember that 
these grants help to ensure that all students, regardless of their 
economic situation, can achieve higher education. Moreover, as 
described above with regard to the SAMHSA Minority Fellowship Program, 
one goal of social work education is recruiting students from diverse 
backgrounds (which includes racial, economic, religious, and other 
forms of diversity) with the hope that they will return to serve 
diverse communities once they have completed their education. In many 
cases, this includes encouraging social workers to return to their own 
communities and apply the skills they have acquired through their 
social work education to individuals, groups, or families in need. 
Without support such as Pell Grants, many low-income individuals would 
not be able to access higher education, and in turn, would not acquire 
skills needed to best serve in the communities that would most benefit 
from their service.
    The Graduate Assistance in Areas of National Need (GAANN) program 
provides graduate traineeships in critical fields of study. Currently, 
social work is not defined as an area of national need for this 
program; however it was recognized by Congress as an area of national 
need in the Higher Education Opportunity Act of 2008. We encourage ED 
to recognize the importance of including social work in the GAANN 
program in future years. Inclusion of social work would help to 
significantly enhance graduate education in social work, which is 
critically needed in the country's efforts to foster a sustainable 
health professions workforce. CSWE urges the Subcommittee to provide 
$31 million for the GAANN Program and include social as an area of 
national need.
    CSWE supports efforts at ED to help students with high debt loads 
serve in low paying positions. The Income-Based Repayment (IBR) program 
and the Public Service Loan Forgiveness programs in particular help 
students graduating from social work programs who wish to serve in 
high-needs communities, often at a low salary level. CSWE urges the 
Subcommittee to support loan repayment programs without a cap on 
repayment support at ED.
    Thank you for the opportunity to express these views. Please do not 
hesitate to call on the Council on Social Work Education should you 
have any questions or require additional information.

    [This statement was submitted by Dr. Darla Spence Coffey, 
President, Council on Social Work Education.]
                                 ______
                                 
  Prepared Statement of the Crohn's and Colitis Foundation of America
              summary of fiscal year 2015 recommendations
_______________________________________________________________________

  --$32 Billion for the National Institutes of Health (NIH) at an 
        increase of $1 billion over fiscal year 2014. Increase funding 
        for the National Cancer Institute (NCI), the National Institute 
        of Diabetes and Digestive and Kidney Diseases (NIDDK) and the 
        National Institute of Allergy and Infectious Diseases (NIAID) 
        by 12 percent.
  --Continued focus on Digestive Disease Research and Education At NIH, 
        including Inflammatory Bowel Disease (IBD) and Colorectal 
        Cancer.
  --$6,860,000 For the Centers For Disease Control and Prevention's 
        (CDC) IBD Epidemiology Activities.
  --$50 Million For the Center for Disease Control and Prevention's 
        (CDC) Colorectal Cancerscreening and Prevention Program.
_______________________________________________________________________

    Thank you for the opportunity to submit testimony to the 
Subcommittee. CCFA has remained committed to its mission of finding a 
cure for Crohn's disease and ulcerative colitis and improving the 
quality of life of children and adults affected by these diseases for 
over 46 years. Impacting an estimated 1.4 million Americans, 30 percent 
of whom are diagnosed in their childhood years, Inflammatory Bowel 
Diseases (IBD) are chronic disorders of the gastrointestinal tract 
which cause abdominal pain, fever, and intestinal bleeding. IBD 
represents a major cause of morbidity from digestive illness and has a 
devastating impact on both patients and their families.
    The social and economic impact of digestive disease is enormous and 
difficult to grasp. Digestive disorders afflict approximately 65 
million Americans. This results in 50 million visits to physicians, 
over 10 million hospitalizations, collectively 230 million days of 
restricted activity. The total cost associated with digestive diseases 
has been conservatively estimated at $60 billion a year.
    The CCFA would like to thank the subcommittee for its past support 
of digestive disease research and prevention programs at the National 
Institutes of Health (NIH) and the Centers for Disease Control and 
Prevention (CDC).
    Specifically the CCFA recommends:
  --$32 billion for the NIH.
  --$2.16 billion for the National Institute of Diabetes and Digestive 
        and Kidney Disease (NIDDK).
    We at the CCFA respectfully request that any increase for NIH does 
not come at the expense of
    other Public Health Service agencies. With the competing and the 
challenging budgetary constraints the Subcommittee currently operates 
under, the CCFA would like to highlight the research being accomplished 
by NIDDK which warrants the increase for NIH.
                       inflammatory bowel disease
    In the United States today about one million people suffer from 
Crohn's disease and ulcerative colitis, collectively known as IBD. 
These are serious diseases that affect the gastrointestinal tract 
causing bleeding, diarrhea, abdominal pain, and fever. Complications 
arising from IBD can include anemia, ulcers of the skin, eye disease, 
colon cancer, liver disease, arthritis, and osteoporosis. The cause of 
IBD is still unknown, but research has led to great breakthroughs in 
therapy.
    In recent years researchers have made significant progress in the 
fight against IBD. The CCFA encourages the subcommittee to continue its 
support of IBD research at NIDDK and NIAID at a level commensurate with 
the overall increase for each institute. The DDNC would like to applaud 
the NIDDK for its strong commitment to IBD research through the 
Inflammatory Bowel Disease Genetics Research Consortium. The CCFA urges 
the Consortium to continue its work in IBD research.
      centers for disease control and prevention ibd epidemiology
    CDC, in collaboration with a nationwide, geographically diverse 
network of large managed healthcare delivery systems, has led an 
epidemiological study of IBD to understand IBD incidence, prevalence, 
demographics, and healthcare utilization. The group, comprised of 
investigators at the Massachusetts General Hospital in Boston, Rhode 
Island Hospital, the Crohn's and Colitis Foundation of America, and 
CDC, has piloted the Ocean State Crohn's and Colitis Registry (OSCAR), 
which includes both pediatric and adult patients. Since 2008, the OSCAR 
investigators have recruited 22 private-practice groups and hospital 
based physicians in Rhode Island and are that enrolling newly diagnosed 
patients into the registry. This study found an average annual 
incidence rate of 8.4 per 100,000 people for Crohn's disease and 12.4 
per 100,000 for Ulcerative Colitis; published in Inflammatory Bowel 
Disease Journal, April 2007.
  --Over the course of the initial 3-year epidemiologic collaboration, 
        CDC laboratory scientists and epidemiologists worked to improve 
        detection tools and epidemiologic methods to study the role of 
        infections (infectious disease epidemiology) in pediatric IBD, 
        collaborating with extramural researchers who were funded by a 
        National Institutes of Health (NIH) research award.
  --Since 2006, CDC epidemiologists have been working in conjunction 
        with the Crohn's and Colitis Foundation of American and a large 
        health maintenance organization to better understand the 
        natural history of IBD and factors that predict the course of 
        disease.
    The Crohn's and Colitis Foundation of America encourages the CDC to 
continue to support a nationwide IBD surveillance and epidemiological 
program in fiscal year 2014.
                      colorectal cancer prevention
    Colorectal cancer is the third most commonly diagnosed cancer for 
both men and woman in the United States and the second leading cause of 
cancer-related deaths. Colorectal cancer affects men and women equally.
    The CCFA recommends a funding level of $50 million for the CDC's 
Colorectal Cancer Screening and Prevention Program. This important 
program supports enhanced colorectal screening and public awareness 
activities throughout the United States. The DDNC also supports the 
continued development of the CDC-supported National Colorectal Cancer 
Roundtable, which provides a forum among organizations concerned with 
colorectal cancer to develop and implement consistent prevention, 
screening, and awareness strategies.
                               conclusion
    The CCFA understands the challenging budgetary constraints and 
times we live in that this Subcommittee is operating under, yet we hope 
you will carefully consider the tremendous benefits to be gained by 
supporting a strong research and education program at NIH and CDC. 
Millions of Americans are pinning their hopes for a better life, or 
even life itself, on digestive disease research conducted through the 
National Institutes of Health. Mr. Chairman, on behalf of our patients, 
we appreciate your consideration of our view. We look forward to 
working with you and your staff.
                                 ______
                                 
          Prepared Statement of the Cystic Fibrosis Foundation
    On behalf of the Cystic Fibrosis Foundation (CFF) and the 30,000 
people with cystic fibrosis (CF) in the United States, we submit the 
following testimony to the Senate Appropriations Committee's 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies on our funding requests for fiscal year 2015. The 
Foundation requests the highest possible funding level for the National 
Institutes of Health (NIH), particularly the National Center for 
Advancing Translational Sciences (NCATS) and programs under its 
jurisdiction, including the Cures Acceleration Network (CAN) and the 
Clinical and Translational Science Awards (CTSA).
Collaboration and Innovation: The Future of Drug Development
    NIH uses appropriated funds wisely and effectively by supporting 
programs that promote efficiency and innovation in drug discovery and 
encouraging collaboration across sectors. Many of these effective, 
collaborative ventures aim to translate basic research into promising 
potential treatments, speeding the discovery of therapies for those 
with serious illnesses like cystic fibrosis. We urge you to ensure that 
these critical programs are sufficiently funded and receive the support 
they need. For those with rare genetic diseases like CF, treatments and 
cures cannot wait.
    As an example of the NIH's cooperative, innovative approach, in 
February the agency announced the establishment of the Accelerating 
Medicines Partnership (AMP), a joint venture between NIH, 
pharmaceutical companies, and several non-profit organizations to 
characterize biomarkers and distinguish biological targets that are 
most likely to respond to new therapies. The AMP will begin with three 
to five year pilot projects in Alzheimer's disease, type 2 diabetes, 
rheumatoid arthritis and systemic lupus erythematosus.
    Through this cross-sector partnership, NIH and industry partners 
share expertise, resources, and data in order to speed the development 
of treatments. Furthermore, industry partners have agreed to make AMP 
data and analyses available to the biomedical community for use in 
future study.
    Drug development is risky, expensive, and time-consuming, and there 
is a 95 percent failure rate for drug candidates. This kind of cross-
sector partnership aims to reduce the time, cost, and risk of drug 
development by sharing resources so diseases can be analyzed in ways 
that drug companies have not been able to do on their own.
    Importantly, industry will fund one-half of the $230 million budget 
while NIH will provide the other half. The Federal money used for this 
project acts as seed money, a jumping off point for private sector 
investment in drug discovery for serious diseases. This type of 
cooperative approach saves taxpayer funds in the long run and can save 
lives.
    While AMP is not administered by the National Center for Advancing 
Translational Sciences (NCATS), this NIH center spearheads similarly 
innovative programs that encourage collaboration, improve the process 
by which diagnostics and therapeutics are developed, and improve the 
efficiency of the translation of basic scientific discoveries into new 
therapies.
    For example, the Cures Acceleration Network (CAN), a program under 
the umbrella of NCATS, funds a variety of initiatives designed to 
address scientific and technical challenges that hinder transitional 
research. For instance, CAN provides funding for the Tissue Chip for 
Drug Screening Initiative, a joint project with the Defense Advanced 
Research Projects Agency (DARPA) and the Food and Drug Administration 
(FDA) to develop 3-D human tissue chips. These chips, composed of 
diverse human cells and tissues, mimic how drugs interact with the 
human body. If successful, these chips could make drug safety and 
efficacy assessments possible at an earlier stage in drug development, 
enabling investigators to concentrate on the most promising new drugs.
    Unfortunately, CAN has been chronically underfunded. Since its 
inception as part of the Patient Protection and Affordable Care Act in 
2010, it has been funded at approximately $10 million per year for 
fiscal years 2012, 2013, and 2014. We urge the Committee to provide at 
least the funding level requested in the President's fiscal year 2015 
budget--$29.8 million. CAN needs additional funding for projects that 
will help move new treatments to patients.
    Similarly, the Clinical and Translational Science Awards (CTSA) 
program in the NCATS Division of Clinical Innovation demonstrates 
NCATS' innovative, collaborative approach. This program supports a 
national consortium of more than 60 medical research institutions that 
work together on research. Its goals are to accelerate the process of 
translating laboratory discoveries into treatments for patients, train 
a new generation of researchers, and engage communities in clinical 
research efforts.
    Institutional CTSA awards provide academic homes for translational 
sciences and support research resources needed by local and national 
research communities to improve the quality and efficiency of all 
phases of translational research. They also support the training of 
clinical and translational scientists and the development of all 
disciplines needed for a robust translational research workforce.
    CTSA funds have the potential to be used in new ways. For example, 
CTSA's academic homes can serve as a platform for sharing patient 
registry data. As the CF Foundation has seen with its Therapeutics 
Development Network of clinical trial sites, the sharing of patient 
registry information, including demographics and health outcomes, among 
sites is integral to conducting CF research. This strategy could be 
beneficial in the wider disease community.
A Culture of Collaboration: The Cystic Fibrosis Model
    The Cystic Fibrosis Foundation has long been engaged in 
partnerships with industry and supports a collaborative network of care 
centers and clinical trial sites. As such, CFF knows firsthand that 
this type of cooperation can lead to the targeted treatments that 
change the face of many life-threatening diseases.
    Because drug research and development is a lengthy, expensive and 
risky process, CFF pioneered a successful ``venture philanthropy'' 
business model to drive drug development for this rare disease. By 
collaborating with pharmaceutical companies and providing financial, 
scientific, and clinical support in order to ``de-risk'' the 
development process, CFF speeds development of much-needed treatments.
    Through its venture philanthropy model, the Foundation is able to 
invest in promising CF research and a robust pipeline of potential 
therapies that target the disease from every angle. Nearly every CF 
drug available today was made possible because of the Foundation's 
support and ongoing work with researchers and the pharmaceutical 
industry to find a cure.
    In January 2012, the Food and Drug Administration approved 
Kalydeco, a groundbreaking cystic fibrosis drug developed by Vertex 
Pharmaceuticals in partnership with the CF Foundation. This targeted 
drug is the first to address the underlying genetic cause of cystic 
fibrosis in a subset of the CF population.
    Kalydeco was approved in only 3 months, one of the fastest 
approvals in the FDA's history. According to Margaret A. Hamburg, M.D., 
Commissioner of the FDA, ``The unique and mutually beneficial 
partnership that led to the approval of Kalydeco serves as a great 
model for what companies and patient groups can achieve if they 
collaborate on drug development.''
    Throughout Kalydeco's review, the Cystic Fibrosis Foundation and 
renowned CF experts worked closely with Vertex Pharmaceuticals and the 
FDA, providing valuable insight on specific issues related to CF, 
clinical research on CF treatments, and other issues related to the 
product and its review. We believe that this collaborative process 
contributed to a more efficient evaluation, and is a testament to what 
can be achieved when stakeholders collaborate across sectors on 
critical drugs for patients.
    Akin to AMP, the Cystic Fibrosis Foundation also recognizes the 
profound importance of data sharing, which is a critical way to enable 
efficient drug development. The Cystic Fibrosis Foundation Therapeutics 
Development Network (TDN) of clinical trial centers has accumulated 
data from over 40 cystic fibrosis studies in the last 15 years. This 
data resides in a repository specifically meant to facilitate sharing 
among our research community.
                                 * * *
    As the Committee determines its funding levels for fiscal year 
2015, we request your attention to the critical nature of NIH's work 
and the innovation it supports, and urge robust funding for this 
important agency. The CF Foundation stands ready to work with the 
Committee, NIH, and Congressional leaders on the challenges ahead. 
Thank you for your consideration.
                                 ______
                                 
     Prepared Statement of the Digestive Disease National Coalition
              summary of fiscal year 2015 recommendations
_______________________________________________________________________

  --$32 Billion for the National Institutes of Health (NIH) at an 
        increase of $1 billion over fiscal year 2014. Increase funding 
        for the National Cancer Institute (NCI), the National Institute 
        of Diabetes and Digestive and Kidney Diseases (NIDDK) and the 
        National Institute of Allergy and Infectious Diseases (NIAID) 
        by 12 percent.
  --Continue focus on Digestive Disease Research and Education at NIH, 
        Including Inflammatory Bowel Disease (IBD), Hepatitis and other 
        Liver Diseases, Irritable Bowel Syndrome (IBS), Colorectal 
        Cancer, Endoscopic Research, Pancreatic Cancer, and Celiac 
        Disease.
  --$50 Million for the Centers For Disease Control and Prevention's 
        (CDC) Hepatitis Prevention and Control Activities.
  --$50 Million for the Center for Disease Control and Prevention's 
        (CDC) Colorectal Cancerscreening and Prevention Program.
_______________________________________________________________________

    Chairman Harkin, thank you for the opportunity to again submit 
testimony to the Subcommittee. Founded in 1978, the Digestive Disease 
National Coalition (DDNC) is a voluntary health organization comprised 
of 35 professional societies and patient organizations concerned with 
the many diseases of the digestive tract. The DDNC promotes a strong 
Federal investment in digestive disease research, patient care, disease 
prevention, and public awareness. The DDNC is a broad coalition of 
groups representing disorders such as Inflammatory Bowel Disease (IBD), 
Hepatitis and other liver diseases, Irritable Bowel Syndrome (IBS), 
Pancreatic Cancer, Ulcers, Pediatric and Adult Gastroesophageal Reflux 
Disease, Colorectal Cancer, and Celiac Disease.
    The social and economic impact of digestive disease is enormous and 
difficult to grasp. Digestive disorders afflict approximately 65 
million Americans. This results in 50 million visits to physicians, 
over 10 million hospitalizations, collectively 230 million days of 
restricted activity. The total cost associated with digestive diseases 
has been conservatively estimated at $60 billion a year.
    The DDNC would like to thank the Subcommittee for its past support 
of digestive disease research and prevention programs at the National 
Institutes of Health (NIH) and the Centers for Disease Control and 
Prevention (CDC).
    Specifically the DDNC recommends:
  --32 billion for the NIH.
  --$2.16 billion for the National Institute of Diabetes and Digestive 
        and Kidney Disease (NIDDK).
    We at the DDNC respectfully request that any increase for NIH does 
not come at the expense of
    other Public Health Service agencies. With the competing and the 
challenging budgetary constraints the Subcommittee currently operates 
under, the DDNC would like to highlight the research being accomplished 
by NIDDK which warrants the increase for NIH.
                       inflammatory bowel disease
    In the United States today about one million people suffer from 
Crohn's disease and ulcerative colitis, collectively known as 
Inflammatory Bowel Disease (IBD). These are serious diseases that 
affect the gastrointestinal tract causing bleeding, diarrhea, abdominal 
pain, and fever. Complications arising from IBD can include anemia, 
ulcers of the skin, eye disease, colon cancer, liver disease, 
arthritis, and osteoporosis. The cause of IBD is still unknown, but 
research has led to great breakthroughs in therapy.
    In recent years researchers have made significant progress in the 
fight against IBD. The DDNC encourages the subcommittee to continue its 
support of IBD research at NIDDK and NIAID at a level commensurate with 
the overall increase for each institute. The DDNC would like to applaud 
the NIDDK for its strong commitment to IBD research through the 
Inflammatory Bowel Disease Genetics Research Consortium. The DDNC urges 
the Consortium to continue its work in IBD research. Therefore the DDNC 
and its member organization the Crohn's and Colitis Foundation of 
America encourage the CDC to continue to support a nationwide IBD 
surveillance and epidemiological program in fiscal year 2015.
              viral hepatitis: a looming threat to health
    The DDNC applauds all the work NIH and CDC have accomplished over 
the past year in the areas of hepatitis and liver disease. The DDNC 
urges that funding be focused on expanding the capability of State 
health departments, particularly to enhance resources available to the 
hepatitis State coordinators. The DDNC also urges that CDC increase the 
number of cooperative agreements with coalition partners to develop and 
distribute health education, communication, and training materials 
about prevention, diagnosis and medical management for viral hepatitis.
    The DDNC supports $50 million for the CDC's Hepatitis Prevention 
and Control activities. The hepatitis division at CDC supports the 
hepatitis C prevention strategy and other cooperative nationwide 
activities aimed at prevention and awareness of hepatitis A, B, and C. 
The DDNC also urges the CDC's leadership and support for the National 
Viral Hepatitis Roundtable to establish a comprehensive approach among 
all stakeholders for viral hepatitis prevention, education, strategic 
coordination, and advocacy.
                      colorectal cancer prevention
    Colorectal cancer is the third most commonly diagnosed cancer for 
both men and woman in the United States and the second leading cause of 
cancer-related deaths. Colorectal cancer affects men and women equally.
    The DDNC recommends a funding level of $50 million for the CDC's 
Colorectal Cancer Screening and Prevention Program. This important 
program supports enhanced colorectal screening and public awareness 
activities throughout the United States. The DDNC also supports the 
continued development of the CDC-supported National Colorectal Cancer 
Roundtable, which provides a forum among organizations concerned with 
colorectal cancer to develop and implement consistent prevention, 
screening, and awareness strategies.
                           pancreatic cancer
    In 2013, an estimated 33,730 people in the United States will be 
found to have pancreatic cancer and approximately 32,300 died from the 
disease. Pancreatic cancer is the fifth leading cause of cancer death 
in men and women. Only l out of 4 patients will live 1 year after the 
cancer is found and only l out of 25 will survive five or more years.
    The National Cancer Institute (NCI) has established a Pancreatic 
Cancer Progress Review Group charged with developing a detailed 
research agenda for the disease. The DDNC encourages the Subcommittee 
to provide an increase for pancreatic cancer research at a level 
commensurate with the overall percentage increase for NCI and NIDDK.
                     irritable bowel syndrome (ibs)
    IBS is a disorder that affects an estimated 35 million Americans. 
The medical community has been slow in recognizing IBS as a legitimate 
disease and the burden of illness associated with it. Patients often 
see several doctors before they are given an accurate diagnosis. Once a 
diagnosis of IBS is made, medical treatment is limited because the 
medical community still does not understand the pathophysiology of the 
underlying conditions.
    Living with IBS is a challenge, patients face a life of learning to 
manage a chronic illness that is accompanied by pain and unrelenting 
gastrointestinal symptoms. Trying to learn how to manage the symptoms 
is not easy. There is a loss of spontaneity when symptoms may intrude 
at any time. IBS is an unpredictable disease. A patient can wake up in 
the morning feeling fine and within a short time encounter abdominal 
cramping to the point of being doubled over in pain and unable to 
function.
    The DDNC recommends that NIDDK increase its research portfolio on 
Functional Gastrointestinal Disorders and Motility Disorders.
                               conclusion
    The DDNC understands the challenging budgetary constraints and 
times we live in that this Subcommittee is operating under, yet we hope 
you will carefully consider the tremendous benefits to be gained by 
supporting a strong research and education program at NIH and CDC. 
Millions of Americans are pinning their hopes for a better life, or 
even life itself, on digestive disease research conducted through the 
National Institutes of Health. Mr. Chairman, on behalf of the millions 
of digestive disease sufferers, we appreciate your consideration of the 
views of the Digestive Disease National Coalition. We look forward to 
working with you and your staff.
                                 ______
                                 
       Prepared Statement of Dystonia Medical Research Foundation
            summary of recommendations for fiscal year 2015
_______________________________________________________________________

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

_______________________________________________________________________

    Dystonia is a neurological movement disorder characterized by 
involuntary muscle spasms that cause the body to twist, repetitively 
jerk, and sustain postural deformities. Focal dystonia affects specific 
parts of the body, while generalized dystonia affects multiple parts of 
the body at the same time. Some forms of dystonia are genetic but 
dystonia can also be caused by injury or illness. Although dystonia is 
a chronic and progressive disease, it does not impact cognition, 
intelligence, or shorten a person's life span. Conservative estimates 
indicate that between 300,000 and 500,000 individuals suffer from some 
form of dystonia in North America alone. Dystonia does not 
discriminate, affecting all demographic groups. There is no known cure 
for dystonia and treatment options remain limited.
    Although little is known regarding the causes and onset of 
dystonia, two therapies have been developed that have demonstrated a 
great benefit to patients and have been particularly useful for 
controlling patient symptoms. Botulinum toxin (e.g., Botox, Xeomin, 
Disport and Myobloc) injections and deep brain stimulation have shown 
varying degrees of success alleviating dystonia symptoms. Until a cure 
is discovered, the development of management therapies such as these 
remains vital, and more research is needed to fully understand the 
onset and progression of the disease in order to better treat patients.
      dystonia research at the national institutes of health (nih)
    Currently, dystonia research at NIH is supported by the National 
Institute of Neurological Disorders and Stroke (NINDS), the National 
Institute on Deafness and Other Communication Disorders (NIDCD), the 
National Eye Institute (NEI), and the Office of Rare Diseases Research 
(ORDR) within the National Center for Advancing Translational Sciences 
(NCATS).
    ORDR coordinates the Rare Disease Clinical Research Network (RDCRN) 
which provides support for studies on the natural history, 
epidemiology, diagnosis, and treatment of rare diseases. RDCRN includes 
the Dystonia Coalition, a partnership between researchers, patients, 
and patient advocacy groups to advance the pace of clinical research on 
cervical dystonia, blepharospasm, spasmodic dysphonia, craniofacial 
dystonia, and limb dystonia. The Dystonia Coalition has made tremendous 
progress in preparing the patient community for clinical trials as well 
as funding promising studies that hold great hope for advancing our 
understanding and capacity to treat primary focal dystonias. DAN urges 
the subcommittee to continue its support for the Dystonia Coalition, 
part of the Rare Disease Clinical Research Network coordinated by ORDR 
within NCATS.
    The majority of dystonia research at NIH is supported by NINDS. 
NINDS has utilized a number of funding mechanisms in recent years to 
study the causes and mechanisms of dystonia. These grants cover a wide 
range of research including the genetics and genomics of dystonia, the 
development of animal models of primary and secondary dystonia, 
molecular and cellular studies in inherited forms of dystonia, 
epidemiology studies, and brain imaging. DAN urges the subcommittee to 
support NINDS in conducting and expanding critical research on 
dystonia.
    NIDCD and NEI also support research on dystonia. NIDCD has funded 
many studies on brainstem systems and their role in spasmodic 
dysphonia, or laryngeal dystonia. Spasmodic dysphonia is a form of 
focal dystonia which involves involuntary spasms of the vocal cords 
causing interruptions of speech and affecting voice quality. NEI 
focuses some of its resources on the study of blepharospasm. 
Blepharospasm is an abnormal, involuntary blinking of the eyelids which 
can render a patient legally blind due to a patient's inability to open 
their eyelids. DAN encourages partnerships between NINDS, NIDCD and NEI 
to further dystonia research.
    In summary, DAN recommends the following for fiscal year 2015:
  --$32 billion for NIH and a proportional increase for its Institutes 
        and Centers
  --Support for the Dystonia Coalition within the Rare Diseases 
        Clinical Research Network coordinated by ORDR within NCATS
  --Expansion of the dystonia research portfolio at NIH through NINDS, 
        NIDCD, NEI, and ORDR
                     the dystonia advocacy network
    The Dystonia Medical Research Foundation submits these comments on 
behalf of the Dystonia Advocacy Network (DAN), a collaborative network 
of five patient organizations: the Benign Essential Blepharospasm 
Research Foundation, the Dystonia Medical Research Foundation, the 
National Spasmodic Dysphonia Association, the National Spasmodic 
Torticollis Association, and ST/Dystonia, Inc. DAN advocates for all 
persons affected by dystonia and supports a legislative agenda that 
meets the needs of the dystonia community.
    DMRF was founded in 1976. Since its inception, the goals of DMRF 
have remained to advance research for more effective treatments of 
dystonia and ultimately find a cure; to promote awareness and 
education; and support the needs and well being of affected individuals 
and their families.
    Thank you for the opportunity to present the views of the dystonia 
community, we look forward to providing any additional information.

    [This statement was submitted by Janet Hieshetter, Executive 
Director, Dystonia Medical Research Foundation.]
                                 ______
                                 
           Prepared Statement of the Elder Justice Coalition
    Chairman Harkin, Ranking Member Moran: On behalf of the Elder 
Justice Coalition, a bipartisan 3000 member organization, we thank you 
for the opportunity to testify in support of the Department of Health 
and Human Services' proposed Elder Justice Initiative in the amount of 
$25 million.
    Our topic has been and must always be a bipartisan issue: 
preventing elder abuse, neglect and exploitation. We ask this 
Subcommittee to provide the necessary funding in a bipartisan fashion 
as part of the solution to the real national disgrace of elder abuse.
    There are more than six million victims of elder abuse; roughly one 
of every ten persons over 60. Victims of elder financial abuse lose an 
estimated $2.9 billion a year which can include entire life savings. 
Other data points to a 16 percent increase in reported cases. However, 
a New York State study said for every elder abuse case known to 
agencies, twenty-four were unknown.
    The $25 million requested in the President's fiscal year 2015 
budget for an Elder Justice Initiative which if approved by Congress 
would be the first direct appropriation for the bipartisan Elder 
Justice Act sponsored in the Senate by Senators Breaux, Hatch and 
Baucus.
    The funding request includes:
  --$13.8 million for Adult Protective Services, including an APS 
        National Data System and Technical Assistance and national 
        demonstration grants to both enhance APS data systems and 
        development of program standards as well as an full evaluation 
        of APS practices.
  --$11.2 million for research including elder abuse screening and to 
        establish a better knowledge base about elder abuse, neglect 
        and exploitation.
    Data collection is important. The lack of good data has hurt the 
elder abuse field and our ability to target efforts to prevent abuse. 
Data often drives dollars. For elder abuse to compete effectively for 
resources, we must have a good system to collect and analyze data. This 
appropriation will also help assess the most likely perpetrators and 
victims and direct resources to those most vulnerable.
    We support the development of APS program standards. Interventions 
for victims of elder abuse are far more complicated than for younger 
victims of abuse and family violence. To be effective, APS programs 
must have consistency and quality on a national basis. Elder abuse is 
happening in all States and districts and in some cases an older person 
can be victimized in more than one State.
    This initial investment of $25 million means existing Federal 
resources could be used more efficiently while also responding to elder 
abuse with a systematic approach. This and slowing future victimization 
is a solid return on investment.
    Why else is this an investment? According to the National Center on 
Elder Abuse, the direct medical costs associated with elder abuse now 
exceed $5 billion. Victims often end up having to turn to other Federal 
programs, especially Medicare and Medicaid, and for financial abuse 
victims they may require other assistance including income support. 
Some of this can clearly be avoided and savings achieved for these 
programs if we make this investment today.
    Elder abuse victims are household names like Mickey Rooney or the 
late Brooke Astor. We testify for them today but also for those who are 
not household names. The voices we don't hear are the ones who need a 
voice that you can listen to today.
    We say that elder justice is a bipartisan issue. Leaders have 
included Senator Hatch, Representative King, as well as former Senator 
Lincoln and Representative Emanuel to name a few. Again on a bipartisan 
basis this Congress reauthorized the Violence Against Women Act. The 
reality is that elder abuse is also a women's issue. The average victim 
is an older woman living alone between 75 and 80 at a time when the 
Census reports that almost 50 percent of all women over 75 now live 
alone--another reason to act now to get resources into elder abuse 
prevention.
    If one in ten seniors in your State were victims of crime, you 
would likely respond by seeking more support for law enforcement as 
first responders in the fight against crime. Elder abuse hits one out 
of every ten seniors. Let us give needed support to Adult Protective 
Services who are the first responders for elder abuse.
    Our Coalition also supports funding the Social Services Block Grant 
the only funding source for Adult Protective Services today at the 
level proposed in the President's budget.
    Just as 40 years ago when witnesses came to this Subcommittee 
seeking initial funding for the Child Abuse Prevention and Treatment 
Act of 1974 we come today asking for this initial $25 million for elder 
justice. What is common? A victim of child abuse, like a victim of 
elder abuse, is never the same. The role of government should always be 
to help the vulnerable of all ages.
    Elder justice warrants considerably more than the requested $25 
million. The Elder Justice Act also includes increased support for long 
term care ombudsmen assisting nursing home residents and funding 
forensic centers important to the prosecution of abusers. Since these 
are not included, please view the $25 million as a floor to build on, 
not a ceiling. We look forward to working with you on ensuring that 
this first time appropriations for elder justice provides us with the 
best possible value and positive outcomes.
                                 ______
                                 
         Prepared Statement of the Eldercare Workforce Alliance
    Mr. Chairman, Ranking Member Moran, and Members of the 
Subcommittee: We are writing on behalf of the Eldercare Workforce 
Alliance (EWA), which is comprised of 30 national organizations united 
to address the immediate and future workforce crisis in caring for an 
aging America. As the Subcommittee begins consideration of funding for 
programs in fiscal year 2015, the Alliance\**\ urges you to provide 
adequate funding for programs designed to increase the number of 
healthcare professionals prepared to care for America's growing senior 
population and to support family caregivers in the essential role they 
play in this regard.
---------------------------------------------------------------------------
    \**\ The positions of the Eldercare Workforce Alliance reflect a 
consensus of 75 percent or more of its members. This testimony reflects 
the consensus of the Alliance and does not necessarily represent the 
position of individual Alliance member organizations.
    The Eldercare Workforce Alliance is a project of The Advocacy Fund.
---------------------------------------------------------------------------
    Today's healthcare workforce is inadequate to meet the special 
needs of older Americans, many of whom have multiple chronic physical 
and mental health conditions and cognitive impairments. It is estimated 
that an additional 3.5 million trained healthcare workers will be 
needed by 2030 just to maintain the current level of access and 
quality. Without a national commitment to expand training and 
educational opportunities, the workforce will be even more constrained 
in its ability to care for the growth in the elderly population as the 
baby boom generation ages. Reflecting this urgency, the Health 
Resources and Services Administration (HRSA) has identified ``enhancing 
geriatric/elder care training and expertise'' as one of its top five 
priorities.
    Of equal importance is supporting the legions of family caregivers 
who annually provide billions of hours of uncompensated care that 
allows older adults to remain in their homes and communities. The 
estimated economic value of family caregivers' unpaid care was 
approximately $450 billion in 2009.
    The number of Americans over age 65 is expected to reach 70 million 
by 2030, representing a 71 percent increase from today's 41 million 
older adults. That is why Title VII and Title VIII geriatrics programs 
and Administration for Community Living (ACL) programs that support 
family caregivers are so critical to ensure that there is a skilled 
eldercare workforce and knowledgeable, well-supported family caregivers 
available to meet the complex and unique needs of older adults.
    We hope you will support a total of $44.7 million in funding for 
geriatrics programs in Title VII and Title VIII of the Public Health 
Service Act, $172.9 million in funding for programs administered by the 
Administration on Aging that support the vital role of family 
caregivers in providing care for older adults, and $3 million to 
convene a White House Conference on Aging. Specifically, we recommend 
the following levels:
  --$39.7 million for Title VII Geriatrics Health Professions Programs;
  --$5 million for Title VIII Comprehensive Geriatric Education 
        Programs;
  --$172.9 million for Family Caregiver Support Programs; and
  --$3 million for a White House Conference on Aging.
    Geriatrics health profession training programs are integral to 
ensuring that America's healthcare workforce is prepared to care for 
the Nation's rapidly expanding population of older adults.
    In light of current fiscal constraints, EWA specifically requests 
$44.7 million in funding for the following programs administered 
through the Health Resources and Services Administration (HRSA) under 
Title VII and VIII of the Public Health Service Act. In the 2012-2013 
Academic Year, these geriatrics and gerontology programs provided 
training to more than 200,000 individuals.
Title VII Geriatrics Health Professions: Appropriations Request: $39.7 
        Million
    Title VII Geriatrics Health Professions programs are the only 
Federal programs that seek to increase the number of faculty with 
geriatrics expertise in a variety of disciplines. These programs offer 
critically important training for the healthcare workforce overall to 
improve the quality of care for America's elders.
  --Geriatric Academic Career Awards (GACA).--The goal of this program 
        is to promote the development of academic clinician educators 
        in geriatrics. Program Accomplishments: In the In the Academic 
        Year 2012-2013, the GACA program funded 62 full-time junior 
        faculty. These awardees delivered over 1,100 interprofessional 
        continuing education courses specific to geriatric-related 
        topics to over 53,000 students and providers. Additionally, 
        they presented on research and other topics at 215 local, State 
        and national conference and published 108 peer-reviewed 
        publications. HRSA, through the Affordable Care Act (ACA), 
        expanded the awards to be available to more disciplines. EWA 
        strongly supports this expansion and requests adequate funding 
        to reflect this change. Currently, new awardees are selected 
        only every 5 years. To meet the need for clinician educators in 
        all disciplines, EWA believes that awards should be made 
        available to clinical educators annually in order to develop an 
        adequate number of faculty that can provide geriatric 
        instruction and training. EWA's fiscal year 2015 request of 
        $5.5 million will support GAC Awardees in their development as 
        clinician educators.
  --Geriatric Education Centers (GEC).--The goal of Geriatric Education 
        Centers is to provide high quality interprofessional geriatric 
        education and training to current members of the health 
        professions workforce, including geriatrics specialists and 
        non-specialists. Program Accomplishments: In Academic Year 
        2012-2013, the 45 GEC grantees developed and provided over 
        1,650 different continuing education and clinical training 
        offerings to more than 135,000 health professionals, students, 
        faculty, and practitioners, significantly exceeding the 
        program's performance target. Three quarters of the continuing 
        education offerings were interprofessional in focus. Of the 
        sites that offered clinical training sessions, 2 out of every 5 
        of these sites were in a medically underserved community and/or 
        Health Professional Shortage Area. The GECs provide much needed 
        education and training. Our funding request of $20 million 
        includes support for the core work of these 45 GECs.
  --Alzheimer's Disease Prevention, Education, and Outreach Program 
        (GECs).--These funds, included in the President's fiscal year 
        2015 budget request, allow HRSA to expand efforts to provide 
        interprofessional continuing education to healthcare 
        practitioners on Alzheimer's disease and related dementias, 
        utilizing the already existing Geriatric Education Centers 
        (GECs). EWA Requests $5.3 million.
  --Geriatric Training Program for Physicians, Dentists, (GTPD) and 
        Behavioral and Mental Health Professions.--The goal of the GTPD 
        program is to increase the number and quality of clinical 
        faculty with geriatrics and cultural competence, including 
        retraining mid-career faculty in geriatrics. Program 
        Accomplishments: In Academic Year 2012-2013, a total of 64 
        physicians-including psychiatrists-, dentists, and 
        psychologists, were supported through this fellowship program. 
        Fellows delivered over 275 courses to 5,600 trainees. This 
        program supports training additional faculty in medicine, 
        dentistry, and behavioral and mental health so that they have 
        the expertise, skills, and knowledge to teach geriatrics and 
        gerontology to the next generation of health professionals in 
        their disciplines. EWA's funding request of $8.9 million will 
        support this important faculty development program.
Title VIII Geriatrics Nursing Workforce Development Programs: 
        Appropriations Request: $5 million
    Title VIII programs, administered by the HRSA, are the primary 
source of Federal funding for advanced education nursing, workforce 
diversity, nursing faculty loan programs, nurse education, practice and 
retention, comprehensive geriatric education, loan repayment, and 
scholarship.
  --Comprehensive Geriatric Education Program.--The goal of this 
        program is to provide quality geriatric education and training 
        to individuals caring for the elderly. Program Accomplishments: 
        In Academic Year 2012-2013, a total of 18 00Comprehensive 
        Geriatric Education Program (CGEP) grantees provided a variety 
        of services, including over 150 different continuing education 
        courses to over 11,600 trainees. This program supports 
        additional training for nurses who care for the elderly; 
        development and dissemination of curricula relating to 
        geriatric care; training of faculty in geriatrics; and 
        continuing education for nurses practicing in geriatrics.
  --Traineeships for Advanced Practice Nurses.--Through the ACA, the 
        Comprehensive Geriatric Education Program was expanded to 
        include advanced practice nurses who are pursuing long-term 
        care, geropsychiatric nursing, or other nursing areas that 
        specialize in care of older adults. In Academic Year 2012-2013, 
        a total of 74 grantees were awarded traineeships. One in every 
        4 grantee is considered an underrepresented minority in their 
        prospective profession. EWA's funding request of $5 million 
        will support the education and training of individuals who 
        provide geriatric care.
Administration for Community Living Family Caregiver Support and White 
        House Conference on Aging: Appropriations Request: $175.9 
        million
    These programs support caregivers, elders, and people with 
disabilities by providing critical respite care and other support 
services for family caregivers, training and recruitment of care 
workers and volunteers, information and outreach, counseling, and other 
supplemental services.
  --Family Caregiver Support Services.--This program provides a range 
        of support services to approximately 700,000 family and 
        informal caregivers annually in States, including counseling, 
        respite care, training, and assistance with locating services 
        that help family caregivers in caring for their loved ones at 
        home for as long as possible. EWA requests $154.5 million.
  --Native American Caregiver Support.--This program provides a range 
        of services to Native American caregivers, including 
        information and outreach, access assistance, individual 
        counseling, support groups and training, respite care and other 
        supplemental services. EWA requests $6.4 million.
  --Alzheimer's Disease Support Services:.--One critical focus of this 
        program is to support the family caregivers who provide 
        countless hours of unpaid care, thereby enabling their family 
        members with dementia to continue living in the community. 
        Funds go towards evidence-based interventions and expand the 
        dementia-capable home and community-based services, enabling 
        older adults to remain in the community for as long as 
        possible. EWA requests $9.5 million.
  --Lifespan Respite Care.--This program funds grants to improve the 
        quality of and access to respite care for family caregivers of 
        children or adults of any age with special needs. EWA requests 
        $2.5 million.
  --White House Conference on Aging.--As recommended by the bi-partisan 
        Commission on Long-Term Care, the President's fiscal year 2015 
        budget request includes $3 million for the convening of a 
        decennial White House Conference on Aging to bring together 
        stakeholders and consumers from across the country to discuss 
        the range of aging issues they face. EWA requests $3 million.
    On behalf of the members of the Eldercare Workforce Alliance, we 
commend you on your past support for geriatrics workforce programs and 
ask that you join us in supporting the eldercare workforce at this 
critical time--for all older Americans deserve quality care, now and in 
the future. Thank you for your consideration.

    [This statement was submitted by Nancy Lundebjerg, MPA, and Michele 
Saunders, DMD, MS, MPH, Alliance Co-Convener.]
                                 ______
                                 
         Prepared Statement of the Emergency Nurses Association
    The Emergency Nurses Association (ENA), with more than 40,000 
members worldwide, is the only professional nursing association 
dedicated to defining the future of emergency nursing and emergency 
care through advocacy, expertise, innovation, and leadership. Founded 
in 1970, ENA develops and disseminates education and practice standards 
and guidelines, and affords consultation to both private and public 
entities regarding emergency nurses and their practice. ENA has a great 
interest in the work of the Senate Labor, Health and Human Services, 
Education Subcommittee and especially its efforts to improve the 
quality of emergency care for patients in the United States.
    For fiscal year 2015, ENA respectfully requests $28 million for 
Trauma and Emergency Care Programs (HHS; ASPR/HRSA), $251 million for 
Nursing Workforce Development programs (HHS; HRSA), $21.116 million for 
the Emergency Medical Services for Children program (HHS; HRSA), $30.1 
million to fund poison control centers (HHS; HRSA), $150 million for 
the National Institute of Nursing Research (HHS; NIH), and $8.927 
million for Rural Health--Access to Emergency Devices (HHS; HRSA).
                   trauma and emergency care programs
    Trauma is the leading cause of death for persons younger than 44 
and the fourth-leading cause of death for all ages. In States with an 
established trauma system, patients are 20 percent more likely to 
survive a traumatic injury. Victims of traumatic injury treated at a 
Level I trauma center are 25 percent more likely to survive than those 
treated at a general hospital.
    Our trauma and emergency medical systems are designed to transport 
seriously injured individuals to trauma centers quickly. However, due 
to a lack of financial resources, 45 million Americans do not have 
access to a major trauma center within the ``golden hour'' following an 
injury when chances of survival are highest.
    Trauma and emergency care programs, which are authorized under the 
Public Health Service Act, provide much-needed money to the States to 
develop and enhance of trauma systems. These programs are critical to 
the efficient delivery of services through trauma centers, as well as 
to the development of regionalized systems of trauma and emergency care 
that ensure timely access for injured patients to appropriate 
facilities. This modest investment can yield substantial returns in 
terms of cost efficiencies and, most importantly, saved lives.
    Therefore, ENA respectfully requests $28 million in fiscal year 
2015 for trauma and emergency care programs.
                 nursing workforce development programs
    The nursing profession faces significant challenges to ensure that 
there will be an adequate number of qualified nurses to meet the 
growing healthcare needs of Americans. It is estimated that 80 million 
Baby Boomers turned 65 last year. This growing elderly population will 
seek healthcare services in a multitude of settings and the care they 
depend upon will require a highly educated and skilled nursing 
workforce. A 2014 projection from the U.S. Bureau of Labor Statistics' 
2013-2014 Employment Outlook Handbook anticipates that the number of 
practicing RNs will grow 19 percent by 2022.
    The aging of the Baby Boom generation will deplete the nursing 
ranks as well. During the next 10 to 15 years, approximately one-third 
of the current nurse workforce will reach retirement age. The 
retirement of these experienced nurses has the potential to create a 
serious deficit in the nursing pipeline. At the same time, our colleges 
cannot keep up with the demand for new nurses. According to the 
American Association of Colleges of Nursing's (AACN) 2013-2014 
Enrollment and Graduations in Baccalaureate and Graduate Programs in 
Nursing survey, 78,089 qualified applications were turned away from 
nursing schools in 2013 alone.
    Title VIII Nursing Workforce Development programs address these 
factors and help support the training of qualified nurses. They not 
only enhance nursing education at all levels, from entry-level to 
graduate study, but they also support nursing schools that educate 
nurses for practice in rural and medically underserved communities. 
Another important part of Title VIII is the Faculty Loan Program which 
is critical to alleviating the large shortage in nursing faculty. 
Overall, more than 80,000 nurses and nursing students were trained and 
educated last year with the help of Title VIII nursing workforce 
development programs.
    Therefore, ENA respectfully requests $251 million in fiscal year 
2015 for the Nursing Workforce Development programs authorized under 
Title VIII of the Public Health Service Act.
                emergency medical services for children
    The Emergency Medical Services for Children (EMSC) program is the 
only Federal program that focuses specifically on improving the 
pediatric components of the emergency medical services (EMS) system. 
EMSC aims to ensure state-of-the-art emergency medical care for ill and 
injured children or adolescents; that pediatric services are well 
integrated into an EMS system backed by optimal resources; and that the 
entire spectrum of emergency services is provided to children and 
adolescents no matter where they live, attend school, or travel.
    The Federal investment in the EMSC program produces a wide array of 
benefits to children's health through EMSC State Partnership Grants, 
EMSC Targeted Issue Grants, the Pediatric Emergency Care Applied 
Research Network, and the National EMSC Data Analysis Resource Center.
    Therefore, ENA respectfully requests $21.116 million in fiscal year 
2015 for the EMSC program.
                         poison control centers
    Poisoning is the second most common form of unintentional death in 
the United States. In 2009, 31,768 deaths nationwide were attributed to 
unintentional poisoning. Children are especially vulnerable to injury 
by poisoning and each day 300 children are treated for poisoning in 
emergency departments across the country and two die.
    The Nation's 56 poison control centers handle 3.4 million calls 
each year, including approximately 680,000 calls from nurses and 
doctors who rely on poison centers for an immediate assessment and 
expert advice on poisoning cases.
    Not only are America's network of poison centers invaluable for 
treating victims of poisonings, but the work of the centers also 
results in substantial savings to our healthcare system. About 90 
percent of people who call with poison emergencies are treated at home 
and do not have to visit an emergency department. In more severe 
poisoning cases, the expertise provided by poison control centers can 
decrease the length of hospital stays. It has been estimated that every 
dollar spent on America's poison control centers saves $13.39 in 
healthcare costs and lost productivity. The positive impact to the 
Federal budget is also significant. A 2012 study by the Lewin Group 
found that poison control centers resulted in $313.5 million in savings 
to Medicare and $390.2 million in savings to Medicaid.
    Therefore, ENA respectfully requests $30.1 million in fiscal year 
2015 for poison control centers
           the national institute of nursing research (ninr)
    As one of the 27 Institutes and Centers at the NIH, NINR funds 
research that lays the groundwork for evidence-based nursing practice. 
NINR's mission is to promote and improve the health of individuals, 
families, communities, and populations. The Institute supports and 
conducts clinical and basic research on health and illness to build the 
scientific foundation for clinical practice, prevent disease and 
disability, manage and eliminate symptoms caused by illness, and 
improve palliative and end-of-life care.
    NINR nurse-scientists examine ways to improve care models to 
deliver safe, high-quality, and cost-effective health services to the 
Nation. Our country must look toward prevention as a way of reducing 
healthcare expenditures and improving outcomes. The work of NINR is an 
important part of this effort.
    Moreover, NINR helps to provide needed faculty to support the 
education of future generations of nurses. Training programs at NINR 
develop future nurse-researchers, many of whom also serve as faculty in 
our Nation's nursing schools.
    Therefore, ENA respectfully requests $150 million in fiscal year 
2015 for the NINR.
        rural and community access to emergency devices program
    Fewer than 10 percent of people who suffer a cardiac arrest outside 
of a hospital setting survive. According to a 2011 study published in 
the New England Journal of Medicine, immediate CPR and prompt 
defibrillation using an automated external defibrillator (AED) can more 
than double a patient's chance of survival.
    The Health Resources and Services Administration (HRSA)'s Rural and 
Community Access to Emergency Devices Program saves lives of patients 
with cardiac arrest. Between August 1, 2008, and July 31, 2010, nearly 
800 cardiac arrest victims were reportedly saved through this program. 
Funding for this initiative is used to buy AEDs, locate them in public 
places where cardiac arrests are more likely to happen, and instruct 
lay rescuers and first responders in their use. Between March 1, 2010, 
and Feb. 28, 2011, 3,928 AEDs were placed and 28,776 people were 
trained in their use.
    Therefore, ENA respectfully requests $8.927 million in fiscal year 
2015 for the Rural and Community Access to Emergency Devices Program.
                                 ______
                                 
              Prepared Statement of The Endocrine Society
    The Endocrine Society is pleased to submit the following testimony 
regarding fiscal year 2015 Federal appropriations for biomedical 
research, with an emphasis on appropriations for the National 
Institutes of Health (NIH). The Endocrine Society is the world's 
largest and most active professional organization of endocrinologists 
representing more than 17,000 members worldwide. Our organization is 
dedicated to promoting excellence in research, education, and clinical 
practice in the field of endocrinology. The Society's membership 
includes thousands of basic and clinical scientists who receive Federal 
support from the NIH to fund endocrine-related research on topics such 
as diabetes, cancer, fertility, aging, obesity and bone disease. The 
Society's membership also includes clinicians who depend on new 
scientific advances to better treat and cure their patients' diseases. 
As a result of Federal investment in endocrine research, individuals 
with diabetes have made dramatic improvements in managing their 
disease, and the obesity rate for children age 2 to 5 years old has 
dropped 43 percent.\1,2\ The Endocrine Society recommends that the NIH 
receive at least $32 billion in fiscal year 2015. This funding 
recommendation represents the minimum investment necessary to avoid 
further erosion of national research priorities and global preeminence, 
while allowing the NIH's budget to keep pace with biomedical inflation.
---------------------------------------------------------------------------
    \1\ Casagrande et al., ``The Prevalence of Meeting A1C, Blood 
Pressure, and LDL Goals Among People With Diabetes, 1988-2010.'' 
Diabetes Care, Aug 36;8 (2013) 2271-9.
    \2\ Sabrina Tavernise, ``Obesity Rate for Young Children Plummets 
43 percent in a Decade.'' The New York Times. Feb 25, 2014.
---------------------------------------------------------------------------
    Sustained investment by the United States Federal government in 
biomedical research has dramatically advanced the health and improved 
the lives of the American people. The United States' NIH-supported 
scientists represent the vanguard of researchers making fundamental 
biological discoveries and developing applied therapies that advance 
our understanding of, and ability to treat human disease. In the past 
year NIH funded scientists have made fundamental insights into how mild 
traumatic brain injury causes brain damage; identified potential drug 
targets for Parkinson's disease; and identified a safe and protective 
candidate malaria vaccine.\3\ In the field of endocrinology, NIH-funded 
researchers have made remarkable contributions in areas of critical 
national interest, for example:
---------------------------------------------------------------------------
    \3\ ``2013 Research Highlights''. December 23, 2013. http://
www.nih.gov/researchmatters/january2014/researchmatters2013recap.htm 
Accessed March 23, 2013.
---------------------------------------------------------------------------
  --Endocrinologists have made insightful discoveries describing newly 
        understood contributors to body weight and obesity.\4\ Obesity 
        is a growing national concern, with related medical costs in 
        the United States as high as $190 billion in 2005 alone.\5\
---------------------------------------------------------------------------
    \4\ Mathur et al., ``Methane and hydrogen positivity on breath test 
is associated with greater body mass index and body fat.'' J Clin 
Endocrinol Metab. 98;4 (2013) 698-702.
    \5\ Cawley and Meyerhoefer. ``The medical care costs of obesity: an 
instrumental variables approach.'' J Health Econ. 31;(2012) 219-30.
---------------------------------------------------------------------------
  --Endocrinologists have discovered that higher vitamin D levels are 
        associated with increased mobility and physical function in 
        older individuals. As the population of the United States 
        increasingly lives longer, this research has the potential to 
        dramatically improve the quality of life for Americans.\6\
---------------------------------------------------------------------------
    \6\ Wohl et al., ``Vitamin D status is associated with functional 
limitations and functional decline in older individuals.'' J Clin 
Endocrinol Metab. 98;9 (2013) 1483-90.
---------------------------------------------------------------------------
  --Endocrinologists are also at the leading edge of research on 
        testosterone therapy and maintaining appropriate levels of sex 
        hormones. For instance, endocrinologists are investigating 
        links between testosterone levels and heart disease in men.\7\
---------------------------------------------------------------------------
    \7\ Ruige et al., ``Beneficial and Adverse Effects of Testosterone 
on the Cardiovascular System in Men.'' J Clin Endocrinol Metab. 98;11 
(2013) 4300-10.
---------------------------------------------------------------------------
    These discoveries represent but a fraction of the contributions 
made by endocrinologists and other NIH funded scientists in the past 
year. The foundation for these research products are the NIH research 
grants that support the basic and clinical research done by scientists. 
Since 2004, the number of NIH research grants to scientists in the 
United States has been declining. Consequently, the likelihood of a 
scientist with a highly-regarded grant application successfully being 
awarded a grant has dropped from 31.5 percent in 2000 to an historic 
low of 16.8 percent in 2013.\8\ This means that experienced scientists 
are increasingly spending time writing grant applications instead of 
applying their expertise to productive research. Additionally, younger 
scientists struggle to find a job in the United States that makes use 
of the unique skills generated during graduate training.
---------------------------------------------------------------------------
    \8\ Salley Rockey, ``fiscal year 2013 By The Numbers: Research 
Applications, Funding, and Awards,'' Rock Talk, January 10, 2014. 
http://nexus.od.nih.gov/all/2014/01/10/fy2013-by-the-numbers/Accessed 
March 20, 2014.
---------------------------------------------------------------------------
    The lack of sustained government support compounded by austerity 
measures such as sequestration has created an environment that is 
leading to a ``brain drain'' as brilliant scientists pursue other 
careers or leave the United States to develop impactful research 
products elsewhere. In 2013, the number of NIH supported scientists 
declined significantly, with nearly 1,000 NIH scientists dropping out 
of the workforce.\9\ NIH scientists run labs that support high-quality 
jobs and education while generating breakthrough innovations. In 2011, 
the NIH directly or indirectly supported over 432,000 jobs across the 
country.\10\ As a result of sequestration, States such as Georgia and 
Connecticut lost $62 million and $32 million respectively.\11\
---------------------------------------------------------------------------
    \9\ Jeremy Berg ``The impact of the sequester: 1,000 fewer funded 
investigators.'' ASBMB Today. March (2014). https://www.asbmb.org/
asbmbtoday/201403/PresidentsMessage/Accessed March 20, 2014.
    \10\ Everett Ehrlich ``Engine Stalled: Sequestration's Impact on 
NIH and the Biomedical Research Enterprise.'' United for Medical 
Research. (2012).
    \11\ ``NIH State Information Factsheets.'' http://www.faseb.org/
Policy-and-Government-Affairs/Advocacy-on-Capitol-Hill/Advocacy-
Resources-for-Scientists/NIH-State-Information-Factsheets.aspx. 
Federation of American Societies for Experimental Biology. Accessed 
March 19, 2014.
---------------------------------------------------------------------------
    We may never be able to quantify the opportunities we have missed 
to improve the health and economic status of the United States due to 
persistent underinvestment in research. We do know however, that when 
``laboratories lose financing, they lose people, ideas, innovations and 
patient treatments.'' \12\ Based on the personal stories of researchers 
who have been forced to curtail research programs, we know that 
research programs to understand how genetics can influence heart 
disease, develop therapeutic treatments for Parkinson's disease, and 
evaluate the effect of metal contaminants on reproductive health; among 
many others, are delayed or terminated.\13\
---------------------------------------------------------------------------
    \12\ Teresa K. Woodruff ``Budget Woes and Research.'' The New York 
Times. September 10, 2013.
    \13\ Sequester Profiles: How Vast Budget Cuts to NIH are Plaguing 
U.S. Research Labs. United for Medical Research. http://
www.unitedformedicalresearch.com/advocacy_reports/sequestration-
profiles/Accessed March 20, 2014.
---------------------------------------------------------------------------
    As the world's largest source of funding for medical research, the 
NIH is vitally important to the United States' global preeminence in 
research. However, this global preeminence is being tested due to flat 
funding that has reduced the inflation-adjusted budget of the NIH to a 
level that is nearly 22 percent below the NIH budget in fiscal year 
2003.\14\ As a consequence of this underinvestment, the United States' 
global share of pharmaceutical industry output has declined, our global 
share of biopharmaceutical patents has declined, and our trade balance 
in pharmaceutical products is worsening.\15\ While the Bipartisan 
Budget Act of 2013 and omnibus appropriations bill have provided some 
much needed additional resources, overall levels of funding remain well 
below the $32 billion required for adequate, sustainable growth in 
biomedical research.
---------------------------------------------------------------------------
    \14\ ``Budget Cuts in 2013 Reduced Biomedical Research'' Federation 
of American Societies
for Experimental Biology. http://www.faseb.org/
pdfviewer.aspx?loadthis=http%3A%2F%2F
www.faseb.org%2FPortals%2F2%2FPDFs%2Fopa%2F2014%2F1.21.14%2520NIH%2520Fu
nding
%2520Cuts%25202-pager.pdf Accessed March 19, 2014.
    \15\ Atkinson et al., ``Leadership in Decline, Assessing U.S. 
International Competitiveness in Biomedical Research.'' The Information 
Technology and Innovation Foundation and United for Medical Research. 
May 2012.
---------------------------------------------------------------------------
    We live during an age of tremendous scientific opportunity that can 
only be realized through Federal funding of biomedical research. 
Researchers are only beginning to harness the power of big data to 
solve complicated problems. Innovative new experiments and clinical 
research hold promise to solve some of the United States' greatest 
medical challenges and discover new ways to improve our quality of 
life. Government support is critical to these opportunities, and we 
encourage the Appropriations Committee to actively support promising 
and innovative research.
    As the Appropriations Committee considers funding for the NIH, the 
Endocrine Society also asks the Committee to encourage the NIH to look 
at ways to increase data reporting to address gaps in gender and sex 
differences in research. Sex differences need to be acknowledged as a 
critical biological variable.\16\ In addition to including more women 
in clinical research, the Endocrine Society believes sex differences 
should be c as part of the design of all basic biological studies and 
clinical research. If the NIH required researchers to consider sex 
differences in grant applications when appropriate, and incorporate 
data on sex as a biological variable in animal and human studies, more 
appropriate conclusions could be drawn from basic research, and 
clinical research would provide more representative data on safety and 
efficacy of drugs.\17\
---------------------------------------------------------------------------
    \16\ Woodruff et al., ``'Leaning in' to Support Sex Differences in 
Basic Science and Clinical Research.'' Endocrinology. 155;4 (2014) 
1181-3
    \17\ Kim et al., ``Sex Bias in Trials and Treatment Must End.'' 
Nature. 465;7299 (2010) 688-9.
---------------------------------------------------------------------------
    The Endocrine Society remains deeply concerned about the future of 
biomedical research in the United States without sustained support from 
the Federal government. Flat funding in recent years, combined with the 
impact of sequestration, threaten the Nation's scientific enterprise 
and make adequate fiscal year 2015 appropriations for the NIH 
increasingly important. The Society strongly supports increased Federal 
funding for biomedical research in order to provide the additional 
resources needed to enable American scientists to address scientific 
opportunities and maintain the country's status as the preeminent 
research engine. The Endocrine Society therefore asks that the NIH 
receive at least $32 billion in fiscal year 2015.

    [This statement was submitted by Teresa K. Woodruff, PhD, 
President, The Endocrine Society.]
                                 ______
                                 
       Prepared Statement of the Entomological Society of America
    The Entomological Society of America (ESA) respectfully submits 
this statement for the official record in support of funding for 
insect-borne disease research at the U.S. Department of Health and 
Human Services (HHS). ESA requests a robust fiscal year 2015 
appropriation for the National Institutes of Health (NIH), including 
increased funding for insect-borne disease research at the National 
Institute of Allergy and Infectious Diseases (NIAID). The Society also 
supports increased investment in the core infectious diseases budget 
and the global health budget within the Centers for Disease Control and 
Prevention (CDC) in order to fund scientific activities related to 
vector-borne diseases.
    Advances in the biological sciences, including the field of 
entomology, help to address some of our most pressing societal needs 
related to environmental and human health. Certain species of insects 
carry, spread, and transmit an array of infectious diseases that 
threaten populations across the globe, including those in the United 
States as well as U.S. military personnel undertaking missions abroad. 
Insect-borne diseases can present an especially challenging health 
problem; few vaccines have been developed against them, and insects are 
often difficult to control and can develop resistance to insecticides. 
The risk of emerging infectious diseases grows as global travel becomes 
easier and environmental factors continue to change. For example, West 
Nile virus, which is transmitted by mosquitoes and was not present in 
the U.S. before 1999, infected 5,674 Americans in 2012.\1\ 
Entomological research to understand the biological relationship 
between insect vectors and the infectious diseases they carry--such as 
dengue, malaria, West Nile virus, and Lyme disease--can significantly 
contribute to our ability to monitor and predict outbreaks, prevent 
disease spread and transmission, and more reliably diagnose and treat 
infection. Given the important role that insect vectors play in 
impacting human health, ESA urges the subcommittee to support vector-
borne disease research programs that incorporate the entomological 
sciences as part of a comprehensive approach to addressing infectious 
diseases.
---------------------------------------------------------------------------
    \1\ CDC DVBD factsheet: http://www.cdc.gov/ncezid/dvbd/pdf/
dvbd_factsheet.pdf.
---------------------------------------------------------------------------
    NIH, the Nation's premier medical research agency, advances human 
health by funding research on basic human biology and disease and the 
development of prevention and treatment strategies. In fiscal year 
2012, about 84 percent of NIH funding was competitively awarded to 
scientists at approximately 2,500 universities, medical schools, and 
other research institutions across the Nation. As one of NIH's 27 
institutes and centers, NIAID conducts and supports fundamental and 
applied research related to the understanding, prevention, and 
treatment of infectious, immunologic, and allergic diseases. One 
example of NIAID-funded research on infectious diseases is a recent 
study examining the mechanism by which certain species of mosquitoes 
known to transmit dengue and malaria are attracted to humans. The 
scientists discovered that specific types of nerve cells in the insects 
act as sensitive detectors of human odors. With this knowledge, the 
researchers were able to identify safe and natural chemical compounds 
with the potential to neutralize or overwhelm the specific insect nerve 
cells, a discovery that could have implications for the control of 
mosquitoes and their associated diseases.\2\ In another recent study 
supported by NIAID, researchers determined that live, disease-free 
ticks can be used as a safe tool for testing for the presence of Lyme 
disease bacteria in patients who have completed antibiotic therapy.\3\ 
To ensure funding for future groundbreaking projects like these, ESA 
requests increased funding for NIAID and encourages the committee to 
support insect-borne disease research at NIH.
---------------------------------------------------------------------------
    \2\ Tauxe, GM, et al. Targeting a dual detector of skin and CO2 to 
modify mosquito host seeking. Cell (2013).
    \3\ Marques, A, et al. Xenodiagnosis to detect Borrelia burgdorferi 
infection: A first-in-human study. Clinical Infectious Diseases (2014).
---------------------------------------------------------------------------
    CDC, serving as the Nation's health protection agency, conducts 
science and provides health information to prevent and respond to 
infectious diseases and other global health threats, whether naturally 
arising or related to bioterrorism. Within the core infectious diseases 
budget of CDC, the Division of Vector-Borne Diseases (DVBD) seeks to 
protect our Nation from the threat of viruses and bacteria transmitted 
primarily by mosquitoes, ticks, and fleas. DVBD's mission is carried 
out by a staff of experts in several scientific disciplines, including 
entomology. For example, among the activities supported by DVBD are the 
ArboNET surveillance system for mosquito-borne diseases and the TickNET 
system for tick-borne diseases. ArboNET is a nationwide network that 
monitors West Nile virus and other diseases through activities such as 
the collection and testing of mosquitoes, and TickNET is a partnership 
between 16 States to track tick-borne-diseases like Lyme disease and 
test preventions. Furthermore, a component of CDC's global health 
budget supports activities on parasitic diseases and malaria; this 
includes the maintenance of a global reference insectary that houses 
colonies of mosquitoes from around the world to be used by the agency 
for studies on malaria transmission. Given the important contributions 
of CDC, ESA requests that the committee provide increased support for 
CDC programs addressing vector-borne diseases and malaria.
    ESA, headquartered in Annapolis, Maryland, is the largest 
organization in the world serving the professional and scientific needs 
of entomologists and individuals in related disciplines. Founded in 
1889, ESA has nearly 7,000 members affiliated with educational 
institutions, health agencies, private industry, and government. 
Members are researchers, teachers, extension service personnel, 
administrators, marketing representatives, research technicians, 
consultants, students, pest management professionals, and hobbyists.
    Thank you for the opportunity to offer the Entomological Society of 
America's support for HHS research programs.

    [This statement was submitted by Frank G. Zalom, PhD, President, 
Entomological Society of America.]
                                 ______
                                 
  Prepared Statement of Families & Friends of Care Facility Residents
    Chairman Harkin, Ranking Member Moran, Members of the Subcommittee: 
Thank you for this opportunity to provide information to the Senate 
Appropriations Subcommittee on Labor, Health & Human Services Education 
& Related Agencies. This is a letter-request that the Subcommittee 
cease funding Federal programs which use public funds to achieve public 
policies of deinstitutionalization of persons identified as benefiting 
from congregate (institutional) care, typically those with severe forms 
of cognitive-developmental disabilities.
    I am the mother and co-guardian of an adult son, aged 45, who from 
birth has lived with the effects of severe brain injuries. John is a 
large, mobile and nonverbal man with pica behavior who functions on the 
mental level of a young toddler. Our son has slight or little awareness 
of danger and his direct care is beyond our family's capacities. For 
many years John's safe home has been a state-operated congregate care 
program, an intermediate care facility for persons with intellectual 
disabilities (formerly known as a medical diagnosis of mental 
retardation). The future viability of John's home is in jeopardy due to 
the undermining work of federally funded entities and programs in the 
U.S. Department of Health and Human Services and the Department of 
Justice/Civil Rights Division.
    I represent as public affairs chairman Families and Friends of Care 
Facility Residents (FF/CFR), Arkansas' statewide parent-guardian 
association. FF/CFR is an all-volunteer organization; we employ no 
lobbyist; we receive no public funds.
    I have reviewed the testimonies of Department of Health and Human 
Services representatives presented before this subcommittee for the 
past several years. DHHS did not disclose that the Department is 
engaged in a social experiment to dismantle the States' residential 
safety net programs for persons who have been adjudicated incompetent 
and that the Department is using public funds to support organizations 
which lobby decision-makers to deinstitutionalize persons who are 
without self-preservation skills, who cannot assist in their own care 
and who cannot communicate their hurts and needs or who can do so only 
in limited ways.
    The following are examples of how government dollars are spent in 
the wrong way by the Department of Health and Human Services:
(1) National Council on Disability (NCD), an independent Federal agency 
        engaged in disability policy recommendations.
    On Tuesday, October 23, 2012, the National Council on Disability 
(NCD) released its policy project--``Deinstitutionalization: Unfinished 
Business.'' The press release read: ``NCD Launches Toolkit to Speed 
Closure of State-Run Institutions.'' Although NCD is a Federal agency, 
it has no congressional oversight and is not accountable for its 
actions, except as Congress may provide. Prior to releasing its 
deinstitutionalization policy recommendations and documents, there were 
no public hearings or Notice to those most affected. There was no 
public in-put process. Arkansas' statewide parent-guardian association, 
FF-CFR, is comprised of volunteer advocates who work in behalf of the 
vulnerable people who live and receive services at our State's five 
human development centers (HDCs). Arkansas' five HDCs provide 24/7 care 
for 950 individuals. Over 64 percent of the residents function in the 
profound range of cognitive ability. We object to use of a Federal 
agency/Federal funds to promote public policies which are harmful. We 
object to empowerment of Federal agencies to formulate public policies 
in camera without public hearings and without the easy involvement of 
those most affected. NCD inappropriately collaborates with others in 
promoting its national de-institutionalization agenda out of the public 
eye.
    REQUEST: Public funds should not be used to support National 
Council on Disability and its extreme agendas. Please discontinue its 
funding.
(2) Programs funded under Public Law 106 402, Developmental 
        Disabilities Assistance and Bill of Rights Act (DD Act). The DD 
        Act funds three discretionary programs which operate in every 
        State: (1) State Councils on Developmental Disabilities, (2) 
        Protection & Advocacy Systems for Developmental Disabilities 
        (P&As) and (3) University Centers for Excellence in 
        Developmental Disabilities. The DD Act also funds a fourth 
        program, Projects of National Significance. The four DD Act 
        programs are administered by DHHS/Adm. on Community Living/Adm. 
        on Intellectual-Developmental Disabilities
    Through litigation, lobbying and other strategies, DD Act programs 
and their national organizations have used and are using public funds 
to achieve forced-deinstitutionalization of individuals with profound 
cognitive-developmental disabilities from their congregate care homes 
and the closures of Medicaid-certified public facilities for these 
individuals with profound disabilities. The DD Act programs' 
administrative office (Adm-IDD) has embraced an extreme agenda and is 
not responsive to the complaints and concerns of families, friends and 
legal guardians of individuals with disabilities who require close 24/7 
care.
    The DD Act was last re-authorized in 2000; its current 
authorization ended in 2007. At the last reauthorization, there was no 
public hearing and no opportunity to object to the ways in which 
grantees (State Councils on DD, Protection & Advocacy (P&A) systems and 
University Centers on DD) were collaborating with each other and with 
others for use of Federal appropriations to undermine and close 
congregate care programs for those persons with the most severe forms 
of developmental disabilities. There have been no hearings on 
reauthorization of the DD Act where families might participate and 
provide information about and objections to the programs' activities. 
The Arkansas DD Act P&A system has: (1) joined with Arc in a Federal 
lawsuit to close all Arkansas human development centers (HDCs), (2) 
brought 3 Federal lawsuits in succession seeking to change our AR HDC 
admission and discharge policies naming HDC residents as plaintiffs 
without notice or consent of their legal guardians (in two of the cases 
the AR P&A sought class certification with no opportunity for residents 
to opt out of the class); (3) filed a complaint with Civil Rights 
Division-U.S. Dept. of Justice regarding care at our HDCs without 
consulting families of HDC residents and cheered in the media when DOJ 
brought a systems-change lawsuit against all HDCs; (4) testified 
against AR HDC funding before State legislative panels; (5) organized a 
public rally calling on the AR Governor to close one of our HDCs; (6) 
denigrated congregate care and AR HDC programs in the media during a 
Federal trial, USA v. State of AR (Conway HDC); (7) provided erroneous 
information to AR policy makers regarding cost of care and the U.S. 
Supreme Court decision in Olmstead v. L. C. (119 S. Ct. 2176); and (8) 
sent financial support to its Washington D.C.-based national 
organization, National Disability Rights Network (NDRN), an 
organization with no oversight which lobbies the Administration, 
Congress and CMS, collaborating with other organizations in campaigns 
to shift Medicaid funding from congregate care programs for persons 
with life-long cognitive and other developmental disabilities. Most 
recently (January & February, 2014), the Arkansas DD Act P&A in 
testimony before a legislative panel and in a letter to members of the 
State legislature worked against funding for capital improvements at 
our State's five human development centers. Families with whom I 
correspond in other States report that DD Act programs have used grant 
funds to fund other organizations to plan and lobby for the closure of 
State-operated congregate care programs for individuals with cognitive-
developmental disabilities. In November and December, 2012 , the 
national organizations for two DD Act programs (Association of 
University Centers on Disabilities (AUCD) and protection and advocacy 
(National Disability Rights Network--NDRN) led the work of lobbying to 
prevent the mark-up of H.R. 2032 in the U.S. House Judiciary Committee. 
Had 2032 passed, some egregious protection and advocacy activities 
employing litigation as a tactic to undermine and close congregate care 
centers might have been addressed and prohibited.
    REQUEST: Public funds should not be used to support the DD Act 
Programs' extreme agendas of deinstitutionalization. Please discontinue 
funding the groups' harmful deinstitutionalization work.
(3) DHHS Financial incentive grants--Money Follows the Person (MFP), 
        Balance Incentive Payment Plan (BIP), Community First Choice 
        Option (CFCO)
    Through generous financial incentive demonstration grants (Money 
Follows the Person, Balance Incentive Plan, Community First Choice 
Option), CMS is promoting thoughtless policies of de-
institutionalization for persons with developmental disabilities by 
funding generous incentive grants for one needed program (home and 
community based waiver care) but not another needed program (licensed 
safety-net congregate care facilities). The majority of persons with 
cognitive-developmental disabilities can and are being served through 
States' home and community based wavier programs. There is no 
``institutional bias'' in our State of Arkansas for persons with 
developmental disabilities: 74.2 percent of Medicaid dollars are spent 
on home and community based waiver programs. Over 4,000 individuals 
with developmental disabilities are served in Arkansas' community-based 
waiver programs versus approximately 950 residents in the State's 
public safety-net institutions for people with developmental 
disabilities. For clinically complex cases and for people with profound 
cognitive-and other severe forms of developmental disabilities 
requiring 24/7 supervision whose needs cannot be successfully met at 
home, or whose families can no longer provide their care, the option of 
institutional programs such as Arkansas' Human Development Centers 
(HDCs) is life-saving. HDCs are cost-efficient and they also provide a 
proven safe model of long term care. When all costs are taken into 
account, there are no cost savings to shift from institutional care to 
community care for this vulnerable population. Persons with little or 
no awareness of danger who cannot or who cannot adequately communicate 
their hurts and needs will be at greater risk of abuse, exploitation 
and death when they are forced from their safe congregate care homes. 
The testimony of Secretary HHS Kathleen Sebelius before House Committee 
on Appropriations (April 25, 2013, ``Protecting Vulnerable 
Populations'') does not comport with our family's experiences with the 
outcomes of DHS/CMS financial incentive grants and other DHHS de-
institutionalization programs. The push by CMS to entice States through 
financial rewards to shift from providing care for persons in 
specialized residential programs does not comport with realities in the 
field of long-term care. The American Medical Association (AMA) has 
designated persons with intellectual--developmental disabilities 
(formerly termed mental retardation) as a medically underserved 
population. The AMA Policy (CMS Rep. 3-1-11) ``encourages support for 
healthcare facilities whose primary mission is to meet the healthcare 
needs of persons with profound developmental disabilities.'' The 
National Crime Victimization Survey (Feb. 2014) found that 
``Individuals with disabilities encountered violent crime at nearly 
three times the rate of those in the general population . . . . . Those 
with cognitive disabilities had the highest rate of victimization and 
about half of violent crime victims with disabilities had multiple 
conditions.''
    The use by CMS of public funds--through financial incentive 
grants--to reward States when they shift Medicaid long-term care 
funding from institutional care programs to community programs which 
generally have less oversight and accountability is misguided and 
dangerous. Families of individuals who require close care had little or 
no opportunity to review, comment and object that CMS incentive grants 
favor one needed program over another critically needed program. The 
extension of Federal funding for Money Follows the Person (MFP) grants 
and Community First Choice Option (CFCO) are optional programs offered 
to the States in the voluminous Affordable Care Act, inserted without 
adequate review, without debate, and without adequate notice to 
families most affected. Extension of MFP, BIP, and CFCO were created by 
DHHS out of the public eye with inadequate opportunity for the public 
to review, comment or object.
    DHHS is too far removed from the realities which families 
understand and which are based on their years of experiences with their 
disabled family members.
    REQUEST: Public funds should not be used to promote DHHS policies 
of deinstitutionalization. Please address the unfair, unsafe CMS de-
institutionalization incentive grants.
                                summary
    Policy decisions which destroyed the Nation's safety net programs 
for persons with mental illness are now understood to be disastrous and 
ill-conceived for a small but significant percent of persons living 
with severe, chronic mental illness.
    Please resist funding DHHS programs and policies which promote 
harmful deinstitutionalization of persons with severest forms of 
developmental disabilities. My son and his peers cannot appear before 
committees, engage in protests or advocate for their health and safety. 
Please use your powerful authority to direct DHHS to cease its partisan 
use of public funds to achieve deinstitutionalization.

    [This statement was submitted by Carole L. Sherman, Arkansas' 
statewide parent-guardian association.]
                                 ______
                                 
    Prepared Statement of the Federation of American Societies for 
                          Experimental Biology
    The Federation of American Societies for Experimental Biology 
(FASEB) respectfully requests a minimum of $32 billion in fiscal year 
2015 for the National Institutes of Health (NIH) within the Department 
of Health and Human Services. Increasing the NIH budget to $32 billion 
would support vital initiatives to train the next generation of 
scientists, and fund at least 600 additional competing research grants.
    FASEB, a federation of 26 scientific societies, represents more 
than 115,000 life scientists and engineers, making it the largest 
coalition of biomedical research associations in the United States. Our 
mission is to advance health and welfare by promoting progress and 
education in biological and biomedical sciences.
    NIH has produced an outstanding legacy of discoveries that have 
generated new knowledge, improved health, and saved lives. Many of 
these advances arose from investigations designed to explain basic 
molecular, cellular, and biological mechanisms. In addition, research 
supported by NIH led to innovative technologies and created entirely 
new global industries resulting in economic growth and new, high-tech 
jobs.
    As a result of our prior investment in NIH, we have reduced the 
death toll of many diseases and reduced the disability and suffering 
from many others. For example, U.S. death rates from heart disease and 
stroke have decreased by more than 60 percent in the last 50 years, the 
rate of acute hepatitis B has been reduced by 80 percent since the 
1980's, and the proportion of older people with chronic disabilities 
has dropped by one-third over the last quarter century. Research funded 
by NIH helped develop new treatments that have significantly reduced 
the transmission of human immunodeficiency virus from mother to child 
and provided insights into traumatic brain injury. In addition, with 
the completion of the Human Genome Project and subsequent technological 
advances in rapidly sequencing DNA, scientists have been able to 
identify genes that are responsible for more than half of the 7,000 
rare diseases known to affect humans and evaluate the genetic 
composition of various cancers with the hopes of pinpointing the most 
effective therapy for each individual patient.
    NIH-supported research is continuing to produce the insights that 
are needed for tomorrow's improvements in health and clinical care. 
Recent discoveries include:
  --Advances in Treating Melanoma: Years of basic research supported by 
        NIH have provided insights into biological changes that occur 
        in the development of cancer, including the observation that a 
        protein called b-Raf appears in a mutated form in more than 50 
        percent of melanomas, the most aggressive form of skin cancer. 
        Studies showing that this protein plays a critical role in 
        melanoma led pharmaceutical companies to develop drugs to 
        inhibit mutant b-Raf. These drugs can s improve quality of life 
        and prolong survival in the majority of patients with advanced 
        melanoma who harbor b-Raf mutations. Since most of these 
        patients eventually relapse and die from their disease, studies 
        are underway to understand why melanomas become resistant to 
        treatment. It is hoped that this will lead to new treatments 
        that can overcome or bypass resistance, with the goal of 
        achieving long-term remissions and cures.
  --Developing Structure-Based Vaccines: Respiratory syncytial virus 
        (RSV) is responsible for nearly 7 percent of deaths of infants 
        under 12 months of age. It also causes death and disability in 
        the elderly. NIH-funded research has illuminated many aspects 
        of RSV infection and pathogenesis, yet an effective vaccine has 
        remained elusive. Recently, investigators made a breakthrough 
        by determining the three-dimensional structure of an RSV 
        protein required for cell entry. This structural information 
        was then used to design a stabilized vaccine antigen that 
        elicited high titers of protective antibodies in mice and non-
        human primates. In the next few years, this promising vaccine 
        candidate will be tested in clinical trials, and it is hoped 
        that this structure-based approach to vaccine design will be 
        successful for other viruses, such as HIV-1.
  --Testing New Anti-Inflammatory Drugs: In the 1990's, NIH supported a 
        few academic researchers to study molecules called glycans for 
        their function in inflammation, the process the body uses to 
        fight infection. In 2013, these studies came to fruition with 
        the first tests of a new, glycan-based anti-inflammatory drug. 
        In an initial test to fight inflammation during the painful 
        crises that occur in sickle cell disease, both children and 
        adult patients who got this treatment had shorter disease 
        crises, spent less time in the hospital, and needed fewer 
        narcotics for pain relief. This new drug that will benefit tens 
        of thousands of people in the U.S. each year could never have 
        been developed without NIH's investment in exploratory basic 
        research.
  --Harnessing the Immune System to Fight Cancer: Science magazine 
        named cancer immunotherapy--using the immune system to attack 
        tumors--the 2013 Breakthrough of the Year. The early work that 
        led to the development of immunotherapy was made possible by 
        NIH-funded research on many basic biological processes, 
        including the biology of T cells, a family of cells that are 
        critical to the immune system. Researchers discovered that when 
        a certain receptor on the outside of T cells is activated, 
        cells cannot mount an effective immune response. They then 
        reasoned that if an antibody blocked the activation of this 
        receptor, T cells could be induced to attack tumor cells. 
        Ongoing clinical trials testing antibody immunotherapies in 
        individuals found that tumors shrunk by almost 50 percent in 31 
        percent of those with melanoma and 29 percent in those with 
        kidney cancer.
Further Progress Depends on Sustained Investment
    Research supported by NIH advances our understanding of the nature 
of living systems and enables us to apply that knowledge to the 
improvement of human health. In a recent op-ed in The Washington Post, 
NIH Director Francis S. Collins, MD, PhD, wrote, ``Biomedical research 
is at a critical juncture--a moment of exceptional opportunities that 
demand exceptional attention if their promise is to be fully 
realized.'' \1\ But without continued support for basic biomedical 
research, Dr. Collins fears that we will miss out on new discoveries 
that will give us the next generation of cures and therapies for such 
conditions as Parkinson's disease and Alzheimer's disease, as well as a 
universal vaccine to protect adults and children against all flu 
strains without needing an annual shot.
---------------------------------------------------------------------------
    \1\ Collins, F. (2013, December 24). Investing in the Nation's 
Health at NIH. Washington Post.
---------------------------------------------------------------------------
    While the opportunities to increase our understanding of diseases 
and develop new therapies are unprecedented, a decade of flat-funding--
followed by $1.55 billion in sequestration cuts in fiscal year 2013--
have taken a significant toll on NIH's ability to support research. In 
constant dollars (adjusted for inflation), the fiscal year 2013 budget 
for NIH was the lowest in thirteen years. The number of competing R01-
equivalent grants, the primary mechanism for supporting investigator-
initiated research, awarded each year fell by 34 percent between 2003 
and 2013. The current situation is decimating the ranks of our 
scientific workforce, causing productive scientists to seek alternative 
careers and discouraging talented trainees from pursuing jobs in 
academic research. It surrenders our future leadership in medical 
research.
    As a first step toward a multi-year program of sustainable growth, 
FASEB recommends a minimum of $32 billion for NIH in fiscal year 2015. 
Thank you for the opportunity to offer FASEB's fiscal year 2015 funding 
recommendation for NIH.
                                 ______
                                 
                   Prepared Statement of Cheryl Felak
    Dear Committee Members: Thank you very much for the opportunity to 
submit personal and professional testimony to this committee.
    I am writing as a healthcare professional with an abundance of 
experience working with clients and family members who experience life 
with developmental disabilities. I am also the parent of a young man 
who has profound developmental disabilities due to a rare genetic 
condition which is similar to pediatric Alzheimer's.
    I would like you to be aware that many of the advocacy agencies in 
this country (The Arc and it's many State and local chapters), 
Developmental Disability Councils and affiliates, all who receive 
Federal funds for advocacy, are forgetting that our citizens with 
developmental disabilities live on a continuum and have a large 
variation in support needs.
    It is shameful that these so-called advocacy groups forget about 
those with the most profound needs, misinterpret the 1999 U.S. Supreme 
Court Olmstead decision on choice and community, and force their 
opinions regarding these issues discriminatory practices.
    It is a fact that people need communities--yet why are these so 
called advocacy groups allowed to determine what ``community'' is for 
those with developmental disabilities. Rather than allowing choice and 
opportunities, they are restricting choice and opportunities to this 
group of people. This is discrimination.
    I am not aware of any other population which has ``community'' 
defined for them, which has funds for housing, medical care, education, 
vocational support tied to the artificial definition of ``community'' 
which is made up for people with developmental disabilities.
    I believe it is time to go back and really read the Olmstead 
Decision--not just take for granted what is heard because what is heard 
is not what the decision States. We need to honor this decision and 
stop discriminating against our most vulnerable citizens.
    Thank you very much.

    [This statement was submitted by Cheryl Felak, RN, BSN, Because We 
Care--Beyond Inclusion.]
                                 ______
                                 
Prepared Statement of the Friends of the Health Resources and Services 
                             Administration
    The Friends of HRSA is a non-partisan coalition of more than 170 
national organizations representing millions of public health and 
healthcare professionals, academicians and consumers invested in HRSA's 
mission to improve health and achieve health equity. For fiscal year 
2015, we recommend restoring HRSA's discretionary budget authority to 
the fiscal year 2010 level of $7.48 billion. We are deeply concerned 
that since fiscal year 2010, HRSA's discretionary budget authority has 
been cut by 19 percent in nominal dollars and 25 percent when adjusted 
for inflation. Funding for HRSA is far too low and keeping austerity 
measures in place will threaten the agency's ability to address the 
present and growing health needs of the U.S. Of additional concern, 
cuts will be compounded by the fact that multiple mandatory programs 
are set to expire at the end of fiscal year 2015. In the absence of 
continued mandatory funding for the National Health Service Corps Fund 
and Community Health Center Fund, the committee will be faced with 
addressing these shortfalls in the following Labor-HHS-Education 
appropriations bill.
    The Nation faces a shortage of health professionals and continues 
to experience an ever growing, aging and increasingly diverse 
population, alongside health professionals that are nearing retirement 
age. Additionally, national estimates of workforce shortages are often 
masked by significant distributional disparities--particularly in rural 
and certain inner-city populations that experience greater shortages. 
By restoring funding to HRSA, the agency will be able to more 
effectively fill the primary and preventive care gaps for people living 
outside of the medical and economic mainstream through supporting a 
well prepared workforce and high-quality health services.
    HRSA operates programs in every State and U.S. territory and is a 
national leader in improving the health of Americans. HRSA programs 
have reduced AIDS-related deaths through providing drug treatment 
regimens for people living with HIV and have the potential to prevent 
the spread of HIV by 96 percent by ensuring that people living with HIV 
have access to regular care and adhere to their antiretroviral 
medications. Less than 10 percent of people who experience a cardiac 
arrest outside of a hospital setting survive. HRSA provides rural 
communities with training and access to emergency devices which can 
more than double a patient's chance of survival. HRSA has contributed 
to the decrease in infant mortality rate, a widely used indicator of 
the Nation's health, which is now at an all-time low. Most recently, 
preliminary data indicates that the infant mortality rate for black 
infants has decreased, resulting in a narrowing of the gap that exists 
between racial groups.
    Now is the time to make a strong investment in a robust workforce 
and to improve access to care to continue achieving the health 
improvements HRSA has made and to pave the way for new achievements. 
The Nation only stands to benefit from a healthier population through a 
thriving workforce and reduced healthcare costs. Our recommendation is 
based on the need to continue improving the health of Americans by 
supporting critical HRSA programs including:
  --Health professions programs support the education and training of 
        primary care physicians, nurses, oral health professionals, 
        optometrists, physician assistants, nurse practitioners, 
        clinical nurse specialists, public health personnel, mental and 
        behavioral health professionals, pharmacists and other allied 
        health providers. With a focus on primary care and training in 
        interdisciplinary, community-based settings, these are the only 
        Federal programs focused on filling the gaps in the supply of 
        health professionals, as well as improving the distribution and 
        diversity of the workforce so health professionals are well-
        equipped to care for the Nation's growing, aging and 
        increasingly diverse population. Additionally, HRSA provides 
        interdisciplinary training to health professionals to 
        accurately screen, diagnose and treat children with autism and 
        other developmental disabilities.
  --Primary care programs support nearly 9,200 service delivery sites 
        in every State and territory, improving access to preventive 
        and primary care to more than 21 million patients in 
        geographically isolated and economically distressed 
        communities. Close to half of the health centers serve rural 
        populations. The health centers coordinate a full spectrum of 
        health services including medical, dental, behavioral and 
        social services--often delivering the range of services in one 
        location. In addition, health centers target populations with 
        special needs, including agricultural workers, homeless 
        individuals and families and those living in public housing. 
        Following health insurance reform in Massachusetts, health 
        centers experienced a substantial increase in newly-insured 
        patients. We expect the same will be true nationally, as health 
        insurance expands to millions of Americans who were previously 
        uninsured. Health centers and other programs administered by 
        HRSA will remain vital sources of care for patients and 
        continue to reduce costs to the health system.
  --Maternal and child health programs, including the Title V Maternal 
        and Child Health Block Grant, Healthy Start and others, support 
        initiatives designed to promote optimal health, reduce 
        disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality healthcare for 43 
        million women and children. MCH programs help assure that 
        nearly all babies born in the U.S. are screened for a range of 
        serious genetic or metabolic diseases and that a community-
        based system of family centered services is available for 
        coordinated long-term follow up for babies with a positive 
        screen and for all children with special healthcare needs.
  --HIV/AIDS programs provide the largest source of Federal 
        discretionary funding assistance to States and communities most 
        severely affected by HIV/AIDS. The Ryan White HIV/AIDS Program 
        delivers comprehensive care, prescription drug assistance and 
        support services for more than half a million low-income people 
        impacted by HIV/AIDS, which accounts for about half of the 
        total population living with the disease in the U.S. 
        Additionally, the programs provide education and training for 
        health professionals treating people with HIV/AIDS and work 
        toward addressing the disproportionate impact of HIV/AIDS on 
        racial and ethnic minorities.
  --Family planning Title X services ensure access to a broad range of 
        reproductive, sexual and related preventive healthcare for over 
        5 million poor and low-income women, men and adolescents at 
        nearly 4,400 health centers nationwide. Healthcare services 
        include patient education and counseling, cervical and breast 
        cancer screening, sexually transmitted disease prevention 
        education, testing and referral, as well as pregnancy diagnosis 
        and counseling. This program helps improve maternal and child 
        health outcomes and promotes healthy families. Often, Title X 
        service sites provide the only continuing source of healthcare 
        and education for many individuals.
  --Rural health programs improve access to care for the nearly 50 
        million people living in rural areas that experience a 
        persistent shortage of healthcare services. The Office of Rural 
        Health Policy serves as the Nation's primary voice for programs 
        and research on rural health issues. Rural Health Outreach and 
        Network Development Grants, Rural Health Research Centers, 
        Rural and Community Access to Emergency Devices Program and 
        other programs are designed to support community-based disease 
        prevention and health promotion projects, help rural hospitals 
        and clinics implement new technologies and strategies and build 
        health system capacity in rural and frontier areas.
  --Special programs include the Organ Procurement and Transplantation 
        Network, the National Marrow Donor Program, the C.W. Bill Young 
        Cell Transplantation Program and National Cord Blood Inventory. 
        These programs maintain and facilitate organ marrow and cord 
        blood donation, transplantation and research, along with 
        efforts to promote awareness and increase organ donation rates. 
        Special programs also include the Poison Control Program, the 
        Nation's primary defense against injury and death from 
        poisoning. For every dollar spent on the poison center system, 
        $13.39 is saved in medical costs and lost productivity, 
        totaling more than $1.8 billion every year in savings.
    While the Bipartisan Budget Act of 2013 and Consolidated 
Appropriations Act of 2014 provided modest and temporary relief from 
sequestration, austerity measures remain firmly in place, which pose 
serious threats for the viability of HRSA's important programs and 
compromise the agency's ability to address our Nation's health needs. 
We urge you to consider HRSA's central role in strengthening the 
Nation's health and advise you to adopt our fiscal year 2015 request of 
$7.48 billion for HRSA's discretionary budget authority. Thank you for 
the opportunity to submit our recommendation to the subcommittee.
                                 ______
                                 
Prepared Statement of Friends of the National Institute of Child Health 
                         and Human Development
    My name is Kate Ryan. I currently serve as Co-Chair of the Friends 
of the National Institute of Child Health and Human Development 
(NICHD). On behalf of the Friends, I urge the Labor, Health and Human 
Services, Education Appropriations Subcommittee to support at least $32 
billion for the NIH, including $1.37 billion for NICHD for fiscal year 
2015. Our coalition includes over 100 organizations representing 
scientists, physicians, healthcare providers, patients and parents 
concerned with the health and welfare of women, children, families, and 
people with disabilities. We are pleased to support the extraordinary 
work of the Eunice Kennedy Shriver National Institute of Child Health 
and Human Development (NICHD).
    Since its establishment in 1963, NICHD has achieved great success 
in meeting the objectives of its broad biomedical and behavioral 
research mission, which includes research on child development before 
and after birth; maternal, child, and family health; learning and 
language development; women's health and reproductive biology; 
population issues; and medical rehabilitation. With sufficient 
resources, NICHD could build upon the promising initiatives described 
in this testimony and produce new insights into human development and 
solutions to health and developmental problems throughout the world, 
including for women, children and families in your districts. 
Scientific breakthroughs supported by NICHD serve to prevent and treat 
many of the Nation's most devastating health problems including infant 
mortality and low birthweight, birth defects, intellectual and 
developmental disabilities, and the reproductive and gynecologic health 
of women throughout their lifespan, among others. Some of these 
research areas are described below.
    Preterm Birth.--NICHD supports a comprehensive research program to 
study the causes of preterm birth and prevention strategies and 
treatment regimens. Pre-term birth costs our Nation $26 billion 
annually and is a leading cause of infant mortality and intellectual 
and physical disabilities. Continued prioritization of extramural 
preterm birth prevention research, the Maternal-Fetal Medicine Units 
Network, the Neonatal Research Network and intramural research program 
related to prematurity are necessary to further this work. Resources 
also should be available to support transdisiplinary science as 
recommended in NICHD's Scientific Vision to study and identify the 
complex causes of preterm birth.
    NICHD supports research on the causes of preterm birth with the 
goal of discovering effective ways to prevent it. In the U.S., the rate 
of preterm birth is approximately 12 percent, one of the highest rates 
in all industrialized countries, resulting in neonatal death, infant 
mortality and severe neurological disability, including cerebral palsy, 
mental retardation, and visual/auditory problems. Preterm birth also 
significantly impacts families emotionally and financially. Although 
research has identified some factors that influence preterm birth 
(e.g., multiple gestation, infections, diabetes, high blood pressure), 
it cannot be fully explained by physical health. There is growing 
evidence of the role of psychological factors such as pregnancy-related 
anxiety and stress, behavioral issues such as substance abuse, and 
sociological issues such as cultural disparities. Thus, support is 
needed for research on the complex interaction of factors including 
psychological, behavioral, social, and environmental factors in 
addition to genetic and biological influences, with the ultimate goal 
of developing efficacious interventions to decrease this country's 
epidemic of babies being born far too soon.
    National Children's Study (NCS).--The NCS is the largest and most 
comprehensive study of children's health and development ever planned 
in the United States. The Friends of NICHD thank the Committee for its' 
longstanding support of the NCS. The Friends look forward to roll-out 
of the main study that includes a science-based design and recruitment 
strategy. When fully implemented, this study will inform the work of 
scientists in universities and research organizations, helping them 
identify precursors to disease and to develop new strategies for 
prevention and treatment. Identifying the root causes of many childhood 
diseases and conditions, including preterm birth, developmental delay, 
asthma, obesity, heart disease, injury and diabetes, will reduce 
healthcare costs and improve the health of children. NCS also provides 
an opportunity to collect data on social and behavioral aspects of 
child and adolescent health, such as important information on the 
sexual and reproductive health of adolescents
    Contraceptive Research and Development.--NICHD's Contraceptive 
Discovery and Development Branch supports basic, applied and clinical 
research on contraceptive methods, including mechanisms of action, the 
effects of contraceptive hormones and drugs, and optimal formulations 
of contraceptive agents. Through its investment in contraceptive 
evaluation research, NICHD plays a key leadership role in ensuring 
acceptability and effective use of existing products in various 
settings and populations and in addressing behavioral issues related to 
fertility and contraceptive use. Specific opportunities and research 
priorities in the area of contraceptive evaluation include evaluation 
of the safety and effectiveness of hormonal contraceptive options for 
women who are overweight or obese. The Institute's investment in 
contraceptive research and development is critical for producing new 
contraceptive modalities that are more effective, affordable, 
acceptable, and easier to deliver, by, for example, offering couples 
options with fewer side-effects and addressing women's other concerns 
about contraceptive use. Specific opportunities and research priorities 
in the area of contraceptive research and development include the need 
for non-hormonal contraception, pericoital contraception, and 
multipurpose prevention technologies that would prevent both pregnancy 
and sexually transmitted infections.
    Reproductive Sciences.--Through its investment in reproductive 
science, NICHD conducts research to improve women's health by 
developing innovative medical therapies and technologies and improving 
existing treatment options for gynecological conditions affecting 
overall health and fertility. The Institute's reproductive science 
research makes a vital contribution to women's health by focusing on 
serious conditions that have been overlooked and underfunded, despite 
the fact that they impact many women. Future work could focus on 
infertility research into the need for treatments for disorders such as 
endometriosis, polycystic ovarian syndrome (PCOS) and uterine fibroids 
which can prevent couples from achieving desired pregnancies.
    Pelvic Floor Disorders Network (PFDN).--Female pelvic floor 
disorders (PFD) represent an under-appreciated but major public health 
burden with high prevalence, impaired quality of life and substantial 
economic costs affecting approximately 25 percent of American women. 
The PFDN is conducting research to improve treatment of these extremely 
painful gynecological conditions. Current research is aimed at 
improving female urinary incontinence outcome measures and ensuring 
high quality patient-centered outcomes.
    Development of the Research Workforce.--Adequate levels of research 
require a robust research workforce. The years of training combined 
with uncertainty in getting grant funding are huge disincentives for 
students considering a career in bio-medical research. This has 
resulted in a huge gap between the too-few women's reproductive health 
researchers being trained and the immense need for research. NICHD's 
Women's Reproductive Health Research (WRHR) Program and Reproductive 
Scientist Development Program (RSDP), both aimed at obstetrician-
gynecologists to further their education and experience in basic, 
translational, and clinical research, provide training grants to 
hundreds of researchers and provide new insight into a host of 
diseases, such as ovarian cancer. Continued investment in these 
training programs is critical to helping ensure future scientific 
advances in women's health research.
    Population Research.--The NICHD Population Dynamics branch supports 
a diverse portfolio of scientific research and research training 
programs, exploring the social, economic and health-related impacts of 
population change on families, children, and communities. The branch is 
well respected for investing wisely in the development of longitudinal, 
representative surveys, providing scientists with reliable data that 
can be used to examine the influence of early life course events on 
long-term health and achievement outcomes in particular. As an example, 
in 2012, NICHD-supported demographers using data from the Panel Study 
of Income Dynamics survey found that growing up in poor neighborhoods 
throughout the entire childhood life course can have a devastating 
effect on educational attainment. In another study, using data from the 
National Study of Adolescent Health, researchers found that women who 
are overweight or obese years during the transition from adolescence to 
adulthood are more likely to later deliver babies with a higher birth 
weight, putting the next generation at a higher risk of obesity-related 
health outcomes.
    Sex Differences in Research.--The Friends encourages NICHD to look 
at ways to increase data reporting to address gaps in gender and sex 
differences in research. Sex differences need to be acknowledged as a 
critical biological variable. In addition to including more women in 
clinical research, we believe sex differences should be included as 
part of the design of all basic biological studies and clinical 
research. If the researchers were to consider sex differences in the 
design of basic science studies, and incorporate data on sex as a 
biological variable in animal and human studies, more appropriate 
conclusions could be drawn from basic research, and clinical research 
would provide more representative data on safety and efficacy of drug.
    Clinical Trials in Pregnant Women.--Pregnant women have 
historically been excluded from most research trials due to concern 
that trial participation could harm the fetus. Although there has been 
substantial progress in the inclusion of women in federally funded 
research, pregnant women are still excluded, even from research that 
would advance our knowledge of medical conditions and treatments in 
pregnancy. Mindful of the important considerations of clinical trials 
on pregnant women, we support establishment of a Federal work group to 
propose how clinical research might be done appropriately in this area.
    Data on Pediatric Enrollment in NIH Trials.--NIH policy mandates 
the inclusion of women, minorities, and children in clinical trials 
whenever appropriate. While NIH collects enrollment data on sex/gender 
and race, it does not collect enrollment data broken down by age. We 
urge NIH, with leadership from NICHD, to improve data collection and 
reporting on pediatric enrollment sufficient to determine if children 
are appropriately represented in trials with relevance to child health.
    Best Pharmaceuticals for Children Act (BPCA).--NICHD funds 
meaningful research into pediatric pharmacology through the BPCA 
program. This program provides for the study of drug products that are 
important to children but have been inadequately studied in pediatric 
populations. We urge continued funding and support for this important 
research, as well as for training the next generation of pediatric 
clinical investigators.
    Brain Development.--Research on learning disabilities--neurological 
disorders that can make it difficult to acquire certain academic and 
social skills--shows that they can be prevented through effective 
evidence-based programs in school and that when children improve their 
reading and math skills, brain function normalizes.
    Rehabilitation Science.--The National Center for Medical 
Rehabilitation Research (NCMRR) currently resides within NICHD, yet 
there is a strong need for elevating the stature of NCMRR. We recommend 
moving the NCMRR to an independent Institute or Center reporting 
directly to the NIH Director, or to establish a new Office of 
Rehabilitation Research within the Office of the NIH Director. 
Implementation of this structural recommendation would require a 
statutory change. Elevation of NCMRR has been viewed from the start as 
a critical step in achieving sufficient critical mass to coordinate 
rehabilitation science across all the Independent Centers at NIH that 
conduct and support research directly addressing or related to 
rehabilitation science.
    These research efforts have made significant contributions to the 
well-being of all Americans, but there is still much to discover. We 
support the NICHD's recently released Scientific Vision and urge you to 
support NICHD at funding levels that meet current needs for addressing 
health issues across the lifespan. Thank you for your consideration and 
we look forward to working with you on these critical issues.
                                 ______
                                 
 Prepared Statement of the Friends of the National Institute of Dental 
                       and Craniofacial Research
    Mr. Chairman, Ranking Member, and distinguished Members of the 
Subcommittee, the members of the Friends of the National Institute of 
Dental and Craniofacial Research (FNIDCR), a leading broad-based 
consortium of individuals, academic institutions, patient advocate 
groups, dental societies, and corporations, that understands the 
importance of dental, oral and craniofacial health to our society, are 
requesting fiscal year 2015 funding under section 301 and Title IV of 
the Public Health Service Act for the National Institute of Dental and 
Craniofacial Research (NIDCR) to be appropriated at a recommended level 
of 1.33 percent of the National Institutes of Health's (NIH's) total 
fiscal year 2015 funding level.
    The fiscal year 2014 level enacted by the omnibus bill is $398.65 
million for NIDCR. After transfers, NIDCR's total amount for obligation 
in fiscal year 2014 is $397.10 million. President Barack Obama's fiscal 
year 2015 budget proposal for NIDCR, $397.13, is at best stagnate if 
compared to total obligations, and at worse, a decrease of $1,519,000 
if compared to the level Congress appropriated in the fiscal year 2014 
omnibus bill. The end result is ongoing diminished grant opportunities 
that will only discourage young and talented researchers. Also, 
stagnated funding means NIDCR will not be able to keep up with the 
increasing rate of medical inflation.
Background
    From 1998 to 2011, NIDCR's percentage of total NIH funding 
decreased from 1.53 percent to 1.33 percent, its lowest percentage, 
amid a period when NIH's budget doubled. Save for a slight bump in 
2012, this percentage remains at 1.33 percent. The Friends of NIDCR has 
been working to reverse this troublesome trend--and return NIDCR 
research to a percentage of total NIH funding that is more appropriate 
and proper. For fiscal year 2014, NIDCR's percentage of total NIH 
funding is 1.33 percent.
  --If Congress enacts the president's fiscal year 2015 budget figures 
        for NIH and NIDCR, then NIDCR's percentage of total NIH funding 
        would be at an all-time low, 1.31 percent.
    The Friends of NIDCR would welcome the opportunity to work with 
members of this Subcommittee to ensure NIDCR funding realizes a 
percentage of total NIH funding that is appropriate, yet realistic. The 
research performed by NIDCR justifies this approach. This is why the 
Friends of NIDCR recommends a modest increase in NIDCR's percentage of 
total NIH funding for fiscal year 2015 of 1.33 percent based upon the 
president's fiscal year 2015 budget request. This is also a consistent 
recommendation based upon the level enacted by Congress for fiscal year 
2014.
NIDCR: A Renown Leader in Research
    For 66 years, NIDCR has been the leading sponsor of research and 
research training in biomedical and behavioral sciences. Its mission is 
to ``improve oral, dental and craniofacial health through research, 
research training, and the dissemination of health information.''
    NIDCR meets its mission by:
  --Performing and supporting basic and clinical research;
  --Conducting and funding research training and career development 
        programs to ensure an adequate number of talented, well-
        prepared and diverse investigators is sustained;
  --Coordinating and assisting relevant research and research-related 
        activities among all sectors of the research community; and
  --Promoting the timely transfer of knowledge gained from research and 
        its implications for health to the public, health 
        professionals, researchers, and policy-makers.
    In addition, NIDCR's Gold Standard Peer Review System ensures that 
taxpayers' dollars are being utilized in a wise, effective and 
productive manner.
NIDCR Research Benefits All Americans
    Proper Federal funding of NIDCR will transform the future of 
medical and dental practice to the benefit of our society and ease the 
burden on our Nation's healthcare system. Examples of where NIDCR 
research has and will benefit society are:
    Tooth Decay: Fluorides and sealants have cut the rate of the number 
of American adults, aged 45 and older, who are without teeth by more 
than half since the 1950s. Government investment in oral health 
research saved Americans $3 for every $1 invested.
    Oral Cancer Detection: Oral cancer affects 38,000 Americans each 
year and approximately 22 Americans die each day from it. Survival 
rates are among the lowest of all the major cancers. It is difficult to 
detect and hard to predict its outcome. However, if detected in early 
stages, the 5-year survival rate is 83 percent. NIDCR-supported 
research has yielded initial success with developing new diagnostic 
techniques that can lead to early detection and life-saving 
interventions. For example, oral cancer is the first cancer to have its 
biomarkers mapped using Salivary Diagnostics and the presence of these 
biomarkers resulted in an early diagnosis of oral cancer 93 percent of 
the time. Furthermore, as a testament to scientific discoveries, oral 
researchers have confirmed that oral cancer (traditionally thought of 
as being driven by extensive use of tobacco and alcohol) possesses a 
strong and growing link to Human Papilloma Virus (HPV). HPV is now the 
cause of more oral cancers than smoking. NIDCR supports research aimed 
to gain a clearer take on HPV-related oral cancers, including their 
incidence, risk factors, natural history and biology.
    Craniofacial Biology. Scientists are defining the genetics that 
underlie the formation of the head and skull, and researchers are 
identifying the key areas for craniofacial malformations. For example, 
NIDCR-supported research has detected proteins associated with 
craniosynostosis, which is the premature fusion of a baby's skull bones 
that causes asymmetric skull growth. NIDCR believes this research could 
provide the foundation for the development of early detection methods 
and more effective treatments.
    Genome-wide Association Studies. NIDCR supports the first genome-
wide association studies (``GWAS'') of cleft lip and/or palate and 
dental caries. The studies offer significant potential for 
understanding the molecular and genetic basis of cleft lip and/or 
palate and dental caries with the goal of improving the ability to 
predict and manage them by providing the first comprehensive 
compilation of the biological instructions required to construct the 
middle region of the human face and to define the genetics that create 
its developmental disorders, according to NIDCR. The dental caries GWAS 
revealed areas of the genome that make an individual more likely to 
develop decay. Moreover, NIDCR researchers have identified six areas of 
the genome that may put a person at risk for moderate or severe 
periodontal disease and patients afflicted with Sjogren's Syndrome and 
TMJD can benefit from this program.
    Moreover, NIDCR research benefits millions of Americans with:
  --Periodontal Disease,
  --Chronic Dry Mouth,
  --Chronic Facial and Oral Pain, such as TMJD, and
  --Bone and Cartilage Regeneration.
How NIDCR Research Makes a Difference
    Because Friends of NIDCR is a broad-based coalition of members, we 
are able to share first-hand perspectives from across the spectrum of 
the oral health community.
    The TMJ Association:
    During the past decade, NIDCR-funded research directed toward 
Temporomandibular Disorders has been a ``game changer.'' Previously 
thought to be a condition about teeth and jaws, research has 
demonstrated that this is a complex condition mediated by genes, sex, 
age, and epigenetics. We now also know that for many, TMD is a chronic 
pain condition and that in addition these patients also present with 
other comorbid pain conditions that co-occur more than by chance. These 
findings have truly revolutionized the way that these conditions are 
researched and will ultimately be treated. It is important to note that 
the National Institutes of Health are the only sources of funding of TM 
Disorders in the United States. We rely on their resources to improve 
the healthcare and quality of life for the 35 million TMJ patients in 
this country. Our hope is in science and the NIH, through its 
Institutes such as NIDCR, provides us with that hope.
    Ostrow School of Dentistry of the University of Southern 
California:
    NIDCR funding is essential to the success of several areas of 
research at USC that directly impact millions of people in the U.S. and 
worldwide. First, thanks to the NIDCR, we have made progress in 
understanding cleft lip and palate, craniosynostosis, and other birth 
defects of the craniofacial region. According to the CDC, the lifetime 
cost of treating the children born each year in the U.S. with cleft lip 
or palate is $697 million. Every day, our researchers come closer to 
better treatments and preventive measures to help reduce this cost and 
improve quality of life. Moreover, we are working to leverage the 
dramatic potential of stem cells to regenerate bone and other tissues 
that may be lost due to birth defects, trauma, or disease. The NIDCR 
also funds our efforts to prevent dental caries, which is a major 
global health concern affecting 92 percent of American adults. Finally, 
the NIDCR supports our community outreach program in California's 
diverse population, through which we are investigating how to improve 
oral health for everyone in America.
Research Drives the Economy, Innovates
    Despite the fact 54 percent of Americans thought Federal spending 
for medical and health research should be exempt from across-the-board 
cuts outlined in the Budget Control Act of 2011 \1\, the ramifications 
of sequestration still linger. However, Friends of NIDCR maintains that 
investment in medical research powers our innovation economy and 
provides life-saving treatments and cures. For example, a typical NIH 
grant supports the salaries of about seven high-tech jobs. Moreover, 
cuts or stagnate funding will only set the U.S. back at a time when 
other countries are rapidly increasing investment in research. Eighty-
five percent of likely voters are concerned about the impact of a 
decreased Federal investment in research, including the possibility of 
scientists leaving their profession or moving abroad to countries with 
a stronger investment in research.\2\ NIDCR-funded grants contribute to 
our Nation's economy and keep scientists from looking abroad for work. 
fiscal year 2013 NIDCR-funded grants had a presence in 120 
congressional districts (often multiple awards for a congressional 
district) in 43 States and territories. This equates to 75 percent of 
NIDCR-funded research being distributed to grantees at universities, 
dental schools, and medical schools, primarily in the U.S. Therefore, a 
significant portion of NIDCR-funded research occurs away from the NIH 
campus. However, this nationwide NIDCR presence will surely decline 
with decreased investment in research.
---------------------------------------------------------------------------
    \1\ ``More than Half of Americans Doubt U.S. Global Leadership in 
2020,'' Research!America press release, March 14, 2012, http://
www.researchamerica.org/release --14march12--poll.
    \2\ 2 Ibid.
---------------------------------------------------------------------------
Health Disparities Research Program
    Finally, through the NIDCR Health Disparities Research Program, a 
difference is being made in meeting the health needs of our Nation's 
low-income, underserved, and high-risk populations. Sadly, this need 
was made apparent with the tragic passing of 12-year-old Deamonte 
Driver who died from a tooth infection in 2007. As a result of the 
program, tailored interventions to prevent dental caries and oral 
cancer are being tested in community settings such as urban public 
housing, community health centers, rural Project Head Start centers, 
low-income senior housing facilities, and primary medical care offices.
                             recommendation
    Eighty-five percent of Americans are concerned about stagnate 
funding for medical research.\3\ Proper funding of medical and health 
research is essential to the overall health and well-being of our 
fellow Americans. We firmly contend that medical discoveries and 
advances from NIDCR funding lead to improvements in dental practices 
and change the scope of public health policies across the Nation. 
Whether it is detecting a clear link between bacteria in the mouth and 
heart disease--or discovering early stages of oral cancer--or searching 
for breakthroughs to help combat facial and oral pain--we all benefit 
when we make NIDCR a priority. Therefore, based upon the merits of the 
research conducted by NIDCR, and its demonstrated benefits to the lives 
of countless Americans, we respectfully request the Subcommittee to 
fund NIDCR at 1.33 percent of NIH's funding level, so that it can 
realize the full potential of its worthy mission and sustain its 
beneficial scientific research.
---------------------------------------------------------------------------
    \3\ ``America Speaks,'' Poll Data Summary Volume 13, 
Research!America, http://www.researchamerica.org/uploads/
AmericaSpeaksV13.pdf.
---------------------------------------------------------------------------
    Thank you for the opportunity to present our written testimony 
before the Subcommittee.

    [This statement was submitted by Christian Stohler, D.D.S., 
DrMedDent, President, Friends of the National Institute of Dental and 
Craniofacial Research.]
                                 ______
                                 
  Prepared Statement of the Friends of the National Institute on Drug 
                                 Abuse
    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to submit testimony to the Subcommittee in support of the 
National Institute on Drug Abuse (NIDA). The Friends of the National 
Institute on Drug Abuse is a coalition of over 150 scientific and 
professional societies, patient groups, and other organizations 
committed to preventing and treating substance use disorders as well as 
understanding their causes through the research agenda of the National 
Institute on Drug Abuse (NIDA).
    We are pleased to provide testimony in support of the work carried 
out by scholars around the country whose work is supported by NIDA. 
Recognizing that so many health research issues are inter-related, we 
request that the subcommittee provide at least $32 billion for the 
National Institutes of Health (NIH) and within that amount a 
proportionate increase for the National Institute on Drug Abuse, in 
your Fiscal 2015 Labor, Health and Human Services, Education and 
Related Agencies Appropriations bill. We also respectfully request the 
inclusion of the following NIDA specific report language.
    Marijuana Research. Efforts to legalize or ``medicalize'' marijuana 
continue across the United States. The Committee understands that 
research from different areas of science is converging on the fact that 
regular marijuana use by young people can have a long-lasting negative 
impact on the structure and function of their brains, resulting in 
lower educational achievement, reduced IQ, etc. Research clearly 
demonstrates that marijuana has the potential to cause problems in 
daily life or make a person's existing problems worse. NIDA is 
encouraged to continue to fund research on preventing and treating 
marijuana abuse and addiction, and the possible health and policy 
implications of proposals to implement ``medical marijuana'' or 
marijuana legalization programs across the U.S.
    Opiate Abuse and Addiction. The Committee is concerned about the 
continued crisis of prescription drug abuse in the U.S. In particular, 
the June 2011 IOM report on pain indicates that abuse and misuse of 
prescription opioid drugs resulted in an annual estimated cost to the 
nation of $72,500,000,000. Further, the Committee is very concerned 
with the potential rise in heroin abuse and addiction as a result of 
successful efforts to combat the prescription drug side of this issue. 
The Committee urges NIDA to 1) continue funding research on medications 
to alleviate pain, including the development of pain medications with 
reduced abuse liability; 2) as appropriate, work with private companies 
to fund innovative research into such medications; and 3) report on 
what we know regarding the transition from opiate analgesics to heroin 
abuse and addiction within affected populations.
    Medications Development. The Committee recognizes that next-
generation pharmaceuticals will surely take advantage of new 
technologies. In the context of NIDA funding, chief among these are 
NIDA's current approaches to develop viable immunotherapeutic or 
biologic (e.g., bioengineered enzymes) approaches for treating 
addiction. The goal of this active area of research is the development 
of safe and effective vaccines or antibodies that target specific 
drugs, like nicotine, cocaine, and heroin, or drug combinations. The 
Committee is excited by this approach--if successful, immunotherapies, 
alone or in combination with other medications, behavioral treatments, 
or enzymatic approaches, stand to revolutionize how we treat, and, 
maybe even someday, prevent addiction. The Committee looks forward to 
hearing more about work in this area.
    Nurturing Talent and Innovation in Research. The Committee commends 
NIDA for its continued support of innovative research on drug addiction 
and related health problems such as pain and HIV/AIDS, and the 
Institute's effort to be at the forefront of training the next 
generation of innovative researchers. The 6 year-old Avant-Garde award 
is a good example of a program that stimulates high-impact research 
that could lead to groundbreaking opportunities for the prevention and 
treatment of HIV/AIDS in drug abusers. The Committee understands that 
NIDA is now crafting a new kind of award, which would blend NIH's 
Pioneer and New Innovator award mechanisms. This new opportunity, 
called ``AVENIR'' awards, is designed to attract creative young 
investigators into HIV/drug abuse public health research. The Committee 
strongly supports this effort, and asks the Institute to report on its 
progress in future appropriations and related requests.
    Research to Assist Military Personnel, Veterans, and Their 
Families. The Committee recognizes the significant health challenges, 
including substance abuse and addiction, faced by military personnel, 
veterans, and their families. Many of these individuals need help 
confronting war-related problems including traumatic brain injury, 
PTSD, depression, anxiety, sleep disturbances, and substance abuse and 
addiction. The Committee commends NIDA for its successful efforts to 
coordinate and support research with the Department of Veterans 
Affairs, Department of Defense, and other NIH Institutes focusing on 
these populations, and strongly urges NIDA to continue work in this 
area.
    Raising Awareness and Engaging the Medical Community in Drug Abuse 
and Addiction Prevention and Treatment. The Committee is very pleased 
with NIDAMed, an initiative designed to reach out to physicians, 
physicians in training, and other healthcare professionals. The 
Committee urges the Institute to continue its focus on activities to 
provide physicians and other medical professionals with the tools and 
skills needed to incorporate drug abuse screening and treatment into 
their clinical practices.
    Drug abuse is costly to Americans; it ruins lives, while tearing at 
the fabric of our society and taking a huge financial toll on our 
resources. Beyond the unacceptably high rates of morbidity and 
mortality, drug abuse is often implicated in family disintegration, 
loss of employment, failure in school, domestic violence, child abuse, 
and other crimes. Placing dollar figures on the problem; smoking, 
alcohol and illegal drug use results in an exorbitant economic cost on 
our nation, estimated at over $600 billion annually. We know that many 
of these problems can be prevented entirely, and that the longer we can 
delay initiation of any use, the more successfully we mitigate future 
morbidity, mortality and economic burdens.
    Over the past three decades, NIDA-supported research has 
revolutionized our understanding of addiction as a chronic, often-
relapsing brain disease --this new knowledge has helped to correctly 
situate drug addiction as a serious public health issue that demands 
strategic solutions. By supporting research that reveals how drugs 
affect the brain and behavior and how multiple factors influence drug 
abuse and its consequences, scholars supported by NIDA continue to 
advance effective strategies to prevent people from ever using drugs 
and to treat them when they cannot stop.
    NIDA supports a comprehensive research portfolio that spans the 
continuum of basic neuroscience, behavior and genetics research through 
medications development and applied health services research and 
epidemiology. While supporting research on the positive effects of 
evidence-based prevention and treatment approaches, NIDA also 
recognizes the need to keep pace with emerging problems. We have seen 
encouraging trends--significant declines in a wide array of youth drug 
use--over the past several years that we think are due, at least in 
part, to NIDA's public education and awareness efforts. However, areas 
of significant concern include the recent increase in lethalities due 
to heroine, as well as the continued abuse of prescription opioids and 
the recent increase in designer drugs availability and their 
deleterious effects. The need to increase our knowledge about the 
effects of marijuana is most important now that decisions are being 
made about its approval for medical use and/or its legalization. We 
support NIDA in its efforts to find successful approaches to these 
difficult problems.
    The Nation's previous investment in scientific research to further 
understand the effects of abused drugs on the body has increased our 
ability to prevent and treat addiction. As with other diseases, much 
more needs be done to improve prevention and treatment of these 
dangerous and costly diseases. Our knowledge of how drugs work in the 
brain, their health consequences, how to treat people already addicted, 
and what constitutes effective prevention strategies has increased 
dramatically due to support of this research. However, since the number 
of individuals continuing to be affected is still rising, we need to 
continue the work until this disease is both prevented and eliminated 
from society.
    We understand that the fiscal year 2015 budget cycle will involve 
setting priorities and accepting compromise, however, in the current 
climate we believe a focus on substance abuse and addiction, which 
according to the World Health Organization account for nearly 20 
percent of disabilities among 15-44 year olds, deserves to be 
prioritized accordingly. We look forward to working with you to make 
this a reality. Thank you for your support for the National Institute 
on Drug Abuse.
                                 ______
                                 
              Prepared Statement of the FSH Society, Inc.
    Honorable Chairwoman Mikulski and Ranking Member Harkin, thank you 
for the opportunity to submit this testimony. Facioscapulohumeral 
muscular dystrophy (FSHD), is one of the most common adult muscular 
dystrophies with a prevalence of 1:15,000--1:20,000.\1 2\ For a half-
million men, women, and children worldwide the major consequence of 
inheriting this genetic form of muscular dystrophy is a lifelong 
progressive loss of all skeletal muscles. FSHD is a crippling and life 
shortening disease. No one is immune. It is both genetically and 
spontaneously transmitted to children. It can affect multiple 
generations and entire families.
---------------------------------------------------------------------------
    \1\ Flanigan KM, et al. Genetic characterization of a large, 
historically significant Utah kindred with facioscapulohumeral 
dystrophy. Neuromuscul Disorders 2001;11:525--529.
    \2\ Mostacciuolo ML, et al. Facioscapulohumeral muscular dystrophy: 
epidemiologicaland molecular study in a north-east Italian population 
sample. Clinical Genetics 2009;75:550--555.
---------------------------------------------------------------------------
    With FSHD there is a loss of muscle strength that ranges between 
one and 4 percent a year during a lifetime. In terms of functional 
impairment, 20 percent of FSHD-affected individuals over age fifty will 
require the use of a wheelchair. FSHD also has very specific non-
muscular manifestations; hearing-loss, restrictive lung disease, 
supraventricular arrhythmias (rare), and retinal vasculopathy. 95 
percent of individuals with FSHD have the FSHD1 (FSHD1A OMIM: 158900) 
genetic variation--caused by the contraction of DNA macrosatellite 
repeat units, termed D4Z4 repeats, on chromosome 4, leading to the 
release of transcriptional repression of a retrogene (DUX4) believed to 
be associated with the cause of disease. Of the 5 percent of FSHD 
individuals remaining, 80 percent of those are the FSHD2 (FSHD1B OMIM: 
158901) genetic variation--caused by mutations in the SMCHD1 gene on 
chromosome 18 that helps to maintain the structure of the D4Z4 repeats 
on the long arm of chromosome 4.
    The National Institutes of Health (NIH) is the principal source of 
funding of research on FSHD currently at the $5 million level. For 
nearly two decades, this Committee has supported the incremental growth 
in funding for FSHD research. I am pleased to report that this modest 
investment has produced huge scientific returns.
    1. Congress has made a major difference in muscular dystrophy. I 
have testified many times before Congress, nearly fifty. When I first 
testified, we did not know the mechanism of this disease. Now we do. 
When I first testified, we assumed that FSHD was a rare form of 
muscular dystrophy. Now we understand it to be one of the most 
prevalent forms of muscle disease, if not the most prevalent muscle 
disease based on new ways of evaluating the disease clinically within 
families. Congress is responsible for this success, through its 
sustaining support of the NIH and the enactment of the Muscular 
Dystrophy CARE Act. We are aware that MD Care Act does not set the 
amount of spending on FSHD or the other dystrophies at the NIH and we 
recognize that funding levels are determined in the appropriations 
process and the numbers of grant applications received and funded by 
the NIH on FSHD. Even though it is a technically separate legislative 
process, the reauthorization of the MD Care Act does raise the 
visibility of all the muscular dystrophies which can be of help in the 
appropriations process--and we thank you for your support of the MD 
Care Act. Further, we recognize and feel at this time in FSHD research 
that there are additional efforts and pathways that Congress can 
request and the NIH can enact to increase the amount of research 
funding on FSHD in the NIH portfolio that neither increases the NIH 
budget required nor takes money from another area of research.
    2. Quantum leaps in our understanding of FSHD have occurred in past 
three and a half years. The past three and a half years have seen 
remarkable contributions made by researchers funded by NIH.
  --On August 19, 2010, American and Dutch researchers published a 
        paper which dramatically expanded our understanding of the 
        mechanism of FSHD.\3\ A front page story in the New York Times 
        quoted the NIH Director Dr. Francis Collins saying, ``If we 
        were thinking of a collection of the genome's greatest hits, 
        this would go on the list.'' \4\
---------------------------------------------------------------------------
    \3\ Lemmers, RJ, et al, A Unifying Genetic Model for 
Facioscapulohumeral Muscular Dystrophy Science 24 September 2010: Vol. 
329 no. 5999 pp. 1650-1653.
    \4\ Kolata, G., Reanimated `Junk' DNA Is Found to Cause Disease. 
New York Times, Science. Published online: August 19, 2010 http://
www.nytimes.com/2010/08/20/science/20gene.html.
---------------------------------------------------------------------------
  --Two months later, another paper was published that made a second 
        critical advance in determining the cause of FSHD.\5\ The 
        research shows that FSHD is caused by the inefficient 
        suppression of a gene that may be normally expressed only in 
        early development.
---------------------------------------------------------------------------
    \5\ Snider, L., Geng, L.N., Lemmers, R.J., Kyba, M., Ware, C.B., 
Nelson, A.M., Tawil, R., Filippova, G.N., van der Maarel, S.M., 
Tapscott, S.J., and Miller, D.G. (2010). Facioscapulohumeral dystrophy: 
incomplete suppression of a retrotransposed gene. PLoS Genet. 6, 
e1001181.
---------------------------------------------------------------------------
  --On January 17, 2012, an international team of researchers based out 
        of Seattle discovered a stabilized form of a normally 
        suppressed gene called DUX4 required to develop chromosome 4 
        linked FSHD.\6\
---------------------------------------------------------------------------
    \6\ Geng et al., DUX4 Activates Germline Genes, Retroelements, and 
Immune Mediators: Implications for Facioscapulohumeral Dystrophy, 
Developmental Cell (2012), doi:10.1016/j.devcel.2011.11.013.
---------------------------------------------------------------------------
  --Six months later, another high profile paper produced by a Senator 
        Paul A. Wellstone Cooperative Research Center of the NIH, used 
        sufficiently ``powered'' large collections of genetically 
        matched FSHD cell lines generated by the NIH center that are 
        both unique in scope and shared with all researchers worldwide, 
        to improve on the Seattle group's finding by postulating that 
        DUX4-fl expression is necessary but not sufficient by itself 
        for FSHD muscle pathology.\7\ This work was also supported by a 
        NIH cooperative research center grant mandated by MD CARE Act.
---------------------------------------------------------------------------
    \7\ Jones TI, et al, Facioscapulohumeral muscular dystrophy family 
studies of DUX4 expression: evidence for disease modifiers and a 
quantitative model of pathogenesis. Hum Mol Genet. 2012 Oct 
15;21(20):4419-30. Epub 2012 Jul 13.
---------------------------------------------------------------------------
  --On July 13, 2012, a team of researchers from the, United States, 
        Netherlands and France identified mutations in a gene causing 
        80 percent of another form of FSHD. This paper furthers our 
        understanding of the molecular pathophysiology of FSHD. This 
        work too was supported in part by a program project grant from 
        NIH.\8\
---------------------------------------------------------------------------
    \8\ Lemmers, RJ, et al, Digenic inheritance of an SMCHD1 mutation 
and an FSHD-permissive D4Z4 allele causes facioscapulohumeral muscular 
dystrophy type 2. Nat Genet. 2012 Dec;44(12):1370-4. doi: 10.1038/
ng.2454. Epub 2012 Nov 11.
---------------------------------------------------------------------------
  --In 2013 and continuing into 2014, papers have been published 
        clearly documenting functional impairment in FSHD, clinical and 
        genetic features of hearing loss FSHD, restrictive lung disease 
        and respiratory insufficiency, Coats syndrome and vision loss 
        in FSHD, high-throughput screening that identify inhibitors of 
        DUX4-induced myoblast toxicity, better definition of epigenetic 
        features of FSHD, Pain and FSHD, MRI/MRS studies, biomarkers 
        for FSHD, the demonstration that although the transcription of 
        the toxic protein DUX4 occurs in only a limited number of 
        nuclei, the resulting protein diffuses into nearby nuclei 
        within the myotubes, thus spreading aberrant gene expression 
        throughout a muscle, to name a few.
    Many of these researchers have started their efforts in FSHD with 
seed funding from the FSH Society and have received continued support 
from the FSH Society, the NIH, and the Muscular Dystrophy Association 
and other partners.
    3. Remarkable progress in FSHD research and the need to keep moving 
forward. Last October, nearly 100 researchers from around the world 
gathered under the direction of Massachusetts Institute of Technology 
professor, David Housman, PhD, Chair of the FSH Society's Scientific 
Advisory Board, at the David H. Koch Center for Integrative Cancer 
Research on the campus of M.I.T. for the annual FSH Society 
International Research Consortium meeting; there was a palpable feeling 
of FSHD research having ``arrived'' in the big time. The general 
discussion of day two covered four major areas. With respect to the 
first area, called DUX4, the unanimous conclusion of the general 
discussion was that over-expression of the toxic transcription factor 
DUX4 is at the root of FSHD1 and FSHD2 and that DUX4 expression is 
necessary but not always sufficient to cause FSHD. Research should 
focus on upstream and downstream molecular pathways and mechanisms as 
they form the most plausible intervention targets. The group also 
discussed needs and priorities in three additional areas: disease 
models, intervention, clinical studies and trial readiness. The 
priorities stated for 2014, at the October 21-22, 2013, FSH Society 
FSHD IRC meetings are as follows: \9\
---------------------------------------------------------------------------
    \9\ 2013 FSH Society FSHD International Research Consortium, held 
October 22-23, 2013 co-sponsored by DHHS NIH NICHD University of 
Massachusetts School of Medicine Senator Paul D. Wellstone MD CRC for 
FSHD. To read the expanded summary and recommendations of the group 
see: http://www.fshsociety.org/pages/sciConsortium.html.
---------------------------------------------------------------------------
  --The DUX4 interactome
  --Understanding DUX4 manifestation and variation
  --Additional genetic heterogeneity; non-FSHD1 and FSHD2
  --Disease models
  --Well documented natural history with reliable endpoints; modulating 
        mechanisms/genes
  --Increasing data depth of patient databases with extensive (follow-
        up) clinical data
  --Prepare for clinical trials: reliable and meaningful outcome 
        measures; with access to discreet patient populations and 
        disease mechanism of action classes.
  --Therapy; proof-of-principle experiments
  --Focus on translational research; from clinic to bench and back
  --Understanding pathophysiology of FSHD: connection to DUX4, 
        heterogeneity, asymmetry, role of inflammation; infiltrates and 
        etiology
    Given the recent developments, there is a need to ramp up the 
preclinical enterprise and build/organize infrastructure needed to 
conduct clinical trials. Our immediate priorities should be to confirm 
the new hypotheses and targets. We need to be prepared for this new era 
in the science of FSHD. Many leading experts are now turning to work on 
FSHD not only because it is one of the most complicated and challenging 
problems seen in science, but because it represents the potential for 
great discoveries, insights into stem cells, transcriptional processes, 
new ways of thinking about disease of epigenetic etiology, and for 
treating diseases.
    4. NIH Funding for Muscular Dystrophy. Mr. Chairman, these major 
advances in scientific understanding and epidemiological surveillance 
are not free. They come at a cost. Since Congress passed the MD CARE 
Act, research funding at NIH for muscular dystrophy has increased 4-
fold. While FSHD research funding has increased 12-fold during this 
period, the level of funding is still anemic and, for FSHD, has been 
astonishingly flat for the past 6 years.

 
                                                                                      [Dollars in millions]
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                           Fiscal Year
                                                               ---------------------------------------------------------------------------------------------------------------------------------
                                                                  2003      2004      2005      2006      2007      2008      2009      2010      2011      2012      2013     2014 e    2015 e
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All MD........................................................      39.1      38.7      39.5      39.9      47.2      56        83        86        75        75        76        78        78
FSHD..........................................................       1.5       2.2       2.0       1.7       3         3         5         6         6         5         5         6         6
FSHD (percent total MD).......................................       4         6         5         4         5         5         6         7         8         7         7         8         8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
FSHD Research Dollars (in millions) and FSHD as a Percentage of Total NIH Muscular Dystrophy Funding.
Sources: NIH/OD Budget Office and NIH OCPL and NIH RCDC RePORT (e = estimate).

    Despite the great success of the past three and a half years in the 
science of FSHD brought about by Congress we are concerned that under 
the current funding environment that new research projects will not be 
funded or existing programs will not be renewed. We have conveyed to 
the NIH leadership at the Office of the Director, NIAMS, NINDS, NICHD, 
NHLBI and the Executive Secretary of the MDCC our grave concern that 
FSHD research is way too under-represented in the NIH portfolio and 
needs a proactive effort on the part of NIH.
    Alan E. Guttmacher, MD., Director, NICHD and chair of the Muscular 
Dystrophy Coordinating Committee (MDCC) recently wrote to me in 
response to a letter I sent to NIH Director, Dr. Francis Collins asking 
for a significant improvement in the overall level of funding for FSHD, 
that though ``it is notable that NIH funding for all forms of muscular 
dystrophy has nearly doubled since the 2006 NIH Action Plan on Muscular 
Dystrophy was released. [and] Since this has been a period of 
relatively flat funding for NIH, increased funding for anyone area 
speaks to the excellent quality of the research applications received 
during that time, and this is true of FSHD research applications where 
funding has almost tripled. We believe that the 2006 Action Plan was 
instrumental in improving coordination among the Institutes and Centers 
at NIH that support research on the muscular dystrophies, so that 
scarce resources are well-spent. We plan to revise the Action Plan this 
year, with a meeting in July to discuss what research opportunities 
have emerged; the goal is to ask the MDCC to approve the revised plan 
at its Fall 2014 meeting.'' While we whole-heartedly agree with these 
statements and we are instrumental and involved in the MD CARE Act and 
most appreciative of all of NIH's efforts and Congress' work in this 
area--we do not however agree on the plus one order of magnitude (x10) 
of difference between muscular dystrophy funding and FSHD funding. 
While all muscular dystrophy increased from $39.9 million to $78 
million; FSHD increased from $1.7 million to $6 million. The economy of 
scale is so different in particular for FSHD, being equally devastating 
and burdensome as the disease receiving the most funding in this 
category, and though it functions in the exact same U.S. Federal 
research infrastructure. NIH needs to redress the imbalance of funding 
in the muscular dystrophy portfolio by fostering opportunities for 
multidisciplinary research on FSHD, a common and complex form of 
dystrophy, commensurate with its prevalence and disease burden. The 
future action plan should address this issue head-on.
    We request for fiscal year 2015, a tripling of the NIH FSHD 
research portfolio to $18 million or a level of approximately 20 
percent of the total muscular dystrophy funding at NIH. This will allow 
an expansion of basic research awards, expansion of post-doctoral and 
clinical training fellowships, dedicated centers to design and conduct 
clinical trials on FSHD and more U.S. DHHS NIH Senator Paul D. 
Wellstone Muscular Dystrophy Cooperative Research Centers.
    Agency: National Institutes of Health (NIH)
    Account: National Institute of Arthritis and Musculoskeletal and 
Skin Diseases (NIAMS), and the National Institute of Neurological 
Disorders and Stroke (NINDS), and the Eunice Kennedy Shriver National, 
Institute of Child Health and Human Development (NICHD)
    Fiscal year 2015 Report Language: The Committee encourages the NIH 
to foster opportunities for multidisciplinary research on 
facioscapulohumeral muscular dystrophy (FSHD), a common and complex 
form of muscular dystrophy, commensurate with its prevalence and 
disease burden. The Committee hopes such advances will be utilized to 
help advance treatments and access to therapies for this grave disease.
    We are aware of the great pressures on the Federal budget, but NIH 
can easily help increase its portfolio on FSHD given the breakneck 
speed of discovery in FSHD. These are easy ways for NIH to convey to 
researchers that it has a revised plan and an interest in funding 
research in FSHD. There are no quotas on peer-reviewed research above 
pay line at the NIH, and NIH can help by issuing written announcements 
that efforts invested in writing FSHD grant applications will be met 
with interest. This is the time to fully and expeditiously exploit the 
advances for which the American taxpayer has paid. Thank you for this 
opportunity to testify before your committee.

    [This statement was submitted by Daniel Paul Perez, President & 
CEO, FSH Society.]
                                 ______
                                 
      Prepared Statement of the GBS/CIDP Foundation International
    Chairman Harkin and distinguished members of the Subcommittee, 
thank you for your time and your consideration of the priorities of the 
community of individuals impacted by Guillain-Barre Syndrome (GBS), 
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), and related 
conditions as you work to craft the fiscal year 2015 Labor, Health and 
Human Services Appropriations Bill.
                           about gbs and cidp
Guillain-Barre Syndrome
    GBS is an inflammatory disorder of the peripheral nerves outside 
the brain and spinal cord. It's also known as Acute Inflammatory 
Demyelinating Polyneuropathy and Landry's Ascending Paralysis.
    The cause of GBS is unknown. We do know that about 50 percent of 
cases occur shortly after a microbial infection (viral or bacterial), 
some as simple and common as the flu or food poisoning. Some theories 
suggest an autoimmune trigger, in which the patient's defense system of 
antibodies and white blood cells are called into action against the 
body, damaging myelin (nerve covering or insulation), leading to 
numbness and weakness.
    GBS in its early stages is unpredictable, so except in very mild 
cases, most newly diagnosed patients are hospitalized. Usually, a new 
case of GBS is admitted to ICU (Intensive Care) to monitor breathing 
and other body functions until the disease is stabilized. Plasma 
exchange (a blood ``cleansing'' procedure) and high dose intravenous 
immune globulins are often helpful to shorten the course of GBS. The 
acute phase of GBS typically varies in length from a few days to 
months, with over 90 percent of patients moving into the rehabilitative 
phase within four weeks. Patient care involves the coordinated efforts 
of a team such as a neurologist, physiatrist (rehabilitation 
physician), internist, family physician, physical therapist, 
occupational therapist, social worker, nurse, and psychologist or 
psychiatrist. Some patients require speech therapy if speech muscles 
have been affected.
    Recovery may occur over 6 months to 2 years or longer. A 
particularly frustrating consequence of GBS is long-term recurrences of 
fatigue and/or exhaustion as well as abnormal sensations including pain 
and muscle aches. These can be aggravated by `normal' activity and can 
be alleviated by pacing activity and rest.
Chronic Inflammatory Demyelinating Polyneuropathy
    CIDP is a rare disorder of the peripheral nerves characterized by 
gradually increasing weakness of the legs and, to a lesser extent, the 
arms.
    It is the gradual onset as well as the chronic nature of CIDP that 
differentiates it from GBS. Fortunately, CIDP is even rarer than GBS. 
The incidence of new cases is estimated to be between 1.5 and 3.6 in a 
million people (compare to GBS: 1-2 in 100,000).
    Like GBS, CIDP is caused by damage to the covering of the nerves, 
called myelin. It can start at any age and in both genders. Weakness 
occurs over two or more months.
    Unlike GBS, CIDP is not self-limiting (with an end to the acute 
phase). Left untreated, 30 percent of CIDP patients will progress to 
wheelchair dependence. Early recognition and treatment can avoid a 
significant amount of disability.
    Post-treatment life depends on whether the disease was caught early 
enough to benefit from treatment options. Patients respond in various 
ways. The gradual onset of CIDP can delay diagnosis by several months 
or even years, resulting in significant nerve damage that may take 
several courses of treatment before benefits are seen. The chronic 
nature of CIDP differentiates long-term care from GBS patients. 
Adjustments inside the home may need to be made to facilitate a return 
to normal life.
                          about the foundation
    The Foundation's vision is that every person afflicted with GBS, 
CIDP, or variants has convenient access to early and accurate 
diagnosis, appropriate and affordable treatments, and dependable 
support services.
    The Foundation's mission is to improve the quality of life for 
individuals and families across America affected by GBS, CIDP, and 
their variants by:
  --Providing a network for all patients, their caregivers and families 
        so that GBS or CIDP patients can depend on the Foundation for 
        support, and reliable up-to-date information.
  --Providing public and professional educational programs worldwide 
        designed to heighten awareness and improve the understanding 
        and treatment of GBS, CIDP and variants.
  --Expanding the Foundation's role in sponsoring research and engaging 
        in patient advocacy.
                             sequestration
    We have heard from the medical research community that 
sequestration and deficit reduction activities have created serious 
issues for Federal funding opportunities and the career development 
pipeline. In order to ensure that research into GBS, CIDP, and related 
disorders can continue to move forward, and, more importantly, to 
ensure that our country is adequately preparing the next generation of 
young investigators, we urge you to avert, mitigate, or otherwise 
eliminate the specter of sequestration. While the Foundation has 
anecdotal accounts of the harms of sequestration, the Federated 
American Societies for Experimental Biology has reported:
  --In constant dollars (adjusted for inflation), the NIH budget in 
        fiscal year 2013 was $6 billion (22.4 percent) less than it was 
        in fiscal year 2003.
  --The number of competing research project grants (RPGs) awarded by 
        NIH has also fallen sharply since fiscal year 2003. In fiscal 
        year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3 
        percent) fewer than in fiscal year 2003.
  --Awards for R01-equivalent grants, the primary mechanism for 
        supporting investigator-initiated research, suffered even 
        greater losses. The number awarded fell by 2,528 (34 percent) 
        between fiscal year 2003 and fiscal year 2013.
    The pay line for some NIH funding mechanisms has fallen from 18 
percent to 10 percent while the average age for a researcher to receive 
their first NIH-funded grant has climbed to 42. These are strong 
disincentives to choosing a career as a medical researcher. Our 
scaling-back is occurring at a time when many foreign countries are 
investing heavily in their biotechnology sectors. China alone plans to 
dedicate $300 million to medical research over the next 5 years; this 
amount is double the current NIH budget over the same period of time. 
Scientific breakthroughs will continue, but America may not benefit 
from the return-on-investment of a robust biotechnology sector. For the 
purposes of economic and national security, as well as public health, 
the Foundation asks that you work with your colleagues to eliminate 
sequestration and recommit to supporting this Nation's biomedical 
research enterprise.
               centers for disease control and prevention
    CIDP is a progressive condition with serious health impacts. 
Patients can end up almost completely paralyzed and on a ventilator. 
The key to limiting serious health impacts is an early and accurate 
diagnosis. The time it takes for a CIDP patient to begin therapy is 
linked to the length of therapy and the seriousness of the health 
impacts. An early diagnosis can mean the difference between a 3 month 
or 18 month hospital stay, or no hospitalization at all. For the 
Federal healthcare system, there is an economic incentive to ensure 
early and accurate diagnosis as longer hospitalizations equate to 
higher costs.
    CDC and NCCDPHP have resources that could be brought to bear to 
improve public awareness and recognition of CIDP and related 
conditions. In order to initiate new, potentially cost-saving programs, 
CDC requires meaningful funding increases to support crucial 
activities.
                     national institutes of health
    NIH hosts a modest research portfolio focused on GBS, CIDP, and 
related conditions. This research has led to important scientific 
breakthroughs and is well positioned to vastly improve our 
understanding of the mechanism behind these conditions. In fact, NINDS, 
NIAID, and the Office of Rare Diseases Research (ORDR) housed within 
NCATS have expressed interest in hosting a State-of-the-Science 
Conference on autoimmune peripheral neuropathies. This conference would 
allow intramural and extramural researchers to develop a roadmap that 
would lead research into these conditions into the next decade. While 
such a conference would not require additional appropriations, the 
Foundation urges you to provide NIH with meaningful funding increases 
to facilitate growth in the GBS, CIDP, and related conditions research 
portfolio.
    Thank you for your time and your consideration of the community's 
requests.
                                 ______
                                 
              Prepared Statement of Girl Scouts of the USA
    As the preeminent leadership development organization for girls, 
Girl Scouts of the USA (Girl Scouts) serves over two million girls each 
year, ages 5 to 17, from every corner of the United States and its 
territories, with value placed on diversity and inclusiveness. We also 
serve nearly 17,000 American girls living outside of the United States 
in over 90 countries. Through our 112 councils and USA Girl Scouts 
Overseas, and more than 800,000 dedicated volunteers, we continue to 
deliver the Girl Scout Leadership Experience (GSLE)--the world's most 
comprehensive and best program for girls' leadership development.
                       building girls leadership
    Girl Scout experiences through GSLE are, as much as possible, girl-
led and encourage hands-on and cooperative learning. Our framework 
specifies 15 outcomes--behaviors, attitudes, skills and values--that 
develop girls of courage, confidence and character. We provide 
significant financial assistance to vulnerable girls who cannot afford 
to pay to belong to Girl Scouts. In many communities, Girl Scouts is 
the single most visible and viable positive choice for these girls as 
opposed to negative behavior. Girl Scouts plays a major role in helping 
girls find their voice in a positive and productive way.
    Women today are well educated but still underrepresented in high-
paying positions and positions of leadership, facing societal barriers 
to leading and achieving success in everything from technology and 
science to business and industry. With this in mind, we need a bold 
policy shift so that girls are able to achieve their full leadership 
potential now and later in life, as women. Girl Scouts is eager to work 
with policymakers to create opportunities and environments that foster 
girls' leadership development.
                             pension relief
    Under Department of Labor, General Provisions, Girl Scouts 
respectfully requests the insertion of the following language as our 
highest priority request:
    Sec.--Election Not To Be Treated as an Eligible Charity Plan.--A 
plan sponsor of an eligible charity plan (as defined in subsection (d) 
of section 104 of the Pension Protection Act of 2006) may elect, 
effective for the first plan year beginning after December 31, 2013, to 
have section 104 of such Act not apply to such plan. In the case of 
such an election, solely for plan years beginning after December 31, 
2013, section 430(c) of the Internal Revenue Code of 1986 and section 
303(c) of the Employee Retirement Income Security Act of 1974 shall 
apply as if such sections had applied to the first two plan years 
beginning after December 31, 2009, and as if the plan sponsor had 
elected to apply section 430(c)(2)(D)(iii) of such Code and section 
303(c)(2)(D)(iii) of such Act with respect to those two plan years.
    The proposed language, which would only affected eligible charities 
and thus should not have an associated cost, would modify the rule 
established by section 202(b) of the Preservation of Access to Care for 
Medicare Beneficiaries and Pension Relief Act of 2010, Public Law 111-
192. The effect of the proposed language is similar in effect to 
section 2 of H.R. 4915, as passed by the Senate in December of 2010, 
which also allowed a plan sponsor of an eligible charity plan not to 
have section 104 of the Pension Protection Act of 2006 apply.
    Girl Scouts organization, on behalf of the millions of girls we 
serve, respectfully requests this technical fix. The language simply 
says that as of 2014, we, and all similarly structured charities, be 
permitted to elect in to the Pension Protection Act funding rules, 
which are the Federal pension rules applicable to corporate America.
In addition to our request pertaining to pension relief, the following 
        are the key policy priority areas where we can offer research 
        and programmatic success stories:
                             stem education
    As the preeminent organization for girls and a leader on informal 
STEM education, Girl Scouts is committed to ensuring that every girl 
has the opportunity to explore and build an interest in science, 
technology, engineering and mathematics. The strength of our Nation 
depends on increasing girls' involvement in STEM, to develop critical 
thinking, problem solving and collaboration skills that are important 
throughout life.
    In 2012, the Girl Scout Research Institute released Generation 
STEM: What Girls Say about Science, Technology, Engineering and Math, 
which found girls are interested in STEM and aspire to STEM careers, 
but need further exposure and education about what STEM careers can 
offer and how STEM can help girls make a difference in the world.
    Among some of Generation STEM's other findings:
  --74 percent of teen girls are interested in the field of STEM and 
        STEM subjects. Girls like the process of learning, asking 
        questions, and problem solving.
  --Girls who are interested in STEM are significantly better students, 
        have higher confidence in their abilities, and higher academic 
        goals.
  --But while 81 percent say they are interested in pursuing STEM 
        careers, only 13 percent say it's their first choice. About 
        half of all girls feel that STEM isn't a typical career path 
        for girls. 57 percent of girls say that if they went into a 
        STEM career, they'd have to work harder than a man just to be 
        taken seriously.
  --African American and Hispanic girls have high interest in STEM, 
        high confidence and work ethic, but say they have fewer 
        supports and less STEM exposure than Caucasian girls.
    Research shows that girl-only settings not only provide a sense of 
belonging, but are more effective environments for personal 
development, including learning new skills and building self-
confidence. In emotionally and physically safe environments, like those 
provided by Girl Scouts, girls partner with positive role models in a 
range of activities not limited by gender stereotypes. Girl Scout 
programs also emphasize partnerships, public education campaigns, 
mentorship programs, career exploration, traditional badges, and 
innovative new programming.
  --As Congress considers consolidations and a redesign of existing 
        Federal STEM programs, we urge you to invest more of a focus on 
        engaging and motivating girls in STEM, in particular girls in 
        underrepresented minorities and at younger ages before their 
        interest wanes in middle school. Strategies include introducing 
        girls to diverse role models and mentors; promoting proven 
        techniques for engaging girls in STEM including, single-gender 
        learning; and, hands-on and experiential learning opportunities 
        in after-school or out-of-school environments.
                           financial literacy
    The world's current economic challenges have made financial 
literacy skills matter now more than ever. Girl Scouts offers a 
financial literacy program at every grade level from K-12. Through our 
Girl Scout financial education programming, girls learn to handle money 
and the basics of budgeting, banking, saving, using credit and planning 
for retirement and even practicing philanthropy.
    Additionally, the Girl Scout Cookie Program is often girls' first 
introduction to business planning and entrepreneurship. The $790 
million Girl Scout Cookie Program is the largest girl-led business in 
the country.
    While lack of financial literacy is a growing concern, relatively 
little research has been conducted on how girls think about and 
experience money and finances. To address this gap, the Girl Scout 
Research Institute recently conducted a study, Having It All: Girls and 
Financial Literacy, with girls and their parents. It found girls need 
and want financial literacy skills to help them achieve their dreams, 
with 90 percent saying it is important for them to learn how to manage 
money; however, just 12 percent of girls surveyed feel very confident 
about making financial decisions.
  --To be successful and sustainable, financial education must begin 
        early, continue throughout elementary and secondary education, 
        and be relevant. And although 93 percent of the public believes 
        all high school students should be required to take a class in 
        financial education, only four States have made a semester-long 
        course in financial literacy a graduation requirement.\1\ In 
        addition to providing teachers with training and materials, we 
        believe policy support for after-school and community-based 
        programs is critical if girls are to learn money-management 
        skills and have real-world financial literacy experiences that 
        will serve them throughout their lives.
---------------------------------------------------------------------------
    \1\ Back to School Survey Shows Americans Want Personal Finance 
Taught in the Classroom, Visa, July 20, 2010.
---------------------------------------------------------------------------
           healthy living--bullying and relational aggression
    As exemplified through our program experience and research, Girl 
Scouts understands the complex issue of healthy living and what 
motivates youth--especially girls--to adopt healthy lifestyles. 
Improving youths' physical health and emotional well-being are not 
mutually exclusive. Youth, especially girls, experience them in an 
interrelated fashion. Girls place the same or even greater emphasis on 
social and emotional health as physical health.
    The Girl Scout Research Institute's original research report, 
Feeling Safe: What Girls Say, found that nearly half (46 percent) of 
girls define safety as not having their feelings hurt, and 
approximately one-third of all girls worry about being teased, bullied, 
threatened, or having their feelings hurt when spending time with 
peers, participating in groups, and trying new things. Our report, The 
New Normal? What Girls Say About Healthy Living, tells us that a girl's 
relationships with her peers are critical components of her health and 
safety.
    Our BFF (Be a Friend First) curriculum is focused on middle-school 
girls and designed to easily integrates into existing health or 
character education classes, or can even serve as an after-school 
program in the community.
  --As the Department of Education has proposed a safe schools 
        initiative that includes a positive school climate focus, Girl 
        Scouts supports this kind of effort that embraces a holistic 
        definition of health that addresses both the physical health 
        and emotional wellness of youth. National youth serving 
        organizations such as Girl Scouts, should be seen as vital 
        partners for schools in developing relevant solutions such as 
        policies to address relational aggression and evaluating and 
        implementing programs that prevent relational aggression and 
        build healthy relationships.
                                closing
    We look forward to being a partner with Congress as you make 
difficult funding decisions in the areas of supporting healthy living, 
improving financial education of our youth, and building a pipeline of 
girls and underrepresented minorities in STEM careers. Thank you, and 
please consider us a resource in these areas.

    [This statement was submitted by Anna Maria Chavez, Girl Scouts of 
the USA.]
                                 ______
                                 
       Prepared Statement of Global Health Technologies Coalition
    Chairman Harkin, Ranking Member Moran, and members of the 
Committee, thank you for the opportunity to provide testimony on the 
fiscal year 2015 appropriations funding for the National Institutes of 
Health (NIH) and the Centers for Disease Control and Prevention (CDC). 
We appreciate your leadership in promoting the importance of 
international development, in particular global health. We hope that 
your support will continue. I am submitting this testimony on behalf of 
the Global Health Technologies Coalition (GHTC), a group of nearly 30 
nonprofit organizations working together to promote policies that 
advance research and development (R&D) of new global health 
innovations--including new vaccines, drugs, diagnostics, microbicides, 
and other tools--to combat global health diseases. The GHTC's members 
strongly believe that to meet the global health needs of tomorrow, it 
is critical to invest in research today so that the most effective 
health solutions are available when we need them. My testimony reflects 
the needs expressed by our member organizations which work with a wide 
variety of partners to develop new and more effective life-saving 
technologies for the world's most pressing health issues. We strongly 
urge the Committee to continue its established support for global 
health R&D by 1) sustaining and supporting U.S. investment in global 
health research and product development and fully funding the NIH at a 
level of at least $32 billion, and providing robust funding for the 
CDC, with $464 million for the CDC Center for Global Health and $445 
million for the CDC Center for Emerging Zoonotic and Infectious 
Diseases (NCEZID), 2) requiring leaders at the NIH, CDC, the Food and 
Drug Administration (FDA), and the Secretariat of the U.S. Department 
of Health and Human Services to join leaders of other U.S. agencies to 
develop a cross-U.S. government global health R&D strategy to ensure 
that U.S. investments in global health research are efficient, 
coordinated, and streamlined, and 3) removing the clinical trial phase 
restriction from the legal language dictating the activities of the 
National Center for Advancing Translational Sciences (NCATS).
Critical need for new global health tools
    Our Nation's investments have made historic strides in promoting 
better health around the world: nearly ten million people living with 
HIV/AIDS now have access to life-saving medicines; new, cost-effective 
tools help us diagnose diseases quicker and more efficiently than ever 
before; and innovative new vaccines are making significant dents in 
childhood mortality. While we must increase access to these and other 
proven, existing health tools to tackle global health problems, it is 
just as critical that we continue to invest in developing the next 
generation of tools to stamp out disease and address current and 
emerging threats. For instance, newer, more robust, and easier to use 
antiretroviral drugs--particularly for infants and young children--are 
needed to treat and prevent HIV, and even an AIDS vaccine that is 50 
percent effective has the potential to prevent one million HIV 
infections every year. Drug-resistant tuberculosis (TB) is on the rise 
globally, including in the United States, however the only vaccine on 
the market is insufficient at 90 years old, and most therapies 
available today are more than 50 years old, extremely toxic, and too 
expensive. New tools are also urgently needed to address fatal 
neglected tropical diseases (NTDs) such as sleeping sickness, for which 
diagnostic tools are inadequate and the few drugs available are toxic 
or difficult to use. There are many very promising technology 
candidates in the R&D pipeline to address these and other health 
issues; however, these tools will never be available if the support 
needed to continue R&D is not supported and sustained.
Research and U.S. global health efforts
    The United States is at the forefront of innovation in global 
health technologies. The U.S. government is involved in 200 of the 365 
global health products currently in the pipeline, with the NIH and CDC 
involved in much of this research.
NIH
    The NIH has helped make the United States a leader in research 
globally. Dr. Francis Collins, director of the NIH, has named global 
health as one of the agency's five top priorities, and recent NIH 
global health research activities helped lead to the development of the 
first-ever microbicide gel effective in preventing HIV/AIDS and the 
development of new tools to combat neglected diseases, including 
vaccines for dengue fever and trachoma, as well as new drugs to treat 
malaria and TB.
    Under the purview of the NIH, NCATS was established to accelerate 
new treatments and cures for diseases. NCATS has the potential to play 
a much needed role in global health research, but we remain concerned 
about the legislative mandate limiting NCATS in their clinical trial 
work. NCATS is the only NIH center to be limited by a legislative 
mandate in its clinical trial work. There is no risk of NCATS 
duplicating the global health activities of private industry as this 
sector does not typically target neglected diseases due to small 
commercial markets. We hope you will consider removing this statutory 
barrier. We must not lose traction on the investments made in global 
health at NIH. Robust investment is needed to ensure that new global 
health tools are available to address current and future health 
challenges.
CDC
    The CDC also plays a critical role in global health and contributes 
to valuable surveillance and health research systems--strengthening 
programs that ensure the sustainability of global health R&D. The work 
of its scientists has led to major advancements against devastating 
diseases, including the eradication of smallpox and early 
identification of the disease that became known as AIDS. Within the 
CDC, the efforts of the Center for Global Health and NCEZID are 
critical to protecting lives and must be continued. Ongoing investments 
in the development of new vaccines, drugs, microbicides and other tools 
have the potential to greatly accelerate efforts to combat HIV/AIDS, 
TB, malaria, diarrheal disease, pneumonia, and other less well known 
diseases such as leishmaniasis, dengue fever, schistomiasis, hookworm, 
sleeping sickness, and Chagas disease, as well as help prevent maternal 
and reproductive health challenges.
Leveraging the private sector for innovation
    The NIH, CDC, and other U.S. agencies involved in global health R&D 
regularly collaborate with the private sector in developing, 
manufacturing, and introducing important technologies such as those 
described above through public-private partnerships, including product 
development partnerships. These partnerships leverage public-sector 
expertise in developing new tools, partnering with academia, large 
pharmaceutical companies, the biotechnology industry, and governments 
in developing countries to drive greater development of products for 
neglected diseases in which private industries have not historically 
invested. This unique model has generated 42 new global health products 
and has enormous potential for continued success if robustly supported. 
NIH Director Francis Collins has stated that such partnership is key to 
the development of therapies and health tools based on NIH-funded 
research.
Innovation as a smart economic choice
    Global health R&D brings life-saving tools to those who need them 
most. However, the benefits these efforts bring are much broader than 
preventing and treating disease. Global health R&D is also a smart 
economic investment in the United States, where it drives job creation, 
spurs business activity, and benefits academic institutions. Biomedical 
research, including global health, is a $100 billion enterprise in the 
United States. Sixty-four cents out of every U.S. dollar invested in 
global health R&D goes directly to U.S.-based researchers. In a time of 
global financial uncertainty, it is important that the United States 
support industries, such as global health R&D, which build the economy 
at home and abroad.
    An investment made today can help save significant money in the 
future. The recently released meningitis A vaccine, MenAfriVac, is on 
course to save nearly $570 million in healthcare costs over the next 
decade. In addition, new therapies to treat drug-resistant TB have the 
potential to reduce the price of TB treatment by 90 percent and cut 
health system costs significantly. The United States has made smart 
investments in research in the past that have resulted in lifesaving 
breakthroughs for global health diseases, as well as important advances 
in diseases endemic to the United States. We must now build on those 
investments to turn those discoveries into new vaccines, drugs, tests, 
and other tools.
Recommendations
    In this time of fiscal constraint, support for global health 
research that improves the lives of people around the world--while at 
the same time creating jobs and spurring economic growth at home--
should unquestionably be among the Nation's highest priorities. In 
keeping with this value, the GHTC respectfully requests that the 
Committee do the following: 1) sustain and support U.S. investments in 
global health research and product development and fully fund the NIH 
at a level of at least $32 billion, and provide robust funding for the 
CDC, with $464 million for the CDC Center for Global Health and $445 
million for the NCEZID, 2) require leaders at the NIH, CDC, the FDA and 
the Office of Global Affairs to collaborate with the U.S. Agency for 
International Development, the State Department, the Department of 
Defense, and Office of the U.S. Global AIDS Coordinator to develop a 
cross-U.S. government global health R&D strategy to ensure that U.S. 
investments in global health research are efficient, coordinated, and 
streamlined, and 3) remove current statutory and legislative barriers 
limiting NCATS' clinical trial mandate and require NCATS to develop and 
report on a plan to include initiatives targeted at neglected diseases 
and global health conditions. As a leader in science and technology, 
the United States has the ability to capitalize upon our strengths to 
help reduce illness and death and ultimately eliminate disabling and 
fatal diseases for people worldwide, contributing to a healthier world 
and a more stable global economy. Sustained investments in global 
health research to develop new drugs, vaccines, tests, and other health 
tools--combined with better access to existing methods to prevent and 
treat disease--present the United States with an opportunity to 
dramatically alter the course of global health while building political 
and economic security across the globe. On behalf of the members of the 
GHTC, I would like to extend my gratitude to the Committee for the 
opportunity to submit written testimony for the record.

    [This statement was submitted by Kaitlin Christenson, Coalition 
Director, Global Health Technologies Coalition.]
                                 ______
                                 
   Prepared Statement of the Government Relations Easter Seals, Inc.
    Mr. Chairman and Members of the Subcommittee: Thank you for the 
opportunity to speak on behalf of Easter Seals about our Federal 
funding priorities for fiscal year 2015. Easter Seals is a national 
nonprofit organization that provides essential community-based services 
to individuals with disabilities, older adults, veterans and other 
underserved populations to help them live, learn, work and contribute 
to their communities. Easter Seals' top priorities are in the people we 
serve like Arlena, Ben, Elijah and Donald whose lives have been 
impacted or could be through Federal investments made by this 
subcommittee. Easter Seals respectfully asks that you consider these 
stories and the critical programs these individuals as the subcommittee 
develops its fiscal year 2015 bill. Specifically Easter Seals requests 
that the Senior Community Service Employment Program be funded at 
$434,371,000 for fiscal year 2015, the Homeless Veterans' Reintegration 
Program be funded at $50,000,000 for fiscal year 2015, the Early 
Intervention Grants for Infants and Families be funded at $458,498,000 
for fiscal year 2015, and the Department of Education Transition Model 
System be funded at $15,000,000 for 2015.
    Meet Arlena: Arlena is an older worker who is contributing to her 
New Jersey community as a full-time security supervisor at a major 
airport. Her success may have seemed out-of-reach less than 2 years 
earlier when the 55-year-old single mother faced dual challenges. 
Arlena had lost her temporary job and was out of work for about a year 
when Hurricane Sandy hit and further complicated matters. She lost her 
home and all of her belonging in the 2012 storm, which left her 
homeless. She was forced to move in with her daughter's family. 
Eventually her daughter moved and gave her the apartment. However, with 
no job she fell behind in her rent and utilities. She turned to Easter 
Seals for help after hearing about the Senior Community Service 
Employment Program (SCSEP) through a friend. The Department of Labor 
program supports employment of older workers by providing part-time, 
paid community service positions and work-based training for 
unemployed, low-income individuals, age 55 and older. Through the 
Federal program, Easter Seals connected Arlena to supportive services 
to help her maintain an apartment, boosted her computer skills and 
matched her with on-the-job training at three different community 
locations. After 9 months in the program, she applied for and secured 
an entry level security position. Based on her previous work history, 
Arlena was promoted to a supervisory position. SCSEP helped to provide 
Arlena the tools and opportunities she needed to prove she could bounce 
back from adversity and contribute again to her community. Easter Seals 
asks that the subcommittee supports a fiscal year 2015 funding level of 
$434,371,000 for SCSEP, the same level the program received in fiscal 
year 2014.
    Meet Ben: Ben was almost among the one million children under age 5 
with disabilities who go undiagnosed every year. Ben's mom felt uneasy 
about her son's language progress when he was 18 months. But her doctor 
attributed the speech delays to being raised in a bilingual household. 
After the birth of Ben's brother 6 months later, Ben's mom became more 
concerned about Ben's development, this time related to his behavior. 
``I knew that Ben needed help.'' So she reached out to her State's 
Birth to Three program--which is funded through Part C of the 
Individuals with Disabilities Education Act--and soon Ben was receiving 
needed speech and occupational services from Easter Seals and was 
diagnosed with a form of autism called PDD-NOS. Within 6 months of 
receiving early invention services, Ben was able to communicate in 
sentences. Now 4 years old, he continues to work hard and is making 
enormous progress. As a result of these early intervention investments, 
Ben continues to reach major milestones which will fundamentally change 
his life and allow him to fully participate in his community. Easter 
Seals asks that you increase funding by $20 million for the Part C 
Early Intervention grants to $458,498,000 in fiscal year 2015 so more 
children like Ben can access the services and supports they need when 
they need them to succeed.
    Meet Elijah: Elijah achieved academic success most parents dream 
for their children. He was high school class valedictorian and a 
college honors student with a Master's Degree. However, his transition 
into the workplace has been challenging. He can't find a job. Elijah 
lives with Asperger's syndrome and, in fact, benefited from early 
intervention services through Easter Seals when he was a child. 
However, Elijah has struggled during this adult transition, 
particularly in job interviews where the repetitive nature of 
Asperger's syndrome makes it challenging for him to stay succinct and 
on track. Elijah is not alone. The Government Accountability Office 
(GAO-12-594) found that students with disabilities face ``several 
longstanding challenges'' during their transition from high school into 
postsecondary education or the workforce. Among the challenges the GAO 
cited was accessing services, such as transportation education and 
travel instruction. The U.S. Department of Education has proposed in 
its fiscal year 2015 budget to test a coordinated model of transition 
planning, services, and supports through a new Transition Model System 
(TMS). The goal of TMS is to help address the many challenges faced by 
youth with disabilities like Elijah. Easter Seals asks that the 
subcommittee to fully support the Administration's fiscal year 2015 
funding request of $15,000,000 for the Transition Model System and asks 
that you include report language to strengthen the connection and 
importance of transportation education and travel instruction within 
TMS to increase and improve postsecondary outcomes for students with 
disabilities.
    Meet Donald: Donald was a proud veteran of the Air National Guard 
but--at age 48--he found himself unemployed for more than 5 years and 
living on the street. Despite the national push to end homelessness 
among veterans, far too many men and women who served our Nation like 
Donald did are among the ranks of America's homeless. Donald was 
connected to Easter Seals, who utilized the holistic, supportive 
services care coordination model used in the Department of Labor's 
Homeless Veterans Reintegration Program (HVRP) to help get Donald back 
on his feet. Easter Seals connected Donald to transitional housing, 
provided him with a monthly bus pass so he could easily attend required 
meetings and trainings, and linked him to the local U.S. Department of 
Veterans Affairs medical center for other services. Donald also 
received individualized training and assistance in creating a resume 
and cover letter and in updating his job search, networking and 
interview skills. Based on his strengths and employment background, 
Easter Seals assisted Donald in a series of temporary jobs through 
staffing agencies, one of which turned into a full time permanent job, 
with benefits, at a local manufacturing company. Donald cited 
``networking skills, online job search assistance, resume update, 
housing stabilization, reliable transportation, and encouragement'' as 
key Easter Seals HVRP services that helped him get employed again. HVRP 
is the only Federal nationwide program focusing exclusively on the 
employment of veterans who are homeless. The program works, in large 
part, due to the holistic, person-centered care coordination model that 
Easter Seals has used for several decades in helping individuals with 
disabilities achieve their dreams. Easter Seals asks that the 
subcommittee supports the authorized level of $50,000,000 for HVRP in 
fiscal year 2015.
    Thank you for the opportunity to share with you Easter Seals' 
appropriations priorities for the fiscal year 2015 Labor, Health and 
Human Services, Education, and Related Agencies appropriations bill. We 
hope that you consider these programs and the thousands of people with 
disabilities, veterans and older adults who are fully participating and 
contributing to their communities as a result of these early Federal 
investments that continue to pay dividends. Thank you again for your 
time and consideration.

    [This statement was submitted by Katy Beh Neas, Senior Vice 
President, Government Relations Easter Seals, Inc.]
                                 ______
                                 
           Prepared Statement of the Harm Reduction Coalition
    We are requesting $5 million for the Substance Abuse and Mental 
Health Services Administration at the Center for Substance Abuse 
Treatment, and $5 million for the Centers for Disease Control and 
Prevention at the office of Unintentional Injury Prevention, to address 
the opioid overdose epidemic.
    The opioid overdose epidemic has reached crisis proportions in 
recent years. The Centers for Disease Control and Prevention reports 
that in 2010, opioids--including both prescription painkillers and 
heroin--were responsible for nearly 20,000 overdose deaths. While 
prescription painkillers continue to account for the majority of opioid 
overdoses, deaths from heroin overdose increased by 45 percent between 
2006 and 2010, fueling concerns in several parts of the country that 
progress in reducing prescription painkiller misuse is being offset by 
a dramatic rise in heroin use and its attendant social and health 
consequences, including addiction, hepatitis C, and overdose. For 
example, in Kentucky, a State on the forefront of comprehensive 
approaches to the prescription drug overdose epidemic, the Kentucky 
Injury Prevention and Research Center recently reported that while 
overall drug overdose deaths have leveled off from 2011 to 2012 after a 
decade of dramatic increases, promising declines in the number of 
prescription painkiller deaths have been accompanied by a 207 percent 
increase in heroin-related overdose deaths from 2011 to 2012.
    For these reasons, Harm Reduction Coalition believes that as 
efforts continue to mount a comprehensive response to prescription 
painkiller overdoses, it is necessary to incorporate the intertwined 
rise in heroin misuse and adopt a broader strategic framework to 
address all opioids. An opioid epidemic framework would maintain and 
intensify the array of activities such as those aimed at opioid 
prescribing practices and monitoring programs, safe disposal, patient 
and public education, regulatory and enforcement actions, and expansion 
of effective addiction treatment and recovery services. At the same 
time, the broader opioid epidemic framework recognizes the vital need 
for additional public health interventions and opportunities, including 
the role of expanded access to naloxone, alongside heightened attention 
to the risks of hepatitis C and other blood-borne viruses transmissible 
through injection drug use.
    Naloxone is a generic medication which acts as an opioid 
antagonist, blocking the effects of opioids such as painkillers or 
heroin and capable of reviving individuals from opioid overdoses. A 
substantial body of research and practice has demonstrated that 
naloxone is safe and effective in the hands of laypersons; in the words 
of Dr. Nora Volkow, Director of the National Institute on Drug Abuse, 
``several experimental overdose education and naloxone distribution 
(OEND) programs have issued naloxone directly to opioid users and their 
friends or loved ones, or other potential bystanders, along with brief 
training in how to use these emergency kits. Such programs have been 
shown to be an effective, as well as cost-effective, way of saving 
lives.''
    Dr. Volkow cites data published by CDC showing that through 2010, 
overdose education and naloxone distribution programs reported 
preventing over 10,000 opioid overdose deaths across the country. As of 
this month, eighteen States have passed legislation to facilitate 
broader access and utilization of naloxone, ranging from Kentucky to 
Connecticut, Ohio to California; Georgia passed naloxone legislation on 
March 18th , which now awaits the governor's signature. These overdose 
education and naloxone distribution programs vary in setting and scope. 
In North Carolina, Project Lazarus trains physicians to co-prescribe 
naloxone to pain patients receiving opioids. In Massachusetts, support 
groups for parents with children struggling with opioid dependence are 
trained and provided with naloxone. In Rhode Island, naloxone is 
provided through pharmacies. In Kentucky, some of the strongest 
advocates for naloxone have been the addiction recovery community. In 
New York, my organization has provided naloxone training to dozens of 
drug treatment programs, syringe exchange programs, shelters, and law 
enforcement agencies. In other parts of the country, overdose education 
and naloxone distribution programs are launching in emergency 
departments, jails, and Veterans Administration Medical Centers.
    These programs are gaining increased Federal attention; in the last 
month, the Attorney General echoed the Office of National Drug Control 
Policy in calling upon first responders and law enforcement officers to 
be trained and equipped with naloxone. The Agency for Healthcare 
Research and Quality highlighted the Massachusetts overdose education 
and naloxone distribution program and featured accompanying quality 
tools, including an overdose and naloxone program manual from the Harm 
Reduction Coalition. Last year, the Substance Abuse and Mental Health 
Services Administration (SAMHSA) released an opioid overdose toolkit 
featuring naloxone. NIDA and FDA have worked to support and facilitate 
the development of new, consumer-friendly formulations of naloxone. The 
Ohio Department of Health's Violence and Injury Prevention Program has 
used a portion of its CDC injury prevention funding to expand Project 
DAWN, an overdose education and naloxone distribution program, to 
additional counties.
    The President's fiscal year 2015 budget requests $26 million to 
prevent prescription drug overdose, of which $16 million would expand 
CDC's Core Violence and Injury Prevention Program grants to States, 
with an expected $10 million directed to prescription drug overdose 
activities, and $10 million to SAMHSA would fund State planning grants 
to develop prevention strategies for prescription drug abuse. The Harm 
Reduction Coalition supports these proposals, and believes that these 
resources would be valuable in establishing a foundation to reverse the 
prescription drug overdose epidemic. We also believe that additional 
emergency funding is necessary to stem the tide of opioid overdose from 
both prescription opioids and, increasingly, heroin. Within the context 
of a comprehensive approach to the opioid epidemic, including expanding 
access to addiction treatment and recovery, the Harm Reduction 
Coalition views the rapid expansion and scale up of overdose education 
and naloxone distribution programs as an urgent and underfunded 
priority to save lives.
    To that end, we request that $5 million be provided to CDC Injury 
Prevention and Control to support opioid overdose fatality prevention 
efforts within State and local health departments and community-based 
organizations to strengthen their ability to deliver overdose 
recognition and intervention training and education, and expand access 
to rescue medications and other evidence-based strategies. We also 
request that $5 million be provided to SAMHSA's Center for Substance 
Abuse Treatment to support community-based opioid overdose fatality 
prevention efforts, with a focus on those initiatives that provide 
overdose recognition and intervention training and education, access to 
rescue medications, and facilitate linkage to treatment and recovery 
services.
    Across the country, emerging overdose education and naloxone 
distribution programs rely on limited funding to meet a growing need. 
The availability of targeted Federal funds through both the public 
health and addiction treatment and recovery communities would hasten 
the expansion of these programs to meet growing need and demand.
    In the battle against opioid overdose, there is much to be done, 
and no time to lose. We need a twofold approach of long-range efforts 
to address the underlying causes and factors which led to the initial 
rise in prescription opioid misuse, coupled with immediate actions to 
avert additional deaths and tragedies in the short-term. As a person 
who has lost friends and loved ones to opioid overdose, and listened to 
the stories of grieving parents who only wish someone had told them 
about naloxone before it was too late for their children, I 
respectfully ask for your consideration of our requests.
    If you have any questions, or would like more information or data 
on naloxone, please feel free to contact: Daniel Raymond, Harm 
Reduction Coalition. Thank you for your attention and consideration.
                                 ______
                                 
  Prepared Statement of the Health Professions and Nursing Education 
                               Coalition
    The members of the Health Professions and Nursing Education 
Coalition (HPNEC) are pleased to submit this statement for the record 
recommending $520 million in fiscal year 2015 for the health 
professions education programs authorized under Titles VII and VIII of 
the Public Health Service Act and administered through the Health 
Resources and Services Administration (HRSA).
    HPNEC is an alliance of national organizations dedicated to 
ensuring the healthcare workforce is trained to meet the needs of the 
country's growing, aging, and diverse population. Titles VII and VIII 
are the only federally-funded programs that seek to improve the supply, 
distribution, and diversity of the health professions workforce, with a 
focus on primary care and interdisciplinary training. By providing 
educational and training opportunities to aspiring and practicing 
health professionals, the programs also play a critical role in helping 
the workforce adapt to meet the Nation's changing healthcare needs.
    Titles VII and VIII are structured to allow grantees to test 
educational innovations, respond to changing delivery systems and 
models of care, and address timely topics in their communities. By 
assessing the needs of the communities they serve, Titles VII and VIII 
are well positioned to fill gaps in the workforce and increase access 
to care for all populations. Further, the programs emphasize 
interprofessional education and training, bringing together knowledge 
and skills across disciplines to provide effective, efficient and 
coordinated care.
    While HPNEC recognizes the Subcommittee faces difficult decisions 
in a constrained budget environment, a continued commitment to programs 
supporting healthcare workforce development should remain a high 
priority. The Nation faces a shortage of health professionals, which 
will be exacerbated by the addition of millions of Americans to the 
healthcare system. Failure to fully fund the Title VII and Title VIII 
programs would jeopardize activities to fill these vacancies and to 
prepare the next generation of health professionals.
    The Title VII and Title VIII programs can be considered in seven 
general categories:
  --The Primary Care Medicine and Oral Health Training programs support 
        education and training of primary care professionals to improve 
        access and quality of healthcare in underserved areas. Two-
        thirds of Americans interact with a primary care provider every 
        year. Over one-third of primary care providers trained through 
        these programs work in underserved areas, compared to 10 
        percent of those trained in other traditional programs. The 
        General Pediatrics, General Internal Medicine, and Family 
        Medicine programs provide critical funding for primary care 
        physician training in community-based settings and support a 
        range of initiatives, including medical student and residency 
        training, faculty development, and the development of academic 
        administrative units. The Rural Physician Training Grants focus 
        on increasing the number of medical school graduates practicing 
        in rural communities. The primary care cluster also provides 
        grants for Physician Assistant programs to encourage and 
        prepare students for primary care practice in rural and urban 
        Health Professional Shortage Areas. The General Dentistry, 
        Pediatric Dentistry, Dental Public Health, and Dental Hygiene 
        programs provide grants to dental schools, dental hygiene 
        schools, and hospitals to create or expand primary care dental 
        training.
  --Because much of the Nation's healthcare is delivered in remote 
        areas, the Interdisciplinary, Community-Based Linkages cluster 
        supports community-based training of health professionals. 
        These programs are designed to encourage health professionals 
        to return to such settings after completing their training and 
        to encourage collaboration between two or more disciplines. The 
        Clinical Training in Interprofessional Practice program 
        supports interdisciplinary training opportunities that prepare 
        providers to deliver coordinated, efficient, and high-quality 
        care. The Area Health Education Centers (AHECs) offer clinical 
        training opportunities to health professions and nursing 
        students in rural and other underserved communities by 
        extending the resources of academic health centers to these 
        areas. AHECs improve health by leading the Nation in the 
        recruitment, training, and retention of a diverse health 
        workforce for underserved communities. By leveraging State and 
        local matching funds to form networks of health-related 
        institutions, AHECs also provide education services to 
        students, faculty, and practitioners. The Geriatric Health 
        Professions programs, including the Geriatric Academic Career 
        Award program and Geriatric Education Centers, are all designed 
        to bolster the number and quality of healthcare providers 
        caring for the rapidly growing number of older adults and to 
        expand geriatrics training to all healthcare professionals. For 
        example, the programs provide interprofessional education and 
        training on Alzheimer's disease and related dementias. The 
        Graduate Psychology Education (GPE) program is the Nation's 
        only Federal program dedicated solely to the education and 
        training of doctoral-level psychologists. GPE supports the 
        interprofessional training of doctoral-level psychology 
        students in providing supervised mental and behavioral health 
        services to underserved populations (i.e. older adults, 
        children, chronically ill, and victims of abuse and trauma, 
        including returning military personnel and their families) in 
        rural and urban communities. The Mental and Behavioral Health 
        Education and Training Grant Program supports the training of 
        psychologists, social workers, and child and adolescent 
        professionals. These programs together work to close the gap in 
        access to quality mental and behavioral healthcare services by 
        increasing the number of qualified mental health clinicians.
  --The Minority and Disadvantaged Health Professionals Training 
        cluster helps improve healthcare access in underserved areas 
        and the representation of minority and disadvantaged 
        individuals in the health professions. Diversifying the 
        healthcare workforce is a central focus of the programs, making 
        them a key player in mitigating racial, ethnic, and socio-
        economic health disparities. Further, the programs emphasize 
        cultural competency for all health professionals, an important 
        role as the Nation's population is growing and becoming 
        increasingly diverse. Minority Centers of Excellence support 
        increased research on minority health, establish educational 
        pipelines, and provide clinical experiences in community-based 
        health facilities. The Health Careers Opportunity Program helps 
        to improve the development of a competitive applicant pool 
        through partnerships with local educational and community 
        organizations and extends the healthcareers pipeline to the K-
        12 level. The Faculty Loan Repayment and Faculty Fellowship 
        programs provide incentives for schools to recruit 
        underrepresented minority faculty. The Scholarships for 
        Disadvantaged Students supports students from disadvantaged 
        backgrounds who are eligible and enrolled as full-time health 
        professions students.
  --The Health Professions Workforce Information and Analysis program 
        provides grants to institutions to collect and analyze data to 
        advise future decisionmaking on the health professions and 
        nursing programs. The Health Professions Research and Health 
        Professions Data programs have developed valuable, policy-
        relevant studies on the distribution and training of health 
        professionals. The National Center for Workforce Analysis 
        performs research and analysis on health workforce issues, 
        including supply and demand, to help inform both public and 
        private decisionmaking.
  --The Public Health Workforce Development programs help increase the 
        number of individuals trained in public health, identify the 
        causes of health problems, and respond to such issues as 
        managed care, new disease strains, food supply, and 
        bioterrorism. The Public Health Traineeships and Public Health 
        Training Centers seek to alleviate the critical shortage of 
        public health professionals by providing up-to-date training 
        for current and future public health workers, particularly in 
        underserved areas. Preventive Medicine Residencies, which do 
        not receive funding through Medicare GME, provide training in 
        the only medical specialty that teaches both clinical and 
        population medicine to improve community health. This cluster 
        also includes a focus on loan repayment as an incentive for 
        health professionals to practice in disciplines and settings 
        experiencing shortages. The Pediatric Subspecialty Loan 
        Repayment Program offers loan repayment for pediatric medical 
        subspecialists, pediatric surgical specialists, and child and 
        adolescent mental and behavioral health specialists, in 
        exchange for service in underserved areas.
  --The Nursing Workforce Development programs under Title VIII provide 
        support for nursing students across the entire education 
        spectrum improve the access to, and quality of, healthcare in 
        underserved areas. These programs provide the largest source of 
        Federal funding for nursing education, providing loans, 
        scholarships, traineeships, and programmatic support that, 
        between fiscal year 2006 and 2012, supported over 450,000 
        nurses and nursing students as well as numerous academic 
        nursing institutions and healthcare facilities. Each year, 
        nursing schools turn away tens of thousands of qualified 
        applications at all degree levels due to an insufficient number 
        of faculty, clinical sites, classroom space, clinical 
        preceptors, and budget constraints. At the same time, the need 
        for nursing services and licensed, registered nurses is 
        expected to increase significantly over the next 20 years. The 
        Advanced Education Nursing program awards grants to train a 
        variety of nurses with advanced education, including clinical 
        nurse specialists, nurse practitioners, certified nurse-
        midwives, nurse anesthetists, public health nurses, nurse 
        educators, and nurse administrators. Workforce Diversity grants 
        support opportunities for nursing education for students from 
        disadvantaged backgrounds through scholarships, stipends, and 
        retention activities. Nurse Education, Practice, and Retention 
        grants help schools of nursing, academic health centers, nurse-
        managed health centers, State and local governments, and other 
        healthcare facilities to develop programs that provide nursing 
        education, promote best practices, and enhance nurse retention. 
        The Loan Repayment and Scholarship Program repays up to 85 
        percent of nursing student loans and offers full-time and part-
        time nursing students the opportunity to apply for scholarship 
        funds in exchange for 2 years of practice in a designated 
        nursing shortage area. The Comprehensive Geriatric Education 
        grants are used to train nursing professionals who will provide 
        direct care to older Americans, develop and disseminate 
        geriatric curricula, train faculty members, and provide 
        continuing education. The Nurse Faculty Loan program provides a 
        student loan fund administered by schools of nursing to 
        increase the number of qualified nurse faculty.
  --The loan programs under Student Financial Assistance support 
        financially disadvantaged health professions students. The 
        NURSE Corps supports undergraduate and graduate nursing 
        students with a preference for those with the greatest 
        financial need. The Primary Care Loan (PCL) program provides 
        loans in return for dedicated service in primary care. The 
        Health Professional Student Loan (HPSL) program provides loans 
        for financially needy health professions students based on 
        institutional determination. These programs are funded out of 
        each institution's revolving fund and do not receive Federal 
        appropriations. The Loans for Disadvantaged Students program 
        provides grants to institutions to make loans to disadvantaged 
        students.
    Title VII and Title VIII programs guide individuals to high-demand 
health professions jobs, helping individuals reach their goals and 
communities fill their health needs. Further, numerous studies 
demonstrate that the Title VII and Title VIII programs graduate more 
minority and disadvantaged students and prepare providers that are more 
likely to serve in Community Health Centers (CHC) and the National 
Health Service Corps (NHSC).
    The multi-year nature of health professions education and training, 
coupled with provider shortages across many disciplines and in many 
communities, necessitate a strong, continued, and reliable commitment 
to the Title VII and Title VIII programs.
    While HPNEC members understand the budget limitations facing the 
Subcommittee, we respectfully urge support for $520 million for the 
Title VII and VIII programs. We look forward to working with the 
Subcommittee to prioritize the health professions programs in fiscal 
year 2015 and into the future.
                                 ______
                                 
           Prepared Statement of the HIV Medicine Association
    The HIV Medicine Association (HIVMA) of the Infectious Diseases 
Society of America (IDSA) represents more than 5,000 physicians, 
scientists and other healthcare professionals who practice on the 
frontline of the HIV/AIDS pandemic. Our members provide medical care 
and treatment to people with HIV/AIDS in the U.S. and globally, lead 
HIV prevention programs and conduct research that has led to the 
development of effective HIV prevention and treatment options. We urge 
you to invest in the medical research supported by the National 
Institutes of Health and sustain and grow funding for the Ryan White 
Program at the Health Resources and Services and Administration and the 
Centers for Disease Control and Prevention's (CDC) HIV and STD 
prevention programs.
    Early access to effective HIV treatment helps patients with HIV 
live healthy and productive lives and is cost effective.\1\ Treatment 
not only saves the lives of individuals with HIV but has critical 
benefits to public health in that it reduces risk of transmitting HIV 
to near zero.\2\ However, despite our remarkable progress in HIV 
prevention, diagnosis and treatment, HIV/AIDS remains a serious 
epidemic in the United States with a record 1.1 million people living 
with HIV and an estimated 50,000 new infections occurring annually. In 
our country, HIV infection disproportionately impacts racial and ethnic 
minority communities and low income people who depend on public 
services for their life-saving healthcare and treatment. The rate of 
new HIV infection in African Americans is 8 times that of whites based 
on population size.\3\ Globally there are more than 35.3 million people 
living with HIV, the great majority of them in Sub-Saharan Africa. We 
are beginning to see improvements thanks in large part to U.S. 
investments in programs like PEPFAR: HIV prevalence has leveled to 
about 0.8 percent, the number of deaths have declined by 30 percent 
since 2005 and new infections have declined by 33 percent since 2001. 
Still there are 2.3 million new infections each year--more than 6,300 
each day.
---------------------------------------------------------------------------
    \1\ Kitahata, Gange, Abraham, et al. Effect of early versus 
deferred antiretroviral therapy for HIV on survival. New Engl J Med 
2009;360:1815-26.
    \2\ Cohen, Myron S., et al. Prevention of HIV-1 Infection with 
Early Antiretroviral Therapy. 2011 New England Journal of Medicine 493-
505: V365, no 6, http://www.nejm.org/doi/full/10.1056/NEJMoa11052.
    \3\ CDC Fact Sheet, February, 2014, accessed online at: http://
www.cdc.gov/hiv/risk/racialethnic/aa/facts/index.html.
---------------------------------------------------------------------------
    The funding requests in our testimony largely reflect the consensus 
of the Federal AIDS Policy Partnership (FAPP), a coalition of HIV 
organizations from across the country, and are estimated to be the 
amounts necessary to mount an effective response to the domestic HIV 
epidemic and meet the need in communities across the country.
    National Institutes of Health (NIH)--Office of AIDS Research (OAR): 
HIVMA strongly supports an fiscal year 2015 funding level of at least 
$32 billion for the NIH, including at least $3.2 billion for the NIH 
Office of AIDS Research. This level of funding is vital to sustain the 
pace of research that will improve the health and quality of life for 
millions of men, women and children in the U.S. and in the developing 
world. Years of flat funding for biomedical research has eroded our 
capacity to sustain our Nation's historic worldwide leadership in HIV/
AIDS research and innovation, and is discouraging cultivation of the 
next generation of scientists.
    Our past investment in comprehensive HIV/AIDS research paid off 
enormously in dramatic gains that resulted in reductions in mortality 
from AIDS of nearly 80 percent in the U.S. and in other countries where 
treatment is available. This research also helped reduce the mother to 
child HIV transmission rate from 25 percent to less than 1 percent in 
the U.S. and to very low levels in other countries where treatment is 
available.
    Strong, sustained NIH funding is a critical national priority that 
will foster better health, economic revitalization and help realize the 
goals of the National HIV/AIDS Strategy. Sustained increases in funding 
are also essential to train the next generation of scientists and 
prepare them to make tomorrow's HIV discoveries. Congress should ensure 
the Nation does not delay vital HIV/AIDS research progress.
    HIV/AIDS Bureau of the Health Resources and Services 
Administration: We strongly urge you to increase funding for the Ryan 
White Program by $123.2 million in fiscal year 2015. For Ryan White 
Part C programs in fiscal year 2015, we urge an allocation of at least 
$225.1 million, or a $24 million increase over the fiscal year 2014 
level for Part C. The comprehensive HIV care model or ``medical home'' 
that is supported by the Ryan White Program has been highly successful 
at achieving positive clinical outcomes with a complex patient 
population. The annual healthcare costs for HIV patients who are not 
able to achieve viral suppression (often due to delayed diagnosis and 
care) are nearly 2.5 times that of healthier HIV patients.\4\
---------------------------------------------------------------------------
    \4\ Based on data from Gilman BH, Green, JC. Understanding the 
variation in costs among HIV primary care providers. AIDS 
Care.2008:20;1050-6.
---------------------------------------------------------------------------
    The HIV medical clinics funded through Part C have been struggling 
to meet the increased demand for patients making an increase in funding 
critical to prevent additional staffing, laboratory and service cuts. 
At a bare minimum, we strongly urge you to support an increase of $24 
million over fiscal year 2014 appropriated funding for Ryan White Part 
C.
    While HIVMA welcomes the $4 million increase for Part C programs 
proposed in the President's fiscal year 2015 budget, we are concerned 
about the proposal to consolidate Ryan White Part D funding into Part 
C. Our specific concerns include:
  --Part D funding supports effective HIV care and treatment services 
        for vulnerable populations, including women and adolescents. 
        With adolescents accounting for 39 percent of new HIV 
        infections in the U.S., it is critical to target resources 
        effectively.
  --A loss of a Part D program could reduce the community's access to 
        HIV care and treatment as programs are forced to compete or 
        consolidate with Part C clinics.
  --Since most Ryan White medical clinics receive funding from multiple 
        parts of the Ryan White Program, reduction of funding to one 
        part can have damaging and unintended consequences to the 
        overall services provided.
    While the ACA provides important new healthcare coverage options 
for many patients, most health insurers fail to support the 
comprehensive care and treatment necessary for many patients to manage 
HIV infection. High cost sharing, benefit gaps and limited state uptake 
of the Medicaid expansion necessitate a vital and ongoing role for the 
Ryan White Program.
    Center for Disease Control and Prevention's (CDC) National Center 
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP): HIVMA 
strongly urges total fiscal year 2015 funding of $1.319 billion for the 
CDC's NCHHSTP, an increase of $198.2 million over the fiscal year 2014 
level, including increases of: $55.1 million for HIV prevention and 
surveillance, $16.4 million for viral hepatitis and $57.4 million for 
tuberculosis prevention. We also support a funding level of at least 
$464.3 million for CDC's global health programs, which includes 
resources for the agency's essential role in implementing PEPFAR 
programs in developing Nations. We are especially concerned about flat 
funding of CDC's global HIV programs, and request an increase of at 
least $3.3 million to that line item for a total of $132 million.
    Policy Riders--Remove the Harmful Ban on Federal Funding for 
Syringe Exchange Programs: HIVMA strongly urges re-instatement in 
fiscal year 2015 report language of policy previously enacted into law 
in fiscal year 2010 and fiscal year 2011 allowing Federal funding to be 
used for syringe exchange programs. Such action will support local 
control by letting local communities make their own decisions about how 
best to prevent new HIV and viral hepatitis infections. We cannot 
afford to forego any of the scientifically proven tools in the HIV 
prevention tool box if we are going to end AIDS in the U.S. and around 
the globe.
    Conclusion: Historically, our Nation has made significant strides 
in responding to the HIV pandemic here at home and around the world, 
but years of flat funding is now causing us to lose ground, as funding 
priorities have shifted away from public health and research programs. 
We must seize the opportunity to limit the toll of this deadly 
infectious disease on our planet, to save the lives of millions who are 
infected or at risk of infection here in the U.S. and around the globe, 
and to realize the vision of an AIDS-free generation.

    [This statement was submitted by Jeanne Keruly, MS, CRNP, Johns 
Hopkins University, HIV Medicine Association.]
                                 ______
                                 
 Prepared Statement of The Humane Society of the United States and the 
                    Humane Society Legislative Fund
    On behalf of The Humane Society of the United States (HSUS) and the 
Humane Society Legislative Fund (HSLF), we appreciate the opportunity 
to provide testimony on our top NIH funding priorities for the Senate 
Labor, Health and Human Services, Education and Related Agencies 
Appropriations Subcommittee in fiscal year 2015.
   capacity at the national chimpanzee sanctuary for federally owned 
        chimpanzees retired by the national institutes of health
    The HSUS and HSLF request NIH be given authority to use $5 million 
of funds appropriated in this and subsequent appropriations bills for 
extramural construction and renovation within the National Chimpanzee 
Sanctuary System. In 2013, NIH announced their plan to retire hundreds 
of government owned chimpanzees to sanctuary. This decision followed 
years of scientific review which determined chimpanzees are not 
necessary for research. Additional sanctuary construction is needed to 
enable NIH to move forward with their plan to retire the vast majority 
of government owned chimpanzees to sanctuary. Even with upfront 
construction expenditures, transferring government owned chimpanzees 
from laboratories to sanctuaries will save significant taxpayer funds 
over the lifetimes of the chimpanzees due to the lower cost of 
sanctuary care.
    Further basis of our request can be found below.
Background information
    In June of 2013, the National Institutes of Health announced their 
plan to retire all but 50 government-owned chimpanzees to sanctuary, 
significantly curtail the use of chimpanzees in NIH funded studies and 
not to revitalize breeding of chimpanzees for research. These decisions 
resulted from an Institute of Medicine study in 2011 which found that 
chimpanzees are not necessary for the vast majority of research. 
Immediately following the announcement of the IOM study results, NIH 
accepted the findings and assembled a panel of experts to advise them 
on the best way to implement the IOM findings. NIH ultimately accepted 
nearly all of the expert panel's recommendations in their final 
decision.
    Prior to announcing their plan, NIH had already begun the transfer 
of the 110 government owned chimpanzees at the New Iberia Research 
Center in Louisiana to Chimp Haven (the National Chimpanzee Sanctuary), 
also located in Louisiana. The transfer is expected to be completed by 
the end of fiscal year 2014. At that point, approximately 350 
government-owned chimpanzees will remain in laboratories--300 of whom 
will be slated for retirement to sanctuary per NIH's plan.
    In late November of 2013, the President signed into law amendments 
to the Chimpanzee Health Improvement Maintenance and Protection (CHIMP 
Act) which provided continued funding for the care, maintenance and 
transportation of federally owned chimpanzees over the next 5 years. 
These amendments have enabled NIH to use their funding judiciously by 
continuing to support chimpanzees in sanctuary and also set the stage 
for NIH to move forward with their plan to retire hundreds more 
chimpanzees.
Costs in laboratories vs. sanctuary
    Accredited sanctuaries provide the highest welfare standards for 
chimps at a lower cost to taxpayers than housing chimpanzees in barren 
labs (see chart below). It is estimated that transferring the 300 
government-owned chimpanzees who are slated for retirement from the 
laboratories where they are currently housed to the national sanctuary 
would save taxpayers anywhere from $1.7 million to $2.7 million per 
year in care and maintenance costs.
    Construction to house more chimpanzees in sanctuary will require an 
upfront expenditure. However, due to the lower per diem cost in 
sanctuary, retiring chimpanzees to sanctuary will still yield a 
significant savings to taxpayers over the long term. The sooner the 
construction is completed and the chimpanzees are moved to sanctuary, 
the more the government will save over the lifetimes of the 
chimpanzees--which can be up to 60 years.
Estimated Costs Related to Care and Maintenance of Government Owned 
        Chimpanzees:

------------------------------------------------------------------------
                                                 NIH cost,
                                    Number of   millions in  NIH cost, $/
             Facility              chimpanzees    dollars/   chimpanzee/
                                                    year         day
------------------------------------------------------------------------
Government Owned Chimpanzees in
 Research Facilities and Research
 Reserve Facilities
    New Iberia Research Center...   \1\ \2\ 59     \3\ 1.01     \4\ 46.7
    Keeling Center for                 \2\ 147     \3\ 2.44         45.4
     Comparative Medicine and
     Research....................
    Keeling Center for                  \2\ 16      \2\ 0.4         68.8
     Comparative Medicine and
     Research, DVR grant.........
    Southwest National Primate          \2\ 22     \3\ 0.65         80.9
     Research Center, U42 grant
     \5\.........................
    Alamogordo Primate Facility..      \2\ 162     \2\ 3.60         61.3
        Totals...................          406         8.10     \6\ 54.7
------------------------------------------------------------------------
\1\ The remaining 59 chimpanzees at New Iberia Research Center are
  scheduled to be moved to Chimp Haven by the end of fiscal year 2014
\2\ Based on information available on NIH website regarding chimpanzee
  maintenance costs for fiscal year 2014
\3\ Based on data available in NIH Research Portfolio Online Reporting
  Tools (RePORT) for fiscal year 2014
\4\ Figure expected to increase significantly as chimpanzees move to
  Chimp Haven and funds are spread over fewer chimpanzees
\5\ In addition to this grant, NIH also supports an additional 91
  chimpanzees at the facility. These chimpanzees are owned by the
  laboratory and are not under the control of NIH.
\6\ Average total.


------------------------------------------------------------------------
                                                 NIH cost,
             Facility               Number of   millions in  NIH cost, $/
                                   chimpanzees  dollar/year   animal/day
------------------------------------------------------------------------
Government Owned Chimpanzees in
 Sanctuary
    Chimp Haven..................  \6\ 118-153      \7\ 1.7        30-39
------------------------------------------------------------------------
\6\ Fifty chimpanzees from New Iberia Research Center were transferred
  to Chimp Haven during this contract year.
\7\ Unlike the other facilities, Chimp Haven has a cost reimbursement
  contract in which they are reimbursed for costs incurred. This number
  represents actual costs billed to NIH over the most recently completed
  contract year (06/30/2012--06/29/2013)

    We respectfully request the subcommittee to consider the following 
language for inclusion in the appropriations bill:
Of the funds appropriated to NIH, $5,000,000 shall be for grants or 
        contracts for construction, renovation, or repair of the 
        sanctuary system established by Section 404K of the Public 
        Health Service Act.
    We appreciate the opportunity to share our views for the Labor, 
Health and Human Services, Education and Related Agencies 
Appropriations Act for fiscal year 2015. We hope the Committee will be 
able to accommodate this request. Thank you for your consideration.
 high throughput screening, toxicity pathway profiling, and biological 
                       interpretation of findings
         national institutes of health--office of the director
    In 2008, NIH, NIEHS and EPA signed a memorandum of understanding to 
collaborate with each other to identify and/or develop high throughput 
screening assays that investigate ``toxicity pathways'' that contribute 
to a variety of adverse health outcomes (e.g., from acute oral toxicity 
to long-term effects like cancer). In addition, the MOU recognized the 
necessity for these Federal research organizations to work with 
``acknowledged experts in different disciplines in the international 
scientific community.'' Much progress has been made, including FDA 
joining the MOU, but there is still a significant amount of research, 
development and translational science needed to bring this vision 
forward to where it can be used with confidence for safety 
determinations by regulatory programs in the government and product 
stewardship programs in the private sector. In particular, there is a 
growing need to support research to develop the key science-based 
interpretation tools which will accelerate using 21st century 
approaches for predictive risk analysis. We believe the Office of the 
Director at NIH can play a leadership role for the entire US government 
by funding both extramural and intramural research.
    We respectfully request the following committee report language as 
a placeholder, which is supported by The HSUS, HSLF, and the American 
Chemistry Council.
NIH Director
    The Committee supports NIH's leadership role in modernizing the 
approach for evaluating the safety of pharmaceuticals and chemicals 
based on the incorporation of advanced molecular biological and 
computational methods that envisions a move away from animal tests. NIH 
has indicated that development of this science is critical to several 
of its priorities, from personalized medicine to tackling specific 
diseases such as cancer and diabetes and including critical initiatives 
such as BRAIN and the National Center for Advancing Translational 
Science. The Committee encourages NIH to continue to expand both its 
intramural and extramural support for the use of human biology-based 
experimental and computational approaches in health research to further 
define human biology, disease pathways, and toxicity and to develop 
tools for their integration into clinical strategies and safety 
determination paradigms. Extramural and intramural funding should be 
made available for the development and evaluation of the relevance and 
reliability of human biology-based and pathway approaches and 
prediction tools to assure readiness and utility for regulatory and 
clinical applications, including pilot studies of pathway-based risk 
assessments. The Committee requests an update on current activities, a 
plan for future activities, and the fiscal year 2015 funding level for 
this area of research in the fiscal year 2016 congressional budget 
justification.
                                 ______
                                 
   Prepared Statement of the Infectious Diseases Society of America's
    On behalf of the Infectious Diseases Society of America (IDSA), I 
am pleased to provide testimony in support of the U.S. Department of 
Health and Human Services (HHS) components that work to prevent, detect 
and treat infectious diseases (ID). IDSA represents more than 10,000 ID 
physicians and scientists devoted to patient care, prevention, public 
health, education, and research. As communicated to the full Senate 
Appropriations Committee through testimony for the record in advance of 
its April 29th hearing ``Driving Innovation through Federal 
Investments,'' IDSA recommends increased fiscal year 2015 Federal 
investments in public health and biomedical research to save lives, 
contain healthcare costs, and promote economic growth. More 
specifically, IDSA encourages the Subcommittee to provide a program 
level of $7.8 billion for the Centers for Disease Control and 
Prevention (CDC) as well as $32 billion for the National Institutes of 
Health (NIH). IDSA is particularly supportive of the proposed CDC 
Detect and Protect Against Antibiotic Resistance Initiative and 
requests that it be fully funded at $30 million. We ask that the 
Subcommittee also advance fiscal year 2015 appropriations that reflect 
the national security and public health significance of the Biomedical 
Advanced Research and Development Authority (BARDA). All of these 
investments are a necessary part of a Federal strategy to decrease the 
incidence and fatality of infectious diseases in our population.
               centers for disease control and prevention
    The ID community's partnership with the CDC has never been more 
necessary, as we work to address the public health crisis of rising 
antibiotic resistance while continuing efforts in other important areas 
such as increasing immunization rates and slowing the spread of HIV.
    Last fall, CDC issued a report, Antibiotic Resistance Threats in 
the United States, 2013 that for the first time ranked and detailed the 
threats posed by antibiotic resistant microbes. Conservative estimates 
reveal that more than two million Americans suffer antibiotic resistant 
infections each year, which result in approximately 23,000 deaths. The 
actual numbers are likely far higher, as our surveillance and data 
collection capabilities cannot yet capture the full disease burden. 
These infections due to antibiotic resistant microbes cost tens of 
billions of dollars to the U.S. healthcare system annually, and the 
problem is worsening. The CDC recommended actions in four core areas to 
address the problem, including prevention, tracking, antibiotic 
stewardship, and development of new antibiotics and rapid diagnostics. 
The CDC has proposed fiscal year 2015 activities in each of these 
areas.
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
    The NCEZID plays a leading role in CDC efforts to address 
antibiotic resistance. As such, we ask that it be provided at least the 
$445 million requested by the Administration, including at least $30 
million for the Detect and Protect Against Antibiotic Resistance 
Initiative. This initiative, which is supported by many stakeholders in 
the health community, would establish regional prevention 
collaboratives to implement best practices for antibiotic use and 
infection prevention, create a detection network of five regional labs 
to speed up identification of the most concerning threats, improve 
antibiotic stewardship, and develop an isolate library that will help 
facilitate the development of desperately needed new antibiotics and 
diagnostics. The initiative directly addresses the recommended actions 
from the CDC 2013 report. The CDC projects that over 5 years the 
initiative will lead to a 50 percent reduction in health-care 
associated Clostridium difficile (C. diff), 50 percent decline in 
health-care associated carbapenem-resistant Enterobacteriaceae (CRE), 
30 percent decline in invasive methicillin-resistant Staphylococcus 
aureus (MRSA), 30 percent decline in health-care associated drug-
resistant Pseudomonas sp., and 25 percent reduction in drug-resistant 
Salmonella infections. These bacteria claim thousands of lives 
annually. CRE, for one, have become resistant to all or nearly all 
currently available antibiotics. Further, nearly 50 percent of those 
who develop bloodstream infections from CRE die.
    IDSA and numerous other stakeholders support the proposed $14 
million increase for the National Healthcare Safety Network (NHSN), 
which would increase the number of healthcare facilities reporting 
antibiotic use and antibiotic resistance data and would develop and 
evaluate new infection prevention strategies.
    IDSA thanks Congress for funding the Advanced Molecular Detection 
(AMD) initiative in fiscal year 2014 and recommends that at least $30 
million be allocated for it in fiscal year 2015. AMD strengthens CDC's 
molecular sequencing tools and bioinformatics capacity to more rapidly 
and accurately detect infectious diseases and resistance.
    A recent World Health Organization report on antimicrobial 
resistance reiterates that we are in the midst of a public health 
crisis that is impacting all regions of the world and requires 
immediate action on the part of governments and society. IDSA applauds 
the Administration for launching a Global Health Security Agenda, which 
would strengthen the capacity of nations to prevent, detect and slow 
the spread of infectious diseases across borders, simultaneously 
reducing threats to the United States. We ask that you provide the 
initiative with funding allocated in the fiscal year 2015 PBR.
National Center for Immunization and Respiratory Diseases (NCIRD)
    We know that vaccines are among the most cost-effective clinical 
preventative services. However, according to the February 2014 CDC 
Morbidity and Mortality Weekly Report (MMWR), adult immunization rates 
remain low for most routinely recommended vaccines and considerably 
short of Healthy People 2020 targets. Each year in the United States, 
more than 40,000 adults die from illnesses that are preventable through 
vaccination.
    IDSA opposes the $51 million program level reduction to the CDC 
Immunization Grant Program (Section 317) contained in the PBR. Although 
the Affordable Care Act requires insurers to cover immunizations, this 
alone will not guarantee access or utilization. The Section 317 funds 
are critical to help providers obtain and store vaccines; establish and 
maintain vaccine registries; as well as to educate providers and the 
public about vaccine recommendations, effectiveness and safety; and 
promote universal vaccination of healthcare workers.
    CDC plays a critical role in seasonal and pandemic influenza 
preparedness and response, including conducting important surveillance 
activities that better inform response efforts and providing public 
communications regarding influenza prevention and treatment. Lack of 
sufficient funding for these efforts could lead to an increased 
incidence and severity of influenza, as well as increased 
hospitalization costs and mortality. In the long term, continuously 
funded efforts will be more cost-effective than the periodic emergency 
supplemental funding approach that historically has been used to fund 
such efforts. IDSA supports the proposed fiscal year 2015 increase of 
$15 million for these efforts.
                     national institutes of health
National Institute of Allergy and Infectious Diseases (NIAID)
    Within NIH, we believe that the National Institute of Allergy and 
Infectious Diseases (NIAID) should be funded at least at the $4.58 
billion requested by the Administration in the fiscal year 2014 PBR. 
Nearly flat-funding NIAID limits investment in new research and serves 
as a disincentive for young people to pursue ID research careers so 
critical to the discovery of new therapies, new diagnostic approaches, 
and new preventive strategies.
    The NIAID recently began funding a new clinical trials network 
focused on antibiotic-resistant bacterial infections. With sufficient 
funding, the new research network/infrastructure will conduct critical 
studies to address antibiotic resistance as well as begin to answer 
questions that will help fill the nearly empty antibiotic R&D pipeline. 
Severe economic disincentives have caused a mass exodus of private 
companies from the antibiotics market, making federally funded research 
in this area more critical than ever. An IDSA report issued in April 
2013 identified only seven new drugs in development for the treatment 
of infections caused by multidrug-resistant Gram-negative bacilli 
(GNB). The Transatlantic Task Force on Antimicrobial Resistance 
(TATFAR) also recently issued a report, which identified the broken 
pipeline of new antibacterial drugs as a key obstacle in dealing with 
resistance. The TATFAR report highlighted NIAID support of clinical 
research aimed at filling gaps in drug R&D and lowering the associated 
economic risk to industry. We applaud NIAID's initiative in launching 
the new network. However, IDSA recommends increased investment in this 
area.
    A recent IDSA report, Better Tests, Better Care: Improved 
Diagnostics for Infectious Diseases, highlighted the need for 
advancements in diagnostic tools to address bacterial, viral and fungal 
infections and recommends strengthened NIAID funding for this priority. 
Faster, more accurate diagnostics lead to better treatments and 
improved patient outcomes. In addition, new diagnostics are needed to 
identify patients with highly contagious illnesses so that containment 
and prevention measures can be undertaken. Diagnostics can improve 
physicians' ability to discern which infections need antibiotics, and 
thereby help reduce the unnecessary use of antibiotics that drives the 
development of antibiotic resistance.
        assistant secretary for preparedness and response (aspr)
Biomedical Advanced Research and Development Authority (BARDA)
    ASPR plays a key leadership role in coordinating Federal efforts to 
sufficiently protect the Nation from biothreats, pandemics and emerging 
infections. IDSA recommends increased funding for BARDA, which has been 
flat-funded for several years. Additional investment in medical 
countermeasure development is critical to prepare for both intentional 
attacks and naturally emerging infections. BARDA is a critical source 
of funding for public-private collaborations for antibiotic, diagnostic 
and vaccine R&D.
    We ask that the Subcommittee move forward with a sense of urgency 
to bolster Federal initiatives aimed at dealing with issues such as 
antimicrobial resistance, antibiotics and rapid diagnostics R&D, adult 
immunizations, and biodefense. The appropriation of sufficient fiscal 
year 2015 resources to address ID issues is a necessary complement to 
efforts that are currently underway within the Senate and House 
authorizing committees.
    Thank you for the opportunity to submit this statement on behalf of 
the Nation's ID physicians and scientists. Please forward any questions 
to Jonathan Nurse.

    [This statement was submitted by Jonathan Nurse, Director, 
Government Relations, Public Policy and Government Relations, 
Infectious Diseases Society of America.]
                                 ______
                                 
   Prepared Statement of the International Foundation for Functional 
                       Gastrointestinal Disorders
_______________________________________________________________________

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

    Thank you for the opportunity to present the views of the 
International Foundation for Functional Gastrointestinal Disorders 
(IFFGD) regarding the importance of functional gastrointestinal and 
motility disorders (FGIMD) research. Established in 1991, IFFGD is a 
patient-driven nonprofit organization dedicated to assisting 
individuals affected by FGMIDs, and providing education and support for 
patients, healthcare providers, and the public. IFFGD also works to 
advance critical research on FGIMDs in order to develop better 
treatment options and to eventually find cures. IFFGD has worked 
closely with the National Institutes of Health (NIH) on many 
priorities, and I served on the National Commission on Digestive 
Diseases (NCDD), which released a long-range plan in 2009, entitled 
Opportunities and Challenges in Digestive Diseases Research: 
Recommendations of the National Commission on Digestive Diseases.
    The need for increased research, more effective and efficient 
treatments, and the hope for discovering a cure for FGIMDs are close to 
my heart. My own experiences of suffering from FGIMDs motivated me to 
establish IFFGD, and I was shocked to discover that despite the high 
prevalence of FGIMDs among all demographic groups, such a lack of 
research existed. This translates into a dearth of diagnostic tools, 
treatments, and patient supports. Even more shocking is the lack of 
awareness among the medical community and the public, leading to 
significant delays in diagnosis, frequent misdiagnosis, and 
inappropriate treatments including unnecessary surgery. Most FGIMDs 
have no cure and limited treatment options, so patients face a lifetime 
of chronic disease management. The costs associated with these diseases 
range from $25-$30 billion annually; economic costs are also reflected 
in work absenteeism and lost productivity.
                        irritable bowel syndrome
    IBS affects 30 to 45 million Americans, conservatively at least 1 
out of every 10 people. It is a chronic disease that causes abdominal 
pain and discomfort associated with a change in bowel pattern, such as 
diarrhea and/or constipation. As a ``functional disorder,'' IBS affects 
the way the muscles and nerves work, but the bowel does not appear to 
be damaged on medical tests. Without a diagnostic test, IBS often goes 
undiagnosed or misdiagnosed for years. Even after IBS is identified, 
treatment options are limited and vary from patient to patient. Due to 
persistent pain and bowel unpredictability, individuals may distance 
themselves from social events and work. Stigma surrounding bowel habits 
may act as barrier to treatment, as patients are not comfortable 
discussing their symptoms with doctors. Many people also dismiss their 
symptoms or attempt to self-medicate with over-the-counter medications. 
Outreach to physicians and the general public remain critical to 
overcome these barriers to treatment and assist patients.
                           fecal incontinence
    At least 12 million Americans suffer from fecal incontinence. 
Incontinence crosses all age groups, but is more common among women and 
the elderly of both sexes. Often it is associated with neurological 
diseases, cancer treatments, spinal cord injuries, multiple sclerosis, 
diabetes, prostate cancer, colon cancer, and uterine cancer. Causes of 
fecal incontinence include: damage to the anal sphincter muscles, 
damage to the nerves of the anal sphincter muscles or the rectum, loss 
of storage capacity in the rectum, diarrhea, or pelvic floor 
dysfunction. People may feel ashamed or humiliated, and most attempt to 
hide the problem for as long as possible. Some don't want to leave the 
house in fear they might have an accident in public; they withdraw from 
friends and family, and often limit work or education efforts. 
Incontinence in the elderly is the primary reason for nursing home 
admissions, an already significant social and economic burden in our 
aging population. In 2002, IFFGD sponsored a consensus conference 
entitled, Advancing the Treatment of Fecal and Urinary Incontinence 
Through Research: Trial Design, Outcome Measures, and Research 
Priorities. IFFGD also collaborated with NIH on the NIH State-of-the-
Science Conference on the Prevention of Fecal and Urinary Incontinence 
in Adults in 2007.
    NIDDK recently launched a Bowel Control Awareness Campaign (BCAC) 
that provides resources for healthcare providers, information about 
clinical trials, and advice for individuals suffering from bowel 
control issues. The BCAC is an important step in reaching out to 
patients, and we encourage continued support for this campaign. Further 
research on fecal incontinence is critical to improve patient quality 
of life and implement the research goals of the NCDD.
                    gastroesophageal reflux disease
    GERD is a common disorder which results from the back-flow of 
stomach contents into the esophagus. GERD is often accompanied by 
chronic heartburn and acid regurgitation, but sometimes the presence of 
GERD is only revealed when dangerous complications become evident. 
There are treatment options available, but they are not always 
effective and may lead to serious side effects. Gastroesophageal reflux 
(GER) affects as many as one-third of all full term infants born in 
America each year and even more premature infants. GER results from 
immature upper gastrointestinal motor development. Up to 8 percent of 
children and adolescents will have GER or GERD due to lower esophageal 
sphincter dysfunction and may require long-term treatment.
                             gastroparesis
    Gastroparesis, or delayed gastric emptying, refers to a stomach 
that empties slowly. Gastroparesis is characterized by symptoms from 
the delayed emptying of food, namely: bloating, nausea, vomiting, or 
feeling full after eating only a small amount of food. Gastroparesis 
can occur as a result of several conditions, and is present in 30 
percent to 50 percent of patients with diabetes mellitus. A person with 
diabetic gastroparesis may have episodes of high and low blood sugar 
levels due to the unpredictable emptying of food from the stomach, 
leading to diabetic complications. Other causes of gastroparesis 
include Parkinson's disease and some medications. In many patients the 
cause cannot be found and the disorder is termed idiopathic 
gastroparesis.
                        cyclic vomiting syndrome
    CVS is a disorder with recurrent episodes of severe nausea and 
vomiting interspersed with symptom free periods. The periods of 
intense, persistent nausea and vomiting, accompanied by abdominal pain, 
prostration, and lethargy, last hours to days. Previously thought to 
occur primarily in pediatric populations, it is increasingly understood 
that this crippling syndrome can occur in many age groups, including 
adults. CVS patients often go for years without correct diagnosis. CVS 
leads to significant time lost from school and from work, as well as 
substantial medical morbidity. The cause of CVS is not known. Research 
is needed to help identify at-risk individuals and develop more 
effective treatment strategies.
                     support for critical research
    IFFGD urges Congress to fund the NIH at level of $32 billion for 
fiscal year 2015. Strengthening and preserving our Nation's biomedical 
research enterprise fosters economic growth and supports innovations 
that enhance the health and well-being of the Nation. Concurrent with 
overall NIH funding, IFFGD supports the growth of research activities 
on FGIMDs to strengthen the medical knowledge base and improve 
treatment, particularly through the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK). Such support would expedite the 
implementation of recommendations from the NCDD. It is also vital for 
NIDDK to work with the National Institute of Child Health and Human 
Development (NICHD) to expand its research on the impact FGIMDs have on 
pediatric populations. Following years of near level-funding, research 
has been negatively impacted across all NIH Institutes and Centers. 
Without additional funding, medical researchers run the risk of losing 
promising research opportunities that could benefit patients.
    We applaud the recent establishment of the National Center for 
Advancing Translational Sciences (NCATS) at NIH. Initiatives like the 
Cures Acceleration Network are critical to overhauling the 
translational research process and overcoming the challenges that 
plague treatment development. In addition, new efforts like taking the 
lead on drug repurposement hold the potential to speed new treatment to 
patients. We ask that you support NCATS and provide adequate resources 
for the Center in fiscal year 2015.
    Thank you for the opportunity to present these views on behalf of 
the FGIMD community.

    [This statement was submitted by Nancy J. Norton, President and Co-
Founder, International Foundation for Functional Gastrointestinal 
Disorders.]
                                 ______
                                 
     Prepared Statement of the Interstate Mining Compact Commission
    We are writing in opposition to the fiscal year 2015 Budget Request 
for the Mine Safety and Health Administration (MSHA), which is part of 
the U.S. Department of Labor. In particular, we urge the Subcommittee 
to reject MSHA's proposed de-funding of the Assistance to States grant 
program pursuant to Section 503(a) of the Mine Safety and Health Act of 
1977. Until fiscal year 2013, MSHA's budget request for state grants 
was approximately $9 million, which approached the statutorily 
authorized level of $10 million, but still did not fully consider 
inflationary and programmatic increases being experienced by the 
states. In fiscal year 2015, based on a realignment of priorities, MSHA 
has once again chosen to zero out funding for state assistance grants 
as it did in fiscal year 2014. We urge the Subcommittee to restore 
funding to the statutorily authorized level of $10 million for state 
grants so that states are able to fully and effectively carry out their 
responsibilities under Sections 502 and 503 of the Act, including the 
training of our Nation's miners.
    The Interstate Mining Compact Commission is a multi-state 
governmental organization that represents the natural resource, 
environmental protection and mine safety and health interests of its 26 
member states. The states are represented by their Governors who serve 
as Commissioners.
    IMCC is greatly appreciative of actions by Congress in January of 
this year as part of the Omnibus Appropriation bill for fiscal year 
2014 to reject MSHA's proposed elimination of funding for the state 
grants program and to restore funding at the fiscal year 2012 level of 
$8.4 million. Given that action and the clear message it sent about the 
importance of state mine safety programs, we had hoped the 
Administration would respond accordingly and include funding for these 
programs in its fiscal year 2015 proposed budget. Clearly, this did not 
happen and as such we appeal to your Subcommittee to once again restore 
funding for these vital miner health and safety programs.
    It should be kept in mind that, whereas MSHA over the years has 
narrowly interpreted Assistance to States grants as meaning ``training 
grants'' only, Section 503 was structured to be much broader in scope 
and to stand as a separate and distinct part of the overall mine safety 
and health program. In the Conference Report that accompanied passage 
of the Federal Coal Mine Health and Safety Act of 1969, the conference 
committee noted that both the House and Senate bills provided for 
``Federal assistance to coal-producing States in developing and 
enforcing effective health and safety laws and regulations applicable 
to mines in the States and to promote Federal-State coordination and 
cooperation in improving health and safety conditions in the Nation's 
coal mines.'' (H.Conf. Report 91-761). The 1977 Amendments to the Mine 
Safety and Health Act expanded these assistance grants to both coal and 
metal/non-metal mines and increased the authorization for annual 
appropriations to $10 million. The training of miners was only one part 
of the obligation envisioned by Congress.
    With respect to the training component of our mine safety programs, 
IMCC's member states are concerned that without full, stable funding of 
the State Grants Program, the federally required training for miners 
employed throughout the U.S. will greatly suffer. States have struggled 
to maintain efficient and effective miner training programs in spite of 
increased numbers of trainees and the incremental costs associated 
therewith. The situation has been further complicated by new statutory, 
regulatory and policy requirements that have grown out of the various 
reports and recommendations attending the Upper Big Branch 
investigation. In spite of all this, MSHA has chosen to eliminate 
funding completely for this critical component of its statutory 
obligations. In addition to state training programs, these assistance 
grants also support state mine rescue training programs, mine rescue 
competitions, EMT training, miner certifications, accident 
investigations and reporting, review and approval of company safety 
plans, and, for those states that operate more comprehensive mine 
safety and health programs (such as PA, WV, VA, OH, IL, AL, KY and OK), 
program administrative costs such as supplies, staff training, and 
travel. We can provide a breakdown of these costs at the Committee's 
request.
    In MSHA's budget justification document (at page 70), the agency 
states that: ``Training plays a critical role in preventing deaths, 
injuries, and illnesses on the job. By providing effective training, 
miners are able to recognize possible hazards and understand which 
procedures are safe to follow. MSHA will continue to increase 
visibility and emphasize on [sic] training, recognizing its critical 
role in reducing the number of injuries and fatalities in the mining 
community.'' We are mystified about how MSHA intends to accomplish 
these stated objectives without the training and other programs that 
are provided by the states pursuant to the grants they receive from 
MSHA--as has been the case since the enactment of the Mine Safety and 
Health Act in 1969.
    By way of an explanation for the drastic cut to state grants, MSHA 
states on page 72 of its budget justification document: ``To meet the 
demand of the agency's higher priority enforcement activities, MSHA 
will defund the program and shift the responsibility for training back 
to mine operators. Mine operators will be required to develop their own 
programs or contract these services. MSHA is transitioning to an 
updated training model, and will develop more of its own training 
curricula, exercises, and materials to assist mine operators with 
providing a complete training program to their employees. Consistent 
with existing statutory requirements, mine operators are required to 
ensure that employees have access to complete training programs.''
    While this idea of shifting training responsibilities and costs 
entirely to mine operators may have merit in limited cases, we are 
uncertain about the ability of the mining industry (especially small 
operators and contractors) to accommodate these new costs and suspect 
that any realignment of training responsibilities from the states to 
the industry will take considerable time and planning. Furthermore, our 
experience over the past 35 years has demonstrated that the states are 
often in the best position to design and offer this training in a way 
that insures that the goals and objectives of Sections 502 and 503 of 
the Mine Safety and Health Act are adequately met. There is clear and 
tangible evidence of training programs offered by mine operators (or 
contractors on their behalf) falling well below what would be 
considered a minimum standard for these types of programs. Furthermore, 
there have never been any suggestions or allegations that the states 
are not already providing the necessary ``training curricula, exercises 
and materials to assist mine operators with providing a complete 
training program''. MSHA appears to be playing the ``training card'' in 
its budget justification to duplicate the excellent work that has 
already been undertaken by the states in this area solely to increase 
funding for MSHA staff.
    There have been limited, and not particularly productive, 
discussions between MSHA and the states about the impacts this proposal 
will have on state training programs and other components of state mine 
safety and health programs, including any sort of transition away from 
how we are currently doing business. To propose such a dramatic shift 
without first working out the details with the states is inappropriate 
and a denigration of the role the states have played in protecting our 
Nation's miners. Furthermore, to expect such a drastic change to occur 
within a single fiscal year is unrealistic and will only result in 
confusion and potential negative impacts to the availability and 
quality of miner training and the overall health and safety of miners.
    MSHA notes in its budget justification document that the State 
Grants Program trained 132,000 miners in 48 states and the Navajo 
Nation in fiscal year 2013, a year in which state grants were cut by 66 
percent. While MSHA does not admit to what the elimination of this 
funding will mean for miner training, we believe the consequences could 
be debilitating. Examples of the direct impacts being reported by just 
some of the IMCC member states as a result of MSHA's decision follow. 
More expanded information from each state is appended to this statement 
and we request that it be included in the record. The most recent 
accounting of the number of miners trained by the states (and whose 
training could be jeopardized by funding cuts) based on fiscal year 
2012 reporting for coal and metal/nonmetal is as follows:
  --Kentucky: Trained or tested over 25,000 people.
  --Louisiana: 1,000 miners trained.
  --Alaska: 2,343 miners trained.
  --New Mexico: 2,265 miners trained.
  --Oklahoma: 5,000 miners trained.
  --Pennsylvania: 7,000 miners trained.
  --Ohio: 8,443 miners trained (including for mine rescue).
  --Colorado: 4,229 miners trained.
  --Arkansas: 2,000 miners trained.
  --Nevada: 2,700 miners trained.
  --North Carolina: 6,000--8,000 miners trained.
  --Maryland: 776 miners and contractors trained.
  --Arizona: 3,056 miners trained.
  --Virginia: 5,455 miners trained.
    Interestingly, while MSHA is proposing to eliminate funding for 
state training grants, it is proposing to increase funding by 
$2,800,000 and 18 FTEs for its Educational and Policy Development 
budget activity. This money will allegedly be used to transition from 
state grants to a ``new training model'' which will include new 
training curricula, materials and online courses, as well as monitoring 
operator training plans and instructors. From our perspective, this 
reflects an acknowledgement on MSHA's part that the transition to a 
totally industry-lead training initiative will likely be fraught with 
difficulties. However, heavy-handed Federal oversight is not the 
solution to an effective training program. We have seen this type of 
approach fail in the past and assert that the training programs 
operated by the states have resulted in a higher level of success, as 
indicated by the significantly reduced rates of injuries and fatalities 
over the past several years. Congress has clearly understood this 
dynamic as well, appropriating the necessary moneys needed to preserve 
and enhance state training programs. It should also be kept in mind 
that effective training programs operated by the states, especially for 
small operators, are the first and best method to reduce accidents, 
injuries and fatalities in mines. On the other hand, enforcement often 
comes too late to be effective, and by its very nature is not 
preventative. We are hopeful that Congress will once again recognize 
these operational realities in fiscal year 2015 and turn back MSHA's 
efforts to undercut these valuable programs.
    While we can appreciate MSHA's desire to realign its resources to 
focus on inspection and enforcement, one of the most effective ways to 
insure miner health and safety in the first place is through 
comprehensive and excellent training. The states have been in the 
forefront of providing this training for over 35 years and are best 
positioned to continue that work into the future. Furthermore, the 
Federal government's relatively modest investment of money in 
supporting the states to handle this training has paid huge dividends 
in protecting lives and preventing injuries. The states are also able 
to provide these services more effectively and at a cost well below 
what it would cost MSHA to do so.
    As you consider our request to reject MSHA's proposed cut and 
instead to increase MSHA's budget for state assistance grants, please 
keep in mind that the states play a particularly critical role in 
providing special assistance to small mine operators (those coal mine 
operators who employ 50 or fewer miners or 20 or fewer miners in the 
metal/nonmetal area) in meeting their required training needs. This has 
been a particular focus in those states where metal/non-metal mining 
operations predominate. These are often small business operators who 
cannot afford to offer the comprehensive training that is required 
under Section 502 of the Mine Safety and Health Act. The states also 
provide specialized training to the Spanish-speaking communities in the 
western United States.
    The ``yo-yo'' effect of inconsistent funding for state assistance 
grants is having a debilitating effect on the way we do business. To 
run effective, meaningful programs, states need continuous, stable, 
reliable and sustainable funding from year to year. We greatly 
appreciate your efforts to make that happen. We also appreciate the 
opportunity to submit our views on MSHA's fiscal year 2015 budget 
request. Please contact us for additional information or to answer any 
questions you may have.
    State Reports re Impacts from De-Funding of Assistance to States 
Grants Program
    In preparation for IMCC's presentation of this statement to the 
House and Senate Appropriations Committees, IMCC asked the states three 
questions, noted below. Responses from each of the reporting states are 
indicated.
What do you anticipate the impacts to your state will be from the 
        elimination of grant funding, including the number of miners 
        who may not be trained?
  --Kentucky: These cuts will have a devastating effect on our program. 
        Kentucky trains over 20,000 miners yearly. The money we get 
        from MSHA pays our instructors' salaries.
  --Louisiana: In Louisiana, the state training is performed through 
        the Louisiana Technical Community College system. If the grant 
        is eliminated, their mine safety training program would be 
        completely eliminated, closing its doors on Sept 30, 2013, and 
        laying off both of its employees. The program trains at least 
        1,000 miners each year (886 miners from Oct 1, 2012 to 
        present).
  --Alaska: Eliminating MSHA training funding potentially impacts each 
        of the 16,400 employees and thousands of owner/operators and 
        contractors working in Alaska's mining industry as of January 
        2013. Up to 2,600 students are MSHA trained and certified each 
        year by the University of Alaska Mine and Petroleum Training 
        Service (``MAPTS''). MAPTS is the MSHA training grant recipient 
        in Alaska. MAPTS staff have pointed out that a loss of MSHA 
        training grant funds will have a disparate impact on small 
        mines located in more remote areas of Alaska.
  --New Mexico: In prior years the State of New Mexico, through New 
        Mexico Institute of Mining and Technology, received $147,000 
        from MSHA that was used to train miners in NM to meet the 
        regulatory requirements of 30 CFR Parts 46 and 48 which are 
        mandated training requirements for miners. We train over 2,000 
        miners in NM yearly. Most of these miners are employed at small 
        business operations in our state that cannot afford trainers at 
        their small operations. In addition we provide Spanish language 
        training to 200-300 miners yearly and are the only service 
        available to Spanish-speaking miners in the State.
  --Oklahoma: The Oklahoma Miner Training Institute (OMTI) is funded in 
        part with the state grant. Utilizing the funding provided, OMTI 
        trains 5,000 miners annually in a variety of courses, such as 
        New Miner and Annual Refresher, in accordance with 30 CFR Parts 
        46 and 48. Without the fully funded support that the state 
        grant provides, the mining community in Oklahoma will be 
        impacted.
  --Pennsylvania: Pennsylvania trains approximately 7,000 miners and 
        contractors in the Anthracite, Bituminous and Industrial 
        Minerals mines and facilities of the Commonwealth. This 
        training is provided at no cost to the mining community by in-
        house staff, Pennsylvania State University and Schuylkill Vo-
        Tech. We also provide a mine rescue program for small coal and 
        industrial minerals mines to comply with Federal mine rescue 
        requirements and required EMT training through Indiana 
        University of PA at no cost to mine operators. Although a 
        majority of large operators provide training for their 
        employees to meet Federal requirements, small mine and facility 
        operators and contractors rely on the MSHA grant for their 
        training needs. Pennsylvania also relies on the MSHA grant to 
        fund other aspects of our mine safety program. These include 
        staff training, health and safety conferences, mine rescue 
        contests, safety equipment, mine rescue supplies, and travel 
        related to these functions.
  --Ohio: After reviewing our total surface training numbers for the 
        year 2012, it would appear that 1,369 trainees would not have 
        been trained if not for receiving funding from the States Grant 
        program.
  --Colorado: The impact of the elimination of the MSHA training grant 
        to the miners of Colorado and our training program will be 
        acute. We trained 5,742 in fiscal year 11 and 4,316 in fiscal 
        year 12. This includes, coal, metal, non-metal and contractors 
        who serve the industry. The reduction would be 2,800--3,700 
        miners not trained, including many that receive training in 
        Spanish. The reduction would be salaries and operating costs 
        for two trainers. (The program has 5 FTE total).
  --Arkansas: While it is difficult for a service provider to estimate 
        the total impact on our state from the elimination of grant 
        funding, we can address how it will impact our ability to 
        provide the mandatory training to the miners and contractors 
        who have utilized our services for years. While the Arkansas 
        MSHA State Training Program has been proactive in trying to 
        maintain the program and continuing to provide effective 
        training to those requesting our service, it has become 
        increasingly difficult to recover the cost for salaries, state 
        match and travel for the sufficient number of staff needed to 
        meet the demand, as well as the costs for maintaining training 
        equipment and supplies. We have already eliminated one part-
        time position and raised our training fees, but feel confident 
        that if we have to raise them again to generate the revenue 
        needed to sustain the program, it will become a financial 
        hardship on the small mining operations and contractors who are 
        our primary clients. At the current rate, without raising fees, 
        it is likely we would have to eliminate another part-time 
        position, therefore decreasing our ability to provide the 
        mandatory training to our clients requesting the service. Also, 
        grant funds have been used for our staff to attend national and 
        state MSHA conferences and training events. This would have to 
        be completely eliminated. The Arkansas MSHA State Training 
        Program trains an average of 2,000 individual miners and 
        contractors each year. We have been providing new miner, annual 
        refresher, and first aid training.
  --North Carolina: If State Grant funding is eliminated, we would be 
        reducing our staff of 6 to a staff of 2 based on our state 
        appropriations and the fact we would not be awarded any 
        additional appropriations. I would estimate there would be 
        6,000 miners we would not be able to provide training for based 
        on previous number of miners and contractors trained. We 
        average training at around 8,000 miners per year. This would be 
        a devastating burden on the small operators who rely on us to 
        assist them with their safety and health programs. Not only 
        will they have to pay a significant amount of money for future 
        training but the quality of training will certainly be a 
        concern. There are many private instructors who do not provide 
        effective, quality training. The mining industry is 
        experiencing the lowest incident rates ever, lowest amount of 
        accidents, and a record low number of fatalities and we feel 
        quality, effective training plays a major role with accident 
        prevention.
  --Maryland: The elimination of the MSHA training grant will be the 
        elimination of the training program in Maryland. Small 
        operators and contractors will have no training. While the 
        national and international companies have their own training 
        programs they still rely on the state to provide training to 
        contractors and often attend statewide forums sponsored by the 
        State Program.
  --Virginia: Eliminating the MSHA state training funds would 
        negatively affect the quality of mine safety training in 
        Virginia and the quantity of assistance the DM and the DMM 
        provide to small operators and their work force. In particular, 
        the DM's Small Mine Safety Service (which is dedicated to 
        assisting the small mine operators) would be adversely 
        impacted.
    Small operators and contractors would be immediately affected 
through any reduction in the state's ability to provide mine safety 
training. Loss of funding would also impact ongoing training 
opportunities for our training staff, and the development of site-
specific training materials, as well as purchase of supplemental 
training materials, now being offered to mine operators.
To what extent will the mining in your state be able to ``develop their 
        own programs or contract these services''? How long do you 
        anticipate this would take?
  --Kentucky: The majority of our mines involve small mines and have no 
        trainers. The small mines send their employees to our Office of 
        Mine Safety and Licensing to receive quality training free of 
        charge. These miners will have to pay a private instructor and 
        in turn receive inadequate training and in some cases will 
        receive no training at all. We've seen many problems in the 
        past with some private instructors not conducting adequate 
        training and they have been reported to the Federal Mine Safety 
        and Health Review Commission for sanctions.
  --Louisiana: In the absence of our state training program, the mining 
        industry would have to return to ``fending for themselves'' to 
        train its miners, resulting in an increased cost to industry 
        and possibly lower quality of training for individual miners.
  --Alaska: The majority of mines in Alaska are small operations with 
        less than 10 employees that do not have the resources or 
        capabilities to develop and maintain their own training and 
        certification systems. It is uncertain how long it may take to 
        develop programs or contract MSHA training services. At this 
        point, there are no MSHA training providers other than MAPTS 
        consistently available for small mines in Alaska.
  --Oklahoma: The training OMTI provides serves all of the mining 
        industry, in particular the smaller mining operations. Without 
        the training courses offered, the smaller mine sites are most 
        susceptible to see increased costs and lack of fully trained 
        miners as required in 30 CFR Parts 46 and 48.
  --Pennsylvania: Without the MSHA funding, small operators will have 
        to either conduct their own training or use training 
        contractors. Penn State University and Schuylkill Vo-Tech have 
        established a reputation and trust with the operators with a no 
        fee option. If the operators wish to continue this arrangement, 
        a significant cost per student must be absorbed by the 
        operators. The quality of training provided by the PA Bureau of 
        Mine Safety, Pennsylvania State University, Schuylkill Vo-Tech 
        and Indiana University of PA is very high and loss of this 
        program will have a negative impact on miner safety. It will 
        also impact Pennsylvania's ability to maintain its world class 
        mine safety program and ability to support program functions 
        identified above. One example: Federal law requires all mine 
        rescue teams to attend at least two competitions each year, 
        with the states supporting this requirement by holding and 
        supporting these contests. With state budgets shrinking, the 
        ability to support these contests without Federal funding is in 
        jeopardy.
  --Ohio: From past experience, the larger mining companies could deal 
        with developing their own programs and could contract out these 
        services if needed. The smaller companies and contract miners 
        would be the ones who either would be left out, or would 
        struggle with maintaining their training programs. As far as 
        the time it would take for these companies and contractors to 
        assume total responsibility for complying with MSHA's training 
        law standards, it would take a considerable amount of time.
  --Colorado: The reduction in support of mine training particularly 
        affects the medium and small operators who make up 95 percent 
        of the mining operations in Colorado. This severely reduces the 
        affect we can all have on preventing accidents and injuries 
        BEFORE they become a major incident. Unfortunately, this will 
        leave many operators with few resources for safety and health 
        and result in an increase in MSHA enforcement inspection time, 
        citations, and most unfortunately, a likely increase in injury 
        and accident rates in our state.
  --Arkansas: Since the Arkansas MSHA State Training Program places 
        emphasis on assisting small mining operations and contractors, 
        we are aware that most of these companies are neither staffed 
        nor equipped to provide effective training; whereas, the State 
        Grant staff has multiple years of combined training experience. 
        Small companies are at a distinct disadvantage in the area of 
        providing their own training.
  --North Carolina: Many small operators will not have the resources to 
        develop their own programs adequately. Many of them would not 
        know how to develop lesson plans, outlines, and have the time 
        or resources to prepare a training program. They would have to 
        contract their training out to consultants. Mine safety 
        training was geared to be site-specific and company-specific 
        which is how we prepare for our classes for mining operations. 
        Consultants will use a ``canned program'' and there are quality 
        control concerns with a canned program. We know of operators 
        who also rely on on-line training and the miners do not like it 
        because there is no interaction or discussion taking place with 
        on-line training. In terms of how long it will take for an 
        operator to implement its own safety and health training 
        program--probably at least a year or longer.
  --Maryland: There is no ability for the small operators, many of whom 
        don't even know they need the training until the state advises 
        them, or contractors to provide safety training. Our most 
        frequent calls are from contractors looking to bid work but who 
        have limited safety training and generally do not know where to 
        go to obtain it.
  --Virginia: Many larger mining companies already have the 
        infrastructure to meet these obligations and do. The true 
        impact of MSHA's decision to eliminate this program will again, 
        fall on the small operators, who have for years depended on the 
        Department of Mines, Minerals, and Energy (DMME) to assist them 
        in meeting their training obligations required by state and 
        Federal regulations. Most small operators will rely on 
        contractors to provide the required training. As a consequence 
        the quality of training may suffer.
  --New Mexico: If the New Mexico grants program is not available to 
        our small businesses in our Part 46 (sand and gravel or 
        aggregate) industries, the quality of annual refresher and new 
        miner training would suffer. I believe the alternative will be 
        that a crusher foreman or pit foreman will be assigned to 
        provide the training. This individual will likely have little 
        training experience and even less interest in providing the 
        training.
What other unanticipated consequences from the elimination of state 
        grant funding might there be, particularly with respect to 
        miner safety and health?
  --Kentucky: In our opinion the miners will be the ones to suffer 
        most. They will have to pay for the classes, they will not get 
        adequate training, and the end result will be an increase in 
        mine fatalities.
  --Louisiana: It strikes us as particularly unfortunate that MSHA 
        would choose this route of cost savings given that many 
        fatalities are found to have insufficient training as a root 
        cause.
  --Alaska: Eliminating training funding is expected to lead to an 
        increase in mining accidents and creates an artificial need for 
        increased enforcement on mine sites. Reduced MSHA-supported 
        training will damage the evolution of safety culture 
        improvements in the mining industry. Focusing solely on 
        enforcement is likely to further deteriorate individual 
        attitudes toward MSHA and voluntary compliance with MSHA 
        requirements.
  --New Mexico: The Mine Act of 1977 was very specific in Sections 502 
        and 503 regarding the requirement to train miners and to fund 
        state programs to meet the requirements of the Act. We are a 
        small organization that uses our funding wisely to provide low 
        cost training services to small business and non-English 
        speaking miners in our state. We believe this to be an 
        efficient use of these funds to educate our miners, thereby 
        providing good paying jobs in a safer environment.
  --Pennsylvania: There is no question that cutting the State Grant 
        Program goes against the intent of Congress, but more important 
        it will have a negative impact on the health and safety of our 
        Nation's miners. Every MSHA accident investigation report 
        highlights the need for quality training to eliminate and 
        reduce accidents. Not funding the State Grant Program at the 
        maximum amount ($10,000,000) is misguided and wrong and will 
        impact our ability to see that all workers go home to their 
        families at the end of each work shift.
  --Ohio: For smaller mines and with the contract miners, their safety 
        training would suffer, thus causing a potential increase in 
        mining accidents and serious injuries.
  --Colorado: Like other states, we maintain a unique and trusting 
        relationship with our mine operators and contractors through 
        regular contact, assistance (such as safety audits, etc.) and 
        education and training. We can quickly access and update our 
        mining community regarding the wide range of regulatory 
        requirements, technological improvements in mine safety and 
        sharing of mine health and safety resources. The state program 
        is the gold standard for providing effective and innovative 
        mine health and safety training and training mine employees and 
        contractors to effectively train their own employees.
  --Arkansas: We believe we will see accidents trend upward. The 
        training provided by the Arkansas MSHA State Training Program 
        has proven to have an impact on reduction in accidents; the 
        statistics reveal that the companies who utilize the State 
        services for their training needs have fewer accidents than the 
        companies who have chosen to go another route to obtain their 
        training. Also, company training might not be comprehensive in 
        certain areas, such as miners' statutory rights, including the 
        right to be provided a safe working environment and the right 
        to refuse to perform unsafe tasks. The State Training program 
        provides comprehensive training that supports accident 
        prevention by focusing on eliminating unsafe practices and 
        conditions that contribute to accidents. State training 
        reinforces miner knowledge of safe work behavior and encourages 
        safe work practices, as well as increasing their knowledge in 
        identifying an unsafe work environment as detailed in the Code 
        of Federal Regulations. In addition to training, the State 
        Training staff receives constant e-mails and phone calls 
        regarding safety and health issues. Many of the companies and/
        or individuals the State Grants staff have worked with over the 
        years are not comfortable going directly to Federal MSHA with 
        questions or concerns; whereas, the State has developed a 
        cooperative relationship that has proven mutually beneficial.
  --North Carolina: Impacts would include not being available to 
        provide special emphasis projects such as mock drills, mine 
        safety and health law seminars, annual mine safety and health 
        state conferences, explosives safety courses, and not being 
        able to properly prepare training programs geared to site-
        specific needs of mining operations. Training plan assistance 
        will not be provided. Fatalities, accidents, and incident rates 
        will be on the rise because of ineffective training.
  --Maryland: Impacts would be to lessen the awareness and importance 
        of safety in day to day work situations. Small operators often 
        perform multiple tasks and may not take time to think through a 
        situation such as electrical disconnects on conveyors or repair 
        of faulty wiring. In addition, the state program goes beyond 
        MSHA and provides CPR training and warning signs of heat 
        stroke, fatigue and other health related issues. Also, 
        individual contractors may not get other safety training as 
        required at a small operation.
  --Virginia: Our most valuable resource, the miner, will be affected 
        the most due to the lack of effective training. Statistics show 
        that, without the proper training, the potential for mining 
        accidents and serious injury does increase significantly. An 
        increase in unsafe acts and conditions, especially at smaller 
        mining operations and with independent contractors, could 
        certainly result in more accidents and injuries to miners and 
        workers.
    The increase in unsafe acts and conditions could also increase 
enforcement action by MSHA and the resulting financial burden could 
potentially drive many small operators out of business.
  --New Mexico: Our number one priority will be to try to continue the 
        training of our states miners using our State funds. This means 
        that we will be unable to fulfill certain functions that we 
        have addressed in the past. These include helping with mine 
        rescue competitions, completing all of our regulatory 
        responsibilities and ensuring interaction with operators on 
        issues such as compliance assistance.
    Addendum from Virginia Department of Mines, Minerals and Energy
    Our State (Virginia) supports the statement submitted today by the 
Interstate Mining Compact Commission, of which we are a member, 
concerning the fiscal year 2015 proposed budget for the Mine Safety and 
Health Administration (MSHA) which urges Congress to appropriate $10 
million for State assistance grants pursuant to Section 503 of the Mine 
Safety and Health Act of 1977.
    This addendum was submitted by Bradley C. (Butch) Lambert, Deputy 
Director, Virginia Department of Mines, Minerals and Energy.

    [This statement was submitted by Gregory E. Conrad, Executive 
Director, Interstate Mining Compact Commission.]
                                 ______
                                 
      Prepared Statement of the Interstitial Cystitis Association
            summary of recommendations for fiscal year 2015
_______________________________________________________________________

  --$660,00 for the IC education and Awareness Program at the Centers 
        for Disease Control and Prevention (CDC).
  --$7.8 billion for CDC.
  --$32 billion for the National institutes of Health (NIH) and 
        Proportional Increases Across All Institutes and Centers.
  --Support for NIH Research on IC, including the Multidisciplinary 
        Approach to the Study of Chronic Pelvic Pain (MAPP) Research 
        Network.

_______________________________________________________________________

    Thank you for the opportunity to present the views of the 
Interstitial Cystitis Association (ICA) regarding interstitial cystitis 
(IC) public awareness and research. ICA was founded in 1984 and is the 
only nonprofit organization dedicated to improving the lives of those 
affected by IC. The Association provides an important avenue for 
advocacy, research, and education. Since its founding, ICA has acted as 
a voice for those living with IC, enabling support groups and 
empowering patients. ICA advocates for the expansion of the IC 
knowledge-base and the development of new treatments. ICA also works to 
educate patients, healthcare providers, and the public at large about 
IC.
    IC is a condition that consists of recurring pelvic pain, pressure, 
or discomfort in the bladder and pelvic region. It is often associated 
with urinary frequency and urgency. This condition may also be referred 
to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and 
chronic pelvic pain (CPP). It is estimated that as many as 12 million 
Americans have IC symptoms. Approximately two-thirds of these patients 
are women, though this condition does severely impact the lives of as 
many as 4 million men. IC has been seen in children and many adults 
with IC report having experienced urinary problems during childhood. 
However, little is known about IC in children, and information on 
statistics, diagnostic tools and treatments specific to children with 
IC are limited.
    The exact cause of IC is unknown and there are few treatment 
options available. There is no diagnostic test for IC and diagnosis is 
made only after excluding other urinary/bladder conditions. It is not 
uncommon for patients to experience one or more years delay between the 
onset of symptoms and a diagnosis of IC. This is exacerbated when 
healthcare providers are not properly educated about IC.
    The effects of IC are pervasive and insidious, damaging work life, 
psychological well-being, personal relationships, and general health. 
The impact of IC on quality of life is equally as severe as rheumatoid 
arthritis and end-stage renal disease. Health-related quality of life 
in women with IC is worse than in women with endometriosis, vulvodynia, 
and overactive bladder. IC patients have significantly more sleep 
dysfunction, and higher rates of depression, anxiety, and sexual 
dysfunction.
    Some studies suggest that certain conditions occur more commonly in 
people with IC than in the general population. These conditions include 
allergies, irritable bowel syndrome, endometriosis, vulvodynia, 
fibromyalgia, and migraine headaches. Chronic fatigue syndrome, pelvic 
floor dysfunction, and Sjogren's syndrome have also been reported.
             ic public awareness and education through cdc
    The IC Education and Awareness Program at CDC is critical to 
improving public and provider awareness of this devastating disease, 
reducing the time to diagnosis for patients, and disseminating 
information on pain management and IC treatment options.
    The IC program has utilized opportunities with charitable 
organizations to leverage funds and maximize public outreach. Such 
outreach includes public service announcements in major markets and the 
Internet, as well as a billboard campaign along major highways across 
the country. The IC program has also made information on IC available 
to patients and the public though videos, booklets, publications, 
presentations, educational kits, websites, self-management tools, 
webinars, blogs, and social media communities such as Facebook, 
YouTube, and Twitter. For healthcare providers, this program has 
included the development of a continuing medical education module, 
targeted mailings, and exhibits at national medical conferences.
    The CDC IC Education and Awareness Program also provides patient 
support that empowers patients to self-advocate for their care. Many 
physicians are hesitant to treat IC patients because of the time it 
takes to treat the condition and the lack of answers available. 
Further, IC patients may try numerous potential therapies, including 
alternative and complementary medicine, before finding an approach that 
works for them. For this reason, it is especially critical for the IC 
program to provide patients with information about what they can do to 
manage this painful condition and lead a normal life.
    ICA recommends a specific appropriation of $660,000 in fiscal year 
2015 for the CDC IC Education and Awareness Program. ICA also 
recommends an appropriation of $7.8 billion for CDC, as well as 
continued support for the National Center for Chronic Disease 
Prevention and Health Promotion which administers the IC program.
         ic research through the national institutes of health
    The National Institutes of Health (NIH) maintains a robust research 
portfolio on IC with the National Institute of Diabetes and Digestive 
and Kidney Diseases (NIDDK) serving as the primary Institute for IC 
research. Research currently underway holds great promise to improving 
our understanding of IC and developing better treatments and a cure. 
The NIDDK Multidisciplinary Approach to the Study of Chronic Pelvic 
Pain (MAPP) Research Network studies the underlying causes of chronic 
urological pain syndromes. The MAPP Study is now in its second phase 
and researchers hope to utilize gathered data on patient experiences 
with IC to identify different phenotypes of the disease. Phenotype 
information will ultimately allow physicians to prescribe treatments 
with more specificity. Research on chronic pain that is significant to 
the community is also supported by the National Institute of 
Neurological Disorders and Stroke (NINDS) as well as the National 
Center for Complementary and Alternative Medicine (NCCAM). 
Additionally, the NIH investigator-initiated research portfolio 
continues to be an important mechanism for IC researchers to create new 
avenues for interdisciplinary research.
    ICA also supports the National Center for Advancing Translational 
Sciences (NCATS), including the Cures Acceleration Network (CAN). 
Initiatives like CAN are critical to overhauling the translational 
research process and overcoming the research ``valley of death'' that 
currently plagues treatment development. In addition, drug 
repurposement and other efforts led by NCATS hold the potential to 
speed access to new treatment for patients. ICA encourages support for 
NCATS and the provision of adequate resources for the Center in fiscal 
year 2015.
    ICA recommends a funding level of $32 billion for NIH in fiscal 
year 2015. ICA also recommends continued support the MAPP Study 
administered by NIDDK.
    Thank you for the opportunity to present the views of the 
interstitial cystitis community.

    [This statement was submitted by Lee Claassen, Executive Director, 
Interstitial Cystitis Association.]
                                 ______
                                 
          Prepared Statement of the Jamestown S'Klallam Tribe
    On behalf of the Jamestown S'Klallam Tribe, I would like to thank 
you for this opportunity to submit this written testimony on fiscal 
year 2015 Appropriations for the Department of Health and Human 
Services. The Federal budget for Tribal health programs and services 
should reflect the U.S. Government's commitment to honor and uphold its 
Treaty and Trust obligations to American Indians and Alaska Natives. 
When Tribal Governments are empowered through Self-Governance with the 
flexibility and resources to provide quality healthcare to their 
citizens, these investments hold tremendous promise for not only Tribal 
communities but for the communities that surround them.
    The Jamestown Family Health and Dental Clinics have demonstrated a 
real return on the Federal investment and reflect the tremendous 
potential Tribes have to not only reduce healthcare costs but to 
increase prevention and treatment services for their Tribal citizens.
            tribal specific health appropriation priorities
  --Restore Sequestered Amounts/Exempt Indian Programs from Budget 
        Reductions
  --Fully Fund Contract Support Costs--Separate Mandatory Appropriation
  --Budget Equity for Tribal Governments/Programs Accessible to Small 
        Tribes
  --Medicare/Medicaid Reimbursement
  --Provide $30 Million for Part A Grants for Native Americans in the 
        Older Americans Act--Title VI
  --Fund SAMHSA's Behavioral Health Tribal Prevention Grant Program at 
        $50 million--make sure programs are accessible to small Tribes
                national health appropriation priorities
  --Definition of Indian
  --Fully Fund the Implementation of ACA Inclusive of the IHCIA
  --Self-Governance Promotes Efficiency and the Effective Use of 
        Federal Funds (Title VI of the ISDEAA
           regional/national health appropriation priorities
    Our Budget Request endorses the requests of The Northwest Portland 
Area Indian Health Board, Affiliated Tribes of Northwest Indians, the 
Indian Health Service Tribal Self-Governance Advisory Committee and the 
National Congress of American Indians and the National Indian Health 
Board.
                       tribal specific priorities
Restore Sequestered Amounts/Exempt Indian Programs from Budget 
        Reductions
    Despite the Federal trust obligation and the well documented and 
profound needs of Indian country, Tribal programs were subjected to 
sequestration and forced spending reductions. These budgetary 
reductions were devastating to our community and will drastically 
impede primary healthcare and disease prevention services for our 
Tribal citizens for years to come. Tribes should be afforded the same 
exemption from funding reductions that are in place for programs 
serving our Nations populations with the highest need, such as, Social 
Security, Medicaid, Medicare, the Children's Health Insurance Program 
and the Veteran's Administration.
Fully Fund Contract Support Costs (CSC) as Required by Law
    Adequate Contract Support Cost (CSC) funding assures that Tribes, 
under the authority of their Self-Governance compacts, have the 
resources necessary to administer and deliver the highest quality 
healthcare services to their members without sacrificing program 
services and funding. We urge you to consider turning CSC into a 
separate mandatory appropriation so that legally enforceable 
contractual obligations are not being funded at the expense of 
programmatic needs.
Budget Equity for Tribal Governments/Programs Accessible to Small 
        Tribes
    Budget inequity compromises our ability to adequately manage our 
health programs and services that we are providing on behalf of the 
Federal Government. When Tribes receive an equitable level of 
resources, we can address the physical, spiritual and mental well-being 
of our Tribal communities in a culturally appropriate manner. There are 
often inconsistencies in how formulas are calculated and funding is 
distributed for Tribal health programs. In addition, Grant 
opportunities often contain criteria and processes that give States and 
other interest groups preferential opportunities for awards. Small 
Tribes, such as ours, are often further disadvantaged when it comes to 
securing these opportunities. It is critical that Tribes receive 
equitable resources and equitable access to funding opportunities that 
allow Tribes to continue to address Tribally-determined levels of 
health and wellness for our communities. Grants provided through the 
Administration for Children and Families (ACF) and the Substance Abuse 
and Mental Health Services Administration (SAMHSA) are critically 
important to our Tribe and we urge you to provide both equitable 
funding and opportunities for all Tribes within the confines of these 
programs.
Medicare/Medicaid Reimbursement
    Federal funding for Medicaid/Medicare expansion is intended to 
reduce health disparities in our Tribal communities. Historic and 
persistent underfunding of the Indian healthcare system has limited the 
ability of Tribes to provide adequate health services that could 
prevent or reduce chronic health conditions in Native people. As a 
result, American Indians/Alaska Natives have a significantly worse 
health status compared to the rest of the Nation.
    Because we do not receive full Federal funding to address our unmet 
healthcare needs, Jamestown has been forced to use innovative 
approaches in order to provide better healthcare services to our Tribal 
citizens. Over 50 percent of our healthcare funding is Medicaid and 
Medicare and we use the revenue that is generated from these programs 
to provide essential health services to our Tribal citizens and their 
families. Any changes to the way we receive Medicare and Medicaid 
funding would negatively impact our ability to provide basic healthcare 
to our Tribal community and the surrounding non-Indian community. Our 
innovative approach to providing healthcare services is an effective 
and efficient use of the Federal investment. It allows us to leverage 
the Federal dollar to provide better health services to more of our 
Tribal citizens, reducing future healthcare costs by lessening the need 
for expensive chronic and emergency care.
$30 Million--Part A Grants to Native Americans under Title VI of the 
        Older Americans Act
    Programs under Title VI of the Older Americans Act are the primary 
funding vehicle for the provision of nutrition and other ancillary 
services to our Tribal Elders. Reducing isolation through community and 
cultural activities and ensuring our Elders receive proper nutrition 
and healthcare is a priority for our Tribe. Without the capacity to 
provide support services to our elders, our cultural traditions, and 
our language is at risk of being lost.
    The Jamestown S'Klallam Elders Meal Delivery Program has been 
around for more than 20 years. The Older Americans Act provides much 
needed funds to keep this program working for our community. Jamestown 
has used Federal funds to prepare and deliver well-balanced nutritional 
meals to our Elders that incorporate traditional foods, such as, elk 
and fish and use vegetables grown in our community garden. All of our 
elders are also given fresh fruit. These services are provided to all 
elders of Native heritage, and their spouses, within our service area.
$50 Million--Behavioral Health Tribal Prevention Program
    American Indians and Alaska Natives have disproportionately higher 
rates of death related to alcohol and substance abuse and suicide. If 
funded, the Behavioral Health Tribal Prevention Grant will allow Tribes 
to provide behavioral health services that address substance abuse and 
suicide prevention and promote overall mental and emotional health. If 
funded, this would be the only grant program that is exclusively 
available for Tribes.
                       national health priorities
Definition of Indian
    The Administrations current interpretation of ``Indian'' in the 
Affordable Care Act (ACA) prevents certain IHS eligible persons from 
access to certain healthcare and services available to American Indians 
and Alaska Natives under the law. A technical amendment that uses the 
Center for Medicare and Medicaid definition of Indian will align the 
eligibility regulations and create consistency among all the 
Administrative agencies which will provide full access to healthcare 
for all American Indians and Alaska Natives.
Fully Fund the Implementation of ACA Inclusive of the IHCIA
    The permanent reauthorization of the Indian Health Care Improvement 
Act (IHCIA) within the ACA is the most significant advancement in 
Federal health policy for Tribes in decades. The purpose of the IHCIA 
is to promote healthcare parity for Indian Tribes by addressing 
deficiencies in health status and resources within the Indian health 
system. Funding for the IHCIA is a top budget priority. Although the 
IHCIA provides the authority and, with it, the opportunity to provide 
essential healthcare to Tribal citizens, it did not provide the 
necessary funds to the IHS to carry out these new statutory 
obligations.
    There are twenty three unfunded provisions in the Indian Health 
Care Improvement Act (IHCIA). Many of the provisions that remain 
unfunded would strengthen the Tribal healthcare workforce, provide 
greater access to behavioral health and support innovative initiatives 
for healthcare delivery to Tribal citizens. Funding these provisions is 
a necessary precursor to increase Tribal capacity, infrastructure and 
most importantly access to healthcare services. Significant Federal 
investment is needed to achieve a fully funded Indian Health Service 
and now is the time to act on opportunities made possible in the newly 
expanded authorities granted under the Indian Health Care Improvement 
Act. Given the unique mission of the IHS as a direct healthcare 
provider fulfilling a Federal trust responsibility, fully funding and 
implementing the ACA and IHCIA will elevate the health status and 
decrease the health disparities experienced by American Indians and 
Alaska Natives.
Self-Governance--An Efficient and Effective Use of Federal Funds (Title 
        VI of the ISDEAA)
    Self-Governance is the most successful policy in the history of 
Tribal--Federal relations and it inspires efficient and effective 
government spending. Through Self-Governance, Tribes are empowered, as 
sovereign nations, to exercise self-determination and to design 
facilities, manage programs and funds, and provide services that are 
responsive to the needs of our communities and Tribal citizens. Tribes 
participating in Self-Governance have become successful in the business 
of healthcare and perform several key roles, serving as, governments, 
employers, healthcare providers and patients.
    Self-Governance Tribes have made every attempt to be innovative to 
operate successful health programs given the budget constraints and 
cuts Tribal programs have incurred the past two decades. For more than 
a decade we have made every effort to expand Self-Governance to other 
programs and our efforts to seek expansion of the program will continue 
until we achieve our goal. We request that this Committee recognizes 
the success of Self-Governance and encourage HHS to work with Tribes to 
make the most efficient and effective use of Federal appropriations to 
fund Tribal programs.
Conclusion
    Thank you for the opportunity to provide this important testimony. 
We respectfully request that these Budget Priorities be included in the 
Appropriations for the fiscal year 2015 Tribal Health Programs Budget.

    [This statement was submitted by Hon. W. Ron Allen, Tribal 
Chairman/CEO, Jamestown S'Klallam Tribe.]
                                 ______
                                 
                 Prepared Statement of Michael Klurfeld
    Members of the subcommittee, my name is Michael Klurfeld, and I am 
testifying to protect my twin sister, Jessica, and others like her who 
require active treatment in campus-based or other settings meeting the 
Federal standards for Intermediate Care Facilities for the Mentally 
Retarded (``ICF/MR'').\1\
---------------------------------------------------------------------------
    \1\ In the interest of disclosure, please be aware that I am the 
New York State Coordinator for VOR, a national organization that 
advocates for high quality care and human rights for people with 
intellectual and developmental disabilities. I am submitting this 
statement solely on my own behalf, and not as a representative of VOR, 
to share my family's story and my personal views with you.
---------------------------------------------------------------------------
    Jessica has autism, intellectual disability, and a rare genetic 
disorder called Cornelia de Lange Syndrome. Not long after our 
thirteenth birthday, Jessica began having severe behavioral challenges, 
including physical aggression. For lack of an appropriate residential 
school in New York State, our school district sent her to out-of-State 
nonpublic residential schools--first in Pennsylvania and then in New 
Hampshire. Though her education funding ended, she remains at the New 
Hampshire program awaiting repatriation by the New York State Office 
for People with Developmental Disabilities to an appropriate adult 
residential program in New York.
    In Jessica's case, an appropriate placement is a campus-based ICF/
MR--she is legally entitled to this as a Medicaid recipient. As 
explained by the Centers for Medicare and Medicaid on the attached page 
from their website, ICF/MR is a benefit said to be offered by all 
States as an alternative to home and community-based services 
(``HCBS'') for individuals at the ICF/MR level of care--individuals in 
need of and receiving ``active treatment.'' \2\ ``Active treatment'' is 
the key concept here: defined as ``a continuous, aggressive and 
consistent implementation of a program of specialized and generic 
training, treatment, and health or related services, directed toward 
helping the enrollee function with as much self-determination and 
independence as possible.'' As CMS points out, ``many ICF/MR residents 
work in the community, with supports, or participate in vocational or 
other activities outside of the residence, and engage in community 
interests of their choice.'' ICF/MR services are provided only in 
licensed and certified residential facilities, providing quality 
control to protect the residents and financial controls over the 
expenditure of public funds--``There are few resources similar to an 
ICF/MR under any payment source.''
---------------------------------------------------------------------------
    \2\ As CMS notes, Federal law and regulations continue to use the 
term ``mentally retarded'' and therefore CMS uses it in this formal 
description of these kinds of facilities; CMS otherwise prefers the 
term ``individuals with intellectual disability.''
---------------------------------------------------------------------------
    Although ``States may not limit access to ICF/MR service, or make 
it subject to waiting lists, as they may for HCBS,'' in reality access 
is drastically limited and, as a practical matter, virtually 
unavailable in many States. The States' failure to provide these 
mandated services, in violation of the right of Medicaid recipients to 
choose ICF/MR over community-based waiver services, has been 
erroneously justified with the notion that deinstitutionalization is 
required by the Supreme Court's 1999 Olmstead decision--a gross 
misstatement of the holding in this important case. Far from requiring 
the closing of all institutions, or the denial of legally required ICF/
MR services to those like Jessica who qualify for and require them, the 
Supreme Court in Olmstead said that ``each disabled person is entitled 
to treatment in the most integrated setting possible for that person--
recognizing on a case-by-case basis, that setting may be an 
institution'' [emphasis added].
    Ironically, HHS brandishes Olmstead as a tool to force people with 
Intellectual and Developmental Disabilities (I/DD) to live in what they 
call ``integrated settings,'' often disregarding both the peoples' 
needs and choices. In a Kafkaesque fashion, HHS often brings lawsuits 
against institutions that it funds--beyond belittling the needs and 
choices of people with I/DD, these egregious lawsuits waste Federal 
funds because, essentially, HHS is suing itself.
    So for the reasons above and for reasons I will explain further, I 
ask the Senate to adopt the following language regarding HHS 
appropriations:

    No funds appropriated for any Department of Health and Human 
Services program shall be expended to promote any law or policy that 
limits the choices of individuals with intellectual and developmental 
disabilities (or, if an individual has a legal representative, the 
legal representative), seeking living arrangements they believe are 
most suitable to their needs and wishes.

    First and foremost, HHS' fallaciously named ``Olmstead 
enforcement'' goes against much of what the Supreme Court said in its 
ruling while ignoring the circumstances of the case. The plaintiffs in 
Olmstead were two women who ``alleged that defendants-petitioners, 
Georgia healthcare officials, failed to afford them minimally adequate 
care and freedom from undue restraint, in violation of their rights 
under the Due Process Clause of the Fourteenth Amendment.''
    The Supreme Court found that the women's rights had in fact been 
violated, but not solely because they were in an institutional setting:
    We emphasize that nothing in the Americans with Disabilities Act or 
its implementing regulations condones termination of institutional 
settings for persons unable to handle or benefit from community 
settings .  .  . Nor is there any Federal requirement that community-
based treatment be imposed on patients who do not desire it.''
    HHS seems to have largely ignored this language, for if they 
hadn't, Olmstead enforcement would be entirely different. Olmstead 
enforcement, properly implemented, would be limited to helping people 
like the plaintiffs in that case who were institutionalized against 
their wills without due process. But instead, HHS spends taxpayer money 
in attempts to shut down the facilities to which my sister and people 
like her are legally entitled under the law, which they have chosen (as 
is their right), and which HHS itself funds. Nothing in Olmstead 
requires--or even authorizes--HHS to deprive Medicaid recipients with 
I/DD from choosing to receive the ``active treatment'' to which they 
are entitled in the ``institutional'' setting of an ICF/MR, and HHS 
should not be allowed to appropriate funds in its efforts to deny these 
recipients their choice.
    And that's really the crux of the issue: HHS appropriation of funds 
in support of deinstitutionalization activities belittles and 
disregards my sister's choice of living situation. My sister and people 
like her, whether by their own choice or through their legal guardians 
(in Jessica's case my mother), are entitled to live in the setting they 
choose and that best meets their needs. HHS would never try to prohibit 
a group of non-disabled people from living on a campus together. My 
sister's disability should not change this.
    If HHS is allowed to continue its campaign, it will continue to 
threaten both my sister's right to the treatment to which she is 
legally entitled, as well as her access to a living situation which she 
chooses and which meets her needs. In a world where HHS completes its 
``Olmstead enforcement,'' there will be no more campus-based settings, 
and Jessica will have to live in a group home where she may nominally 
be ``in the community'' but not a part of it in any meaningful sense. 
Because she becomes anxious when in close proximity to others, she 
would isolate herself in her bedroom and rarely venture out. Because of 
her aggressive behaviors, any interactions with neighbors or others 
outside the group home setting would be rare to nonexistent. Her life 
would be that of Mrs. Rochester from Jane Eyre, which is no life at 
all.
    Thank you for your time and consideration in this manner.

    The below text comes from CMS' website:
Intermediate Care Facilities for Individuals with Mental Retardation 
        (ICF/MR)
    Intermediate Care Facilities for individuals with Mental 
Retardation (ICF/MR) is an optional Medicaid benefit that enables 
States to provide comprehensive and individualized healthcare and 
rehabilitation services to individuals to promote their functional 
status and independence. Although it is an optional benefit, all States 
offer it, if only as an alternative to home and community-based 
services waivers for individuals at the ICF/MR level of care.
    IMPORTANT NOTE: Federal law and regulations use the term 
``intermediate care facilities for the mentally retarded''. CMS prefers 
to use the accepted term ``individuals with intellectual disability'' 
(ID) instead of ``mental retardation.'' However, as ICF/MR is the 
abbreviation currently used in all Federal requirements, that acronym 
will be used here.
Eligibility for ICF/MR Benefit
    ICF/MR is available only for individuals in need of, and receiving, 
active treatment (AT) services. AT refers to aggressive, consistent 
implementation of a program of specialized and generic training, 
treatment and health services. AT does not include services to maintain 
generally independent clients who are able to function with little 
supervision and who do not require a continuous program of habilitation 
services. States may not limit access to ICF/MR service, or make it 
subject to waiting lists, as they may for HCBS. Therefore in some cases 
ICF/MR services may be more immediately available than other long term 
care options. Many individuals who require this level of service have 
already established disability status and Medicaid eligibility.
State Variation
    Need for ICF/MR is specifically defined by States, all of whom have 
established ICF/MR level of care criteria. State level of care 
requirements must provide access to individuals who meet the coverage 
criteria defined in Federal law and regulation. In addition to level of 
care for AT, the need for AT must arise from ID or a related condition. 
The definition of related condition is primarily functional, rather 
than diagnostic, but the underlying cause must have been manifested 
before age 22 and be likely to continue indefinitely. States vary in 
practical application of the concept of related condition. In some 
States individuals applying for ICF/MR residence may be eligible for 
Medicaid under higher eligibility limits used for residents of an 
institution.
Services Included in the ICF/MR Benefit
    ICFs/MR provides active treatment (AT), a continuous, aggressive, 
and consistent implementation of a program of specialized and generic 
training, treatment, and health or related services, directed toward 
helping the enrollee function with as much self-determination and 
independence as possible. ICF/MR is the most comprehensive benefit in 
Medicaid.
    Federal rules provide for a wide scope of required services and 
facility requirements for administering services. All services 
including healthcare services and nutrition are part of the AT, which 
is based on an evaluation and individualized program plan (IPP) by an 
interdisciplinary team. Facility requirements include staffing, 
governing body and management, client protections, client behavior and 
physical environment, which are specified in the survey and 
certification process.
Day Programs
    Many ICF/MR residents work in the community, with supports, or 
participate in vocational or other activities outside of the residence, 
and engage in community interests of their choice. These activities are 
collectively often referred to as day programs. The ICF/MR is 
responsible for all activities, including day programs, because the 
concept of AT is that all aspects of support and service to the 
individual are coordinated towards specific individualized goals in the 
IPP.
Where ICF/MR Services are Provided
    Medicaid coverage of ICF/MR services is available only in a 
residential facility licensed and certified by the State survey agency 
as an ICF/MR. Medicaid ICF/MR services are available only when other 
payment options are unavailable and the individual is eligible for 
Medicaid. There are few resources similar to an ICF/MR, under any 
payment source.
                                 ______
                                 
          Prepared Statement of the KNI Parent Guardian Group
    Dear Senate Appropriations Sub-committee, thank you for the 
opportunity to provide testimony. It is with a heavy heart that I 
submit outside witness testimony today, respectfully requesting your 
full consideration of the effects of pervasive Intermediate Care 
Facility (institutional--ICF/ID) closure activities.
    Numerous federally funded agencies under the Department of Health 
and Human Services (HHS) are pursuing an idealistic agenda that puts 
the weakest members of our society into harm's way, while ignoring 
significant deficiencies in the home and community based service system 
(HCBS).
    I am calling on this Sub-committee to PROHIBIT the use of Federal 
HHS appropriations supporting deinstitutionalization activities which 
evict without cause, and without regard to individual choice, people 
with the most profound intellectual and developmental disabilities (I/
DD) from HHS-licensed ICF homes.
                         community deficiencies
  --Stagnant Direct Support Staff wages, high turnover rates, staff 
        rationing, and inadequate professional oversight of scattered 
        homes are affecting quality of care for those served in HCBS 
        waiver systems. The most helpless on the disability spectrum 
        are particularly affected by these systemic deficiencies.
  --Diminishing incentive to retain quality staff is reflected in the 
        pervasive, stagnant wage crisis, while re-imbursement rates 
        have not changed significantly for over a decade. As a result, 
        the profoundly disabled often do not get to choose who cares 
        for them, even if they somehow could indicate with whom they 
        would like to live. This reality flies in the face of 
        idealism--pushing ``community for all.''
  --There is no adequate system in place which represents persons 
        adjudicated incompetent, who have no or extremely limited self-
        advocacy skills, particularly to express abusive acts committed 
        against them in poorly supervised community homes with rationed 
        staff and limited professional oversight.
    As the Guardian of a profoundly disabled young man, I have 
navigated and utilized a broad array of community services for over 15 
years. My final recourse after exhausting every option, was to place my 
loved one at the Kansas Neurological Institute (KNI), because no one in 
the HCBS system was able to handle him.
    Since his placement at KNI our grandson has been very well cared 
for, being restored to a place of stability unparalleled in the 
community. We have tried without success, to reintegrate him into 
community as unfortunately, more than a a few community providers have 
refused to serve him.
    Facilities like KNI are the safety net for those whom the community 
is not suitable or has failed to keep safe, yet these havens are under 
attack nation-wide. A number of HHS funded programs are displacing our 
most vulnerable without regard to clarifications in the Supreme Court 
Olmstead ruling, which highlights individual choice, need and safety.
    Groups including the ARC, National Council on Disabilities, State 
DD Councils, Universities for Excellence, and State Protection & 
Advocacy have ignored mounting evidence of abhorrent community outcomes 
for the most helpless within the disability spectrum. These federally 
funded entities appear to collaborate and push the extreme agenda of 
forced closure of all State ``institutions''. This radical agenda fails 
to recognize community capacity issues and an increasing number of 
documented tragedies occurring within the community system.
    Why are these agencies pushing to close facilities where 
compassionate staff care for our weakest, forcing our most vulnerable 
into questionable environments?
    How is ``justice'' served when the most helpless are placed in 
community settings, suffering neglect and death after a few months time 
at the hands of poorly trained staff who have little or no professional 
oversight?
    ``Is it ever right to handcuff and over-medicate someone with 
disabilities, just so you can `handle' them?'' This question was 
presented to the National Council on Disabilities in December by a 
guardian whose brother had been de-institutionalized, and subsequently 
bounced around to unsuccessful community placements.
HCBS tragedies are happening to such a degree that your colleague, 
        Senator Chris Murphy has called for a nation-wide 
        investigation.
    Parents and guardians are speaking out for those who cannot speak 
for themselves, many of whom had experienced failed community 
placements, yet these parents are vilified as obstacles to ``systems 
change.''
Do current HCBS deficiencies and tragic outcomes for the weakest 
        reflect sound policy?
    There is a compelling need for both community-based and congregate 
care settings. States need to operate a range of services to meet the 
diverse requirements of persons with disabilities as clarified within 
the Supreme Court Olmstead ruling:
                                olmstead
    ``We emphasize that nothing in the ADA or its implementing 
regulations condones termination of institutional settings for persons 
unable to handle or benefit from community settings...Nor is there any 
Federal requirement that community-based treatment be imposed on 
patients who do not desire it.'' Id. at 601-602.
    A plurality of Justices noted:
    ``[N]o placement outside the institution may ever be appropriate .  
.  . `Some individuals, whether mentally retarded or mentally ill, are 
not prepared at particular times-perhaps in the short run, perhaps in 
the long run-for the risks and exposure of the less protective 
environment of community settings' for these persons, `institutional 
settings are needed and must remain available''' (quoting Amicus Curiae 
Brief for the American Psychiatric Association, et al).
    Justice Kennedy noted in his concurring opinion, ``It would be 
unreasonable, it would be a tragic event, then, were the Americans with 
Disabilities Act of 1990 (ADA) to be interpreted so that States had 
some incentive, for fear of litigation to drive those in need of 
medical care and treatment out of appropriate care and into settings 
with too little assistance and supervision.'' Id. at 610.
    The real civil rights issue is the disregard for those who have 
been forced from safe environments by pervasive deinstitutionalization, 
without addressing the mounting capacity issues. As a Nation, we have 
neglected to ensure supports necessary for success, including 
adequately paid support staff and solid accountability parameters, 
while pursuing an over-reaching push of ``Community for all.''
    Until the community Direct Support Staff wage issue is honestly 
solved, the deficient abuse reporting system remedied, and systemic 
assurances providing adequate oversight for the most defenseless living 
in scattered homes across our States, we have no true, successful 
inclusion for the profoundly disabled who cannot speak or defend 
themselves.
    On behalf of ``the least of these,'' our most vulnerable, I provide 
comment today, and ask the Committee to take compassionate actions on 
their behalf.

    [This statement was submitted by Joan Kelley, Legal Guardian; Vice-
president, KNI Parent Guardian Group.]
                                 ______
                                 
                  Prepared Statement of Susan G. Komen
    On behalf of Susan G. Komen, I appreciate the opportunity to 
submit written testimony regarding the need for increased Federal 
funding for breast cancer early detection programs and cancer research. 
Specifically, we call on you to increase funding for the National 
Breast and Cervical Cancer Early Detection Program (NBCCEDP), funded 
through the Centers for Disease Control and Prevention (CDC), to $275 
million and for the National Institutes of Health (NIH) to $32 billion 
in fiscal year 2015, including $5.26 billion for the National Cancer 
Institute (NCI).
    Komen is the world's largest grassroots network of breast cancer 
survivors and advocates fighting to save lives, empower people, ensure 
quality care for all, and energize science to find the cures. With our 
network of local Affiliates across the U.S. and the 2.9 million breast 
cancer survivors we represent, we have long considered ourselves key 
partners with the Federal Government in the fight against breast 
cancer. Since 1983, we have invested more than $2.5 billion for breast 
cancer research and life-saving community programs across the country.
    While I recognize the difficult task in balancing competing budget 
priorities in the current fiscal climate, the only way to eradicate 
breast cancer is through a renewed investment and commitment to 
discovering and delivering the cures and improved access to affordable, 
quality and timely breast health screening and treatment services.
National Breast and Cervical Cancer Early Detection Program
    We call on Congress to increase funding for the National Breast and 
Cervical Cancer Early Detection Program (NBCCEDP), funded through the 
Centers for Disease Control and Prevention (CDC), to $275 million in 
fiscal year 2015.
    NBCCEDP is a State-Federal partnership that provides lifesaving, 
free or low-cost breast and cervical cancer screenings, diagnostic 
services, and follow-up services to low-income, uninsured and 
underinsured women who do not qualify for Medicaid. Since its inception 
in 1991, NBCCEDP has provided over 11 million screening exams to more 
than 4.5 million women, detecting more than 62,000 breast cancers, 
3,400 cervical cancers and 163,000 premalignant cervical lesions.\1\ 
Despite the critical services this program provides, at current funding 
levels, NBCCEDP can still only serve less than one-fifth to one-third 
of those who are projected to be eligible after the implementation of 
health reform for the program.\2\
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention, http://www.cdc.gov/
cancer/nbccedp/about.htm, accessed 5/21/14.
    \2\ Levy AR, Bruen BK, Ku L. Health Care Reform and Women's 
Insurance Coverage for Breast and Cervical Cancer Screening. Prev 
Chronic Dis 2012;9:120069.
---------------------------------------------------------------------------
    While the Affordable Care Act increases access to mammography 
coverage for many women, it is estimated that, in 2014, 4.5 million 
women will remain uninsured and eligible for the program.\3\ This 
assumes that all States will implement all the provisions of the ACA 
and expands Medicaid. For these women, NBCCEDP continues to fill a 
critical gap in the healthcare delivery system, providing access to 
annual breast and cervical cancer screenings that can lead to easy 
detection and effective treatment for breast cancer.\4\ Without 
NBCCEDP, many uninsured women could be forced to delay or forego 
screenings, leading to later stage diagnoses, which are deadlier and 
more costly to treat. In fact, breast cancer can be up to five times 
more expensive to treat when it has spread to other parts of the 
body.\5\
---------------------------------------------------------------------------
    \3\ Levy AR, Bruen BK, Ku L. Health Care Reform and Women's 
Insurance Coverage for Breast and Cervical Cancer Screening. Prev 
Chronic Dis 2012;9:120069.
    \4\ ACS Cancer Prevention and Early Detection Facts and Figures 
2013-http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/
documents/document/acspc-037535.pdf.
    \5\ Cost of Breast Cancer Treatment in Medicaid- Med Care. 2011 
Jan;49(1):89-95. doi: 10.1097/MLR.0b013e3181f81c32.
---------------------------------------------------------------------------
    Many women with health insurance still face substantial barriers to 
obtaining health services, including of lack of health literacy, 
geographic isolation and limited language proficiency. Among these 
harder to reach populations, NBCCEDP fills a critical gap by providing 
outreach and navigation services, which can improve healthcare access 
and increase breast cancer screening rates.\6\
---------------------------------------------------------------------------
    \6\ Levy AR, Bruen BK, Ku L. Health Care Reform and Women's 
Insurance Coverage for Breast and Cervical Cancer Screening. Prev 
Chronic Dis 2012;9:120069.
---------------------------------------------------------------------------
    It is clear that there will still be unmet need; millions of low-
income and uninsured women will still lack access to services. We 
believe the CDC can build on the 20+ year investments made through the 
NBCCEDP and leverage the extensive capacity and infrastructure the 
program has built with the clinical care system to increase screening 
on a population level.
    CDC can also work with various healthcare systems (FQHCs, Medicaid, 
provider networks, etc.), to increase widespread participation in 
screening by expanding key public health roles such as public education 
and outreach; provision of screening services and care coordination; 
quality assurance, surveillance and monitoring; and strategies to 
enable more organized systems of care.
    In 2014, CDC would like to begin transitioning the program by 
enabling grantees to expand public health roles that can increase 
population level screening rates, while still being able to provide 
limited screening services to the most vulnerable.
    Increasing current funding levels is critical to ensure that the 
CDC can raise awareness, provide lifesaving cancer screenings to women, 
and continue to reach those who will remain vulnerable and without 
access.
National Institutes of Health
    We urge you to increase funding for the National Institutes of 
Health (NIH) to $32 billion in fiscal year 2015, including $5.26 
billion for the National Cancer Institute (NCI), in order to restore 
funding to inflation-adjusted, pre-sequestration levels.
    Cancer is an expensive disease--the most costly to our Nation in 
terms of direct medical costs and lost productivity due to premature 
deaths and disability--making research which will accelerate cures and 
improve treatment a sound investment. Federal funding must keep pace 
with biomedical inflation as we stand on the threshold of life-saving 
discoveries in the biomedical sciences.
    This investment in research will not only protect Americans against 
disease and illness, but will serve as one of our Nation's primary 
paths to innovation, global competitiveness, and economic growth. As 
other nations aggressively invest in research and development, the U.S. 
is losing ground. We stand to lose the young scientists, high quality 
jobs, industries and private-sector capital that have made America a 
global leader.\7\ Studies show each dollar in NIH funding generates 
more than twice as much in new business activity, and NIH grants and 
contracts created and supported more than 400,000 jobs across the 
country in 2013.
---------------------------------------------------------------------------
    \7\ Research!America (www.researchamerica.org).
---------------------------------------------------------------------------
    Our Nation's investment in biomedical research has helped drive 
progress against cancer, furthered our understanding of disease 
mechanisms and spurred the translation of scientific discoveries into 
new and better ways to prevent, detect, diagnose, and treat cancer. It 
is important to highlight some of the important advances, which have 
revolutionized the way in which breast cancer patients are screened, 
diagnosed and treated. These investments have also positively impacted 
survival rates beyond 5 years.
    It is now established that routine mammographic screening is an 
accepted standard for the early detection of breast cancer. The results 
of eight randomized trials, the NIH-ACS Breast Cancer Detection 
Demonstration Projects, and other research studies showed that 
mammographic screening can reduce the mortality from breast cancer. In 
the treatment of breast cancer, lumpectomy followed by local radiation 
has replaced mastectomy as the preferred surgical approach for treating 
early-stage breast cancer. The approaches to treatment, by learning 
critical differences among the types of breast cancer, with 
chemotherapy and hormonal therapies have allowed patients different 
options and more personalized treatment plans. Tamoxifen and another 
SERM, raloxifene, have been approved by the FDA as treatments to reduce 
the risk of breast cancer in women who have an increased risk of 
developing the disease.\8\
---------------------------------------------------------------------------
    \8\ National Cancer Institute (www.cancer.gov/cancertopics/
factsheet/cancer-advances-in-focus/breast).
---------------------------------------------------------------------------
    Finally, several breast cancer susceptibility genes have now been 
identified, including BRCA1, BRCA2, TP53, and PTEN/MMAC1. Approximately 
60 percent of women with an inherited mutation in BRCA1 or BRCA2 will 
develop breast cancer sometime during their lives, compared with about 
12 percent of women in the general population. Women with inherited 
BRCA1 or BRCA2 gene mutations also have an increased risk of ovarian 
cancer.\9\ This knowledge can help patients make more informed 
decisions about their risks and potential treatment options. We are 
poised to apply this new knowledge to make significant strides in 
saving lives.
---------------------------------------------------------------------------
    \9\ National Cancer Institute (www.cancer.gov/cancertopics/
factsheet/cancer-advances-in-focus/breast).
---------------------------------------------------------------------------
    As a Nation, we are facing a crisis in cancer care. As the 
population ages, the number of new cancer cases in the United States is 
projected to increase by as much as 42 percent, 2.3 million new cases 
annually, by 2025.\10\
---------------------------------------------------------------------------
    \10\ AACR Cancer Progress Report 2013 (http://
cancerprogressreport.org/2013/Documents/2013_AACR_CPR_FINAL.pdf).
---------------------------------------------------------------------------
    Despite these staggering statistics, cancer research funding at the 
NCI as a share of the NIH budget has declined. In the late 1990s, NCI's 
budget made up nearly 19 percent of the NIH budget. Today, NCI accounts 
for approximately 16 percent. In real dollars, this decline means that 
NCI's funding has been reduced by $680 million below what it would have 
received in fiscal year 2014 if its share of NIH's total budget had 
been maintained.\11\ It is imperative that our Nation's investment in 
cancer research remains a priority, and that funding for NIH increases.
---------------------------------------------------------------------------
    \11\ One Voice Against Cancer (www.ovaconline.org).
---------------------------------------------------------------------------
    On behalf of the many Americans who are suffering with cancer, I 
ask that you consider our requests for increased support for the 
NBCCEDP and the NIH in fiscal year 2015. Susan G. Komen stands ready to 
serve as a national resource for Congress and for all Americans on 
breast health issues.

    [This statement was submitted by Judith A. Salerno, MD, MS, 
President and Chief Executive Officer, Susan G. Komen.]
                                 ______
                                 
   Prepared Statement of the Lenders Coalition for Community Health 
                                Centers
    The Lenders Coalition for Community Health Centers (LCCHC) is 
pleased to provide the following written testimony related to proposed 
fiscal year 2015 HRSA funding for federally Qualified Health Centers 
(FQHCs) funded under Section 330 of the Public Health Services Act. 
This testimony includes recommendations to assist the Administration 
and Congress in developing policies that will help meet a near 
universal goal--expanding community health centers in an affordable and 
sustainable manner to meet the healthcare needs of millions of families 
in underserved communities throughout the United States.
    LCCHC is a coalition of community development financial 
institutions (CDFIs) and related entities whose main goal is to 
advocate for resources and policies that will strengthen health 
centers' access to capital and CDFIs' ability to finance health center 
growth. The CDFIs that form the LCCHC are all currently undertaking 
health center lending. They have made loans totaling more than $1.4 
billion to develop primary care capacity that gives more than 3 million 
patients access to primary care every year.
    The LCCHC has been on record in support of increased--and 
continued--operational funding support for health centers. Our 
institutions sent a letter to the President advocating the full 
operational increase in mandatory funds from the Health Centers Fund in 
fiscal year 2015, and underscored the need to sustain and grow that 
investment over the next 5 years to ensure the financial stability of 
our client FQHCs moving forward.
    We note that the President's fiscal year 2015 budget proposes 
utilizing $800 million in health center funding for one-time capital 
grants. We believe that to the extent any new funding for capital 
projects is included in this year's final appropriation, HHS should 
encourage awardees to use these scarce dollars to leverage other 
sources of capital--both grants and loans from the public and private 
sector--to maximize their impact on health center growth. Given that 
$800 million represents less than 10 percent of the estimated $10 
billion of capital funding that will be needed in order to meet the 
goal of serving 35 million patients in FQHCs by the end of 2018, 
developing policies that promote the availability of multiple public 
and private sources of capital will be critical to health centers' 
successful growth. By incorporating incentives to encourage leveraging 
into the HHS review process of any potential capital grant funding for 
those FQHCs that can raise other sources of capital and/or afford to 
take on some reasonable amount of debt, HHS will be able to support a 
much larger number of FQHCs around the country.
    We also recognize that capital from the Health Centers Fund--even 
if it is leveraged--is not a complete solution to address the capital 
needs of FQHCs. We strongly encourage the consideration of robust 
Federal credit enhancement programs targeting FQHCs expansion, which 
would leverage much greater levels of private sector financing for 
FQHCs.. Programs such as these are available and have been used to 
considerable success for a number of vital sectors, including small 
businesses (SBA), rural and agricultural enterprises (USDA), charter 
schools (ED) housing and hospitals (HUD).
    We wish to be clear that we reject policies encouraging FQHCs to 
pursue leverage irresponsibly. Over-leverage is a real risk in any 
sector; where it involves the development of critical health 
infrastructure and the use of public funds, it simply must be 
prevented. Indeed, as community lenders, our mission is aligned with 
our borrowers, and we have a stake in their sustainability and success.
    Attached, please find a brief that highlights the benefits of 
leveraging HHS capital dollars. The arguments in this brief assume that 
FQHCs work with responsible lenders, develop financially and 
operationally sustainable expansion projects, and assume a level of 
debt that supports their expansion without negatively impacting their 
current operations or financial stability. Based on our collective 
experience in the FQHC sector itself, as well as across a broad range 
of other capital needs within low income communities (e.g., affordable 
housing, healthy food financing, and school financing), we are 
confident that the Administration and Congress can maintain policies 
that enable these conditions.
  why leveraging of hrsa capital grants is essential to the future of 
               federally qualified health centers (fqhcs)
    HRSA has set, and the health center field has embraced, the goal of 
expanding health centers to meet the stated goal of serving 35 million 
patients by the end of 2018 (from approximately 22 million today). 
Based on an estimate from Capital Link, more than $10 billion in 
additional capital will need to flow into FQHC facility development and 
expansion to meet this target.
    If public funding alone will not suffice to meet the FQHC field's 
collective expansion goal, the only feasible alternative is instead to 
ensure that limited public funds be deployed strategically to bring 
private sector capital to bear. Such an approach can stretch scarce 
Federal resources, attract more lenders into the market, lower 
borrowing costs, and incentivize FQHCs to develop projects with greater 
impact on patients than would be possible otherwise.
The Lack of a Clear, Unambiguous Signal that Leverage is Integral to 
        HRSA's Future Plans for FQHCs Causes Inefficiencies in FQHC 
        Financing to Persist
    Capital Grant Funding Rounds that Fail to Incentivize Leverage 
Disrupt the Existing FQHC Pipeline and Distort Project Sizing.--Today, 
FQHCs often work with CDFIs and other lenders across the country to 
generate a pipeline with hundreds of viable FQHC expansion projects in 
varying stages of development. When HRSA announces a capital grant 
round (or even the possibility of a capital grant round) that holds out 
the promise of a one-stop, debt-free financing strategy, that pipeline 
largely freezes, as FQHCs understandably put development plans on hold 
in the hope of avoiding the need to borrow money at all.
    Unfortunately, that hope is often in vain, given the reality that 
demand far outstrips the funding available, leading to lengthy grant 
application and review processes and many unfunded projects. 
Additionally, FQHCs size their projects to the HRSA grant maximum 
rather than to the size that best serves the healthcare needs of the 
community and that CDFIs or other responsible lenders will underwrite. 
The result is delays or cancellation of FQHC expansion projects that 
could have served hundreds of thousands of patients.
Thoughtful Incentives to Promote Leverage would Enable HRSA to Magnify 
        the Impact of its Capital Grants and Supplement its Own 
        Oversight of FQHCs with Private Sector Underwriting
    Leverage is a `Force Multiplier' for Limited HRSA Capital Grants.--
Simply put, a given level of Federal operating and capital funding can 
yield dramatically increased FQHC expansion if it unlocks access to 
private sector capital. When FQHCs are required to supplement Federal 
grant funding with outside capital, they are more likely to develop 
projects that are scaled to the needs of the community rather than to 
the size of the grant award, offering the opportunity for greater 
impact on the community's health.
    To offer an instructive experience in another sector, in fiscal 
year 2014, Congress enacted the Administration's Rental Assistance 
Demonstration (RAD), providing public housing authorities new 
flexibilities to leverage their annual public housing operating and 
capital grants from the Department of Housing and Urban Development 
(HUD) to rehab or redevelop up to 60,000 units of public housing. 
Notably, no `new' money was appropriated--i.e., the operating and 
capital fund allocations that the local agencies received remained the 
same (well below their annual operating costs and accumulated capital 
backlog). To date, applications submitted to HUD under this `no cost' 
leveraging strategy have proposed to bring to bear in excess of $6 
billion in private and other public sector capital to the rehab and 
redevelopment of public housing units previously assisted exclusively 
by Federal funds.
    If Congress appropriates capital funding for health centers in 
fiscal year 2015, HRSA should draw from the experience of the 
affordable housing field, and other sectors, in the effort to deploy 
leverage strategically in service of health center capital expansion 
goals. Health centers have, for the moment, the further good fortune of 
being `ahead of the curve,' relative to the field's funding levels and 
capital needs (the public housing field, for example, embraced policy 
reforms like RAD only after years of underfunding and a capital backlog 
in excess of $27 billion).
    Leverage Leads to Superior `Front End' Underwriting and Faster 
Project Development.--When an FQHC uses debt financing for a project, 
the project goes through a rigorous review by the lender (or lenders) 
as part of the underwriting process, creating a higher likelihood for 
successful development of the project. Scrutiny of the experience and 
capacity of the project's development team ensures that the right 
pieces are in place for construction that is on time and within budget. 
Furthermore, the lenders' scrutiny of underlying financials and 
staffing plans and testing of revenue projections can lead to an FQHC 
making constructive modifications to its plans. To be clear, this is 
not a substitute for the conscientious and diligent oversight conducted 
by HRSA staff on behalf of the taxpayer, but rather a useful supplement 
to their efforts by project development experts whose livelihood 
depends on having their loans paid back.
    Leverage Builds in `Early Warning' Systems that Prevent FQHC 
Project Failure.--Experience across capital financing sectors, 
including affordable housing (e.g., three decades of experience with 
the Low Income Housing Tax Credit), has demonstrated that private 
sector oversight of project operations is a useful supplement to the 
scrutiny of dedicated, competent but often overextended public 
servants, Lenders, as part of their loan servicing and monitoring, keep 
a monthly watch on every borrower, enabling them to see financial 
problems early on, before they have grown more expensive and difficult 
to fix. When lenders provide financing to FQHCs, they are responsible 
for ensuring regular loan repayments. Borrowers are required to submit 
regular financial statements showing cash flow, accounts payables and 
receivables, and other indicators of financial health. If the borrower 
misses loan payments or shows other signs of financial distress, a CDFI 
can work with borrowers to develop solutions that will bring a health 
center back to financial stability. When necessary, this assistance may 
involve working with other stakeholders, including foundations, State 
Medicaid agencies, or HRSA to make sure a community is not deprived of 
vital primary care capacity.
    Leverage Creates Financial, Community and Political Partners in 
Ensuring Health Center Sustainability.--Critically, the involvement of 
other stakeholders in FQHC health--from philanthropy to CDFIs to banks 
and private sector investors--is not limited to the all-hands-on-deck 
project workouts described above. When FQHCs are required to assemble 
matching or contributing funds for a project, they seek funding 
assistance from a range of other public and private sources, including 
grants and loans. The act of assembling these funds generates community 
``buy-in'' and support for a proposed project, which ultimately 
contributes to its success by aligning community priorities and 
resources toward a common end.
    Indeed, the broadening of the constituency of stakeholders with 
`skin in the game' when it comes to both individual FQHCs and the field 
more broadly, is essential to FQHCs' long-term sustainability: it 
creates a bulwark against appropriations risk while simultaneously 
helping to ensure that FQHCs remain viable and competitive in the 
rapidly evolving field of primary care provision to low income 
neighborhoods and populations.
                                 ______
                                 
    Prepared Statement of the Local Initiatives Support Corporation
    Chairman Harkin, Ranking Member Moran, and Distinguished Members of 
the Senate Appropriations Subcommittee on Labor, Health and Human 
Services, Education and Related Agencies: Thank you for the opportunity 
to offer written testimony on the Administration's fiscal year 2015 
Budget Request for the Department of Health and Human Services, 
Administration for Children and Families. The Local Initiatives Support 
Corporation (LISC) views this hearing as a positive step toward 
understanding the importance of early childhood development and 
securing critically needed investments to ensure that all children, 
especially low-income children, are given a strong start and enter 
kindergarten ready to learn. As you consider ways that Congress can 
help children get an early start on the pathway to success, we 
encourage you to recognize the critical role that early childhood 
facilities play in preparing young children for achievement in school 
and in life, and urge you to ensure that Federal policies adequately 
finance the acquisition, construction, and improvement of these spaces.
                               about lisc
    Established in 1979, the Local Initiatives Support Corporation 
(LISC) is a national nonprofit with Community Development Financial 
Institution (CDFI) designation, dedicated to helping community 
residents transform distressed neighborhoods into healthy places of 
choice and opportunity--good places to work, do business and raise 
children. LISC mobilizes corporate, government and philanthropic 
support to provide local community development organizations with 
loans, grants and equity investments; local, statewide and national 
policy support; and technical and management assistance.
    LISC has local offices in 30 cities and partners with more than 50 
organizations serving rural communities throughout the country. We 
focus our activities across five strategic community revitalization 
goals:
  --Expanding Investment in Housing and Other Real Estate
  --Increasing Family Income and Wealth
  --Stimulating Economic Development
  --Improving Access to Quality Education, and
  --Supporting Healthy Environments and Lifestyles.
    For more than three decades, LISC has developed programs and raised 
investment capital to help local groups revive their neighborhoods. 
Because we recognize the link between human opportunity and social and 
economic vitality, we have spent the last 17 years working to bring 
high quality early care and education settings to low-income 
neighborhoods where children enter the world at high risk for negative 
outcomes. Through our signature early childhood program, the Community 
Investment Collaborative for Kids (CICK), LISC has invested $48 million 
in planning and developing 184 new facilities serving 20,000 children 
in more than 65 low-income urban and rural neighborhoods across the 
country.
                                overview
    Early childhood is a critical development period. Research shows 
that a complex interplay between genetics and environment profoundly 
influences how children grow physically, socially, and emotionally. 
Investments in high quality early childhood programs can help promote 
healthy development and strong communities. Those active in community 
revitalization believe without question, that early care and education 
programs are essential parts of every neighborhood--they prepare young 
children for success in school and life, support working parents, and 
improve family well-being.
    Regrettably, many families--particularly those who are low-income 
or in rural areas--lack access to the stable, high-quality early 
childhood centers that parents need to maintain gainful employment and 
children need to grow and thrive. Additionally, while there is 
appropriate focus on the need for high quality curriculum and qualified 
teachers, the physical environment is an essential feature that is 
often forgotten.
    In this testimony, we highlight the important role that physical 
environments play in supporting the quality of early learning programs 
and healthy early childhood development and encourage Congress to 
address the need for comprehensive early childhood facility policies.
                               background
Early Childhood is a Critical Development Period
    Decades of research has shown that early life experiences are 
extremely important to the social, emotional, and academic development 
of children.\1\ Positive experiences promote healthy brain development 
and behavior, while negative experiences undermine development--and, in 
severe circumstances, permanently impair a child's nervous and immune 
system, stunting healthy growth.\2\ High quality early care and 
education is widely regarded as the single most effective intervention 
to promote healthy development and close the academic achievement gap 
for low-income children at-risk for poor social and economic 
outcomes.\3\ The data are clear: the quality of one's early childhood 
experiences profoundly influence that person's future life trajectory.
---------------------------------------------------------------------------
    \1\ Jack P. Shonkoff and Deborah A. Phillips, Editors, From Neurons 
to Neighborhoods: The Science of Early Childhood Development, National 
Research Council Institute of Medicine, National Academy Press, 
Washington, DC 20000
    \2\ National Scientific Council on the Developing Child. 
``Excessive Stress Disrupts the Architecture of the Developing Brain. 
Working Paper No. 3'' (2005) http://www.developingchild.net/pubs/wp/
Stress_Disrupts_Architecture_Developing_Brain.pdf. (Accessed June 17, 
2009).
    \3\ http://www.readynation.org/uploads//
20130919_ReadyNationVitalLinksLowResEndnotes.pdf, Schweinhart, L. J., 
Montie, J., Xiang, Z., Barnett, W. S., Belfield, C. R., & Nores, M. 
(2005). Lifetime Effects: The High/Scope Perry Preschool Study Through 
Age 40. Ypsilanti, MI: High/Scope Press. And Reynolds, A. J., Temple, 
J. A., Robertson, D. L., & Mann, E. A. (2002). Age 21 Cost-Benefit 
Analysis of the Title I Chicago Child-Parent Centers. Madison, WI: 
Institute for Research on Poverty. And FPG Child Development Center. 
(1999). Early Learning, Later Success: The Abecedarian Study. Chapel 
Hill, NC: University of North Carolina.
---------------------------------------------------------------------------
The Quality of Early Childhood Facilities Matters
    While many factors contribute to program quality, the physical 
environment is an essential feature that is often overlooked. The link 
between the quality of buildings and the quality of programs tends to 
be only vaguely understood and largely undocumented among child care 
providers. Despite this inclination, evidence about the connection 
between space and effectiveness has been found even when physical space 
is not the focal point of the research undertaken. A study conducted at 
the School for Young Children (SYC), a distinguished preschool program 
housed at St. Joseph College in West Hartford, Connecticut, provides a 
compelling example.\4\
---------------------------------------------------------------------------
    \4\ Tony Proscio, Carl Sussman & Amy Gillman, Authors, Child Care 
Facilities: Quality by Design, (2004). http://www.lisc.org/content/
publications/detail/815 .
---------------------------------------------------------------------------
    Every State has a minimum adult-child ratio for licensed centers, 
in large part because attention from nurturing adults is a prime 
indicator of quality in child care programs. SYC is a highly regarded 
preschool program with a more than ample staffing ratio; the program is 
largely viewed as meeting if not exceeding minimum quality standards. 
Yet, when a research team set out to monitor enrolled children's 
contact with adults during free play time they found shocking results: 
Only 3 percent of the children's time was spent engaged in meaningful 
interactions with a teacher.
    While the SYC executive director was digesting the researchers' 
negative findings in order to develop a workable solution, her 
organization moved to new accommodations. A routine follow-up test in 
the new space immediately showed a strikingly higher result. Teacher-
child interactions increased to 22 percent. There had been no change in 
the management, staff, or program, only the physical space. The new 
space, which Bye had taken pains to design, was considerably roomier 
and there were bathrooms, telephones, storage space, and other 
logistical necessities in each classroom. Adults no longer had to leave 
the room to escort children to the bathroom, retrieve or store 
supplies, or take a phone call. Fewer distractions and interruptions 
for adults naturally meant more time for children.
    Both children and staff benefited from the new space configuration. 
The more generous square footage allowed staff to configure each 
classroom into well-defined areas for different activities. Children 
were no longer crowded together into inadequate space and distracted by 
one another, so they ran into conflicts less often, and had better play 
experiences--making their interactions with adults and other children 
more constructive. Teachers were able to use their time in a more 
effective and rewarding way, resulting in higher morale and lower staff 
turnover for. Overall, the effect of the new space on the content of 
the program was considerable and measurable--even when not a single 
change had been made in the program itself.
    Space matters: a facility's layout, size, materials and design 
features can improve program quality and contribute positively to child 
development while a poorly adapted and overcrowded environment 
undermines it.\5\ Bathrooms adjacent to classrooms, accessible cubbies, 
and child-sized sinks, counters, furnishings and fixtures increase 
children's autonomy and competence while decreasing the demands on 
teachers. Early learning centers with ample classrooms divided into 
well-configured activity areas support uninterrupted self-directed pay 
and exploration. The physical configuration of early care and education 
spaces directly affect adult/child interaction and influence how 
children grow and learn.
---------------------------------------------------------------------------
    \5\ http://www.lisc.org/docs/publications/2007 
_nieer_cick_facilities_brief.pdf
---------------------------------------------------------------------------
    The National Association for the Education of Young Children 
(NAEYC) acknowledges the importance of a quality environment in the 
following statement: ``The physical environment sets the stage and 
creates the context for everything that happens in any setting--a 
classroom, a play yard, a multipurpose room. A high-quality environment 
welcomes children; engages children in a variety of activities; 
provides space for individual, small-group, and large-group activities; 
and generally supports the program's philosophy and goals. Ultimately, 
the physical environment must convey values and messages about who is 
welcomed, what is important, and what the beliefs are about how 
children learn.'' \6\
---------------------------------------------------------------------------
    \6\ http://www.naeyc.org/store/node/402
---------------------------------------------------------------------------
What Facilities Experts Know
    Although physical spaces play an important role in promoting 
program quality and healthy development, it is rare to find high 
quality facilities designed to meet the unique needs of very young 
children, especially in low-income communities. Early childhood 
specialists have long maintained that the physical environments where 
learning takes place--and where young children spend the majority of 
their waking hours--significantly influence the quality of early care 
and education programs.
    Facilities experts and those proficient in financing the design, 
acquisition, construction, and improvement of early care and education 
spaces concur and largely agree that:
  --Well-designed facilities enhance child development and program 
        quality;
  --An adequate supply of facilities is needed to support rapidly 
        increasing preschool education programs;
  --The quality and location of the facilities can encourage enrollment 
        and parent involvement;
  --Facilities can help promote a positive workplace in an industry 
        challenged to retain experienced teachers;
  --Child care program income, especially in low-income communities, is 
        typically not sufficient to cover the full cost of delivering 
        quality early education services and doesn't allow for the 
        added cost of constructing or improving appropriate facilities; 
        and
  --Few centers have the experience or personnel to handle the 
        complexities of real estate development tasks and require 
        specialized technical assistance to address their facilities 
        needs.
    Early Childhood Facilities Financing Challenges
    Despite what is known about the importance of the spaces where 
learning takes place, there is no dedicated source of capital to help 
early care and education programs develop well-designed facilities 
suitable for our youngest learners. Programs serving low-income 
communities are highly dependent on public operating revenues that 
don't cover the cost of purchasing or renovating an appropriate 
facility. Without a consistent and effective financing system or 
capital subsidies, providers are left to pursue piecemeal approaches, 
cobbling together small donations and grants from a variety of sources. 
This prevents the early childhood field from addressing its physical 
facility needs and creating the kind of environments that support high 
quality programs.
    Historically, private financial institutions have not made 
significant infrastructure investments in early care and education--
particularly in economically distressed areas. Few mainstream banks, 
credit unions, and lending institutions are willing to finance early 
childhood facility projects, which tend to require relatively small, 
complex loans often characterized by uncertain future funding for 
repayment through government operating subsidies. The projects 
generally have little to no equity, and limited collateral value. In 
addition, private banks typically don't employ staff with specialized 
knowledge of the child care sector, consequently they are unable to 
understand the needs of child care or preschool centers and assist 
program directors lacking experience with real estate development and 
financing.
    Certified Community Development Financial Institutions (CDFI) 
working in market niches that are underserved by traditional financial 
entities are among the small number of organizations who have made 
investments in early childhood physical spaces. They have a proven 
track record in economically challenged regions and are experienced 
with providing a unique range of financial products and services that 
spur private investment in their target markets. Unfortunately, given 
the limited funding available to CDFIs to carry out their comprehensive 
mission, demand for early childhood facilities capital far outstrips 
supply.
                            recommendations
    As Congress considers ways to help children get an early start on 
the pathway to success, we urge you to:
      1. Recognize the critical role that early childhood facilities 
        play in preparing young children for achievement in school and 
        in life.
      Congress has the power to influence and support State and local 
        early childhood priorities. We believe that conversations about 
        early care and education should always acknowledge the 
        significant impact of early childhood physical settings on 
        early learning.
      2. Ensure that Federal policies adequately finance the 
        acquisition, construction, and improvement of early care and 
        education spaces.
      Currently, there is no dedicated source of funding for the 
        acquisition, construction, and improvement of early care and 
        education spaces. Additionally, the economic instability of the 
        past 5 years has resulted in very little investment in early 
        childhood physical infrastructure. Capital must be available in 
        order for early care and education providers to create high 
        quality physical spaces that promote early learning. We are 
        encouraged by the national dialogue on the importance of 
        investments in early childhood development, and request that 
        you create the supportive policy, regulatory, and funding 
        environment that is needed to enable the early care and 
        education field to meet its physical capital needs.
                               conclusion
    As investments are made to increase access to preschool and child 
care, attention must be paid to the physical environment where many 
young children spend the majority of their waking hours. Without 
support for facilities, programs will locate in the least expensive and 
most readily available spaces--makeshift, donated, or surplus space 
such as basements and storefronts or outdated classrooms for older 
students that have not been adapted for our youngest children and fall 
far short of standards to support high quality programs.
    We look forward to continuing conversations with you and your 
staff. Our organization serves on the Executive Committee of the 
National Children's Facilities Network (NCFN), a coalition of like-
minded nonprofit financial and technical assistance intermediaries 
involved in planning, developing, and financing facilities for low-
income child care and early education programs. Both LISC and NCFN 
would welcome an opportunity to serve as a resource.
    Thank you again for your leadership.

    [This statement was submitted by Matthew Josephs, Senior Vice 
President, Policy, and Amy Gillman, Senior Program Director, Community 
Investment Collaborative For Kids.]
                                 ______
                                 
          Prepared Statement of the March of Dimes Foundation

       MARCH OF DIMES: FISCAL YEAR 2015 FEDERAL FUNDING PRIORITIES
                         [Dollars in thousands]
------------------------------------------------------------------------
                                                        Fiscal year 2015
                       Program                              request
------------------------------------------------------------------------
National Institutes of Health (Total)................         32,000,000
National Institute of Child Health and Development...          1,370,000
National Human Genome Research Institute.............            536,967
National Institute on Minority Health and Disparities            289,426
Centers for Disease Control and Prevention (Total)...          7,800,000
National Center for Birth Defects and Developmental              139,000
 Disabilities........................................
 Birth Defects Research and Surveillance.............             22,300
 Folic Acid Campaign.................................              2,800
Immunizations........................................            720,000
Polio Eradication....................................            146,000
Safe Motherhood Initiative...........................             46,000
 Preterm Birth.......................................              2,000
National Center for Health Statistics................            182,000
Health Resources and Services Administration (Total).          7,480,000
Title V, Maternal and Child Health Block Grant.......            639,000
 SPRANS- Infant Mortality and Preterm Birth..........              3,000
Heritable Disorders..................................             18,000
Universal Newborn Hearing............................             18,660
Healthy Start........................................            103,532
Children's Hospitals Graduate Medical Education......            300,000
Agency for Healthcare Research and Quality (Total)...            375,000
------------------------------------------------------------------------

    The three million volunteers and 1,200 staff members of the March 
of Dimes Foundation appreciate the opportunity to submit Federal 
funding recommendations for fiscal year 2015. The March of Dimes is a 
unique partnership of scientists, clinicians, parents, members of the 
business community and other volunteers affiliated with chapters in 
every State, the District of Columbia and Puerto Rico. The March of 
Dimes recommends the following funding levels for programs and 
initiatives that are essential investments in maternal and child 
health.
                             preterm birth
    Preterm birth is a serious health problem that costs the United 
States more than $26 billion annually. Employers, private insurers and 
individuals bear approximately half of the cost of healthcare for these 
infants, and another 40 percent is paid by Medicaid. One in nine 
infants in the U.S. is born preterm. Prematurity is the leading cause 
of newborn mortality and the second leading cause of infant mortality. 
Among those who survive, one in five faces health problems that persist 
for life such as cerebral palsy, intellectual disabilities, chronic 
lung disease, and deafness. For the past 6 years preterm birth rates 
have declined, resulting in 176,000 fewer babies being born preterm and 
saving more than $9 billion. The March of Dimes believes a key factor 
behind this continued decline was Congress' passage of the 2006 PREEMIE 
Act (Public Law 109-450), which brought the first-ever national focus 
to prematurity prevention and generated a public-private agenda to spur 
innovative research at the National Institutes of Health (NIH) and 
Centers for Disease Control and Prevention (CDC) and advanced evidence-
based interventions to prevent preterm birth. In 2013 Congress passed 
the PREEMIE Reauthorization Act (Public Law 113-55), which renews our 
Nation's commitment to giving every baby a healthy start. The March of 
Dimes' fiscal year 2015 funding requests regarding preterm birth are 
based on continuing to enhance public and private investment into 
understanding the causes of preterm birth and promoting known 
interventions.
Eunice Kennedy Shriver National Institute of Child Health and Human 
        Development (NICHD)
    The March of Dimes recommends at least $32 billion for the National 
Institutes of Health and $1,370 billion for the NICHD in fiscal year 
2015. This funding will allow NICHD to sustain its preterm birth-
related research through extramural grants, Maternal-Fetal Medicine 
Units, the Neonatal Research Network and the intramural research 
program. This funding would also allow for NICHD to continue 
investments in transdisciplinary research to identify the causes of 
preterm birth, as recommended in the Director's 2012 Scientific Vision 
for the next decade, the Institute of Medicine 2006 report on preterm 
birth, and the 2008 Surgeon General's Conference on the Prevention of 
Preterm Birth. The March of Dimes fully supports NICHD's pursuit of 
transdisiplinary science, which facilitates the exchange of scientific 
ideas and leads to novel approaches to understanding complex health 
issues and their prevention.
Centers for Disease Control and Prevention--Preterm Birth
    The mission of the CDC's National Center for Chronic Disease 
Prevention and Health Promotion's Safe Motherhood Initiative is to 
promote optimal reproductive and infant health. The March of Dimes 
recommends funding of $46 million for the Safe Motherhood program and 
re-instatement of the preterm birth sub-line at $2 million, as 
reauthorized in the PREEMIE Reauthorization Act, to reflect current 
preterm birth research within the CDC.
    The CDC funds state-based Perinatal Quality Collaboratives, 
networks of hospitals, healthcare providers, State health departments, 
consumer groups, and others that advance evidence-based clinical 
practices and processes. These networks collect data in real time on 
healthcare practices and outcomes and provide immediate feedback for 
quality improvement. For example, the New York State Obstetrical and 
Neonatal Quality Collaborative reduced deliveries without indication 
from 25 percent in 2010 to 7-8 percent in 2012. Reducing elective 
deliveries before 39 weeks gestation is a proven way to lower preterm 
birth and improve infant outcomes.
Health Resources and Services Administration (HRSA)--Preterm Birth
    The March of Dimes recommends the Subcommittee specify $3 million 
within the Title V Special Projects of Regional and National 
Significance account be used to support current preterm birth and 
infant mortality initiatives, as authorized in the PREEMIE Act, and to 
support the expansion of its initiatives nationwide. The PREEMIE 
Reauthorization Act renewed preterm birth-related demonstration 
projects, which are aimed at improving education, treatment and 
outcomes for babies born preterm. This funding will support HRSA's 
Collaborative Improvement & Innovation Network (COIIN) to Reduce Infant 
Mortality, which assists State agencies focusing on a range of 
interventions proven to reduce preterm birth and improve maternal and 
child health.
                             birth defects
    According to the CDC, an estimated 120,000 infants in the U.S. are 
born with major structural birth defects each year. Birth defects are 
the leading cause of infant mortality and the causes of more than 70 
percent are unknown. Federal investments are sorely needed to support 
research to discover the causes of all birth defects and for the 
development of effective interventions to prevent them or reduce their 
prevalence.
CDC--National Center on Birth Defects and Developmental Disabilities 
        (NCBDDD)
    For fiscal year 2015, the March of Dimes recommends funding of $139 
million for NCBDDD. We also request the Subcommittee provide at least 
$22.3 million to support birth defects research and surveillance and 
$2.8 million to support folic acid education. Birth defects research 
and surveillance activities have been severely curtailed due to funding 
reductions which means a slowed pace to research identifying causes of 
birth defects and decreased ability to track birth defects and connect 
families to services. Specifically, two Centers for Birth Defects 
Research and Prevention have been eliminated. Specific expertise from 
the previously funded Centers in Texas and Utah (medications used 
during pregnancy, environmental exposures of concern, maternal 
infections, and birth defects risk among Hispanics) is no longer 
contributing to the study and 25 percent fewer families are 
participating in CDC birth defects research. Birth defects surveillance 
programs funded by NCBDDD have gone from 28 in 2004 to 14 in 2013, with 
a 40 percent (800,000) reduction in the number of live births monitored 
by States.
                           newborn screening
    Newborn screening is a vital public health activity designed to 
identify genetic, metabolic, hormonal and functional disorders in 
newborns. Screening detects conditions in newborns that, if left 
untreated, can cause disability, developmental delays, intellectual 
disabilities, serious illnesses or even death. If diagnosed early, many 
of these disorders can be managed successfully. The March of Dimes 
urges the Subcommittee to provide $18 million for HRSA's heritable 
disorders program, which plays a critical role in assisting States in 
the adoption of additional screenings, enhancing provider and consumer 
education, and ensuring coordinated follow-up care. Also funded by this 
program is the work of the Advisory Committee on Heritable Disorders in 
Newborns and Children, which provides States with a Recommended Uniform 
Screening Panel (RUSP) to ensure that every infant is screened for 
conditions having a known treatment. The RUSP has helped bring about 
comprehensive newborn screening in every State. In 2007, only 10 States 
and DC required infants to be screened for the recommended disorders; 
today, 42 States and DC require screening of at least 29 of the 31 
treatable conditions.
                                closing
    The Foundation's volunteers and staff in every State, the District 
of Columbia and Puerto Rico look forward to working with Members of 
this Subcommittee to secure the resources needed to improve the health 
of the Nation's mothers, infants and children.
                                 ______
                                 
              Prepared Statement of The Marfan Foundation
    Chairman Harkin and distinguished members of the Subcommittee, 
thank you for your time and your consideration of the priorities of the 
heritable connective tissue disorders community as you work to craft 
the fiscal year 2015 Labor, Health and Human Services Appropriations 
Bill.
    about marfan syndrome and heritable connective tissue disorders
Marfan Syndrome
    Marfan syndrome is a genetic disorder that affects the body's 
connective tissue. Connective tissue holds all the body's cells, organs 
and tissue together. It also plays an important role in helping the 
body grow and develop properly.
    Connective tissue is made up of proteins. The protein that plays a 
role in Marfan syndrome is called fibrillin-1. Marfan syndrome is 
caused by a defect (or mutation) in the gene that tells the body how to 
make fibrillin-1. This mutation results in an increase in a protein 
called transforming growth factor beta, or TGF-b. The increase in TGF-b 
causes problems in connective tissues throughout the body, which in 
turn creates the features and medical problems associated with Marfan 
syndrome and some related disorders.
    Because connective tissue is found throughout the body, Marfan 
syndrome can affect many different parts of the body, as well. Features 
of the disorder are most often found in the heart, blood vessels, 
bones, joints, and eyes. Some Marfan features--for example, aortic 
enlargement (expansion of the main blood vessel that carries blood away 
from the heart to the rest of the body)--can be life-threatening. The 
lungs, skin and nervous system may also be affected. Marfan syndrome 
does not affect intelligence.
Related Conditions
    There are disorders related to Marfan syndrome that can cause 
people to struggle with some of the same or similar physical problems. 
Some examples are Loeys-Dietz syndrome, Ehlers-Danlos syndrome, and 
Familial Thoracic Aortic Aneurysm and Dissection.
    Disorders related to Marfan syndrome can also cut lives short, 
particularly when they go unchecked, and they can deeply affect the 
quality of life of the individuals and families who must cope with 
them. Just like people with Marfan syndrome, those affected by related 
disorders need early and accurate diagnosis to ensure they receive 
proper care and treatment.
    Many of these disorders are genetic conditions that, like Marfan 
syndrome, cause the aorta (the main blood vessel that carries blood 
from the heart to the rest of the body) to enlarge, a problem that 
requires medicine and regular monitoring to determine appropriate 
treatment. Other features that may overlap with Marfan syndrome include 
those involving the heart, bones, joints and eyes. Related connective 
tissue disorders include:
  --Loeys-Dietz Syndrome
  --Ehlers-Danlos Syndrome
  --Familial Thoracic Aortic Aneurysm and Dissection
  --Mass Phenotype
  --Ectopia Lentis Syndrome
  --Beals Syndrome
  --Bicuspid Aortic Valve
  --Stickler Syndrome
  --Shprintzen-Goldberg Syndrome
                          about the foundation
    The Marfan Foundation creates a brighter future for everyone 
affected by Marfan syndrome and related disorders.
  --We pursue the most innovative research and make sure that it 
        receives proper funding.
  --We create an informed public and educated patient community to 
        increase early diagnosis and ensure life-saving treatment.
  --We provide relentless support to families, caregivers, and 
        healthcare providers.
    We will not rest until we've achieved victory--a world in which 
everyone with Marfan syndrome or a related disorder receives a proper 
diagnosis, gets the necessary treatment, and lives a long and full 
life.
                           one family's story
    Hector Roman was 36 years old when he died on June 25, 2012, of an 
aortic dissection caused by Marfan syndrome. He was never diagnosed 
with Marfan syndrome--despite being treated by several medical 
specialists for myriad health issues--and he did not know he was a risk 
of a sudden early death. He was in pain for days and didn't rush to the 
hospital because he was frustrated with the lack of help he was getting 
with his health concerns. He had no idea this delay would be deadly. 
After a few days in pain, he went into shock and a friend call 911. He 
died 3 days later during his third surgery.
    Now, his partner, Teresita Mompeller, of Phoenix, AZ, is raising 
their three boys--Jovan,5, Joel, 3, and Justus, 2--alone. After Hector 
died, Teresita learned about Marfan syndrome. Most alarming to her was 
that affected people have a 50 percent chance of passing it to their 
offspring. She had her sons checked immediately. Joel and Justus have 
been diagnosed with Marfan syndrome and already have aortic 
enlargement. While their condition is the same as their dad; their 
prognosis is better. The boys can live a normal life span because they 
have the diagnosis and are being monitored. They can avoid a fatal 
situation because they know.
    Teresita, who has a Facebook page called ``Do You Know Marfan?'' 
(and a parallel page in Spanish) recently wrote: ``Thanks to the work 
of The Marfan Foundation, I know that my boys have a greater chance of 
living a long life. I know first-hand what it is to be a mother with 
many questions and concerns about a rare disorder that nobody seemed to 
know anything about. The Marfan Foundation has guided me through all of 
my concerns. They have given me all the support and information needed 
to advocate for my children [so they receive] proper treatment. The 
Foundation has given me and thousands of other people, the peace of 
mind that they are working hard to better the lives of those 
affected.''
                             sequestration
    We have heard from the medical research community that 
sequestration and deficit reduction activities have created serious 
issues for Federal funding opportunities and the career development 
pipeline. In order to ensure that research into heritable connective 
tissue disorders can continue to move forward, and, more importantly, 
to ensure that our country is adequately preparing the next generation 
of young investigators, we urge you to avert, mitigate, or otherwise 
eliminate the specter of sequestration. While the Foundation has 
anecdotal accounts of the harms of sequestration, the Federated 
American Societies for Experimental Biology has reported:
  --In constant dollars (adjusted for inflation), the NIH budget in 
        fiscal year 2013 was $6 billion (22.4 percent) less than it was 
        in fiscal year 2003.
  --The number of competing research project grants (RPGs) awarded by 
        NIH has also fallen sharply since fiscal year 2003. In fiscal 
        year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3 
        percent) fewer than in fiscal year 2003.
  --Awards for R01-equivalent grants, the primary mechanism for 
        supporting investigator-initiated research, suffered even 
        greater losses. The number awarded fell by 2,528 (34 percent) 
        between fiscal year 2003 and fiscal year 2013.
    The pay line for some NIH funding mechanisms has fallen from 18 
percent to 10 percent while the average age for a researcher to receive 
their first NIH-funded grant has climbed to 42. These are strong 
disincentives to choosing a career as a medical researcher. Our 
scaling-back is occurring at a time when many foreign countries are 
investing heavily in their biotechnology sectors. China alone plans to 
dedicate $300 million to medical research over the next 5 years; this 
amount is double the current NIH budget over the same period of time. 
Scientific breakthroughs will continue, but America may not benefit 
from the return-on-investment of a robust biotechnology sector. For the 
purposes of economic and national security, as well as public health, 
the Foundation asks that you work with your colleagues to eliminate 
sequestration and recommit to supporting this Nation's biomedical 
research enterprise.
               centers for disease control and prevention
    People with Marfan syndrome are born with it, but features of the 
disorder are not always present right away. Some people have a lot of 
Marfan features at birth or as young children--including serious 
conditions like aortic enlargement. Others have fewer features when 
they are young and don't develop aortic enlargement or other signs of 
Marfan syndrome until they are adults. Some features of Marfan 
syndrome, like those affecting the heart and blood vessels, bones or 
joints, can get worse over time.
    This makes it very important for people with Marfan syndrome and 
related disorders to receive accurate, early diagnosis and treatment. 
Without it, they can be at risk for potentially life-threatening 
complications. The earlier some treatments are started, the better the 
outcomes are likely to be.
    Knowing the signs of Marfan syndrome can save lives. Our community 
of experts estimates that nearly half the people who have Marfan 
syndrome don't know it. CDC and NCBDDD have critical programs that can 
help improve awareness and recognition of warning signs, which can save 
lives. Some of these programs including CDC's Million Hearts Campaign 
and NCBDDD's newborn screening activities. Meaningful funding increases 
will allow CDC and NCBDDD to expand their successful awareness efforts 
to include additional conditions.
                     national institutes of health
    NIH has worked closely with the Foundation to investigate the 
mechanisms of these conditions. In recent decades, this research has 
yielded significant scientific breakthroughs that have the potential to 
improve the lives of affected individuals. In order to ensure that the 
heritable connective tissue disorders research portfolios can continue 
to expand and advance, NIH requires meaningful funding increases to 
invest in emerging and promising activities.
NHLBI
    The Marfan Foundation anxiously await the results of this first-
ever multicenter clinical trial for our patient population conducted by 
the National Heart, Lung and Blood Institute's Pediatric Heart Network 
(PHN). After 4 years of recruitment and 3 years of follow-up 
evaluations, the results are expected to be released in November 2014 
at the American Heart Association Meeting. 604 Marfan syndrome patients 
(age 6 months to 25 years) are enrolled in the study. Patients are 
randomized onto either losartan or atenolol (a beta blocker that is the 
current standard of care for Marfan patients with an enlarged aortic 
root). The Marfan Foundation thanks both NHLBI and NIAMS for their 
dedicated support and careful execution of this trial.
NEI
    Ectopia lentis, dislocation of the lens, occurs in up to 60 percent 
of patients with Marfan syndrome. The central positioning of the lens 
depends on the zonule of Zinn, a fibrous structure which has fibrillin-
1 as a major component. NEI-supported investigators are studying the 
protein interactions of fibrillin-1 in health and disease in the zonule 
of Zinn to understand the disease mechanisms that cause ectopia lentis. 
It is hoped that this research will provide therapeutic insights to 
better treat this complication of Marfan syndrome.
NIAMS
    NIAMS continues to support the Consortium for Translational 
Research in Marfan Syndrome, which is investigating the disease process 
in MFS. These studies, building on previous advances, are aimed at 
identifying new biological targets for therapy, as well as predictive 
biomarkers of vascular and skeletal manifestations, which are the major 
causes of mortality and morbidity in MFS.
ORDR
    The National Center for Advancing Translational Sciences houses 
ORDR and leads other important activities. In addition to the Rare 
Disease Clinical Research Consortia, translational treatment 
development programs hold promise for the heritable connective tissue 
disorders community.
                                 ______
                                 
    Prepared Statement of Mary A. Vitale, Guardian/Sibling/Advocate
    Dear Committee Members: The opportunity to submit personal 
testimony to this committee is much appreciated. As 2015 appropriation 
requests are being considered, this submission of testimony is a 
request for a review of the misuse of Federal funds by the Health and 
Human Services (HHS) agencies that promote forced 
deinstitutionalization of persons with severe and profound intellectual 
disabilities.
    I have been an active guardian for 35 years for my 61 year old 
brother who has severe intellectual disabilities, behavior challenges, 
and ongoing medical concerns. He has never been able to walk or talk. 
He has only partial use of one of his arms. He needs maximum assistance 
for all his needs. Despite his many disabilities, he is a happy man. 
His care at his intermediate care facility for individuals with 
intellectual disabilities (ICF/IID) home is successful, stable, 
sustainable, consistent, comprehensive, and cost-effective.
    HHS agencies, such as State Planning Councils and State Protection 
and Advocacy Services, are misusing Federal funds to promote the 
closing of ICF/IID homes like where my brother lives, despite the 
objections of legal guardians.
    The Supreme Court 1999 Olmstead ruling states: ``It would be 
unreasonable, it would be a tragic event, then, were the Americans with 
Disabilities Act of 1990 (ADA) to be interpreted so that States had 
some incentive, for fear of litigation to drive those in need of 
medical care and treatment out of appropriate care and into settings 
with too little assistance and supervision.''
    To the great dismay of families, this ``tragic event'' is exactly 
what is happening across the United States by the misuse of HHS 
funding.
    Appropriate, cost-effective care for those with the severest 
disabilities is available in ICF/IID homes, and yet they are 
aggressively targeted for closure, flagrantly ignoring the educated 
choice of guardians.
    Many community settings have too little assistance and too little 
supervision to be appropriate for those with severe multiple 
intellectual and physical impairments. Tragically, the result is an 
increase in neglect and abuse.
    I ask each member of this committee to seriously question HHS about 
misusing Federal funds to promote forced total deinstitutionalization 
for persons with intellectual disabilities. Help us keep our beloved 
family members safe and healthy.
                                 ______
                                 
    Prepared Statement of the Meals On Wheels Association of America
    Chairman Harkin and Ranking Member Moran: Thank you for the 
opportunity to present testimony to your Subcommittee concerning fiscal 
year 2015 funding for Older Americans Act (OAA) Nutrition Programs 
administered by the Administration for Community Living/Administration 
on Aging within the U.S. Department of Health and Human Services. We 
are sincerely grateful for your longstanding support, as well as your 
leadership in ensuring that these programs received a restoration of 
funding in fiscal year 2014 over the devastating fiscal year 2013 
sequestration cuts.
    Last month, we sent a joint letter with the National Association of 
Nutrition and Aging Services Program (NANASP) to you, Chairman Mikulski 
and Ranking Member Shelby urging increased investments in OAA Nutrition 
Programs, including the Congregate Nutrition Program, Home-Delivered 
Nutrition Program (commonly referred to as Meals on Wheels), and the 
Nutrition Services Incentive Program. Specifically, we requested 
funding these programs at their fiscal year 2010 levels--totaling $819 
million. During the fiscal year 2015 appropriations process, we implore 
you to give this modest request your utmost consideration due to the 
significant moral and economic benefits these programs offer.
    This week, a new report released by the National Foundation to End 
Senior Hunger shows that nearly 9.3 million Americans over the age of 
60 struggled with hunger in 2012, up from 8.8 million in 2011--and a 
28% increase since the start of the recession in 2007. Because OAA 
funding has not kept pace with needs, the chasm continues to widen. 
Through OAA Nutrition Programs, we are only able to provide nutritious 
meals to 2.5 million of them,\1\ leaving a staggering gap of nearly 7 
million seniors still in need. The infrastructure and network exists to 
serve more of our seniors in need, but the financial resources fall 
substantially short. That is why we are asking for a critical boost in 
funding levels.
---------------------------------------------------------------------------
    \1\ 2011 Older Americans Act State Program Reports. U.S. Department 
of Health and Human Services, Administration on Aging. March 2013. 
http://www.agid.acl.gov/.
---------------------------------------------------------------------------
    Senior hunger is a growing epidemic that has serious implications 
for our current and future Mandatory spending. Without proper nutrition 
and the critical social connection that comes along with it, one's 
health deteriorates and inevitably fails. It is extremely costly not 
only in personal terms for the individuals who struggle with hunger, 
but also for our Nation in terms of increased healthcare costs. As 
such, we hope that you recognize the need to invest in Discretionary 
programs, like OAA Nutrition Programs, that help prevent and mitigate 
the effects of chronic diseases, improve quality of life, expedite 
recovery after an illness or injury, and reduce unnecessary Medicare 
and Medicaid expenses both today and in the future. These programs are 
part of the solution to our Nation's fiscal challenges.
    For over 40 years, OAA Nutrition Programs in communities large and 
small, urban and rural have been effectively serving our country's most 
vulnerable, frail and isolated seniors. What started as a demonstration 
project has grown into a highly effective community-based, nationwide 
network of more than 5,000 local programs. While not all programs 
receive OAA funds, the majority rely, in part, on the Federal dollars 
authorized under Title III of the Act as a foundation on which to 
leverage other funding. This enables a very successful public-private 
partnership to help raise the remaining resources needed to provide 
daily nutritious meals and social contact to seniors 60 years of age 
and older who are at significant risk of hunger and losing their 
ability to remain independent and able to live in their homes.
    The evidence demonstrates that these programs are not only saving 
lives and taxpayer dollars every day, but they are doing precisely what 
they were designed to do by effectively reaching our Nation's most at-
risk seniors.
    Data from the 2012 National Survey of OAA Participants shows that 
the seniors receiving Meals on Wheels and congregate meals are 
primarily over age 75, impoverished, live alone, are in poor health and 
functionally impaired. For the majority of the individuals served, the 
meal that they receive provides one half or more of their total food 
for the day.
    Of the seniors receiving Meals on Wheels:
  --60 percent have six to 14 chronic health conditions
  --51 percent take from six to at least 23 medications daily
  --29 percent have three or more limitations in everyday activities, 
        such as bathing, getting dressed and toileting
    Of the seniors receiving congregate meals:
  --40 percent have six to 14 chronic health conditions
  --29 percent take from six to at least 23 medications daily
  --50 percent have at least one limitation in everyday activities, 
        such as preparing meals or grocery shopping
    Each day, Meals on Wheels programs in Iowa, Kansas and in every 
State across the Nation are serving far more than just meals to seniors 
in need. They are delivering a caring and efficient service--nutritious 
meals, friendly visits, and safety checks--enabling more than 2.5 
million seniors to continue to live independently in their own homes 
and without the worry of hunger and isolation. In short, these programs 
are a lifeline.
    The following comments from individuals served illustrate the 
degree to which these OAA Nutrition Programs are delivering far more 
than just a meal.
  --``The companionship and fellowship as well as the nutritious meals 
        keep me getting up in the morning, getting dressed and to the 
        site to eat.''
  --``My husband needs lots and lots of help . . .  If it wasn't for 
        meals, I wouldn't be able to continue taking care of him in our 
        home.''
  --``If it wasn't for Meals on Wheels, I would starve.''
  --``Once a day a knock at my door means I eat for that day.''
  --``I am so grateful for the volunteer drivers . . . sometimes it is 
        the only human contact I have for days.''
  --``I had major surgery. I feel these meals are big step toward 
        keeping me from going to a nursing home.''
  --``I do not get much social security so at least I have food to eat; 
        this is my only meal; I am 89 and need Meals on Wheels or I 
        can't stay in my home; the friendly volunteers are the only 
        people I see most days.'' \2,3\
---------------------------------------------------------------------------
    \2\ Lloyd, Jean & Greuling, Holly. The Older Americans Act 
Nutrition Program Sets a New Table. Aging Today Online. American 
Society on Aging. March 2014. http://bit.ly/ONK7eK.
    \3\ Don't Empty My Plate Campaign: http://bit.ly/1oUgRQ9 and http:/
/bit.ly/1jvLSGO.
---------------------------------------------------------------------------
    Beyond the real people and lives these programs impact on a daily 
basis, there is increasing and irrefutable evidence that improving and 
bolstering funding for OAA Nutrition Programs will substantially reduce 
healthcare costs--both in the short- and long-term. A recent report 
from the Center for Effective Government found that for every $1 
invested in Meals on Wheels, up to $50 could be saved in Medicaid 
alone.\4\ Brown University conducted a recent study which found that by 
investing more in Meals on Wheels, more seniors can be kept out of 
nursing homes. Specifically, the research found that for every 
additional $25 a State spends on home-delivered meals each year, per 
person over 65, the low-care nursing home population--seniors who are 
nursing home eligible but could remain in their homes with only a 
little outside support--decreases by a percentage point.\5\ One 
percentage point can translate to billions of dollars in savings 
annually.
---------------------------------------------------------------------------
    \4\ Schieder, Jessica & Lester, Patrick. Sequestering Meals on 
Wheels Could Cost the Nation $489 Million per year. The Center for 
Effective Government. April 2013. http://bit.ly/16jmmRU.
    \5\ Thomas, Kali & Mor, Vincent. The Relationship between Older 
Americans Act Title III State Expenditures and Prevalence of Low-Care 
Nursing Home Residents. Brown University. December 2012. http://bit.ly/
16wl0B2.
---------------------------------------------------------------------------
    On top of the social and economic cases for investing in OAA 
Nutrition Programs, the public overwhelmingly supports them. In fact, 
an October 2013 survey found that 7 in 10 Americans agree that the 
government should pay for Meals on Wheels.\6\ The growing problem of 
senior hunger in America requires the continued public-private 
partnerships that have been a pivotal foundation; however, the Federal 
Government must serve as the strongest and most reliable fiscal partner 
by elevating its support to higher levels that keep pace with a rapidly 
aging population, increased need and ever-rising costs.
---------------------------------------------------------------------------
    \6\ SSRS, independent research company. Survey among a nationally 
representative sample of respondents age 18+. October 2013.
---------------------------------------------------------------------------
    We understand the difficult decisions you and your colleagues are 
tasked with in fiscal year 2015 and beyond. However, the evidence 
demonstrates that these programs are not only saving lives and taxpayer 
dollars every day, but they are effectively reaching our Nation's most 
vulnerable seniors and have the capacity to serve more if properly 
resourced. In short, these proven and effective programs are a part of 
the solution to our Nation's fiscal challenges and should be looked to 
as such.
    As your Subcommittee crafts and considers the fiscal year 2015 
Labor-HHS-Education appropriations bill, we ask that you provide fiscal 
year 2010 appropriations levels for all three nutrition programs 
authorized under the OAA--Congregate Nutrition Program, Home-Delivered 
Nutrition Program, and the Nutrition Services Incentive Program. You 
have the ability to shorten waiting lists and increase the number of 
nutritious meals we can serve to seniors today. At the same time you 
will be investing in a stronger fiscal path for our country by reducing 
future healthcare costs.
    Again, we thank you for the opportunity to present this testimony 
to you, and for your continued support.
                                 ______
                                 
 Prepared Statement of the Medical Library Association and Association 
                 of Academic Health Sciences Libraries
              summary of fiscal year 2015 recommendations
  --Continue the commitment to the National Library of Medicine (NLM) 
        by supporting the President's budget proposal which requests 
        $372.85 million, and an additional $8.2 million from amounts 
        under Section 241 of the Public Health Service Act, for the 
        National Information Center on Health Services Research and 
        Health Care Technology.
  --Continue to support the medical library community's role in NLM's 
        outreach, telemedicine, disaster preparedness, health 
        information technology initiatives, and healthcare reform 
        implementation.
                              introduction
    The Medical Library Association (MLA) and Association of Academic 
Health Sciences Libraries (AAHSL) thank the Subcommittee for the 
opportunity to submit testimony regarding fiscal year 2015 
appropriations for the National Library of Medicine (NLM), an agency of 
the National Institutes of Health (NIH). Working in partnership with 
the NIH and other Federal agencies, NLM is the key link in the chain 
that translates biomedical research into practice, making the results 
of research readily available to all who need it.
NLM Leverages NIH Investments in Biomedical Research
    In today's challenging budget environment, we recognize the 
difficult decisions Congress faces as it seeks to improve our Nation's 
fiscal stability. We thank the Subcommittee for its long-standing 
commitment to strengthening NLM's budget. While extramural funding 
comprises the largest portion of funding for institutes within the NIH, 
some eighty percent of NLM's budget supports intramural services and 
programs that sustain the Nation's biomedical research enterprise and 
more--it builds, sustains, and augments NLM's suite of more than 200 
databases which provide information access to health professionals, 
researchers, educators, and the public. Intramural funding also 
supports all aspects of library operations and programs, including the 
acquisition, organization, preservation, and dissemination of the 
world's biomedical literature, no matter the medium.
    In fiscal year 2015 and beyond, it is critical to continue 
augmenting NLM's baseline budget to support expansion of its 
information resources, services, and programs which collect, organize, 
and make readily accessible rapidly expanding biomedical knowledge 
resources and data. NLM maximizes the return on the investment in 
research conducted by the NIH and other organizations. The Library 
makes the results of biomedical information more accessible to 
researchers, clinicians, business innovators, and the public, enabling 
such data and information to be used more efficiently and effectively 
to drive innovation and improve health. NLM is a leader in Big Data and 
plays a critical role in accelerating nationwide deployment of health 
information technology, including electronic health records (EHRs), by 
leading the development, maintenance and dissemination of key standards 
for health data interchange that are now required of certified EHRs. 
NLM also contributes to Congressional priorities related to drug safety 
through its efforts to expand its clinical trial registry and results 
database (ClinicalTrials.gov) in response to legislative requirements, 
and to the Nation's ability to prepare for and respond to disasters.
Growing Demand for NLM's Basic Services
    NLM delivers more than a trillion bytes of data to millions of 
users daily that helps researchers advance scientific discovery and 
accelerate its translation into new therapies; provides health 
practitioners with information that improves medical care and lowers 
its costs; and gives the public access to resources and tools that 
promote wellness and disease prevention. Every day, medical librarians 
across the Nation use NLM services to assist clinicians, students, 
researchers, and the public in accessing information they need to save 
lives and improve health. Without NLM, our Nation's medical libraries 
would be unable to provide the quality information services that our 
Nation's health professionals, educators, researchers and patients 
increasingly need.
    NLM's data repositories and online integrated services such as 
GenBank, PubMed, and PubMed Central are revolutionizing medicine and 
ushering in an era of personalized medicine in which care is based on 
an individual's unique genetic profile. GenBank is the definitive 
source of gene sequence information. PubMed, with more than 23 million 
citations to the biomedical literature, is the world's most heavily 
used source of bibliographic information. Approximately 760,000 new 
citations were added in fiscal year 2013, and the database provided 
high quality medical information to about 2.3 million users each day. 
PubMed Central is NLM's digital archive which provides public access to 
the full-text versions of more than 3 million biomedical journal 
articles, including those produced by NIH-funded researchers. On a 
typical weekday more than one million users download 1.65 million full-
text articles, including those submitted in compliance with the NIH 
Public Access Policy.
    As the world's largest and most comprehensive medical library, 
NLM's traditional print and electronic collections continue to steadily 
increase each year, standing at more than 21 million items--books, 
journals, technical reports, manuscripts, microfilms, photographs and 
images. By selecting, organizing and ensuring permanent access to 
health sciences information in all formats, NLM ensures the 
availability of this information for future generations, making it 
accessible to all Americans, irrespective of geography or ability to 
pay, and guaranteeing that citizens can make the best, most informed 
decisions about their healthcare.
Encourage NLM Partnerships
    NLM's outreach programs are essential to MLA and AAHSL membership 
and to the profession. Through the National Network of Libraries of 
Medicine (NN/LM), with over 6,000 members in communities nationwide, 
these activities educate medical librarians, health professionals and 
the general public about NLM's services and train them in the most 
effective use of these services. The NN/LM promotes educational 
outreach for public libraries, secondary schools, senior centers and 
other consumer-based settings, and its emphasis on outreach to 
underserved populations helps reduce health disparities among large 
sections of the American public. NLM's ``Partners in Information 
Access'' program improves access by local public health officials to 
information which prevents, identifies and responds to public health 
threats and ensures every public worker has electronic health 
information services that protect the public's health.
    NLM's MedlinePlus provides consumers with trusted, reliable health 
information on more than 900 topics in English and Spanish. It has 
become a top destination for those seeking information on the Internet, 
attracting more than 1.2 million visitors daily. NLM has continued to 
make enhancements to MedlinePlus, with selected materials now available 
in forty other languages. Other products and services that benefit 
public health and wellness include the NIH MedlinePlus Magazine and NIH 
MedlinePlus Salud, available in doctors' offices nationwide, and NLM's 
MedlinePlus Connect--a utility which enables clinical care 
organizations to implement links from their electronic health records 
systems to relevant patient education materials in MedlinePlus.
    MLA and AAHSL applaud the success of NLM's outreach initiatives, 
and we look forward to continuing to work with NLM on these programs.
Emergency Preparedness and Response
    Through its Disaster Information Management Research Center, NLM 
collects and organizes disaster-related health information, ensures 
effective use of libraries and librarians in disaster planning and 
response, and develops information services to assist responders. NLM 
responds to specific disasters worldwide with specialized information 
resources appropriate to the need, including information on 
bioterrorism, chemical emergencies, fires and wildfires, earthquakes, 
tornadoes, and pandemic disease outbreaks. MLA and NLM continue to 
develop the Disaster Information Specialization (DIS) program to build 
the capacity of librarians and other interested professionals to 
provide disaster-related health information outreach. Working with 
libraries and publishers, NLM's Emergency Access Initiative makes 
available free full-text articles from hundreds of biomedical journals 
and reference books for use by medical teams responding to disasters. 
MLA and AAHSL ask the Subcommittee to support NLM's role in this 
crucial area which ensures continuous access to health information and 
use of libraries and librarians when disasters occur.
Health Information Technology and Bioinformatics
    For more than 40 years, NLM has supported informatics research, 
training and the application of advanced computing and informatics to 
biomedical research and healthcare delivery including telemedicine 
projects. Many of today's biomedical informatics leaders are graduates 
of NLM-funded informatics research programs at universities nationwide. 
A number of the country's exemplary electronic and personal health 
record systems benefit from findings developed with NLM grant support.
    The importance of NLM's work in health information technology 
continues to grow as the Nation moves toward more interoperable health 
information technology systems. A leader in supporting the development, 
maintenance, and dissemination of standard clinical terminologies for 
free nationwide use (e.g., SNOMED), NLM works closely with the Office 
of the National Coordinator for Health Information Technology to 
promote the adoption of interoperable electronic records, and has 
developed tools to make it easier for EHR developers and users to 
implement accepted health data standards in their systems.
Organizational Bios
    The Medical Library Association (MLA) is a nonprofit, educational 
organization with 4,000 health sciences information individual and 
institutional members. Founded in 1898, MLA provides lifelong 
educational opportunities, supports a knowledge base of health 
information research, and works with a network of partners to promote 
the importance of quality information for improved health to the 
healthcare community and the public.
    The Association of Academic Health Sciences Libraries (AAHSL) 
supports academic health sciences libraries and directors in advancing 
the patient care, research, education and community service missions of 
academic health centers through visionary executive leadership and 
expertise in health information, scholarly communication, and knowledge 
management.
    Thank you again for the opportunity to present our views. We look 
forward to continuing this dialogue and supporting the Subcommittee's 
efforts to secure the highest possible funding level for NLM in fiscal 
year 2015 and the years beyond to support the Library's mission and 
growing responsibilities. Information about NLM and its programs can be 
found at http://www.nlm.nih.gov.
                                 ______
                                 
   Prepared Statement of the Mesothelioma Applied Research Foundation
    Chairman Harkin, Ranking Member Moran and Members of the 
Subcommittee, thank you for the opportunity to provide written 
testimony on behalf of the mesothelioma community. My name is Mary 
Hesdorffer and I am the Executive Director of the Mesothelioma Applied 
Research Foundation. I am testifying on behalf of the mesothelioma 
community composed of patients, physicians, caregivers and family 
members. I am a Nurse Practitioner with over sixteen years' experience 
working with mesothelioma patients in the clinical setting. I would 
like to use this opportunity to emphasize the great need for increased 
funding for the National Institutes of Health (NIH), including the 
National Cancer Institute (NCI), both of which play a critical role in 
improving treatment for mesothelioma.
    Mesothelioma is an aggressive cancer known to be caused by exposure 
to asbestos. Doctors say it is among the most painful of cancers, and 
the prognosis is poor even with the best available treatment.
    The harsh reality for patients with malignant mesothelioma is that 
it is a terminal illness; the five-year survival rate is five to ten 
percent, making it one of the most deadly cancers. Left untreated, 
survival ranges from six to 9 months, and if treated with the sole Food 
and Drug Administration (FDA) approved therapy, median survival is only 
12.3 months.
    With only one FDA approved treatment available, mesothelioma 
patients must take a trial and error approach to treatment, making 
agonizing decisions each step of the way. Most patients must make the 
tough decision to go into a clinical trial, use off label treatments, 
or undergo drastic surgeries knowing they may see no benefit 
whatsoever. They choose to do this with a powerful hope they can help 
doctors learn how to treat mesothelioma, possibly live a while longer 
and prevent future mesothelioma patients from enduring the same 
difficult experience.
    Fortunately, there are brilliant researchers dedicated to 
mesothelioma. The Mesothelioma Applied Research Foundation has made a 
significant investment, funding a total of $8.7 million to support 
research in hopes of giving researchers the first seed grant they need 
to get started. We need the continued partnership with the Federal 
Government to develop the promising findings into effective treatments.
    In research, innovative and personalized therapies from the mapping 
of the human genome or those that utilize the body's own immune system 
are becoming a reality for mesothelioma. These developments have the 
potential to reduce the human toll of mesothelioma, but need continued 
research funding to bring the advances from the bench to the bedside.
    Recent research findings have linked mesothelioma to a germline 
mutation in the BAP1 gene and a somatic mutation in the NF2 gene. 
Currently, the research goal of the BAP1 and NF2 genes is for 
prevention and early detection of mesothelioma. For example, 
individuals known to be exposed to asbestos who carry this gene can be 
studied to determine if a cancer signal can be picked up before the 
development of mesothelioma. The idea is that if you have a germ line 
mutation, you and your immediate family will be screened for cancers 
associated with this gene in the hope of picking up an early 
malignancy. Also, researchers will study ways to turn off this gene, if 
defective. There is great potential in these findings.
    Immunotherapy is another exciting area of research. An 
immunotherapy is a treatment that uses certain parts of a person's 
immune system to target cancer, and is one of the most exciting areas 
in cancer research. Dr. Raffit Hassan at the NCI and his collaborators 
have shown that mesothelin, a tumor antigen which was discovered at the 
NCI, is a useful target for tumor-specific therapy of malignant 
mesothelioma. His group is presently conducting clinical trials of 
three different agents targeting mesothelin. Namely, SS1P which is an 
anti-mesothelin immunotoxin, MORAb-009 which is a chimeric anti-
mesothelin monoclonal antibody and CRS-207 which is a mesothelin tumor 
vaccine. They have seen some success, and it has given patients a 
reason to be optimistic.
    It is efforts like these that give mesothelioma patients hope. I am 
grateful for the Federal Government's investment in mesothelioma 
research and I want to see it continued and increased. Unless 
researchers have the funds to continue, these discoveries will not 
yield improved treatments, patients will run out of options and 
continue to die from this disease.
    Cancer research funding as a share of the NIH budget has declined 
while the scientific and public health need has gone up. In the late 
1990s, NCI's budget made up 18.7 percent of the NIH budget. Today, it 
is 16.4 percent of the NIH budget . That decline has reduced NCI's 
funding by $680 million below what it would have received in fiscal 
year 2014 if its share of NIH's total budget had been maintained.
    The mesothelioma community asks that the Subcommittee recognize the 
National Institutes of Health (NIH) as a critical national priority by 
providing at least $32 billion, including $5.26 Billion for the 
National Cancer Institute in funding in the fiscal year 2015 Labor-HHS-
Education Appropriations bill. This funding recommendation represents 
the minimum investment necessary to avoid further loss of promising 
research and at the same time allows the NIH's budget to keep pace with 
biomedical inflation.
    I look to the Labor, Health and Human Services, Education and 
Related Agencies Appropriations Subcommittee to provide continued 
leadership and hope to the people who develop this fatal cancer. Thank 
you for the opportunity to submit testimony and for funding the 
National Institutes of Health and the National Cancer Institute at the 
highest possible level.
    About the Mesothelioma Applied Research Foundation:
    The Mesothelioma Applied Research Foundation is the nonprofit 
collaboration of patients and families, physicians, advocates, and 
researchers dedicated to eradicating the life-ending and vicious 
effects of mesothelioma. We believe in a cure for mesothelioma. Given 
the human toll of suffering the disease causes, the compassion and 
energy of the mesothelioma community, the moral, legal and economic 
aspects of asbestos, and the benefits of mesothelioma research to 
cancer research generally, we believe that the resources to accomplish 
this cure are available and must be mobilized. We seek to marshal and 
utilize these resources responsibly, as effectively as possible, with 
financial transparency and by adhering to health policy guidelines that 
foster ethical clinical and administrative practices, and ethical 
decisionmaking to:
  --Offer hope and support to patients and families by educating them 
        on the disease, helping them to obtain the most up-to-date 
        information on treatment options and to connect with 
        mesothelioma treatment specialists, and providing them 
        assistance, emotional support and community with others;
  --Fund the highest quality and most promising mesothelioma research 
        projects from around the world through rigorous peer-review; 
        and
  --Raise awareness of mesothelioma, and advocate that the public and 
        private sectors partner in the effort to cure it by directing 
        the resources needed to stop this global tragedy
                                 ______
                                 
          Prepared Statement of the National AHEC Organization
    The members of the National AHEC Organization (NAO) are pleased to 
submit this statement for the record recommending $75 million in fiscal 
year 2015 for the Area Health Education Center (AHEC) Program 
authorized under Title VII of the Public Health Service Act and 
administered through the Health Resources and Services Administration 
(HRSA) at the Department of Health and Human Services.
    The NAO is the professional organization representing AHECs. The 
AHEC Program is an established and effective national primary care 
training network built on committed partnerships of 53 medical schools 
and academic centers. Additionally, 253 AHEC centers within 48 States 
and tens of thousands of community practitioners are affiliated with 
the AHEC's national clinical training network.
    AHEC is one of the Title VII Health Professions Training programs, 
originally authorized at the same time as the National Health Service 
Corps (NHSC) to create a complete mechanism to provide primary care 
providers for Community Health Centers (CHCs) and other direct 
providers of healthcare services for underserved areas and populations. 
The plan envisioned by creators of the legislation was that the CHCs 
would provide direct service. The NHSC would be the mechanism to fund 
the education of providers and supply providers for underserved areas 
through scholarship and loan repayment commitments.
    The AHEC program would be the mechanism to recruit providers into 
primary healthcareers, diversify the workforce, and develop a passion 
for service to the underserved in these future providers, i.e. Area 
Health Education Centers are the workforce development, training and 
education machine for the Nation's healthcare safety-net programs. The 
AHEC program is focused on improving the quality, geographic 
distribution and diversity of the primary care healthcare workforce and 
eliminating the disparities in our Nation's healthcare system.
    AHECs develop and support the community based training of health 
professions students, particularly in rural and underserved areas. They 
recruit a diverse and broad range of students into healthcareers, and 
provide continuing education, library and other learning resources that 
improve the quality of community-based healthcare for underserved 
populations and areas.
    The Area Health Education Center program is effective and provides 
vital services and national infrastructure. Nationwide, over 379,000 
students have been introduced to healthcareer opportunities, and over 
33,000 mostly minority and disadvantaged high school students received 
more than 20 hours each of healthcareer exposure. Over 44,000 health 
professions students received training at 17,530 community-based sites, 
and furthermore; over 482,000 health professionals received continuing 
education through AHECs. AHECs perform these education and training 
services through collaborative partnerships with Community Health 
Centers (CHCs) and the National Health Service Corps (NHSC), in 
addition to Rural Health Clinics (RHCs), Critical Access Hospitals, 
(CAHs), Tribal clinics and Public Health Departments.
Justification for Recommendations
    The AHEC network is an economic engine that fuels the recruitment, 
training, distribution, and retention of a national health workforce. 
AHEC stands for JOBS.
  --AHECs are critical in the recruitment, training, and retention of 
        the primary care workforce.
  --Research has demonstrated that the community-training network is 
        the most effective recruitment tool for the health professions 
        and those who teach remain longer in underserved areas and 
        communities.
  --AHECs are in almost every county in the United States.
  --With the aging and growing population, the demand for primary care 
        workforce is far outpacing the supply.
  --AHECs continue to educate and train current workforce, as well as 
        recruiting and preparing future workforce
  --In 2012, AHEC's trained 476,585 Health Professionals in 48 States 
        in 13,842 Health Professions Shortage Areas (HPSAs)--26.4 
        percent of those trained were physicians (125,818).
  --In 2012, the AHEC's introduced nearly 403,000 students to the 
        healthcareers professions and workforce from grades K-College.
  --The AHEC network's outcomes are the backbone of the Nation's 
        community-based health professions training, with a focus on 
        training primary care workforce.
  --Continued funding for the AHEC program is necessary as demonstrated 
        by 1) a growing unmet need for primary care doctors in rural 
        areas, and 2) the use of the national network of AHEC programs 
        to carry out administrative priorities.
    1.   The National Health Service Corps (NHSC), has been mentioned 
            as a program that addresses the priority of increasing 
            diversity in the health professions workforce in 
            underserved and rural areas and addresses the end of the 
            pipeline. The AHEC program engages in pre-pipeline, 
            pipeline, and post-pipeline activities that works to move 
            individuals through a healthcareers pathway and beyond, 
            with a special focus on primary care doctors.
    2.   The national network of the AHEC program has been tasked with:

      -- Training 13,000+ providers nationwide in OIF/OEF/OND Veteran's 
            behavioral and mental health, substance abuse, traumatic 
            brain injury and post-traumatic stress, for those not 
            utilizing the VA system
      -- Working with the Food and Drug Administration to educate 
            healthcare professionals nationwide on proper opioid 
            prescribing habits to address the epidemic of prescription 
            drug abuse
      -- HRSA has encouraged functional linkage between Bureau of 
            Primary Care and Bureau of Health Professions Programs. 
            AHECs have partnerships with over 1,000 Community Health 
            Centers nationally to recruit, train, and retain health 
            professionals who have the cultural and linguistic skills 
            to serve in HRSA designated underserved areas
      -- Affordable Care Act activities such as increasing the 
            enrollment of individuals, training community health 
            workers, and educating providers nationwide on health 
            insurance exchanges

    [This statement was submitted by Rob Trachtenberg, Executive 
Director, National AHEC Organization.]
                                 ______
                                 
Prepared Statement of the National Alliance for Eye and Vision Research
                           executive summary
    The National Alliance for Eye and Vision Research (NAEVR) requests 
fiscal year 2015 NIH funding of $32 billion, which would fully restore 
the $1.7 billion fiscal year 2013 sequester cut partially restored in 
fiscal year 2014 and enable an inflationary increase-the NIH has lost 
22 percent of its purchasing power since fiscal year 2003, in terms of 
constant dollars-and provide for modest growth. This request improves 
on the President's proposal to increase NIH funding by only $200 
million over fiscal year 2014 and which also increases the Program 
Evaluation Transfer to 3 percent, effectively reducing NIH's increase 
by $150 million. fiscal year 2015 NIH funding of $32 billion is an 
important step toward consistent and sustained funding increases which 
are necessary to build upon past investment that has created an 
unprecedented scientific opportunity in biomedical research.
  --$32 billion NIH funding is critical for supporting Research Project 
        Grants, as the number of RPGs awarded in fiscal year 2013 was 
        20 percent less than in fiscal year 2003. R01s, or 
        investigator-initiated grants, have been affected even more 
        dramatically, as the number awarded fell by 24 percent between 
        fiscal year 2003 and fiscal year 2013.
  --NIH-funded basic and clinical research has helped to understand the 
        basis of disease, thereby resulting in innovations in 
        healthcare to save and improve lives. Its research serves an 
        irreplaceable role the private sector could not duplicate.
  --As an economic driver, in fiscal year 2011NIH-funded research 
        supported 432,000 jobs across the United States and generated 
        more than $62 billion in new economic activity. Every $1 of NIH 
        funding generates $2.21 in local economic growth.
    NAEVR requests National Eye Institute (NEI) funding at $730 
million, concomitant with $32 billion NIH funding. The President's 
budget proposes a minimal NEI increase of $0.9 million or 0.15 percent, 
based on its fiscal year 2014 operational net of $675 million-not its 
$682 million appropriation. This is unacceptable since NEI has lost 25 
percent of its purchasing power since fiscal year 2003, and the fiscal 
year 2013 sequester has already resulted in NEI awarding 30 fewer 
grants-any one of which may have held the promise to save sight and 
restore vision.
As NEI's Budget Decreases, the Incidence of Eye Disease and Vision 
        Impairment Increases, As Does the Associated Cost, Estimated at 
        $139 Billion Annually in the United States
    Although the fiscal year 2013 sequester cut reduced NEI's budget by 
$36 million to $662 million, $20 million of that was restored in fiscal 
year 2014 through an appropriation of $682 million. In each year, 
however, NEI's appropriation was reduced even further by $5.6 million 
and $6.9 million to operational nets of $657 million and $674 million, 
respectively, due to the transfer back to the NIH Office of AIDS 
Research (OAR) for funding of the dissolved NEI-sponsored Ocular 
Complications of AIDS studies. Although OAR's funding to NEI was not 
committed into perpetuity, its return to NIH Central effectively 
reflects a cut in NEI funding and results in a new baseline upon which 
future funding will be based. For example, the President's fiscal year 
2015 budget request bases its 0.15 percent NEI increase on the fiscal 
year 2014 operational net of $674 million, which results in just a $0.9 
million increase in NEI funding to $675 million.
    The funding nets described above are well below NEI's highest 
appropriation-that of $707 million in fiscal year 2010 (prior to 
addition of American Recovery and Reinvestment Act (ARRA) funding. 
Unfortunately, as NEI funding has decreased, the challenges it faces 
have grown, due to dramatic increases in the incidence and cost of 
vision impairment and eye disease.
    The NEI estimates that more than 38 million Americans age 40 and 
older experience blindness, low vision, or an age-related eye disease 
such as age-related macular degeneration (AMD), glaucoma, diabetic 
retinopathy, or cataracts. This is expected to grow to more than 50 
million Americans by year 2020. Much of this is being driven by the 
aging of the population, for example, the ``Silver Tsunami'' of the 78 
million baby boomers who will turn age 65 this decade and experience 
the greatest risk for eye disease. Other demographic changes are also 
contributing to NEI's challenges, for example, African Americans and 
Hispanics which increasingly account for a larger share of the U.S. 
population and who experience a disproportionately greater prevalence 
of eye disease. Vision loss can also be a co-morbid condition of 
chronic disease, such as diabetes, which is at epidemic levels due to 
the increased incidence of obesity.
    In June 2013, Prevent Blindness America, in conjunction with the 
National Opinion Research Center at the University of Chicago, released 
updated estimates of the cost of vision disorders. NORC estimates the 
annual costs of vision disorders at $139 billion annually, inclusive of 
direct and indirect costs. Most importantly, the direct medical costs 
associated with vision disorders are the fifth highest-only less than 
heart disease, cancers, emotional disorders, and pulmonary conditions.
    NEI's fiscal year 2014 operational net funding of $674 million, as 
well as the President's fiscal year 2015 proposed funding of $675 
million, are each less than 0.5 percent of this $139 billion annual 
vision disorder cost burden. The U.S. is spending only $2.10 per-
person, per-year for vision research at the NEI, while NORC estimates 
that the cost of treating low vision and blindness is $6,690 per-
person, per-year.
    In 2009, Congress spoke volumes in passing S. Res 209 and H. Res. 
366, which designated 2010-2020 as The Decade of Vision and recognized 
NEI's 40th anniversary as the lead institute in funding research to 
save sight and restore vision. With the fiscal year 2015 LHHS spending 
bill, Congress can act upon its past resolutions regarding vision and 
ensure that NEI is adequately funded to meet these challenges.
$730 million fiscal year 2015 funding enables nei to pursue its primary 
                 ``audacious goal'' of restoring vision
    NEI has lost 25 percent of its purchasing power since fiscal year 
2003. The fiscal year 2013 sequester cut resulted in NEI awarding 30 
fewer grants, and the President's fiscal year 2015 proposal would 
result in 23 fewer awards. Any one of those missed funding 
opportunities could have held the promise to save sight and restore 
vision-goals that would have seemed unattainable just a few short years 
ago. The NEI has long been a leader in biomedical research. As NIH 
Director Francis Collins, M.D., Ph.D. stated in February 2013:

    ``It's often, it seems to me, that vision research is a couple of 
steps in front of things that are happening in biomedical research. 
It's clear that vision research has played a disproportionately large 
share in scientific breakthroughs.''

    Dr. Collins made his comments at NEI's Audacious Goals Development 
meeting, where more than 200 attendees reflecting every sector of the 
vision community, including government scientists and regulators from 
various disciplines, discussed topics built around the ten winning 
submissions from a pool of nearly 500 entries selected through NEI's 
Audacious Goals in Vision Research and Blindness Rehabilitation 
Challenge. This initiative, conducted by NEI with its National Advisory 
Eye Council (NAEC) and through The America Competes Act, yielded such 
ideas as restoring light sensitivity to the blind through gene-based 
therapies and visual prosthetics, pinpoint correction of defective 
genes, and growing healthy tissue from stem cells for ocular tissue 
transplants.
    In consultation with the NAEC, the NEI converged on its primary 
Audacious Goal for vision research: To Regenerate Neurons and Neuronal 
Connections in the Eye and Visual System.'' As NEI Director Paul 
Sieving, M.D., Ph.D. stated in February 2014:

    ``The goals are bold but achievable. They are beyond what medicine 
currently can do. We are planning for a 10-12-15 year effort to reach 
these endpoints. Success would transform life for millions of people 
with eye and vision diseases. It would have major implications for 
medicine of the future, for vision diseases, and even beyond this, for 
neurological diseases.''

    As NEI works to achieve this goal, it will build upon its 
breakthrough research funded through past Federal investment. For 
example, NEI has been a leader in determining the genetic basis of 
disease-the research it has funded has identified more than 500 genes 
associated with both common and rare eye diseases, which is 7.5 percent 
of all disease-causing genes discovered to-date. Understanding the 
genetic basis of the disease and underlying mechanisms will lead to 
better diagnostics and therapies. Since last year's testimony, NEI has 
announced that:
  --The AMD Gene Consortium, a network of international investigators 
        representing 18 research groups, has discovered seven new 
        regions of the human genome-called loci-that are associated 
        with increased risk of AMD. They also confirmed 12 loci already 
        identified in previous studies. These loci implicate a variety 
        of biological functions, including regulation of the immune 
        system, maintenance of cellular structure, growth and 
        permeability of blood vessels, lipid metabolism, and 
        atherosclerosis. AMD is the leading cause of vision loss 
        overall, as well as the leading cause in individuals are 60-
        plus.
  --The NEI Glaucoma Human Genetics Collaboration (NEIGHBOR) 
        Consortium, which involves clinicians and geneticists at 
        multiple institutions throughout the U.S. who are studying 
        genetic variants associated with Primary Open Angle Glaucoma-
        the most common form of the disease-has identified the first 
        common genetic risk factors for normal pressure glaucoma. 
        NEIGHBOR, unique because it is the largest Genome-Wide 
        Association Study to-date, will generate new insights into the 
        molecular pathogenesis, effective screening and prevention 
        strategies, and more rational treatment approaches for this 
        disease. Glaucoma is three-to-four times more prevalent in 
        African Americans than non-Hispanic Whites and is the leading 
        cause of blindness in the Latino population.
    These are ambitious goals that require increased-not decreased-
funding. Our Nation's investment in vision health is an investment in 
its overall health. NEI's breakthrough research is a cost-effective 
investment, since it is leading to treatments and therapies that can 
ultimately delay, save, and prevent health expenditures, especially 
those associated with the Medicare and Medicaid programs. It can also 
increase productivity, help individuals to maintain their independence, 
and generally improve the quality of life, especially since vision loss 
is associated with increased depression and accelerated mortality.
    The very health of the vision research community is also at stake 
with the decrease in NEI funding. Not only will funding for new 
investigators be at risk, but also that of seasoned investigators, 
which threatens the continuity of research and the retention of trained 
staff, while making institutions more reliant on bridge and 
philanthropic funding. .
                              about naevr
    NAEVR, which serves as the ``Friends of the NEI,'' is a 501(c)4 
non-profit advocacy coalition comprised of 55 professional 
(ophthalmology and optometry), patient and consumer, and industry 
organizations involved in eye and vision research. Visit NAEVR's Web 
site at www.eyeresearch.org.
                                 ______
                                 
     Prepared Statement of the National Alliance on Mental Illness
    Chairman Harkin and members of the Subcommittee, I am Mary 
Giliberti, Executive Director of NAMI (the National Alliance on Mental 
Illness). I am pleased today to offer NAMI's views on the 
Subcommittee's upcoming fiscal year 2015 bill. The National Alliance on 
Mental Illness (NAMI) is the Nation's largest grassroots advocacy 
organization representing persons living with serious mental illness 
and their families. Through our 1,100 affiliates in all 50 States, we 
support education, outreach, advocacy and research on behalf of persons 
with serious mental illness such as schizophrenia, manic depressive 
illness, major depression, severe anxiety disorders and mental health 
conditions affecting children.
    An estimated 11.5 million American adults live with a mental 
illness, such as schizophrenia, bipolar disorder, and major depression. 
Based on estimates for 2010, mental disorders accounted for 21.3percent 
of all years lived with disability in the United States. Among the top 
20 causes of years lived with disability, five were mental disorders: 
major depressive disorder (8.3 percent of the total), anxiety disorders 
(5.1 percent), schizophrenia (2.2 percent), bipolar disorder (1.6 
percent) and dysthymia (1.5 percent). Suicide is the 10th leading cause 
of death in the U.S., accounting for the loss of more than 38,000 
American lives each year, more than double the number of lives lost to 
homicide. The social and economic costs associated with these disorders 
are tremendous. A cautious estimate places the direct and indirect 
financial costs associated with mental illness in the U.S. at well over 
$300 billion annually, and it ranks as the third most costly medical 
condition in terms of overall healthcare expenditure, behind only heart 
conditions and traumatic injury.
    These costs are not only financial, but also human in terms of lost 
productivity, broken families and lives lost to suicide. Investment in 
mental illness research and services are--in NAMI's view--the highest 
priority for our Nation and this Subcommittee.
National Institute of Mental Health Research Funding
    As a member of the Ad Hoc Group for Medical Research Funding, NAMI 
supports a $32 billion overall allocation for the National Institutes 
of Health (NIH). This increase is needed to avoid having our country 
continue to fall behind China, India and other emerging Nations in 
terms of our public investment in scientific research. As you know, the 
President is requesting a $23 million increase for the National 
Institute of Mental Health (NIMH) for fiscal year 2015, boosting 
funding for the agency to $1.44 billion. NAMI would urge the 
Subcommittee to fund investments beyond this amount with an overall 
higher allocation for the entire NIH.
    NAMI also supports the President's BRAIN Initiative (Brain Research 
through Advancing Innovative Neurotechnologies) and the request for a 
$40 million boost, up to $100 million. The BRAIN Initiative is multi-
agency collaborative with a number of foundations designed to unleash 
new technologies and undertake basic mapping of circuits and neurons in 
the most complex organ in the human body.
Accelerating the Pace of Psychiatric Drug Discovery
    In NAMI's view, there is an urgent need for new medications to 
treat serious mental illness. Existing medications can be helpful, but 
they often have significant limitations; in some cases requiring weeks 
to take effect; failing to relieve symptoms in a significant proportion 
of patients; or, resulting in debilitating side effects. However, 
developing new medications is a lengthy and expensive process. Many 
promising compounds fail to prove effective in clinical testing after 
years of preliminary research. To address this urgent issue, NAMI is 
encouraging NIMH to accelerate the pace of drug discovery through an 
`experimental medicine' approach to evaluate novel interventions for 
mental illnesses. This ``fast-fail'' strategy is designed not only to 
quickly identify candidates that merit more extensive testing, but also 
to identify targets in the brain for the development of additional 
candidate compounds. Through small trials focused on proof-of-concept 
experimental medicine paradigms, we can make progress to demonstrate 
target engagement, safety, and early signs of efficacy.
Advancing Services and Intervention Research
    NAMI enthusiastically supports the NIMH Recovery After an Initial 
Schizophrenia Episode (RAISE) Project, aimed at preventing the long-
term disability associated with schizophrenia by intervening at the 
earliest stages of illness. The RAISE Early Treatment Program (RAISE 
ETP) will conclude this year. The RAISE Connection Program has 
successfully integrated a comprehensive early intervention program for 
schizophrenia and related disorders into an existing medical care 
system. This implementation study is now evaluating strategies for 
reducing duration of untreated psychosis among persons with early-stage 
psychotic illness. When individuals with schizophrenia and bipolar 
disorder progress to later stages of their illness, they become more 
likely to develop--and die prematurely--from medical problems such as 
heart disease, diabetes, cancer, stroke, and pulmonary disease than 
members of the general population. NIMH funded research is 
demonstrating progress advancing the health of people with serious 
mental illness. NIMH needs to advance this research to large-scale 
clinical trials aimed at reducing premature mortality for people living 
with serious mental illness.
Investing in Early Psychosis Prediction and Prevention (EP3)
    As many as 100,000 young Americans experience a first episode of 
psychosis (FEP) each year. The early phase of psychotic illness is a 
critical opportunity to alter the downward trajectory and social, 
academic, and vocational challenges associated with serious mental 
illness such as schizophrenia. The timing of treatment is critical; 
short- and long-term outcomes are better when individuals begin 
treatment close to the onset of psychosis. Unfortunately, the majority 
of people with mental illness experience significant delays to seeking 
care--up to 9 years in some cases. Such delays result in periods of 
increased risk for poor outcomes, especially suicide.
    NIMH-funded research has focused on the prodrome, the high-risk 
period preceding the onset of the first psychotic episode of 
schizophrenia. Through North American Prodrome Longitudinal Study 
(NAPLS) and other studies focused on early prediction and prevention of 
psychosis, NIMH has launched Early Psychosis Prediction and Prevention 
(EP3) initiative. EP3 is showing promise in detecting risk States for 
psychotic disorders and reducing the duration of untreated psychosis in 
adolescents that have experienced FEP.
Advancing Precision Medicine
    NAMI supports efforts at NIMH to translate basic research findings 
on brain function into more person-centered and multifaceted diagnoses 
and treatments for mental disorders. The Research Domain Criteria 
(RDoC) is showing promise toward efforts to build a classification 
system based more on underlying biological and basic behavioral 
mechanisms than on symptoms, RDoC should begin to give us the precision 
currently lacking with traditional diagnostic approaches to mental 
disorders.
Funding for Programs at SAMHSA's Center for Mental Health Services
    As noted above, the costs of untreated mental illness to our Nation 
are enormous--as high as $300 billion when taking into account lost 
wages and productivity and other indirect costs. These costs are 
compounded by the fact that across the Nation States and localities 
devote enormous resources addressing the human and financial costs 
untreated mental illness through law enforcement, corrections, homeless 
shelters and emergency medical services. This phenomenon of ``spending 
money in all the wrong places'' is tragic given that we have a vast 
array of proven evidence-based interventions that we know work--
assertive community treatment, supported employment, family psycho-
education and supportive housing.
    NAMI supports programs at the Center for Mental Health Services 
(CMHS) at SAMHSA that are focused on replication and expansion of these 
evidence-based practices that serve children and adults living with 
serious mental illness. The most important of these programs is the 
Mental Health Block Grant (MHBG). NAMI is extremely grateful for the 
increases in funding for the MHBG that this Subcommittee has made in 
recent years, boosting funding from $420 million in fiscal year 2010, 
up to its current level of $484 million in fiscal year 2014. This 
increase has been important to helping States fills gaps in services 
that have occurred as States cut more than $4 billion from State mental 
health budgets since the recession began in 2008.
    NAMI also supports the 5 percent set aside in the in the MHBG that 
this Subcommittee enacted in fiscal year 2014 for early intervention in 
psychosis. As noted above, the NIMH RAISE study validated the most 
effective approaches for providing coordinated care for adolescents 
experiencing FEP. Among these is Coordinated Specialty Care (CSC), a 
collaborative, recovery-oriented approach that emulates the assertive 
community treatment combining evidence-based services into an effective 
package. CSC emphasizes shared decisionmaking--which NAMI strongly 
supports--with the recipient of services taking an active role in 
determining treatment preferences and recovery goals.
    In April, CMHS issued guidance to the States specifying that 
funding as part of the 5 percent set aside must be used for those who 
have developed the symptoms of early serious mental illness, not for 
``preventive intervention for those at high risk of serious mental 
illness.'' NAMI supports this guidance and we recommend that the 
Subcommittee continue this 5 percent set aside for FEP in fiscal year 
2015 and beyond.
    NAMI would also recommend the following priorities for CMHS for 
fiscal year 2015:
  --Continuation of the Children's Mental Health program at $117 
        million, and
  --Support the President's proposal for a $6 million increase for 
        suicide prevention activities at CMHS (up to $54.2 million), 
        including funding for the Garrett Lee Smith Memorial Act.
Addressing Early Mortality and Serious Mental Illness, Integrating 
        Primary and Behavioral Health Care
    The CMHS Primary Behavioral Health Care Integration (PBHCI) program 
supports community behavioral health and primary care organizations 
that partner to provide essential primary care services to adults with 
serious mental illnesses. Because of this program, more than 33,000 
people with serious mental illness and substance use disorders are 
screened and treated at 100 grantee sites for diabetes, heart disease, 
and other common and deadly illnesses in an effort to stem the alarming 
early mortality rate from these health conditions in this population. 
NAMI urges the Subcommittee to fund the PBHCI for fiscal year 2015 at 
$50 million.
    Addressing the Needs of Homeless Individuals Living with Serious 
Mental Illness
    On any given night, according to 2013 data, 610,042 people are 
homeless, and 15 percent of these individuals are defined as long-term 
or chronically homeless. Years of reliable data and research 
demonstrate that, for single individuals with serious mental illness 
who live with complex needs, the most successful intervention for 
ending and preventing homelessness is linking housing to appropriate 
support services. Although there is a need for more affordable housing, 
funding the supportive services is even more difficult. SAMHSA homeless 
programs fill a gap created by a preference of HUD to fund housing 
rental assistance and capital needs. HHS must take responsibility to 
fund the critically important services that are necessary for programs 
to be effective.
    In 2013, SAMHSA was not able to award any new community-based 
services grants. For the first time, eleven States (AZ, GA, HI, WA, LA, 
IL, NV, PA, MA, MI and CO) did receive funding to improve statewide 
alignment of resources but every State could use SAMHSA assistance in 
their efforts to end homelessness. Over the years, hundreds of 
government entities and local providers have been unable to move 
forward with important work due to inadequate funding levels. The 
current fiscal year 2014 funding level of SAMHSA homeless programs is 
$74 million, divided between CMHS and CSAT. NAMI supports an increase 
for this joint program up to $100 million, equally divided between CMHS 
and CSAT.
    NAMI also supports funding for the PATH program (Projects for 
Assistance in Transition from Homelessness) that allocates funds by 
formula to States to serve homeless people with serious mental illness. 
Eligible services include outreach, screening and diagnosis, 
habilitation and rehabilitation, community mental health services, 
substance abuse treatment, case management, residential supervision, 
and housing. PATH supported programs reached over 191,839 people in 
fiscal year 2013. Of these, 65 percent were unsheltered at the time of 
engagement, 42 percent were not engaged in mental illness treatment and 
53 percent had co-occurring substance use disorders. NAMI recommends at 
least $75 million for the PATH program for fiscal year 2015 (the 
authorized amount). In fiscal year 2014, the PATH program is funded at 
$65 million.
Conclusion
    Chairman Harkin, thank you for the opportunity to share NAMI's 
views on the Labor-HHS-Education Subcommittee's fiscal year 2015 bill. 
NAMI's consumer and family membership thanks you for your leadership on 
these important national priorities.

    [This statement was submitted by Mary Giliberti, Executive 
Director, National Alliance on Mental Illness.]
                                 ______
                                 
   Prepared Statement of the National Alliance to End Sexual Violence
    On behalf of the National Alliance to End Sexual Violence (NAESV) 
representing 56 state and territorial sexual assault coalitions and 
more than 1300 local rape crisis centers, I am respectfully requesting 
fiscal year 2015 Federal funding to support comprehensive rape 
prevention and education and direct services for victims of sexual 
violence. Specifically, NAESV is requesting $50.6 million, $45 million 
for the program and $5.6 million in PHS evaluation tap funds, for the 
Rape Prevention & Education Program (RPE) in the Centers for Disease 
Control and Prevention's (CDC) National Center for Injury Prevention 
and Control budget. In addition, NAESV is requesting level funding of 
$160 million for the Preventive Health and Health Services Block Grant, 
which includes a $7 million set-aside for rape prevention services, in 
CDC's National Center for Chronic Disease Prevention and Health 
Promotion budget. Together, we must make our communities safer.
    One in five women has been the victim of rape or attempted rape. 
Nearly one in two women has experienced some form of sexual violence 
and one in five men has experienced a form of sexual violence other 
than rape in their lifetime. The CDC National Intimate Partner and 
Sexual Violence Survey study confirmed that the impacts of sexual 
violence on society are enormous. Over 80 percent of women who were 
victimized experienced significant short and long-term impacts related 
to the violence such as Post-Traumatic Stress Disorder (PTSD), injury 
(42 percent) and missed time at work or school (28 percent). The CDC 
report also shows that most rape and partner violence is experienced 
before the age of 24, highlighting the importance of preventing this 
violence before it occurs.
    The 2013 Rape Crisis Center Survey, distributed by NAESV, 
demonstrated that over 75 percent of these programs lost funding in the 
last year, causing programs to have to reduce services, lay off staff 
or even close. Over one third of rape crisis centers reported having a 
waiting list for services, with victims waiting most often for 
counseling services and support groups. Three out of four programs 
cannot meet current requests for community prevention programs. As you 
begin the fiscal year 2015 appropriations process, please fund the 
following priorities.
    Rape Prevention and Education (RPE).--The National Alliance to End 
Sexual Violence urges Congress to provide $45 million for the program 
and an additional $5.6 million in PHS evaluation tap funds for RPE 
program evaluation, with the goal of creating a more extensive evidence 
base for sexual violence prevention. Funding for RPE through CDC's 
Injury Center provides formula funding to every State and territory to 
raise awareness of the problem of sexual assault, support efforts to 
prevent first-time perpetration and victimization, and bring together 
diverse partners to develop, implement and evaluate statewide sexual 
assault prevention plans. The RPE program engages boys and men as 
partners, supports interdisciplinary research collaborations, fosters 
cross-cultural approaches to prevention, promotes healthy 
relationships, and funds the critically important National Sexual 
Violence Resource Center. High profile cases have increased the demand 
for prevention and education beyond the current capacity of State 
sexual assault coalitions and local rape crisis centers. The expansive 
media attention also points to the need for comprehensive community 
responses to sexual violence like those funded by RPE. With fiscal year 
2013 funding, the program educated more than 1.8 million students, 
answered 340,000 hotline calls, and conducted over 105,000 trainings 
nationwide.
    Formula Shortfall.--Beginning in fiscal year 2014, a new RPE 
funding formula is being implemented based on VAWA 2013. While the 
formula provides a base funding of $150,000 for all 50 States, 
Washington, DC and Puerto Rico, and $50,000 for territories, it reduces 
the funding provided to large States. In addition, CDC is altering the 
fiscal year of the program which results in reduced funding stretched 
over a span of 15 months, further penalizing State coalitions and local 
rape crisis centers at the same time demand for rape prevention and 
education is increasing due to high profile cases causing alarm in 
local communities. Increased funding is required to avoid critical 
shortfalls.
    Program Evaluation.--There is a need to increase the evidence base 
for sexual violence prevention. However, those efforts should be funded 
by additional funding--not from program funds to States and local rape 
crisis centers. Most recently, CDC decided to make ``State level 
evaluation'' mandatory despite many States starting local, regional or 
targeted evaluation efforts. It is the CDC's stated perspective that 
this would be ``less labor intensive.'' However, this strategy forces 
everyone down one path, without a recognition of the work and progress 
that is currently underway in many States, nor of each State's 
individual goals, projects or bandwidth to accomplish the work. To 
date, CDC has not demonstrated that they have developed any significant 
sexual violence specific research and evaluation over the years. 
Rather, all indicators suggest that they are relying on proxy measures 
that have been developed for other issues such as alcohol use, which 
are not suited to measure sexual violence. We support the CDC proposal 
to use PHS evaluation tap funding for this purpose. We do not want 
program funds diverted from the communities at a time when demand for 
prevention and education, as well as services, is increasing at such a 
rapid rate.
    Preventive Health & Health Services Block Grant (PHHSBG).--We are 
very grateful for the fiscal year 2014 funding of $160 million enacted 
by Congress and disappointed with the Administration's efforts to 
eliminate the program which provides much needed resources to 
communities. The Public Health Service Act of 2010 authorizes the block 
grant (CDC, Chronic Disease) and provides a rape set-aside provision 
which guarantees at least $7 million for rape services and prevention. 
Please retain the block grant funding that supports local rape crisis 
centers providing services, statewide training and technical assistance 
to increase capacity to assist rape victims and prevent future 
victimization. Maximum funding is requested.
    We must have the resources to meet the education and prevention 
needs in the community. Victims deserve support, our young people 
deserve to grow up safely, and research tells us that appropriate and 
early intervention and prevention can mitigate the costs and 
consequences of sexual violence and prevent that violence from 
occurring in the first place. The best way to prevent victimization is 
to prevent first time perpetration. The best way to convict a rapist is 
to support and advocate for the victim, obtain evidence and provide 
assistance and training to law enforcement.
    Thank you for the opportunity for the National Alliance to End 
Sexual Violence to present testimony for the record as the Senate 
Committee on Appropriations Subcommittee on Labor, Health and Human 
Services, Education, and Related
Agencies begins the process to prepare the fiscal year 2015 
Appropriations Bill. If you need further information, I can be reached 
at [email protected] and www.endsexualviolence.org.

    [This statement was submitted by Monika Johnson-Hostler, Board 
President, National Alliance to End Sexual Violence.]
                                 ______
                                 
     Prepared Statement of the National Alopecia Areata Foundation
    Chairman Harkin and distinguished members of the Subcommittee, 
thank you for your time and your consideration of the priorities of the 
community of individuals affected by alopecia areata as you work to 
craft the fiscal year 2015 Labor, Health and Human Services 
Appropriations Bill.
                         about alopecia areata
    Alopecia areata is a prevalent autoimmune skin disease resulting in 
the loss of hair on the scalp and elsewhere on the body. It usually 
starts with one or more small, round, smooth patches on the scalp and 
can progress to total scalp hair loss (alopecia totalis) or complete 
body hair loss (alopecia universalis).
    Alopecia areata affects approximately 2.1 percent of the 
population, including more than 6.5 million people in the United States 
alone. The disease disproportionately strikes children and onset often 
occurs at an early age. This common skin disease is highly 
unpredictable and cyclical. Hair can grow back in or fall out again at 
any time, and the disease course is different for each person. In 
recent years, scientific advancements have been made, but there remains 
no cure or indicated treatment options.
    The true impact of alopecia areata is more easily understood 
anecdotally than empirically. Affected individuals often experience 
significant psychological and social challenges in addition to the 
biological impact of the disease. Depression, anxiety, and suicidal 
ideation are health issues that can accompany alopecia areata. The 
knowledge that medical interventions are extremely limited and of minor 
effectiveness in this area further exacerbates the emotional stresses 
patients typically experience.
                          about the foundation
    NAAF, headquartered in San Rafael, California, supports research to 
find a cure or acceptable treatment for alopecia areata, supports those 
with the disease, and educates the public about alopecia areata. NAAF 
is governed by a volunteer Board of Directors and a prestigious 
Scientific Advisory Council. Founded in 1981, NAAF is widely regarded 
as the largest, most influential, and most representative foundation 
associated with alopecia areata. NAAF is connected to patients through 
local support groups and also holds an important, well-attended annual 
conference that reaches many children and families.
    Recently, NAAF initiated the Alopecia Areata Treatment Development 
Program (TDP) dedicated to advancing research and identifying 
innovative treatment options. TDP builds on advances in immunological 
and genetic research and is making use of the Alopecia Areata Clinical 
Trials Registry which was established in 2000 with funding support from 
the National Institute of Arthritis and Musculoskeletal and Skin 
Diseases; NAAF took over responsibility financial and administrative 
responsibility for the Registry in 2012 and continues to add patients 
to it. NAAF is engaging scientists in active review of both basic and 
applied science in a variety of ways, including the November 2012 
Alopecia Areata Research Summit featuring presentations from the Food 
and Drug Administration (FDA) and NIAMS.
                             deidre's story
    It has been 15 years since I first found the bald patch on my head 
that would completely change the course of my life. As a student at 
Florida State University during my junior year I found a perfectly 
round bald patch while blow-drying my very thick long hair--my pride 
and joy! Little did I know then the significant effect alopecia areata 
would have on my life.
    I followed the typical patient profile for this disease. I started 
with one patch the size of a 50 cent piece, which later evolved into 
patches of varying sizes all over my head, and then to total loss of 
all scalp hair, which progressed to the most severe form of the 
disease: total loss of all body hair including my scalp, eyebrows, 
eyelashes, etc. Recently, my hair has inexplicably started to grow back 
in a very patchy and strange fashion on my head, while most of my body 
still remains hairless; a perfect example of the completely 
unpredictable course of this disease, which can cause significant 
emotional turmoil and distress for the sufferer.
    As a professional woman, this disease has had a severe impact on my 
life. I have to present a confident image to the outside world. Living 
in constant fear of being discovered as a bald woman, being thought to 
be sick, bizarre, or worse has always been on the forefront of my mind.
    The exorbitant cost for treatments such as cortisone injections, 
extremely painful with questionable efficacy, has been an issue for me 
along with the expensive cranial prosthetics. Over the course of the 
years these have cost me thousands of dollars. If a lawyer like myself 
has financial difficulty when it comes to paying for treatments and 
prosthetics (which are not covered by insurance due to lack of CMS 
coverage benefits for those with Alopecia Areata), can you imagine the 
plight facing those patients that live on limited or fixed income?
    The fact that there is so little known about the causes or possible 
treatments/cure for this disease only adds to the pain and suffering. 
This is a disease that alters the way you see yourself and the way the 
outside world treats you, and also causes significant and often 
debilitating emotional distress. The fact that there is little that can 
currently be done adds to that pain and suffering. Patients face a 
bleak outlook. For me, it has been a constant battle. I have not lived 
a single moment in the 5,475 days since that I have not looked in the 
mirror and wanted to scream or cry, not a single day that I haven't 
thought that I am damaged, abnormal, or ugly because of my hair loss, 
not a single day that I haven't worried about how a client, colleague, 
friend, or love-interest might see and judge me. Many will say to me 
that ``it is only hair'' or ``at least it's not cancer.'' These 
comments only frustrate and upset me more. The feelings of being 
ostracized as an outcast can become deafening, even for a confident, 
intelligent professional. I shudder to think how others who don't 
possess my strength of character handle the stresses of this disease.
    It is only with additional funding for research that we might hope 
to improve the lives of the millions in the U.S. living with alopecia 
areata. Few have even heard of the disease. That fact alone creates 
additional stresses and difficulties for those of us with the disease, 
constantly having to explain what is ``wrong'' with us. Increased 
research into viable treatment options and a potential cure could 
significantly impact millions of lives, from small children to adults, 
facing the constant battle that comes from a total loss of self image 
and confidence.
    I thank you on behalf of myself and of the entire alopecia areata 
community for consideration of NAAF's requests.
                             sequestration
    We have heard from the medical research community that 
sequestration and deficit reduction activities have created serious 
issues for Federal funding opportunities and the career development 
pipeline. In order to ensure that research into alopecia areata, skin, 
and autoimmune disorders can continue to move forward, and, more 
importantly, to ensure that our country is adequately preparing the 
next generation of young investigators, we urge you to avert, mitigate, 
or otherwise eliminate the specter of sequestration. While the 
Foundation has anecdotal accounts of the harms of sequestration, the 
Federated American Societies for Experimental Biology has reported:
  --In constant dollars (adjusted for inflation), the NIH budget in 
        fiscal year 2013 was $6 billion (22.4 percent) less than it was 
        in fiscal year 2003.
  --The number of competing research project grants (RPGs) awarded by 
        NIH has also fallen sharply since fiscal year 2003. In fiscal 
        year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3 
        percent) fewer than in fiscal year 2003.
  --Awards for R01-equivalent grants, the primary mechanism for 
        supporting investigator-initiated research, suffered even 
        greater losses. The number awarded fell by 2,528 (34 percent) 
        between fiscal year 2003 and fiscal year 2013.
    The pay line for some NIH funding mechanisms has fallen from 18 
percent to 10 percent while the average age for a researcher to receive 
their first NIH-funded grant has climbed to 42. These are strong 
disincentives to choosing a career as a medical researcher. Our 
scaling-back is occurring at a time when many foreign countries are 
investing heavily in their biotechnology sectors. China alone plans to 
dedicate $300 million to medical research over the next 5 years; this 
amount is double the current NIH budget over the same period of time. 
Scientific breakthroughs will continue, but America may not benefit 
from the return-on-investment of a robust biotechnology sector. For the 
purposes of economic and national security, as well as public health, 
the Foundation asks that you work with your colleagues to eliminate 
sequestration and recommit to supporting this Nation's biomedical 
research enterprise.
               centers for disease control and prevention
    CDC and NCCDPHP are well-positioned to improve our understanding of 
alopecia areata through surveillance and surveys. There are many 
opportunities in this area due to the fact that alopecia areata is the 
most easily observable autoimmune disease. Robust epidemiology could 
yield important information for all autoimmune diseases, not just 
alopecia areata. CDC requires a meaningful investment in fiscal year 
2015 so that it can expand its crucial public health activities beyond 
winnable battles.
                     national institutes of health
    NIH hosts a modest alopecia areata research portfolio, and the 
Foundation works closely with NIH to advance critical activities. NIH 
projects, in coordination with the Foundation's TDP, have the potential 
to identify biomarkers and develop therapeutic targets. In fact, 
alopecia areata research has a strong value proposition as scientific 
advancements may have applications for other autoimmune and skin 
diseases. Please provide NIH with meaningful funding increases to 
facilitate growth in the alopecia areata research portfolio.
    One exciting emerging opportunity is the new Accelerating Medicines 
Partnership (AMP) that was recently announced by NIH. This effort is 
outcomes-oriented and based on a public private-partnership model. 
Industry, patient organizations, and researchers work together to 
conduct research with the goals of improving treatments and diagnostic 
tools. Rheumatoid arthritis is one of the diseases being examined in 
the first round of study, which should generate opportunities for 
alopecia areata due to the similarities between the conditions. Please 
support AMP and encourage NIH to expand activities in this area, 
particularly when there is research overlap between conditions
                         additional activities
    FDA nominated alopecia areata as a potential condition for specific 
review through the Patient-Focused Drug Development Initiative (PFDDI). 
This is because many of the impacts of alopecia areata have to be 
reported by patients and cannot be measured biologically. While we 
appreciate that FDA falls under the guise of the Agriculture 
Appropriations Subcommittee, we ask that you work with your colleagues 
on the Appropriations Committee to support this important program. 
Further, FDA should be encouraged to review all originally-nominated 
conditions in a timely manner so the PFDDI can continue to move 
forward.
    Thank you for your time and your consideration of the community's 
requests.
                                 ______
                                 
 Prepared Statement of the National Association for Geriatric Education
    The National Association for Geriatric Education (NAGE) is pleased 
to submit this statement for the record recommending $41.997 million in 
fiscal year 2015 to support geriatrics programs under the Health 
Resources and Services Administration (HRSA), Title VII, Section 753 of 
the Public Health Service Act. NAGE respectfully requests that the 
Subcommittee return to its approved level for fiscal year 2010, which 
was also included that year in the Administration's request, but was 
not included in the final bill. Unfortunately, only $34 million was 
funded in the final bill, and that has been cut to under $34 million in 
subsequent years.
    NAGE is a non-profit membership organization representing Geriatric 
Education Centers (GECs) and other programs that provide education and 
training to health professionals in the areas of geriatrics and 
gerontology. Our mission is to help America's health workforce be 
better prepared to render age-appropriate care to today's older 
Americans and those of tomorrow.
    NAGE recognizes the Subcommittee faces difficult decisions in a 
constrained budget environment, a continued commitment to programs 
supporting the growing need for geriatric education programs that help 
the Nation's health professions better serve the older and disabled 
population should remain a top priority. The Nation faces a shortage of 
geriatric health professionals. Every day in America 10,000 more 
persons reach the age of 65 years. There simply are not enough 
geriatricians, gerontological nurse practitioners and the myriad other 
health professions needed to provide interprofessional care to this 
burgeoning older population.
    Three geriatric health professions programs are financed under 
Title VII, Section 753 of the Public Health Service Act and are 
included in the Health Resources and Services Administration (HRSA). 
Geriatric Education Centers (GECs) and their related programs, the 
Geriatric Academic Career Awards and the Geriatric Faculty Fellowships, 
provide much needed interdisciplinary geriatric and gerontology 
training to a broad range of health professionals who serve our rapidly 
growing aging population.
    GECs train healthcare professional faculty, students, and 
practitioners in the interprofessional diagnosis, management and 
prevention of disease, disability, and other health problems of the 
elderly. This program also provides interprofessional continuing 
education for healthcare practitioners related to prominent issues in 
the field of geriatrics, such as Alzheimer's disease, dementia, and 
advances in palliative care, among others. The GEC program currently 
funds 45 GECs in 34 States, including statewide and multi-state 
programs. About half of GECs provide education for areas that are more 
than 50 percent rural and one-fourth of GECs focuses on training in 
areas that are 25-49 percent rural. In the 2012-2013 Academic Year, GEC 
programs provided over 1,650 different continuing education courses to 
over 94,000 trainees. GEC grantees exceeded the program's performance 
goal by 58.5 percent.
    Geriatrics Training for Physicians, Dentists, and Behavioral/Mental 
Health Professionals (GTPD) support faculty fellowships that help 
physicians, dentists, and behavioral and mental health professionals 
who plan to teach geriatrics in their selected fields. The aim of the 
program is increase the number of quality, culturally competent 
geriatric faculty and to retain mid-career faculty in geriatrics. GTPD 
provided funding for 64 fellows in the academia field of geriatric 
medicine, dentistry, and psychiatry. The GTPD fellows received clinical 
training in over 200 different healthcare locations across the Nation. 
The majority were trained in Veteran's Affairs hospitals, private 
hospitals and academic centers with nearly half of the sites located in 
medically underserved communities. Notably, each fellow dedicated at 
least 25 percent of their time for teaching health students about 
geriatric-related topics. In Academic Year 2012-2013, it is estimated 
that over 275 courses, workshops and other activities were delivered by 
GTPD fellows.
    Geriatrics Academic Career Awards (GACAs) provide a financial 
incentive for junior faculty to pursue an academic career in 
geriatrics. GACA currently supports 62 newly trained geriatric 
physicians. Award recipients delivered over 1,110 different health 
courses, workshops and other types of training activities to over 
53,000 trainees across the health profession spectrum. The most common 
health professions include medical school students, residents in 
internal medicine and residents in geriatrics.
    These successful programs improve the education, supply, 
distribution, diversity, and quality of healthcare professionals who 
care for our Nation's growing older adult population, including the 
underserved and minorities. Thus, we need your continued support for 
geriatric programs to adequately prepare the next generation of health 
professionals for the rapidly changing and emerging needs of the 
growing and aging population.
    On behalf of NAGE, thank you for this opportunity to share our 
requests for support for these important programs. We ask that you 
thoughtfully consider our request for funding in fiscal year 2015.

    [This statement was submitted by Thomas Caprio, MD, MPH, CMD, FACP, 
University of Rochester, Division of Geriatrics & Aging; Co-Director, 
Finger Lakes Geriatric Education Center, President, National 
Association for Geriatric Education.]
                                 ______
                                 
  Prepared Statement of the National Association for State Community 
                           Services Programs
    Mr. Chairman and Members of the committee, thank you for the 
opportunity to submit this testimony on behalf of the National 
Association for State Community Services Programs (NASCSP), a 
membership association for the administrators of the federally-funded 
Community Services Block Grant which serves millions of American 
families in communities across the country. As the Executive Director 
of NASCSP, I submit this testimony on behalf of the States in their 
work to improve the lives of low-income families and strengthen local 
economies. We are requesting that the Committee approve $710 million in 
fiscal year 2015 to adequately fund the CSBG network. This level of 
funding is the same as the fiscal year 2014 enacted funding for CSBG. 
We strongly believe that CSBG is a wise strategic investment not only 
in America's ongoing economic recovery, but in our Nation's long-term 
economic stability as well. Maintaining funding is necessary not only 
to continue CSBG's well-documented role in strengthening our economy, 
but also for the ongoing reforms to the block grant which adapt it to 
new realities and strengthen it for the next generation. We strongly 
oppose the reduction in funding for CSBG as proposed by the 
Administration, and I welcome this opportunity to explain exactly why.
    First, however, I'd like to thank Congress for its past support of 
CSBG. The services provided by this network are crucial to the millions 
of Americans facing poverty and economic insecurity at a time when the 
impact of the slow economy is affecting every Congressional District in 
America. Right now, more than 46 million Americans are living below the 
Federal poverty level (defined as $23,050 a year for a family of four). 
CSBG directly addresses the need to help hard-working Americans who are 
struggling in the present economy and to prevent people from slipping 
further into poverty. The strength and productivity of our Nation 
depends on the economic well-being of all of its citizens, and CSBG is 
a proven strategy to support millions of low-income Americans on the 
path to economic security. The CSBG network uses grassroots, innovative 
strategies to alleviate poverty and provides a significant return on 
taxpayers' investment. In fiscal year 2012, the CSBG network leveraged 
$22.75 for every Federal dollar invested in CSBG.
    By acting as a conduit between the Federal administration and local 
community action agencies (CAA's), States build public-private 
partnerships, support innovation, and advance best practices to ensure 
the most effective use of taxpayers' money. Local agencies utilize CSBG 
funds to leverage additional funds to eliminate poverty through a 
variety of programs and services. While CAAs across the Nation address 
similar issues, local needs determine unique approaches to addressing 
them.
    Poverty is a national problem, but can only be effectively 
addressed at the grassroots level. The CSBG network strives to find 
local solutions to these community issues by conducting community needs 
assessments to keep in touch with the needs, challenges, and resources 
in their community. The community needs assessments enable CAAs to 
provide the most effective and efficient strategies and services. These 
efforts fall into nine service categories outlined in the CSBG Act; 
employment, education, income management, housing, emergency services, 
nutrition, linkages, self-sufficiency, and health.
    National data compiled by NASCSP shows that CSBG serves a broad 
segment of low-income individuals and families. Data from fiscal year 
2012 shows:
  --There are 1,045 CAAs across the country, serving 99 percent of U.S. 
        counties;
  --CSBG serves 1 out of every 5 people in America below the poverty 
        line;
  --The majority of clients are female (58 percent), white (59 
        percent), renters (60 percent) and between the ages of 24--44 
        years old (24 percent)--the second largest group was children 
        ages 0-5 years old (14 percent);
  --The majority of clients are receiving incomes from employment-
        related sources (50 percent);
  --Many of the families served (33 percent) were in ``severe 
        poverty,'' with incomes below 50 percent of the Federal Poverty 
        Guideline.
    The successes of the CSBG network are well documented:
  --CSBG served 16 million Americans including 76.9 million families in 
        fiscal year 2012.
  --Over the past 5 years, the CSBG network helped over 630,000 people 
        obtain employment.
  --Over the past 5 years, the CSBG network addressed 21.2 million 
        barriers to employment through helping people to either acquire 
        jobs, obtain employment supports, or to receive job training.
  --Over the past 5 years, the CSBG network expanded 19.8 million 
        community opportunities or resources to stimulate community and 
        economic development.
  --Over the past 5 years, the CSBG network facilitated 18.5 million 
        opportunities for infants, children, youth, parents and other 
        adults through developmental or enrichment programs.
    States provide administrative oversight to ensure that eligible 
entities are meeting State and Federal requirements as well as their 
locally driven Community Action Plans. This includes monitoring 
eligible entities, providing training and technical assistance, 
investing in innovation, and maintaining effective performance 
measurement and management systems. Adequate funding is needed to 
maintain a high level of accountability and performance in the 
following areas:
Support High Achievement and Innovation
    Adequate funding, sufficient to meet national standards and 
incentives must be provided to States, local agencies, and national 
partners for high achievement and innovation. CSBG appropriations 
should include sufficient resources for local agencies, States, and 
national partners to engage in the work necessary to achieve the goals 
of the CSBG Act and the Promise of Community Action, which includes 
addressing the needs of vulnerable people and building strong 
communities. It should create the opportunity to provide a consistent 
resource to the people, families and communities that benefit from the 
activities conducted under the Act. It should also provide funds to 
extend the work to create and test innovative approaches as well as 
include and engage an ever wider circle of partners.
Support Coordination of Services
    NASCSP believes that a $710 million funding level for CSBG is 
essential for continued innovation and stronger coordination. It will 
also maintain the stature of the CSBG in both State and Federal 
administrations. Further, adequate funds in the CSBG will create 
additional opportunities and development for low-income programs and 
will allow for further coordination with agencies outside our Network 
that share a similar mission.
    Mr. Chairman, I respectfully request the Committee to fund CSBG at 
the level of $710 million in fiscal year 2015 to support America's 
ongoing economic recovery and future economic stability. Maintaining 
CSBG funding is an investment in both strengthening our economy and in 
adapting our efforts to new realities for future generations of hard-
working Americans. Thank you.

    [This statement was submitted by Jenae Conti Bjelland, Executive 
Director, National Association for State Community Services Programs.]
                                 ______
                                 
  Prepared Statement of the National Association of Chain Drug Stores
    The National Association of Chain Drug Stores (NACDS) thanks the 
Members of the Subcommittee on Labor, Health and Human Services, 
Education and Related Agencies for the opportunity to submit the 
following statement for the record regarding pharmacy-related 
provisions contained within the fiscal year 2015 Department of Health 
and Human Services (HHS) Budget. NACDS and the chain pharmacy industry 
are committed to partnering with Congress, HHS, patients, and other 
healthcare providers to improve the quality and affordability of 
healthcare services.
    NACDS represents traditional drug stores and supermarkets and mass 
merchants with pharmacies. Chains operate more than 40,000 pharmacies, 
and NACDS' 125 chain member companies include regional chains, with a 
minimum of four stores, and national companies. Chains employ more than 
3.8 million individuals, including 175,000 pharmacists. They fill over 
2.7 billion prescriptions yearly, and help patients use medicines 
correctly and safely, while offering innovative services that improve 
patient health and healthcare affordability. NACDS members also include 
more than 800 supplier partners and nearly 40 international members 
representing 13 countries. For more information, visit www.NACDS.org.
    As the face of neighborhood healthcare, community pharmacies and 
pharmacists provide access to prescription medications and over-the-
counter products, as well as cost-effective health services such as 
immunizations and disease screenings. Through personal interactions 
with patients, face-to-face consultations and convenient access to 
preventive care services, local pharmacists are helping to shape the 
healthcare delivery system of tomorrow--in partnership with doctors, 
nurses and others.
    In recent years, retail community pharmacies have played an 
increasingly important role in providing patient care, including 
medication therapy management (MTM) and expanded immunization services. 
Moreover, policymakers have begun to recognize the vital role that 
local pharmacists can play in improving medication adherence. The role 
of appropriate medication use in lowering healthcare costs has been 
acknowledged by the Congressional Budget Office (CBO). The CBO revised 
its methodology for scoring proposals related to Medicare Part D and 
found that for each 1 percent increase in the number of prescriptions 
filled by beneficiaries there is a corresponding decrease in overall 
Medicare spending. When projected to the entire population, this 
translates into a savings of $1.7 billion in overall healthcare costs, 
or a savings of $5.76 for every person in the U.S. for every 1 percent 
increase in the number of prescriptions filled.
    Congress has recognized the importance of pharmacist-provided 
services such as MTM by including it as a required offering in the 
Medicare Part D program. The experiences of Part D beneficiaries, as 
well as public and private studies, have confirmed the effectiveness of 
pharmacist-provided MTM. A 2013 Centers for Medicare and Medicaid 
Services (CMS) report found that Part D MTM programs consistently and 
substantially improved medication adherence and quality of prescribing 
for evidence-based medications for beneficiaries with congestive heart 
failure, COPD, and diabetes. The study also found significant 
reductions in hospital costs, particularly when a comprehensive 
medication review (CMR) was utilized. This included savings of nearly 
$400 to $525 in overall hospitalization costs for beneficiaries with 
diabetes and congestive heart failure. The report also found that MTM 
can lead to reduced costs in the Part D program as well; showing that 
the best performing plan reduced Part D costs for diabetes patients by 
an average of $45 per patient.
    How and where MTM services are provided also impact its 
effectiveness. A study published in the January 2012 edition of Health 
Affairs identified the key role of retail pharmacies in providing MTM 
services. The study found that a pharmacy-based intervention program 
increased adherence for patients with diabetes and that the benefits 
were greater for those who received counseling in a retail, face-to-
face setting as opposed to a phone call from a mail-order pharmacist. 
The study suggested that interventions such as in-person, face-to-face 
interaction between the retail pharmacist and the patient contributed 
to improved adherence behavior with a return on investment of 3 to 1.
    Since pharmacists have the proven ability to provide services that 
lead to better clinical outcomes and lower healthcare costs, we urge 
the implementation of budget proposals that allow all healthcare 
providers, including retail pharmacists, to practice to their maximum 
capabilities, working in partnership to provide accessible, high 
quality care to patients.
    NACDS appreciates HHS's proposed goals to reduce healthcare costs 
and produce a more efficient healthcare system; however, we have 
concerns with some proposals contained in the fiscal year 2015 HHS 
Budget. HHS has proposed excluding brand and authorized generic drugs 
from the calculation of average manufacture price (AMP), thereby 
calculating Medicaid Federal Upper Limits (FULs) based only on generic 
drug prices. While the goal of this provision may be to decrease 
Medicaid costs, we believe it may in fact reduce access to prescription 
drugs and pharmacy services for Medicaid patients, resulting in 
increased overall healthcare expenditures.
    Given that AMP has never been used as a basis for pharmacy 
reimbursement, and that AMP-based FULs remain in draft form, we believe 
the fiscal year 2015 budget provisions changing the calculation of FULs 
are premature. In fact, based on NACDS' most recent analysis, 
approximately 35 percent of the draft FULs are below National Average 
Drug Acquisition Cost (NADAC). This analysis confirms that additional 
efforts by CMS are necessary to ensure that pharmacies are not 
reimbursed below their costs using the reimbursement formula created by 
the Affordable Care Act. We urge CMS to utilize the rulemaking process 
to implement the Medicaid pharmacy provisions in a manner consistent 
with Congressional intent, rather than pursuing policies that would 
further cut pharmacy reimbursement.
    The fiscal year 2015 HHS Budget includes a proposal to limit 
Medicaid reimbursement of durable medical equipment (DME) to the rates 
paid by Medicare. Implementing a blanket proposal to reduce payment for 
Medicaid DME has the potential to disrupt access to DME and produce 
poorer health outcomes. This is particularly true in the case of 
diabetes testing supplies (DTS). Last year, CMS established a new 
Medicare single payment of $10.41 for DTS. This amount drastically 
decreased Medicare reimbursement by an average of 72 percent for retail 
pharmacies. The current reimbursement amount barely covers a pharmacy's 
costs-of-goods plus dispensing and counseling for these products and 
services. Reducing Medicaid reimbursement for DTS to match the Medicare 
rate could similarly produce hardships for Medicaid beneficiaries in 
terms of reducing access to needed supplies and threatening the health 
of an already fragile population. NACDS urges CMS to refrain from 
making any changes to Medicaid reimbursement for DTS.
    The fiscal year 2015 budget also includes several provisions to 
increase the utilization of generic drugs. NACDS applauds the inclusion 
of these important provisions, which would encourage the use of generic 
medications by Medicare Low Income Subsidy (LIS) beneficiaries, and 
promote generic competition for biologics. Increasing generic 
utilization is one of the most effective ways of controlling 
prescription drug costs, and the generic dispensing rate of retail 
pharmacies--80 percent--is higher than any other practice setting.
    Finally, the fiscal year 2015 HHS Budget includes a number of 
proposals to cut waste, fraud and abuse in the Medicare and Medicaid 
programs, including the ability to suspend coverage and payment for 
questionable Part D prescriptions. NACDS applauds HHS for working to 
ensure that such activity does not exist in these Federal programs. 
However, NACDS urges HHS to move forward in a cautious manner which 
does not disrupt beneficiary access or jeopardize beneficiary health. 
This can be done by ensuring that overly-burdensome requirements are 
not placed on providers to the point that it interferes with the 
ability to treat and care for patients.
    NACDS thanks the Subcommittee for consideration of our comments. We 
look forward to working with policymakers and stakeholders on these 
important issues.
                                 ______
                                 
  Prepared Statement of the National Association of Community Health 
                                Centers
Introduction
    Chairman Harkin, Ranking Member Moran, and Distinguished Members of 
the Subcommittee: on behalf of health centers across the Nation, we 
wish to thank you for the opportunity to submit testimony for the 
committee to review as you craft the fiscal year 2015 Labor-Health and 
Human Services-Education and Related Agencies Appropriations bill.
Health Centers- General Background
    Health Centers are community-owned and operated non-profit entities 
providing primary medical, dental, and behavioral healthcare as well as 
pharmacy and a variety of enabling and support services. Today, there 
are over 1,200 health centers operating at more than 9,000 urban and 
rural communities nationwide. We are the ``healthcare home'' for more 
than 22 million patients in all 50 States and nearly every 
Congressional district.
    By statute and mission, health centers are located in medically 
underserved areas or serve a medically underserved population. Health 
centers are directed by patient-majority boards, a model which helps to 
ensure they are responsive to the needs of each individual community 
they serve. Health centers offer comprehensive care to all residents of 
the community who seek their care, regardless of ability to pay or 
insurance status and offer services on a sliding fee scale. Our unique 
model of care has enabled us to save the entire health system 
approximately $24 billion annually. Health Centers reduce preventable 
hospitalizations and Emergency Department use, as well as the need for 
more expensive specialty care. The services provided at health centers 
save $1,263 per patient per year compared to expenditures for non-
health center users.
    In addition to reducing costs, health centers also serve as small 
businesses and economic drivers in their communities. In 2012, health 
centers employed 153,000 individuals and in 2009 generated $20 billion 
in total economic benefits in poor urban and rural communities.
Fiscal year 2014 Funding Background
    In fiscal year 2014, health centers received a total of $3.7 
billion in total Federal funding. This includes $1.49 billion in 
discretionary funding provided by the Health Resources and Services 
Administration (HRSA) and $2.2 billion in mandatory funding for health 
centers through the Health Center Fund. We want to thank the members of 
this Subcommittee for their support of health centers within the 
Consolidated Appropriations Act of 2014 to ensure health center funding 
continues to reach communities in need.
Access to a Health Center Reduces Barriers to Primary Care
    NACHC's recently released a report entitled: Access is the Answer 
finds 62 million Americans lack regular access to primary care and the 
vast majority of these medically disenfranchised Americans actually 
have insurance coverage. Many individuals still face barriers such as 
availability, affordability, and accessibility to primary and 
preventive care. Even among people who have an insurance card, access 
may be out of reach because of who they are and where they live. As 
health reform changes the healthcare landscape, we know that demand for 
health centers will continue to climb among the uninsured, underinsured 
and underserved due to the lack of other healthcare providers willing 
to see our patients.
    True ``access'' means having a regular, reliable source of quality 
preventive and primary healthcare and simply having an insurance card 
does not guarantee ready access to primary care. With our unique model 
of care, Health Centers can help address these primary care demands in 
a cost effective manner. However, Health Centers cannot continue to 
deliver results without a sound financial base.
Fiscal year 2015 Funding Request and Health Center Funding Cliff
    In fiscal year 2015, Health Centers are respectfully requesting 
level discretionary funding of $1.49 billion for the Health Center 
program. Together with the $3.6 billion in funding available in fiscal 
year 2015 through the mandatory Health Center Fund, health centers are 
requesting a total of $5.1 billion in total program funding. This 
funding for the Health Center program, which requires no new 
appropriation from this Subcommittee, should be fully utilized during 
fiscal year 2015 to increase access to primary care in medically 
underserved communities. With access to all available funding for the 
program in fiscal year 2015, Health Centers could build the capacity to 
serve up to 11 million new patients, both in new communities and 
through expanded services and capacity at existing health centers. In 
addition, existing Health Centers could ensure they are keeping up with 
current patient demand.
    The President's proposed fiscal year 2015 Health Resources and 
Services Administration (HRSA) budget provides $1 billion in 
discretionary funding for the Health Centers program. Together with the 
$3.6 billion in fiscal year 2015 mandatory funding available for health 
centers, under the President's proposal, health centers would receive a 
net increase of $960 million in total programmatic funding for fiscal 
year 2015 equaling total funding of $4.6 billion. Within this proposal, 
the President will allocate $860 million for one-time quality 
improvement and capital development awards and $100 million to fund new 
health center sites.
    We strongly oppose the President's proposed $500 million 
discretionary funding reduction for health centers as it further 
reduces the discretionary allocation for the program beyond the levels 
in place prior to the inception of the Health Center Fund. Health 
centers simply cannot survive further decreases to their base 
discretionary funding which undermines the long-term sustainability of 
the program, and may well threaten access for existing patients.
    We do appreciate the President's acknowledgement and recognition of 
the looming funding crisis for health centers upon the expiration of 
the Health Center Fund after fiscal year 2015. Under current law the 
Health Center Fund will end after fiscal year 2015, resulting in as 
much as a 70 percent reduction in health center grant funding in fiscal 
year 2016. Averting the health center cliff is critical to ensuring 
that health centers remain financially viable and able to serve the 
diverse needs of their communities. However, the President only 
proposes a temporary (3 year) solution reducing program funding down to 
fiscal year 2014 levels after a one-time increase in fiscal year 2015. 
Given the number of communities and individuals in need of access to 
healthcare, longer-term solutions must encompass both stability and 
expansion of access to care.
Conclusion
    We understand this Subcommittee must make difficult budgetary 
decisions as you work within the funding limits set for the 
subcommittee's bill. As the fiscal year 2015 appropriations process 
moves forward, we urge you to keep in mind that without their local 
health center, many individuals located in medically underserved 
communities will seek care in emergency departments and hospitals, 
often waiting until they are sicker get treatment. This will mean 
poorer health for these patients and much higher costs to the system. 
Health centers have continually proven to be a worthwhile investment by 
delivering high quality, affordable healthcare while generating savings 
to the entire health system in these communities. We are extremely 
grateful for your past support and ask for the Subcommittee's continued 
support for the Health Center program. We look forward to working with 
you and thank you for your consideration.

    [This statement was submitted by Daniel R. Hawkins, Jr., Senior 
Vice President, Public Policy and Research.]
                                 ______
                                 
   Prepared Statement of the National Association of County and City 
                            Health Officials
    The National Association of County and City Health Officials 
(NACCHO) is the voice of the 2,800 local health departments across the 
country that work every day to ensure the safety of the water we drink, 
the food we eat, and the air we breathe. On behalf of local health 
departments, NACCHO submits the following requests:
Prevention and Public Health Fund
    In fiscal year 2015, NACCHO requests $1 billion for the Prevention 
and Public Health Fund (PPHF), a dedicated Federal investment in 
programs that prevent disease at the community level. NACCHO wishes to 
thank Congress for allocating the PPHF in fiscal year 2014 and setting 
specific funding levels to support the prevention of disease and 
promotion of health in communities across the Nation.
CDC Public Health Emergency Preparedness
    NACCHO urges the Subcommittee to provide $675 million for the 
Public Health Emergency Preparedness (PHEP) grant program in fiscal 
year 2015. PHEP protects communities by strengthening local and State 
public health department capacity to effectively respond to public 
health emergencies including terrorist threats, infectious disease 
outbreaks, natural disasters, and biological, chemical, nuclear, and 
radiological emergencies. These grants have been cut more than 30 
percent since fiscal year 2007 with more than 55 percent of local 
health departments relying solely on Federal funds for emergency 
preparedness activities. NACCHO urges inclusion of language asking CDC 
to provide information on how much of the State PHEP grants are being 
allocated to local health departments and on what basis or formula each 
State is determining such allocations, including the method through 
which States reach statutorily-required concurrence with local health 
departments.
Assistant Secretary for Preparedness and Response
    NACCHO urges the Subcommittee to fund the Hospital Preparedness 
Program (HPP) at $300 million in fiscal year 2015 and restore some of 
the $104 million (35 percent) cut from the program in fiscal year 
2014.. HPP supports health department preparedness coordinators to 
organize coalitions of public health and healthcare providers to plan 
and prepare for public health emergencies, including medical surge 
following terrorist attacks, mass casualty incidents, an influenza 
pandemic or other infectious disease outbreak. NACCHO is concerned that 
the 35 percent cut to HPP in fiscal year 2014 will erode medical system 
preparedness, making communities across the country more vulnerable. 
NACCHO urges Congress to request information from Assistant Secretary 
for Preparedness and Response (ASPR) on how State HPP funding is 
distributed at the local level, including how much is being allocated 
to local health departments and on what basis or formula each State 
making such allocations. This information should be publicly available.
CDC Section 317 Immunization Program
    NACCHO urges the Subcommittee to provide $650 million for the 
Section 317 Immunization Program in fiscal year 2015. The Section 317 
Immunization Program funds 50 States, six large cities and eight 
territories for vaccine purchase for at-need populations and 
immunization program operations, including support for implementing 
immunization billing systems at public health clinics to sustain high 
levels of vaccine coverage. NACCHO supports directing $8 million of the 
funding, as proposed in the President's Budget, to continue projects to 
facilitate billing by health departments of public and private 
insurance for covered immunization services.
CDC Chronic Disease Prevention
    Partnerships to Improve Community Health (Community Prevention 
Grants).--NACCHO urges the Subcommittee to provide $100 million to 
support continuation of the Partnerships to Improve Community Health 
program in fiscal year 2015, which supports implementation of evidence-
based strategies to address heart attacks, strokes, cancer, diabetes, 
and other chronic diseases which contribute to the soaring cost of 
healthcare. Local health departments lead efforts to reduce tobacco 
use, increase physical activity and expand access to nutrition in order 
to reduce costly chronic diseases like heart disease and diabetes. 
NACCHO urges Congress to encourage CDC to conduct a comprehensive 
national evaluation of the program including recommendations for 
national qualitative and quantitative standards for quality preventive 
services and a report of how much of the funding was granted to the 
local level and to which eligible entities.
    Heart Disease and Stroke.--NACCHO urges the Subcommittee to 
continue to support Heart Disease and Stroke Prevention at $130 million 
in fiscal year 2015. In fiscal year 2014, Congress provided a $76 
million increase for heart disease and stroke prevention and urged CDC 
to ensure that some portion of the increase in funding is sub-granted 
to the local level. The risk factors of obesity and smoking must be 
addressed at the community level to combat disease. Local health 
departments who are experts on community needs and prevention 
interventions in the area of heart disease and stroke.
    Diabetes Prevention and Control.--NACCHO urges the Subcommittee to 
continue to support Diabetes Prevention at $150 million in fiscal year 
2015. In fiscal year 2014, Congress provided a $76 million increase for 
diabetes prevention and urged CDC to ensure that some portion of the 
increase in funding is sub-granted to the local level. Because 
evidence-based disease self-management programs are effective at 
improving health, greater emphasis must be placed on enhancing the 
reach of these community level interventions.
CDC Preventive Health and Health Services Block Grant
    In fiscal year 2015, NACCHO urges the Subcommittee to continue to 
support the Preventive Health and Health Services (PHHS) Block Grant at 
$160 million. This unique funding gives States the flexibility to 
address State problems and provide similar support to local 
communities, while demonstrating the local, State, and national impact 
of this investment. NACCHO urges Congress to encourage CDC to enhance 
reporting and accountability for the PHHS Block Grant including 
providing capacity building to States for core public health capacities 
that may not be supported through other CDC categorical funding 
streams. In order to make sure that funding supports the needs of local 
communities, local health departments should be full partners in 
developing State plans. CDC should also require States to report the 
funding allocation used to subgrant funds to local health departments 
and to encourage they include locals in their statewide planning 
efforts.
CDC Food Safety
    NACCHO urges the Subcommittee to support CDC's Food Safety Program 
at $54 million in fiscal year 2015. Local and State health departments 
are an essential part of the process that ensures that food is safe to 
eat at home, at community events, in restaurants, and in schools.
    As the Subcommittee drafts the fiscal year 2015 Labor-HHS-Education 
Appropriations bill, NACCHO urges consideration of these 
recommendations for programs that protect the public's health and 
safety.
                                 ______
                                 
 Prepared Statement of the National Association of State Directors of 
               Career and Technical Education Consortium
    Dear Chairman Mikulski, Ranking Member Shelby, Chairman Harkin and 
Ranking Member Moran: On behalf of the National Association of State 
Directors of Career and Technical Education Consortium (NASDCTEc), I am 
writing to urge the committee to support Career Technical Education 
(CTE) through a strong Federal investment in the Carl D. Perkins Career 
and Technical Education Act (Perkins). The passage of the Consolidated 
Appropriations Act of 2014 has helped to alleviate most of the harmful 
sequester cuts which have negatively impacted important Federal 
investments in CTE programs through this legislation. However, our 
organization recognizes that there are still difficult decisions to be 
made regarding individual program funding levels in fiscal year 2015. 
To that end, NASDCTEc is requesting that the committee restore funding 
for the Perkins Basic State Grant to at least $1.264 billion, 
equivalent to the pre-sequestration level of 2010, and make investing 
in Perkins a top priority in the fiscal year 2015 Labor, Health and 
Human Services, and Education appropriations bill.
    Perkins is the principal source of Federal support for CTE programs 
at secondary and postsecondary institutions across the county. This 
Federal investment is crucial to ensuring that students have the 
academic, technical and employability skills that are needed for 
expanding fields like engineering, information technology, advanced 
manufacturing and healthcare. Perkins-funded CTE programs are working 
with business and industry partners to help fill positions that are 
available today, while preparing a qualified workforce for the careers 
of tomorrow. In a rapidly changing job market, CTE provides students 
with transferable skills that ensure they are college-and career-ready, 
while offering retraining opportunities to many adult or dislocated 
workers.
    CTE produces a strong return on the Federal investment and has an 
unmistakably positive societal and economic impact. Students enrolled 
in CTE programs are more engaged, perform better academically and 
graduate at higher rates. CTE supports the development of an educated 
and highly skilled workforce that provides a direct benefit to 
employers, while strengthening the economy through increased 
productivity and innovation.
    However, funding for CTE has not been immune to significant budget 
cuts over the past several years. The Perkins Act basic State grant 
program still remains approximately $5 million below pre-sequestration 
levels. In addition to sequestration, funding for Perkins was reduced 
by over $140 million between fiscal year 2010 and fiscal year 2012, 
dramatically reducing the capacity of CTE programs to offer 
academically rigorous instruction and career training that is aligned 
to the needs of business and industry. Dozens of States are currently 
receiving funding allocations close to the levels they received in 
1998. When taking into account inflation over this period, the relative 
investment in CTE through the Perkins Act has declined considerably 
more. This erosion has hurt high schools, CTE centers, community and 
technical colleges, employers and millions of CTE students nationwide. 
This pathway of disinvestment in our Nation's CTE system is 
unsustainable-- we cannot cut our way to a 21st century workforce! 
Instead, Perkins funding must be restored to meet the needs of CTE 
programs around the country and ensure students are fully prepared for 
their future academic and career goals.
    Thank you for your continued leadership in this difficult fiscal 
environment and for your thoughtful consideration during the 
appropriations process. NASDCTEc looks forward to working with the 
committee in a bipartisan fashion to restore funding for CTE and 
support the millions of CTE students across the Nation.

    [This statement was submitted by Kimberly Green, Executive 
Director, National Association of State Directors of Career and 
Technical Education Consortium.]
                                 ______
                                 
  Prepared Statement of the National Association of State Head Injury 
                             Administrators
    Dear Chairman Tom Harkin and Ranking Member Jerry Moran: On behalf 
of the National Association of State Head Injury Administrators 
(NASHIA), thank you for the opportunity to submit testimony regarding 
the fiscal year 2015 appropriations for programs authorized by the 
Traumatic Brain Injury (TBI) Act within the Department of Health and 
Human Services (HHS). The TBI Act programs are the only programs 
providing Federal assistance to help States with developing an array of 
rehabilitation, home and community-based services and other short-term 
and long-term supports specific to the cognitive and behavioral needs 
of individuals with TBI and their families. These programs are designed 
to restore and improve functioning and assist individuals to return to 
school, engage in employment and to live as independently as possible. 
To assist States in improving and expanding service delivery, NASHIA 
recommends the following:
Centers for Disease Control and Prevention (CDC), National Injury 
        Center
    The CDC National Injury Center supports State TBI registries, 
surveillance, data collection and analysis; State and local prevention 
interventions to address falls related, motor vehicle related, and 
sports-related injuries, including concussions (mild TBI); as well as 
educates primary clinicians and other professionals to be able to 
identify, diagnose and manage TBIs appropriately and effectively.
NASHIA recommends an increase in funding for the CDC TBI Program in the 
        amount of $10 million to address the expanding population of 
        TBI.
    CDC's National Injury Center is the primary Federal agency 
responsible for translating science into effective programs and 
policies to prevent and minimize the consequences of TBI when they 
occur. Through its funded programs and activities, the Injury Center 
works with national organizations, Federal agencies, State health 
agencies, and other key groups to develop, implement, and promote 
effective injury and violence prevention and control practices.
Health Resources and Services Administration (HRSA), Federal TBI 
        Program
    NASHIA recommends $12 million total for the HRSA TBI Federal 
Program, which is split by HRSA between two programs: HRSA Federal TBI 
State Grant Program and the HRSA Federal TBI Protection & Advocacy 
(P&A) Systems Grant Program.
HRSA Federal TBI State Grant Program
    Since 1997, HRSA has awarded grants to 48 States, District of 
Columbia and one Territory, although not concurrently, to develop and 
improve services and systems to address the short-term and long-term 
needs. These grants have been time limited and are relatively small. 
Five years ago, HRSA increased the amount of the award from 
approximately $100,000 to $250,000 to make it more feasible for States 
to carry out their grant goals and the legislative intent. While this 
increased amount is more attractive to States, this change reduced the 
number of grantees to 21--less than half of the States and Territories 
receive funding. As a result, States that do not have Federal grant 
funding are finding it increasingly difficult to sustain their previous 
efforts, let alone expand and improve service delivery, due to other 
budget constraints within their States. Therefore, NASHIA recommends:
$8 million in total for the HRSA Federal TBI State Grant Program to 
        increase the number of State grant awards.
    Over the course of the grant program, States have developed State 
plans and implemented initiatives for improving service delivery; 
information & referral systems; service coordination systems; outreach 
and screening among unidentified populations such as children, victims 
of domestic violence, and veterans; and training programs for direct 
care workers and other staff. States have conducted public awareness 
and educational activities that have helped States to leverage and 
coordinate funding in order to maximize resources within States to the 
benefit of individuals with TBI.
    While NASHIA is well aware that Federal funds are becoming 
increasingly difficult to obtain, NASHIA is recommending increased 
funding for the Federal TBI Act programs because:
  --The number of Americans who sustain a TBI is increasing, especially 
        among older adults and young children, and among our men and 
        women in uniform as a result of the wars in Iraq and 
        Afghanistan.
  --All States have enacted legislation to develop return to play 
        guidelines with regard to sports-related concussions among our 
        youth. Two States have recently expanded their laws to include 
        ``return to learn'' guidelines to help with the identification 
        of TBI and appropriate accommodations and related educational 
        assistance that may be needed after a mild TBI (concussion) in 
        order to be successful academically. Through these efforts, 
        children and youth are now being identified and screened for 
        potential assistance.
  --State budgets have not been able to keep up with the demand for 
        services.
HRSA Federal TBI Protection & Advocacy (P&A) Systems Grant Program
    HRSA also administers the Federal TBI P&A Systems Grant Program 
which is a formula-based program that allows 57 States, Territories, 
and the Native American Protection and Advocacy Project to assess their 
State P&A Systems' responsiveness to TBI issues and provide advocacy 
support to individuals with TBI and their families. Together, P&As 
comprise the Nation's largest provider of legally based advocacy 
services for people with disabilities. To further the work of the P&As, 
NASHIA recommends:
$4 million in total be appropriated to increase the amount of grant 
        awards administered by HRSA Federal TBI P&A Systems Grant 
        Program.
    The TBI Act, which was last reauthorized in 2008, is due for 
reauthorization. TBI stakeholders are working with key Congressional 
leaders to extend authorization of appropriations for these critical 
programs. In addition:
NASHIA recommends transferring the HRSA TBI State Grant and P&A 
        programs to the Administration for Community Living to maximize 
        resources to support the array of services and supports needed 
        following a brain injury.
    Transferring the TBI State Grant and P&A Grant programs within ACL 
would:
  --Integrate TBI into the HHS long-term services initiatives, which 
        also rely on Aging and Disability Resource Centers (ADRCs) as 
        the entry point into these systems;
  --Promote collaboration with the Administration on Aging (AoA) on 
        falls related TBIs among older adults;
  --Include TBI in the veterans initiatives between HHS and Department 
        of Veterans Affairs to support Home and Community-Based 
        Services (HCBS) for veterans and returning servicemembers 
        coordinated by the ACL's Office of Disability and Aging 
        Policy's Office of Integrated Programs;
  --Coordinate and enhance services for individuals with TBI who could 
        benefit from the ACL's Administration on Intellectual/
        Developmental Disabilities (AIDD) initiatives to improve 
        education, transition services, employment outcomes and self-
        advocacy for children and youth; and
  --Include TBI in the Office of Disability and Aging Policy's Office 
        of Integrated Policy initiatives (i.e. Lifespan Respite Care 
        Program, Participant Direction Program, Evidenced-Based Care 
        Transitions, and Transportation Research and Demonstration 
        Program).
    In keeping with the Olmstead decision, States are taking advantage 
of Federal initiatives and opportunities to expand community long-term 
services options. Unfortunately, most States focus on the traditional 
populations of I/DD, physical disabilities, aging and mental health and 
are omitting TBI in their long-term care initiatives. This leaves 
individuals with TBI with little options, other than nursing facilities 
or other segregated living programs, for assistance with activities of 
daily living and residential or housing needs. We believe that aligning 
the Federal TBI State Grant Program with these other programs will help 
address these concerns.
About the National Association of State Head Injury Administrators 
        (NASHIA)
    NASHIA is a non-profit organization representing and assisting 
State governmental officials who administer an array of short-term and 
long-term rehabilitation and community services and supports for 
individuals with TBI and their families. Since 1990, NASHIA has held an 
annual State-of-the-States conference, and has served as a resource to 
State TBI program managers and others seeking public programs and 
services. Membership also includes associate members who are 
professionals, provider agencies, State affiliates of the Brain Injury 
Association of America (BIAA) or U.S. Brain Injury Alliance, family 
members and individuals with TBI.
    Over the past 30 years, States have initiated efforts to develop 
capacity for offering information and referral services, service 
coordination, rehabilitation, in-home support, personal care, 
counseling, transportation, housing, vocational and other support 
services for persons with TBI and their families. These services vary 
in size and scope across the country and even within a State. Twenty-
four States have enacted legislation to assess fines or surcharges to 
traffic related offenses or other criminal offenses and/or assessed 
additional fees to motor vehicle registration or drivers license to 
generate funding for TBI programs and services, generally referred to 
as trust fund programs. About the same number of States have 
implemented TBI Home and Community-Based Medicaid Waiver Programs with 
twelve States having the advantage of administering both a trust fund 
and waiver program. These programs are administered by State public 
health, Vocational Rehabilitation, mental health, Medicaid, 
intellectual disabilities, education or social services agencies within 
the States.
    Thank you.
                                 ______
                                 
Prepared Statement of the National Association of State Long-Term Care 
                           Ombudsman Programs
    I am pleased to present this testimony on behalf of residents and 
tenants residing in Iowa's long-term care facilities in collaboration 
with the National Association of State Long-Term Care Ombudsman 
Programs (NASOP). This statement and the following funding 
recommendations for fiscal year 2015 for the Long-Term Care Ombudsman 
Programs administered through the Administration for Community Living 
(ACL) is submitted for the record.
  --$5 million authorized under the Elder Justice Act for Long-Term 
        Care Ombudsman Program (LTCOP) services and training to fight 
        elder abuse, neglect, and exploitation;
  --$16.83 million authorized under Title VII of the Older Americans 
        Act for LTCOPs to restore funding back to the fiscal year 2011 
        level;
  --$20 million for LTCOP services in assisted living facilities; and
  --$1 million authorized under Title II of the Older Americans Act for 
        the National Long-Term Care Ombudsman Resource Center (NORC).
    NASOP, formed in 1985 as a non-profit organization, is composed of 
state long-term care ombudsmen representing their State programs 
created by the Older Americans Act (OAA). The primary function of the 
LTCOP in the Federal OAA is to identify, investigate, and resolve 
complaints that relate to action, inaction or decisions that may 
adversely affect the health, safety, welfare, and rights of residents 
of long-term care facilities. Ombudsman representatives work with the 
consent and at the direction of residents in the resolution of their 
problems. They visit residents living in nursing homes and residential 
care homes. Ombudsman representatives ask them about problems or 
concerns they have and if they need or want our help to resolve these 
issues. Ombudsman representatives act as their advocates. We strongly 
believe that our work not only improves the quality of life for 
millions of long-term care facility residents, but also saves Medicare 
and Medicaid resources by avoiding unnecessary costs associated with 
poor quality care.
    Nationally, n Federal fiscal year 2012, over 11,000 volunteers, 
including 8,712 individuals certified to investigate complaints, and 
1,180 staff served in 573 local LTCOPs. Ombudsmen investigated and 
worked to resolve 193,650 complaints made by 126,398 individuals. 
Ombudsmen were able to resolve or partially resolve 73 percent, or 
almost three out of every four complaints investigated. In addition, 
ombudsmen provided information on rights, care and related services 
405,589 times.
    Iowa's LTCOP is responsible for advocating for 53,287 residents and 
tenants residing within 844 long-term care facilities. The Iowa Office 
of State Long-Term Care Ombudsman consists of the State Long-Term Care 
Ombudsman; 8 Local Long-Term Care Ombudsman; 2 Volunteer Coordinators; 
numerous volunteers, and an Administrative Assistant. Currently, the 
Federal funding for our program only fully funds two (2) of the twelve 
(12) paid positions.
    In Federal fiscal year 2013, Iowa's LTCOP received 1,174 complaints 
by or on behalf of residents and tenants; directly served 3,226 
residents and tenants; provided 4,445 hours of advocacy services beyond 
complaint handling; and provided 5,360 consultations, education 
sessions, visits, and other activities. Our office advocates for 53, 
287 residents/tenants in 844 facilities and we do this with just a few 
staff. We are grateful for the staffing that we do have, but feel that 
our efforts are just a drop in the bucket. According to two national 
studies from the Institute of Medicine and the Bader Report, the 
national recommendation for States to follow is 1 long-term care 
ombudsman for 2,000 beds or people. With the current number of long-
term care ombudsman staff in Iowa, our ombudsmen are serving 6,661 beds 
or people. Iowa would need a total of 27 local long-term care ombudsmen 
to fully meet this Federal recommendation. This would ensure that all 
individuals residing in long-term care would have immediate access to 
an advocate who can represent their interests.
    We understand that this Subcommittee faces a strained financial 
situation, but a continued commitment to Ombudsman programs advocating 
for the healthcare needs and safety of millions of older adults living 
in nursing homes and assisted living facilities across the Nation 
should remain a high priority. Since 1978, the LTCOP has been a core 
program of the OAA. It is the only program in the OAA that specifically 
serves residents of nursing homes and assisted living facilities. We 
all appreciate and value the importance of living in one's own home. 
The OAA provides critically needed home and community based services 
that often delay institutionalization. However, some elders can no 
longer live safely in their own homes and must move at some point in 
their lives to either an assisted living facility or a nursing home. 
These residents are usually frail and extremely vulnerable and rely on 
the advocacy services of the LTCOP.
    Demand for our services and advocacy is growing. The number of 
complex and very troubling cases that long-term care ombudsmen 
investigate has been steadily increasing. In addition, there continues 
to be a disturbing increase in the frequency and severity of citations 
for egregious regulatory violations by long-term care providers. These 
violations put facility residents in immediate jeopardy of harm. This 
trend suggests a frightening decline in the quality of long-term care 
services. Ombudsmen are needed now more than ever in nursing homes, 
board and care facilities, and in assisted living communities. As well, 
the demand placed on the program by the need to assist residents who 
are relocating from long-term care facilities that are downsizing or 
closing their doors continues to complicate ombudsman programs' daily 
operations.
    Administrators in many long-term care facilities have recognized 
the value and benefit of having ombudsmen assist with staff training 
and consultation and this form of outreach has also placed an 
increasing strain on available advocacy resources. In order to improve 
advocacy and services available to residents of long-term care 
facilities, NASOP recommends, and the Iowa Office of the State Long-
Term Care Ombudsman supports, several augmentations to appropriations 
that support the work of LTCOP.
    NASOP requests $5 million to support the work of the LTCOP under 
the Elder Justice Act. This appropriation would allow States to hire 
additional staff and leverage that staff to recruit additional 
volunteers to help support the investigation of complaints of abuse, 
neglect, and exploitation of residents of nursing home and assisted 
living facilities.
    NASOP request $16.83 million authorized under Title VII of the 
Older Americans Act for LTCOPs to restore funding back to the fiscal 
year 2011 level. Programs in every district and State are suffering 
from recent cuts. These funds would help in a partial way to restore 
our reduced ability to visit residents in nursing homes.
    NASOP requests $20 million to support 333 additional Ombudsman 
salaried staff at an estimated $60,000 average annual salary/fringe 
benefits and necessary staff training. The requests adds new ombudsman 
positions specifically dedicated to providing Ombudsman services to 
residents of assisted living facilities and other community-based long- 
term care delivery systems, which currently suffer from a significant 
lack of personnel resources around the country.
    Finally, NASOP wants to acknowledge the importance and value of the 
National Long-Term Care Ombudsman Resource Center (NORC). The NORC 
provides valuable and reliable technical assistance, training, and 
support to State and local LTCOPs.
    NASOP requests an appropriation of $1 million to support the work 
of the NORC in providing training and technical assistance to State and 
local LTCOPs. Congress funds the NORC at $550,000 per year; the very 
same level of funding it has received since 1993. This request adds 
$450,000 to the line item for the NORC, which is such a critical 
component of the ombudsman program. The NORC plays an integral role in 
assuring the overall effectiveness of LTCOPs across the country through 
its training, educational materials, data analysis, and best practices 
efforts.
    Overall, Ombudsmen offer valuable consumer protections to residents 
and provide a voice for those unable to speak for themselves. Every day 
in America, 10,000 more persons reach the age of 65 years. With a 
rapidly growing older population, LTCOPs can continue to enhance the 
quality of life, improve the level of care, protect the individual's 
rights and promote the dignity of Americans across the Nation.
    On behalf of residents, tenants and State Long-Term Care Ombudsmen 
across this Nation, thank you for this opportunity to share these 
requests for support of this important program that protects the 
health, safety, welfare, and rights of vulnerable older adults and 
persons with disabilities. We ask that you thoughtfully consider our 
detailed request for funding in fiscal year 2015.

    [This statement was submitted by Deanna Clingan-Fischer, JD, Iowa 
State Long-Term Care Ombudsman.]
                                 ______
                                 
  Prepared Statement of the National Association of States United for 
                         Aging and Disabilities
    Chairman Harkin, Ranking Member Moran: Thank you to for the 
opportunity to submit this testimony. As you work to develop fiscal 
year 2015 funding priorities, the National Association of States United 
for Aging and Disabilities (NASUAD) urges you to consider the 
Administration for Community Living's (ACL) fiscal year 2015 request 
for $25 million to address the all-too prevalent problem of elder 
abuse. This investment would support initial implementation of the 
Elder Justice Act's (EJA) Adult Protective Services (APS), research, 
and evaluation activities.
    NASUAD represents the 56 officially designated State and 
territorial agencies on aging and disabilities. Each of our members 
oversees the implementation of the Older Americans Act (OAA), and many 
also serve as the operating agency in their State for Medicaid waivers 
that serve older adults and individuals with disabilities. Together 
with our members, we work to design, improve, and sustain State systems 
delivering home and community based services and supports for people 
who are older or have a disability, and their caregivers.
    According to ACL, an estimated 2.1 million older Americans are 
victims of elder abuse, neglect, or exploitation each year. As the 
Nation's older population increases, so too does the incidence of elder 
abuse. While there is no single set of national elder abuse prevalence 
data, the number of reported cases is on the rise. A 2004 national 
survey of State APS programs showed a 16 percent increase in the number 
of elder abuse cases from an identical study conducted in 2000. 
Additionally, an overwhelming number of cases of abuse, neglect, and 
exploitation go undetected and untreated each year. Experts estimate 
that for every case of elder abuse or neglect reported, as many as five 
cases go unreported.
    Despite the clear and growing need, there is no dedicated Federal 
funding for, or corresponding Federal oversight of, elder abuse 
prevention services. Absent a national framework, States have been left 
to address this issue independently from one another, and must rely on 
multiple funding streams to support their work, ultimately resulting in 
a fragmented system. Though each State has developed an APS program 
that responds to reports of elder abuse, neglect, and exploitation, 
these programs vary greatly from State to State--from the populations 
they serve, to the reporting mechanisms they use, and the budget 
structures under which they operate. These discrepancies, which 
continue to be exacerbated by the absence of Federal APS funding, 
necessarily impede efforts to compare, evaluate, and improve State 
approaches to reducing and preventing elder abuse.
    To address the systemic inadequacies in our Nation's approach to 
eradicating elder abuse, neglect, and exploitation, we urge you to 
support ACL's request of $25 million in discretionary funding to 
implement the EJA in fiscal year 2015. This critical funding would be 
used to develop much-needed program standards and data collection 
efforts, as well as to support the implementation of a nationwide APS 
data system; these dollars would also fund research activities, 
including efforts to translate promising interventions from other 
violence prevention areas to elder abuse, and evaluations of the 
effectiveness of these interventions.
    NASUAD believes that efforts to improve the response to, awareness 
of, and intervention in elder abuse, neglect, and exploitation could be 
more effectively coordinated through the establishment of a national 
APS program. Accordingly, we urge you to fully fund the Elder Justice 
Initiative in fiscal year 2015.
    Thank you for the opportunity to provide input on this critical 
issue, and for your leadership. NASUAD looks forward to working with 
all of you to preserve the dignity, independence, and health of older 
adults, and to protect those who may no longer be able to protect 
themselves.
                                 ______
                                 
         Prepared Statement of the National Blood Clot Alliance
    The National Blood Clot Alliance (NBCA) is pleased to submit this 
statement in support of increased appropriations for fiscal year 2015 
for the Centers for Disease Control and Prevention's (CDC) Division of 
Blood Disorders, a component of CDC's National Center on Birth Defects 
and Developmental Disabilities. NBCA's statement addresses the programs 
specific to blood clots, known scientifically as Deep Vein Thrombosis 
(DVT) and Pulmonary Embolism (PE), a major public health problem facing 
this Nation. Combined, these disorders are known as venous 
thromboembolism (VTE). Preventing death and disability from VTE is an 
important public health priority, and the Division is responsible for 
all CDC activities related to blood clots and other bleeding disorders.
    NBCA asks the Subcommittee to restore funding for the Division to 
its fiscal year 2010 level, $19.9 million. The fiscal year 2014 funding 
has dropped precipitously to $13 million. Of this, support for blood 
clot prevention has been cut in half, to a mere $560,000, hardly enough 
to make a dent in a major public health problem that annually kills 
more Americans than AIDS, breast cancer and motor vehicle accidents 
combined. NBCA further requests that the Subcommittee establish a 
budget line item specific to blood clots and clotting disorders and 
that $4 million be appropriated for this line each year for the next 5 
years.
    Funding this program at the requested level will be a major step in 
advancing the Surgeon General's 2008 ``Call to Action to Prevent Deep 
Vein Thrombosis (DVT) and Pulmonary Embolism (PE)'' and the Nation's 
``Healthy People 2020 Objectives.'' The urgency of this request is 
underscored by the fact that the great majority of blood clots could be 
prevented. We have the tools to do that, but the resources to deploy 
them are woefully inadequate.
    Blood clots are the leading cause of unnecessary hospital 
readmissions in the U.S., costing our Nation an estimated $10 billion 
dollars in avoidable healthcare expenses annually. According to the 
American Public Health Association, DVT deaths are the most common 
preventable cause of hospital death. Researchers at Johns Hopkins 
University School of Medicine recently reported that as many as 70 
percent of healthcare associated VTE could be eliminated with the 
application of improved prevention protocols. Other targeted 
population-based prevention tools can be applied to avert disability 
and death from blood clots due to aging, lengthy travel, immobility, 
obesity and other risk factors.
The National Blood Clot Alliance
    Founded in 2003, NBCA is a patient led non-profit, voluntary health 
organization dedicated to advancing the prevention, early diagnosis and 
successful treatment of life-threatening blood clots such as deep vein 
thrombosis, pulmonary embolism and clot-provoked stroke. We work on 
behalf of people who have or could be susceptible to blood clots, 
including, but not limited to, people with clotting disorders, atrial 
fibrillation, cancer, traumatic injury, and risks related to surgery, 
lengthy immobility, child birth and birth control. NBCA accomplishes 
its mission through programs that build public awareness, educate 
patients and healthcare professionals and promote supportive public and 
private sector policy. Our content is reviewed by an internationally 
recognized Medical and Scientific Advisory Board. We invite the Members 
of the Subcommittee to visit our website at www.stoptheclot.org to 
learn more about blood clots and the programs of NBCA.
Who Has Blood Clots and What Are They?
    No American is immune from life-threatening blood clots, regardless 
of age, gender, race, ethnicity or health status. Normal blood clots 
play an important role in protecting our health because they stop 
bleeding from a cut or wound. However, blood clots can also form 
abnormally, causing a heart attack, stroke, or other serious medical 
problems. Experts estimate that two million Americans suffer such 
venous and arterial blood clots every year. More than 200,000 Americans 
die from them annually. An often silent killer, death can be sudden 
with no forewarning. But in most instances, the damage can be averted 
or contained. Age, smoking, obesity can all contribute to clotting 
risk, but so can birth control or pregnancy or cancer. Even prominent 
athletes in peak physical condition have suffered career- ending, life 
-threatening clots. It can happen to any of us. In fact, the memories 
of former U.S. Reps. Walter Capps (D-CA) and Jennifer Dunn (R-WA), who 
died due to blood clots while serving in Congress, motivated the 
creation of National Blood Clot Awareness Month in March of 2009.
    Physicians estimate that as little as 20 percent of blood clots are 
actually recognized for what they are. Misdiagnosis and delayed 
diagnosis are all too common and all too often fatal. The general 
public is even farther behind, with surveys showing that nearly three 
quarters of the population has little or no knowledge about blood 
clots, their risks, their signs and symptoms and their prevention. The 
Government must play a greater role in educating the general public, 
people who are at special risk and health professionals. This is the 
``low hanging fruit'' of public health prevention that has yet to be 
adequately picked and the return on invest can be tens of thousands of 
lives saved and billions of dollars in unnecessary healthcare expenses 
avoided!
The Federal Government Has a Vital Role in Meeting this Acknowledged 
        Public Health Priority
    Many Federal agencies play important roles in the effort to reduce 
death and disability from blood clots and clotting disorders. The 
National Institutes of Health and the National Science Foundation 
support the work of basic scientists in their efforts to understand the 
causes and effects of blood clots and identify improved treatments. The 
VA also supports research in this field and strives to prevent blood 
clots in the special population of Americans it serves. The Agency for 
Healthcare Research and Quality in 2001 was among the first to 
recognize that blood clot prevention in hospitals was our best 
opportunity for patient safety improvement. The Partnership for 
Patients makes made blood clot prevention a key component of improved 
hospital care. CMS includes surgery-related blood clot prevention as a 
key measure of hospital quality. DOD has examined how blood clots can 
be prevented in the military, affecting soldiers who must often live in 
cramped conditions, suffer dehydration and experience bone fractures 
and more severe injuries that require surgery.
    Each of these agencies plays a special role in the effort to reduce 
clotting death and injury. However, the CDC, the Nation's leading 
prevention agency, is the one best suited to guide and coordinate 
Federal efforts targeted at populations more broadly. No other agency 
possesses its unique capabilities in public health outreach, education 
and promotion. Regrettably the agency best suited for leadership is the 
one with the fewest resources. NBCA believes it is imperative that 
Congress act now to provide adequate, sustained funding for this 
specific activity at CDC--the reduction of death and disability due to 
blood clots.
    The funding request presented at the beginning of this statement 
will provide CDC with the resources it needs to begin seriously to meet 
this public health challenge. fiscal year 2014 funding for blood clot 
programs is only $560,000, half of what was available in the last 
fiscal year. The Administration's proposed fiscal year 2015 budget 
would make no change to this level. The current funding situation for 
the Blood Disorders Division has already forced CDC to cut or curtail 
the few programs it has been able to support. These include two pilot 
programs to improve community-based VTE surveillance and evaluation; 
one focused on healthcare provider education; one targeted at women's 
health (e.g., blood clots are the leading cause of maternal mortality); 
and a collaboration with the VA and academia to develop new VTE 
surveillance tools. Staffing of the Division has also been cut nearly 
in half, decreasing by 18 FTEs, including essential personnel with 
specialized laboratory, IT and analytic skills. At a time when this 
public health problem is growing, we have allowed even the small 
investment in CDC to address it become further negligible. This is 
neither thoughtful public policy nor wise economically.
    NBCA believes that our citizens deserve better and that Federal 
support for this acknowledged public health priority should be equal to 
the task. Tragically, it is not at present. NBCA urges the Subcommittee 
to take the lead in making the changes needed to provide CDC with the 
funds it needs to combat this major public health issue--blood clots, 
clotting disorders and the ensuing disability that consumes far too 
many lives and dollars in the U.S. unnecessarily.

    [This statement was submitted by Joseph C. Isaacs, Chief Executive 
Officer, National Blood Clot Alliance.]
                                 ______
                                 
  Prepared Statement of the National Center for Learning Disabilities
    The National Center for Learning Disabilities (NCLD) works to 
ensure that the Nation's 60 million children, adolescents and adults 
with learning disabilities and attention issues have every opportunity 
to succeed in school, work and life. NCLD asks you to consider our 
request as you work on the fiscal year 2015 Labor, Health and Human 
Services, and Education Appropriations bill.
    As you begin work on the fiscal year 2015 Labor, Health and Human 
Services, and Education Appropriations bill, we urge you to support 
continued funding for special education at the President's request 
level of $11.57 billion for the Individuals with Disabilities Education 
Act (IDEA) and the President's $100 million for Results Driven 
Accountability Incentive Grants which would provide competitive grants 
to States to implement promising, evidence-based reforms that would 
improve service delivery for children with disabilities while building 
State and local capacity to improve long--term outcomes for those 
children
    We also urge you to support funding for the National Technical 
Assistance Center within the Higher Education Opportunity Act (Section 
777(a)) at $2 million to provide useful and comprehensive information 
to students with disabilities on the choices available to them in 
higher education and to provide much-needed training, technical 
assistance, and professional development to institutes of higher 
education.
IDEA Part B Grants to States & Results Driven Accountability Incentive 
        Grants
    Currently, there are over 6.5 million children eligible for special 
education services under the disability categories of the Individuals 
with Disabilities Education Act (IDEA). The comprehensive assessment 
and support services authorized by IDEA help to close the academic 
achievement gap and ensure a meaningful education for every student. We 
owe it to all students to provide a quality education that will help 
them graduate and enter successful careers.
    We support the Administration's request that would maintain funding 
for IDEA, Part B (Grants to States program) at $11.57 billion, which 
the Administration estimates would provide $1,758 per child for an 
estimated 6.6 million students with disabilities. Additionally we 
support the President's $100 million for Results Driven Accountability 
Incentive Grants, which would provide competitive grants to States to 
implement promising, evidence-based reforms that would improve service 
delivery for children with disabilities. We encourage innovation in the 
realm of service delivery to students receiving special education and 
believe that these grants have the potential to spark innovative ideas 
and a renewed focused on improved outcomes for students.
The National Technical Assistance Center
    In the HEA reauthorization of 2008, Congress authorized the 
establishment of National Center for Information and Technical Support 
for Postsecondary Students with Disabilities. This Center was intended 
to serve three primary purposes: (1) serve as a resource to parents and 
students with disabilities on the services available at various IHEs; 
(2) serve as a technical assistance center to IHEs and provide training 
to faculty and staff on how to improve services for students with 
disabilities; and (3) serve as an online database for the collection 
and dissemination of a variety of disability-related information for 
students with disabilities who are interested in higher education. 
Though the Center was authorized, it has never been funded.
How Students with Disabilities are Faring in Higher Education
    In recent years, due to the services provided to students with 
disabilities through the Individuals with Disabilities in Education Act 
(IDEA) or Section 504 of the Rehabilitation Act, students with learning 
and attention issues have graduated from high school at higher rates 
than ever before. In fact, a majority (54 percent) of students with 
learning disabilities have the goal to attend a 2- or 4-year 
college.\1\ Students with learning disabilities make up the largest 
population of students with disabilities who attend postsecondary 
schools, at 69 percent of all students with disabilities in 
postsecondary programs.\2\
---------------------------------------------------------------------------
    \1\ Cortiella, Candace and Horowitz, Sheldon H. The State of 
Learning Disabilities: Facts, Trends and Emerging Issues. New York: 
National Center for Learning Disabilities, 2014.
    \2\ Newman, L.A. & Madaus, J. W. (2013). Reported Accommodations 
and Supports Provided to Secondary and Postsecondary Students with 
Disabilities: National Perspective. Publication forthcoming.
---------------------------------------------------------------------------
    Unfortunately, students with disabilities are not attending 
postsecondary education programs at the same rate as students in the 
general population. In the general education population, within 4 years 
of graduating high school, 53 percent of students continue on to 
postsecondary education programs, compared to only 45 percent of youth 
with disabilities. Even worse, young adults with learning disabilities 
(LD) attend four-year colleges at half the rate of the general 
population.\3\ Students with disabilities would benefit from better 
outreach, recruitment, and assistance programs to bridge the gap 
between high school and postsecondary education programs. Comprehensive 
information on higher education programs and services is needed now 
more than ever. With more students with disabilities setting goals of 
attending college but few actually enrolling and completing college 
programs, it is critical that they have access to the information and 
support services they need.
---------------------------------------------------------------------------
    \3\ Cortiella & and Horowitz (2014).
---------------------------------------------------------------------------
The Lack of Comprehensive Information on Post-Secondary Education 
        Programs
    The U.S. Department of Education (ED) has made efforts to improve 
parent and student access to timely and useful information regarding 
colleges and universities through the development of the College 
Navigator. The Department of Education collects data from IHEs through 
Integrated Postsecondary Education Data System (IPEDS) surveys, 
including data on enrollment, program completion, graduation rates, 
faculty and staff, finances, institutional prices, and student 
financial aid. The data is made available to students and parents via 
College Navigator--a public website that allows users to perform a 
search of colleges. The data and information provided through the 
College Navigator--has the potential to support and improve rates of 
transition for all young adults from high school into the postsecondary 
setting. However, this information alone is not enough to ensure a 
smooth transition for students with disabilities into their 
postsecondary education programs.
    NCLD has conducted its own survey of the information provided by 
IHEs on College Navigator. College Navigator provides a place for every 
IHE to provide information on the disability services offered at the 
institution. We examined the responses that nearly 400 institutions 
submitted, including private, public, and for profit institutions as 
well as community colleges. Only 6 of the institutions surveyed listed 
any information to students and the public regarding disability 
services.\4\
---------------------------------------------------------------------------
    \4\ For more information on the survey conducted by NCLD and the 
IHEs we surveyed to find this data, please contact us.
---------------------------------------------------------------------------
The Need for a Smoother Transition to Post-Secondary Programs
    Research shows that students with disabilities are getting less 
support in college than in high school, despite wishing they had more 
assistance. Even though 87 percent of students with disabilities 
received some type of accommodation or support in high school, that 
number drops off sharply when students with disabilities enter college, 
decreasing to only 19 percent of students who receive accommodations or 
support.\5\ For students with learning disabilities, 17 percent of 
young adults receive accommodations and supports in postsecondary 
education compared with 94 percent in high school.\6\ Of the many 
students who did not receive any help at all, 43 percent felt that it 
would have been helpful to receive assistance.\7\ We know that self-
advocacy is one of the keys to student success, but it is clear that 
students are not aware of their rights and responsibilities, are not 
adequately prepared to advocate for themselves, and are not provided 
adequate transition assistance to be successful in postsecondary 
education programs.
---------------------------------------------------------------------------
    \5\ Newman, L., Wagner, M., Knokey, A.-M., Marder, C., Nagle, K., 
et al. (2011). The PostHigh School Outcomes of Young Adults With 
Disabilities up to 8 Years After High School. A Report From the 
National Longitudinal Transition Study-2 (NLTS2) (NCSER 2011-3005). 
Menlo Park, CA: SRI International.
    \6\ Cortiella & and Horowitz (2014).
    \7\ Newman, Wagner, Knokey, Marder, et al. (2011).
---------------------------------------------------------------------------
    The Purpose of the National Technical Assistance Center
    We recognize that providing useful and comprehensive information to 
parents and students on the choices available is not an easy task. 
Therefore, we recommend funding the National Technical Assistance 
Center, found in the 2008 authorization of HEA, at $2 million. The 
Center would serve several key purposes: (1) providing information and 
resources to students and parents on disability services and programs 
at IHEs; (2) providing training and technical assistance to IHEs; (3) 
providing training and professional development to faculty and staff at 
IHEs; and (4) information collection and dissemination on best 
practices, documentation requirements, financial aid, services 
available, policies, and accessible instructional materials.
    We urge you to continue your investment in students with 
disabilities through funding of IDEA and the RDA grants and support 
funding in fiscal year 2015 for the National Technical Assistance 
Center. Thank you for your consideration of our request.

    [This statement was submitted by Lindsay E. Jones, Esq., Director, 
Public Policy & Advocacy, National Center for Learning Disabilities.]
                                 ______
                                 
    Prepared Statement of the National Children's Facilities Network
    Chairman Harkin, Ranking Member Moran, and distinguished Members of 
the Appropriations Subcommittee on Labor, Health and Human Services, 
Education, and Related Agencies: Thank you for the opportunity to offer 
written testimony on the Administration's fiscal year 2015 Budget 
Request for the Department of Health and Human Services, Administration 
for Children and Families. I write on behalf of the National Children's 
Facilities Network (NCFN) to express support for the funding of Head 
Start, Early Head Start-Child Care Partnerships and other programs that 
provide access to high quality early care and education. These 
initiatives are critical to ensuring that all children, especially low-
income children, are given a strong start and the tools necessary to 
succeed in life. As you make important funding decisions about programs 
that provide children with the opportunity to obtain an early start on 
the pathway to success, we encourage you to recognize the critical role 
that early childhood facilities play in preparing young children for 
achievement in school and in life, and support Federal policies that 
adequately finance the acquisition, construction, and improvement of 
these spaces.
    NCFN is a national coalition of nonprofit organizations that 
provide financing, technical assistance and training on the design, 
development and financing of early care and education facilities in 
low-income communities throughout the country. We see the positive 
impact of high quality early learning on children's lives and on the 
future economic health and development of neighborhoods. Our coalition 
also recognizes the importance of the spaces where these programs take 
place. A growing body of research shows that a well-designed, well-
equipped physical environment supports learning and good outcomes for 
children, while a poorly adapted and overcrowded space undermines it. 
For example, bathrooms adjacent to classrooms, accessible cubbies, and 
child-sized sinks, counters, furnishings and fixtures increase 
children's autonomy and competence while decreasing the demands on 
teachers.
    Infants, toddlers, and young children should be educated and cared 
for in high quality physical spaces that meet their needs and 
complement high quality programs. Federal programs focused on improving 
families' access to high quality early care and education options 
should include adequate funding for the acquisition, construction, and 
improvement of facilities.
    Thank you for your leadership on these issues. Please consider us 
as a resource as you advance early childhood policies. If you would 
like additional information about our work, please contact Karen 
O'Mansky, Center for Community Self-Help, Chair, National Children's 
Facilities Network.
                                 ______
                                 
    Prepared Statement of the National Congress of American Indians
    On behalf of the National Congress of American Indians (NCAI), this 
testimony addresses programs in the Departments of Education and Labor 
and the Corporation for Public Broadcasting. NCAI also supports the 
testimony of the National Indian Child Welfare Association, the 
American Indian Higher Education Consortium, and the National Indian 
Education Association. NCAI is the oldest and largest American Indian 
organization in the United States. Tribal leaders created NCAI in 1944 
as a response to termination and assimilation policies that threatened 
the existence of American Indian and Alaska Native tribes. Since then, 
NCAI has fought to preserve the treaty rights and sovereign status of 
tribal governments, while also ensuring that Native people may fully 
participate in the political system. As the most representative 
organization of American Indian tribes, NCAI serves the broad interests 
of tribal governments across the Nation.
Department of Education
    Investing in the education of American Indian and Alaska Native 
students is not only one most of the most important cornerstones of the 
Federal trust responsibility to tribes, but is also critical strategy 
for creating jobs and securing the Nation's future prosperity in 
today's challenging economic climate. Education provides tribal 
economies with a more highly-skilled workforce while also directly 
spurring economic development and job creation. The profound value of 
education for Native Nations extends beyond just economics, however. 
Education drives personal advancement and wellness, which in turn 
improves social welfare and empowers communities--elements that are 
essential to maintaining tribes' cultural vitality and to protecting 
and advancing tribal sovereignty.
    Despite the enormous potential of education for transforming tribal 
communities, Native education is in a state of emergency. American 
Indian and Alaska Native students lag far behind their peers on every 
educational indicator, from academic achievement to high school and 
college graduation rates. For example, in 2011, only 18 percent of 
Native fourth graders and 22 percent of Native eighth graders scored 
proficient or advanced in reading, and only 22 percent of Native fourth 
graders and 17 percent of Native eighth graders scored proficient or 
advanced in math.\1\ The crisis of Indian education is perhaps most 
apparent in the Native high school dropout rate, which is not only one 
of the highest in the country, but is also above 50 percent in many of 
the States with high Native populations.\2\
---------------------------------------------------------------------------
    \1\ National Indian Education Study 2011, NCES 2012-466. National 
Center for Education Statistics, Institute of Education Sciences, 
United States Department of Education.
    \2\ School Year 2010-2011 4-Year Regulatory Adjusted Cohort 
Graduation Rates, Department of Education.
---------------------------------------------------------------------------
    Title I, Part A Local Education Agency Grants--Provide $25 billion 
for Title I, Part A.--Title I of the Elementary and Secondary Education 
Act provides critical financial assistance to local educational 
agencies and schools with high percentages of children from low-income 
families that ensure all children meet challenging State academic 
standards. Currently, there are over 600,000 Native students across the 
country with nearly 93 percent of those students attending non-Federal 
institutions, such as traditional public schools in rural and urban 
locations. A drastic increase in funding to counter annual inflation 
and sequestration is necessary to meet the needs of Native students and 
students from low-income families.
    Impact Aid--Provide $2 billion for Impact Aid, Title VIII of the 
Elementary and Secondary Education Act (ESEA).--Impact Aid provides 
direct payments to public school districts as reimbursements for the 
loss of traditional property taxes due to a Federal presence or 
activity, including the existence of an Indian reservation. With nearly 
93 percent of Native students enrolled in public schools, Impact Aid 
provides essential funding for schools serving Native students. In 
fiscal year 2014, Impact Aid saw an increase of $64 million over fiscal 
year 2013 that restored most of the destructive sequestration cuts 
tribal communities faced in Indian Country. In order to ensure Native 
students have access to education, however, Impact Aid must be fully 
funded at $2 billion. Furthermore, Impact Aid should be converted to a 
forward-funded program to eliminate the need for cost transfers and 
other funding issues at a later date.
    Title VII (Indian Education Formula Grants)--Provide $198 million 
for Title VII of the ESEA.--This grant funding is designed to 
supplement the regular school program and assist Native students so 
they have the opportunity to achieve the same educational standards and 
attain equity with their non-Native peers. Title VII provides funds to 
school divisions to support American Indian, Alaska Native, and Native 
Hawaiian students in meeting State standards. Furthermore, Title VII 
funds support early-childhood and family programs, academic enrichment 
programs, curriculum development, professional development, and 
culturally-related activities. Currently, funding for Title VII only 
reaches 500,000 Native students leaving over 100,000 without 
supplementary academic and cultural programs in their schools.
    State-Tribal Education Partnership (STEP) Program--Provide $5 
million for the State-Tribal Education Partnership Program..--Congress 
appropriated roughly $2 million dollars for the STEP program to five 
participating tribes in fiscal year 2012 and fiscal year 2013 under the 
Tribal Education Department appropriations' line that is administered 
by the Department of Education. In order for this program to continue 
to succeed and thrive, it must receive its own line of appropriations 
in fiscal year 2015. Collaboration between tribal education agencies 
and State educational agencies is crucial to developing the tribal 
capacity to assume the roles, responsibilities, and accountability of 
Native education departments and increasing self-governance over Native 
education.
    Alaska Native Education Equity Assistance Program--Provide $35 
million for Title VII, Part C of the ESEA.--This assistance program 
funds the development of curricula and education programs that address 
the unique educational needs of Alaska Native students, as well as the 
development and operation of student enrichment programs in science and 
mathematics. This funding is crucial to closing the gap between Alaska 
Native students and their non-Native peers. Other eligible activities 
include professional development for educators, activities carried out 
through Even Start programs and Head Start programs, family literacy 
services, and dropout prevention programs.
    Native Hawaiian Education Program--Provide $35 million for Title 
VII, Part B of the ESEA.--This program funds the development of 
curricula and education programs that address the education needs of 
Native Hawaiian students to help bring equity to this Native 
population. Where Native Hawaiians once had a very high rate of 
literacy, today Native Hawaiian educational attainment lags behind the 
general population.
Department of Labor
    Fund the Department of Labor's Indian and Native American Program 
(INAP) at a minimum of $60.5 million. Fund the Native American 
Employment and Training Council at $125,000 from non-INAP resources.--
In order to reduce the education and employment disparity between 
Native people and other groups, a concentrated effort is required that 
provides tailored and sufficient assistance to enhance education and 
employment opportunities, to create pathways to careers and skilled 
employment, and to secure a place for Native people within the Nation's 
middle class. The Workforce Investment Act (WIA) Section 166 program 
(INAP) serves the training and employment needs of over 38,000 American 
Indians and Alaska Natives via a network of 175 grantees through the 
Comprehensive Service Program (Adult) and Supplemental Youth Service 
Program (Youth), and the Indian Employment and Training and Related 
Services Demonstration Act of 1992, Public Law 102-477. Furthermore, 
the number of American Indians and Alaska Natives served through WIA 
does not fully capture its impact in Indian Country, as many more are 
served by grantees that leverage WIA funding, along with other similar 
federally funded employment and training programs, through PL 102-477.
    There has been a trend of decreasing funds for INAP, and a failure 
to appropriate at the statutory minimum level of $55 million. These 
decreases in funding are detrimental and hamper progress in Indian 
Country's labor situation. According to the Census, the average 
unemployment rate on reservations dropped more than 3 percentage points 
since 2000,\3\ but more still needs to be done as American Indians and 
Alaska Natives still lag significantly behind. With the average 
unemployment rate in Indian Country cited up to 17 percent \4\ and an 
average rate of joblessness of approximately 50 percent,\5\ INAP is 
vital to helping reverse these trends.
---------------------------------------------------------------------------
    \3\ U.S. Census Bureau. Census 2000 Summary File 4, 2006-2010, 
2009-2011 American Community Survey.
    \4\ U.S. Census. 2011 American Community Survey.
    \5\ U.S. Department of Interior. Bureau of Indian Affairs. 2005 
American Indian Labor Force Report.
---------------------------------------------------------------------------
    Further, because INAP is the only Federal employment and job 
training program that serves American Indians and Alaska Natives who 
reside both on and off reservations, it is imperative that its funding 
is preserved. For Native citizens living on remote reservations or in 
Alaska Native villages, it can be difficult to access the State and 
local workforce systems. In these areas, INAP can be the lone 
employment and training provider. Since 2003, WIA has been up for 
reauthorization; and over this 11-year period, WIA has not accounted 
for the population growth of tribal communities, nor the economic 
environment that has drastically changed. WIA authorizes the INAP to be 
funded at ``not less than $55 million,'' but Section 166 is currently 
being funded at approximately $46 million. WIA also authorizes the 
Native American Employment and Training Council to advise the Secretary 
on the operation and administration of INAP, but it uses funds that are 
intended for INAP grantees. Since the current INAP funding is already 
below $55 million, the Secretary should use other streams of funding to 
support its advisory council. Without an increase in funding, not 
enough tribes are able to benefit from the support and training 
activities for employment opportunities in Indian Country.
    Restore the YouthBuild Program funding to a minimum of $102.5 
million, restore the rural and tribal set-aside in the YouthBuild 
program, and reinstate a dedicated 10 percent rural and tribal set-
aside of at least $10.25 million.--The YouthBuild program is a 
workforce development program that provides significant academic and 
occupational skills training and leadership development to youth ages 
16-24, and engages approximately 10,000 youth annually. According to 
YouthBuild, in 2010, 4,252 youth participated in the program and had a 
completion rate of 78 percent, and 60 percent of those who completed 
the program were placed in jobs or further education.\6\ There are a 
number of tribal YouthBuild programs in several States, and Native 
Americans make up roughly 4 percent of YouthBuild participants. With 
the recent reduction in tribal YouthBuild programs, high unemployment 
rates, serious housing challenges in Indian Country, and the growing 
Native youth population (42 percent of American Indian/Alaska Native 
population is under 25 years old),\7\ it is critical that the 10 
percent rural and tribal set- aside be restored.
---------------------------------------------------------------------------
    \6\ See youthbuild.org/research.
    \7\ U.S. Census Bureau, 2010 Census, Summary File 1.
---------------------------------------------------------------------------
Corporation for Public Broadcasting
    In the CPB, NCAI supports an advanced fiscal year 2016 
appropriation of $5 million for American Indian and Alaska Native radio 
stations. This $5 million appropriation would come out of the fiscal 
year 2015 advanced appropriation of $445 million for the overall CPB 
budget. This is the same budget amount enacted for fiscal year 2014 and 
requested for fiscal year 2015.
    For more than 30 years, decisions on the amount of Federal support 
for public broadcasting have been made 2 years ahead of the fiscal year 
in which the funding is allocated. Since 1976, CPB's 2-year advance 
appropriation has served as a Congressional strategy to protect public 
media from any immediate political pressure. Community Service Grants 
(CSGs) account for approximately 70 percent of CPB's appropriation, 
which directly funds 1,300 local public television and radio stations 
including 35 Native radio stations.
    In Indian Country, Native radio stations are essential to the 
tribal communities they serve since they are often the first source of 
emergency reporting and information. Public broadcasters use datacast 
technology for homeland security, public alert and warning systems, and 
public safety purposes. In Oklahoma, KCNP Chickasaw radio provided real 
time weather reports that saved lives during the 2013 tornado season. 
In Arizona, KUYI Hopi radio provides ``House Calls,'' a health call-in 
show that connects listeners with a local doctor on questions about 
hanta virus, diabetes, HIV, and other local health issues. In Alaska, 
KNBA covers news from Alaska Native villages about climate change 
refugees, language revitalization, and other hyper local stories 
important and relevant to Alaska Native communities. Often, the only 
place where Native stories and issues are heard is on Native radio 
stations.
    Local public media stations and their employees have experienced 
significant reductions through cuts to other Federal programs that 
benefit public media. The elimination of CPB's Digital appropriation 
and the Public Telecommunications Facilities Program coupled with cuts 
to programs at the Departments of Education and Agriculture represent a 
$57.5 million, or 7.3 percent, funding cut between fiscal year 2010 and 
fiscal year 2012. These cuts come at a time when stations are 
struggling to maintain service to their communities in the face of 
shrinking nonFederal revenues--a $239 million, or 10.8 percent, drop 
between fiscal year 2008 and fiscal year 2011.
    CPB also funds the essential system-wide station support services 
provided by Native Public Media, Inc., and content production and 
satellite programming distribution by Koahnic Broadcast Corporation. 
Access to these funds allows Native Public Media, Inc., to ensure that 
Native radio stations stay on the air by maintaining compliance with 
FCC and other Federal rules and regulations, and by providing the 
training and support Native broadcasters need. Native public radio 
stations still exist as one of the primary sources of public 
information on tribal lands, and represent cornerstones of tribal 
efforts for information dissemination. Much of Indian Country remains 
disconnected from vital telecommunications services, radio should not 
be counted among them. Radio has always existed as a key component of 
public information and 55 tribal radio stations among this country's 
566 federally recognized tribes illustrates the need for these services 
in Indian Country.
                                 ______
                                 
 Prepared Statement of National Council of Social Security Management 
                              Associations
    On behalf of the National Council of Social Security Management 
Associations (NCSSMA), thank you for the opportunity to submit this 
testimony regarding the Social Security Administration's (SSA's) fiscal 
year 2015 Appropriation.
    NCSSMA is a membership organization of nearly 3,300 SSA managers 
and supervisors who provide leadership in over 1,200 community-based 
field offices and teleservice centers throughout the country. We are 
the front-line service providers for SSA in communities all over the 
Nation. Since the founding of our organization over 44 years ago, 
NCSSMA has considered a stable SSA, which delivers quality and timely 
community-based service to the American public, our top priority. We 
also consider it a top priority to be good stewards of the taxpayers' 
monies and the Social Security programs we administer.
    We would like to express our appreciation for the fiscal year 2014 
Limitation on Administrative Expenses (LAE) account funding of $11.697 
billion provided to SSA. Increased resources, especially in SSA's field 
offices and teleservice centers, will have a positive impact on 
delivering vital services to the American public and in fulfilling the 
agency's stewardship responsibilities. Since October 2010, SSA field 
offices had lost almost 4,100 permanent employees prior to the first 
wave of fiscal year 2014 hiring. The teleservice centers (TSCs) lost 
1,159 employees during the same timeframe. For the first time in over 3 
years, we are replacing some of these losses. Because of the fiscal 
year 2014 funding, authority was granted to field offices and 
teleservice centers to hire 2,350 and 850 permanent employees, 
respectively. In addition, 550 permanent hires were approved for 
Workload Support Units (WSUs) that are expected to ease the burden 
placed on field offices.
    The dramatic growth in SSA workloads, along with the attrition in 
our offices over the last several years, has highlighted the need to 
receive necessary resources to maintain service levels vital to the 
nearly 65 million Social Security beneficiaries and Supplemental 
Security Income (SSI) recipients. Despite agency strategic planning, 
expansion of online services, significant productivity gains, and the 
best efforts of management and employees, SSA still faces many 
challenges providing the service the American public has earned and 
deserves.
    Over the last several years, SSA has experienced a significant 
increase in Social Security claims. The additional claims receipts are 
driven in large part by the initial wave of the nearly 80 million baby 
boomers who will be filing for Social Security benefits by 2030, an 
average of 10,000 per day.
  --In fiscal year 2013, SSA field offices assisted 43.3 million 
        visitors, received 4.9 million retirement, survivor and 
        Medicare applications, and 2.9 million initial disability 
        claims.
  --In fiscal year 2013, SSA completed 2,987,883 initial disability 
        claims. Since fiscal year 2007, initial disability claims 
        receipts have increased by over 25 percent.
  --In fiscal year 2013, SSA completed 5,006,855 retirement, survivor, 
        and Medicare claims (5,001,092 in fiscal year 2012)--a record 
        number and over a million more than completed in fiscal year 
        2007.
  --In fiscal year 2013, retirement, survivor, and Medicare claims were 
        30 percent higher as compared to fiscal year 2007.
  --Each day over 155,000 people visit SSA field offices and more than 
        436,000 call SSA for a variety of services.
    We fully support the President's budget request of $12.024 billion 
for SSA's LAE account in fiscal year 2015. While this would be a much-
appreciated increase of $327 million over the fiscal year 2014 level of 
funding, it would only address fixed cost increases. The fiscal year 
2015 Budget Request submitted by Acting Commissioner Carolyn Colvin to 
President Obama for SSA's administrative funding was $12.6 billion. 
This level of funding will allow SSA to continue improving and 
modernizing customer service, enhance program integrity efforts, detect 
and deter fraud and errors, and continue to address high volumes of 
work. In November of 2013, NCSSMA co-authored a letter with 29 other 
organizations, which was submitted to the Office of Management and 
Budget (OMB) and recommended a funding level consistent with the Acting 
Commissioner's request for SSA's administrative funding. Specifically 
the letter stated:
     SSA teleservice centers, hearing offices, program service centers, 
        disability determination services (DDS), and field offices are 
        in critical need of adequate resources to address their growing 
        workloads. The recommended fiscal year 2015 budget of no less 
        than $12.6 billion would allow SSA to cover inflationary 
        increases, resume efforts to reduce hearings and disability 
        backlogs, complete deficit-reducing program integrity work, and 
        replace critical staffing losses in SSA's components, including 
        field offices, teleservice centers, and DDSs.

     Adequate funding would also help to minimize the closure of 
        additional field offices. Since fiscal year 2010, SSA 
        consolidated 92 field offices into 46 field offices and closed 
        521 contact stations. The agency also cancelled plans to open 
        eight new hearing offices and a new teleservice center due to 
        limited resources. In many cases, applicants for benefits or 
        those approaching retirement age who have questions about their 
        eligibility or benefits have been forced to travel greater 
        distances to visit a Social Security field office.
    The fiscal year 2014 appropriation for SSA provided $1.197 billion 
dedicated to program integrity activities to ensure that disability and 
other benefits are properly paid. SSA plans to process 2.6 million SSI 
redeterminations and 510,000 full medical continuing disability reviews 
(CDRs) in fiscal year 2014. Despite these efforts, the agency continues 
to have 1.3 million CDRs backlogged due to budgetary shortfalls. The 
fiscal year 2015 budget request would provide $1.396 billion dedicated 
to program integrity. With these funds, the agency would be able to 
complete 880,000 full medical CDRs and 2.6 million SSI 
redeterminations. Completing more than 880,000 CDRs would more than 
double the CDRs completed in 2013, saving billions of taxpayer dollars.
    While it is critical SSA focus on cost-effective program integrity 
work to protect taxpayer dollars, there must be a balance between these 
efforts, preventing fraud and improper payments before they occur, and 
service to the American public. One way we can help stop fraud before 
it starts is through the work of Cooperative Disability Investigation 
(CDI) units. With the increased fiscal year 2014 funding, SSA will be 
able to add 7 units to the existing 25. We recognize CDI unit expansion 
is not enough and advocate for additional focus on program integrity 
initiatives including providing in-depth training for identifying and 
reporting fraud for our front-line employees. Field office employees 
are the first line of defense against fraud, and must have the training 
and resources necessary to identify and report questionable activities 
and claims. Additional training initiatives have begun in fiscal year 
2014, but must continue.
    SSA is challenged by ever-increasing workloads, very complex 
programs to administer, and increased program integrity work with 
diminished staffing and resources. With the current fiscal challenges 
confronting SSA, we encourage Congress to consider changes to the 
Social Security and SSI programs that have the potential to increase 
administrative efficiency and lower operational costs.
    It is critical SSA receives adequate, yet flexible funding for the 
LAE account to respond to requests for assistance from the American 
public, and to fulfill our stewardship responsibilities. SSA TSCs, 
hearing offices, program service centers (PSCs), DDS, and the over 
1,200 field offices are in grave need of adequate resources to address 
their growing workloads. Many of SSA's field offices are currently 
experiencing wait times in excess of 60 minutes. One out of every 8 
visitors waits more than 1 hour to receive services, which is 177 
percent more than in fiscal year 2012 and 224 percent more than fiscal 
year 2011. Without adequate funding, SSA will not be able to provide 
the high-quality customer service Americans deserve and will be unable 
to process program integrity workloads, which save taxpayer dollars and 
reduce the Federal budget and deficit.
    We realize the fiscal year 2015 funding level requested above is 
not insignificant, particularly in this difficult Federal budget 
environment. However, Social Security serves as the largest most vital 
component of the social safety net of America and is facing 
unprecedented challenges. The American public expects and deserves 
SSA's assistance.
    On behalf of NCSSMA members nationwide, thank you for the 
opportunity to submit this written testimony. We respectfully ask that 
you consider our comments, and would appreciate any assistance you can 
provide in ensuring the American public receives the critical and 
necessary service they deserve from the Social Security Administration.

    [This statement was submitted by Scott Hale, President, National 
Council of Social Security Management Associations.]
                                 ______
                                 
    Prepared Statement of the National Energy Assistance Directors' 
                              Association
    The members of the National Energy Assistance Directors' 
Association (NEADA), representing the State directors of the Low Income 
Home Energy Assistance Program (LIHEAP) would first like to take this 
opportunity to thank the members of the Subcommittee for considering 
our funding request for fiscal year 2015 and advance funding for fiscal 
year 2016.
    We would also like to thank the members of the Committee for 
increasing the funding for fiscal year 2014. These additional funds 
allowed States to increase grants for low income families to help them 
pay a portion of their higher home heating costs during this year's 
bitterly cold winter. The additional funds will also allow States to 
maintain at least a minimal level of support for cooling programs this 
summer.
Purchasing Power of LIHEAP Continues to Decline
    The increase in program funding in fiscal year 2014, however, was 
not sufficient to stem the continuing decline in the purchasing power 
of the average LIHEAP grant. Since fiscal year 2010, the purchasing 
power of the average grant has declined from 60.2 percent of the cost 
of home heating to 44.7 percent. In other words, in fiscal year 2010, 
the average grant could purchase approximately 72 days of home heating, 
whereas in fiscal year 2014, the average grant could only purchase 54 
days of home heating.
    The program's purchasing power is declining for two reasons:
  --First and foremost is the decline in the program's appropriation. 
        Between fiscal year 2010 and fiscal year 2013, LIHEAP's annual 
        appropriation declined from $5.1 billion to $3.25 billion. As a 
        result, during this time States were forced to reduce the 
        average grant from $520 to $398 and the number of households 
        served from 8.1 million to 6.7 million. The increase in funding 
        in fiscal year 2014 to $3.4 billion allowed States to increase 
        the average grant by $21 to $419, still almost $100 less than 
        the average grant awarded in fiscal year 2010.
  --Second, average home heating costs increased from $796 during the 
        winter heating season of 2011--12 (fiscal year 2012) to $936 
        during this recent winter heating season. During this period, 
        the average increase for those using natural gas went from $567 
        to $663; for electricity, from $840 to $934; for heating oil, 
        from $1,735 to $2,243; and for propane, from $1,563 to $2,269.
    LIHEAP is the primary source of heating and cooling assistance for 
some of the poorest families in the United States. In fiscal year 2014, 
the number of households receiving heating assistance is expected to 
remain at about 6.7 million households, or about 19 percent of those 
eligible to receive assistance. In addition, the program is expected to 
reach about 600,000 households for cooling assistance, the same level 
that received assistance in fiscal year 2013.
President's Budget Would Severely Reduce the Number of Households 
        Served
    The President's fiscal year 2015 Budget request for LIHEAP would 
result in even greater cuts to the program's effectiveness by reducing 
the amount available for program grants to $2.7 billion. In order to 
maintain the program's purchasing power, States would have no choice 
but to reduce the number of households served from about 6.7 million to 
5.3 million, or about 15 percent of eligible households.
Fiscal year 2015 Funding Request and fiscal year 2016 Advanced Funding 
        Request
    For fiscal year 2015 we are requesting that the Subcommittee 
restore funding for LIHEAP to the authorized level of $5.1 billion. The 
additional funds would allow States to increase the number of 
households served to 8.1 million, raise the average grant to at least 
50 percent of the cost of home heating, and expand the number of 
households served by home cooling.
    In addition, we are concerned that States will be hampered in their 
ability to administer their programs efficiently due to the lack of 
advanced funding. The lack of a final program appropriation prior to 
the beginning of the fiscal year creates significant administrative 
problems for States in setting their program eligibility guidelines. To 
address this concern, we are requesting advance appropriations of $5.1 
billion for fiscal year 2016.
What Is the Impact of Declining Federal Funds?
    Surveys of families receiving Federal assistance have been 
consistent over the years. Poor families struggle to pay their home 
energy bills. When they fall behind, they risk shut-off of energy 
services or they are not able to afford the purchase of delivered 
fuels. In fiscal year 2011, NEADA conducted a survey of approximately 
1,800 households that received LIHEAP benefits. The results show that 
LIHEAP households are among the most vulnerable in the country:
  --40 percent had someone age 60 or older.
  --72 percent had a family member with a serious medical condition.
  --26 percent used medical equipment that requires electricity.
  --37 percent went without medical or dental care.
  --34 percent did not fill a prescription or took less than their full 
        dose of prescribed medication.
  --19 percent became sick because the home was too cold.
  --85 percent of people with a medical condition were seniors.
    Many LIHEAP recipients were unable to pay their energy bills:
  --49 percent skipped paying or paid less than their entire home 
        energy bill.
  --37 percent received a notice or threat to disconnect or discontinue 
        their electricity or home heating fuel.
  --11 percent had their electric or natural gas service shut off in 
        the past year due to nonpayment.
  --24 percent were unable to use their main source of heat in the past 
        year because their fuel was shut off, they could not pay for 
        fuel delivery, or their heating system was broken and they 
        could not afford to fix it.
  --17 percent were unable to use their air conditioner in the past 
        year because their electricity was shut off or their air 
        conditioner was broken and they could not afford to fix it.
    LIHEAP's impact in many cases goes beyond providing bill payment 
assistance by playing a crucial role in maintaining family stability. 
It enables elderly citizens to live independently and ensures that 
young children have safe, warm homes to live in. Although the 
circumstances that lead each client to seek LIHEAP assistance are 
different, LIHEAP links these stories by enabling people to cope with 
difficult circumstances with dignity.
The Need for LIHEAP
    Households reported enormous challenges despite the fact that they 
received LIHEAP assistance. However, they reported that LIHEAP was 
extremely important. About 64 percent reported that they would have 
kept their home at unsafe or unhealthy temperatures and/or had their 
electricity or home heating fuel discontinued if it had not been for 
LIHEAP. Almost 98 percent said that LIHEAP was very or somewhat 
important in helping them to meet their needs. In addition, 53 percent 
of those who did not have their electricity or home heating fuel 
discontinued said that they would have if it had not been for LIHEAP.
    The members of NEADA recognize the difficult budget decisions that 
you face as you consider funding levels for LIHEAP for fiscal year 2015 
and advance funding for fiscal year 2016. We appreciate your interest 
and continued support for LIHEAP. Please feel free to call upon us if 
we can provide you with additional information.

    [This statement was submitted by Mark Wolfe, Executive Director, 
National Energy Assistance Directors' Association.]
                                 ______
                                 
   Prepared Statement of the National Family Planning & Reproductive 
                           Health Association
    Summary: Requesting $337 million in funding for fiscal year 2015 
for the national family planning program (Title X of the Public Health 
Service Act).
    My name is Clare Coleman; I'm the President & CEO of the National 
Family Planning & Reproductive Health Association (NFPRHA), a 
membership organization representing the Nation's safety-net family 
planning providers--nurse practitioners, nurses, physicians, 
administrators and other key healthcare professionals. Many of NFPRHA's 
members receive Federal funding from Medicaid and through Title X of 
the Federal Public Health Service Act, the only federally funded, 
dedicated, family planning program for the low income and uninsured. 
These critical components of the Nation's public health safety net are 
essential resources for those providing access to high-quality services 
in communities across the country. As the Committees work on the fiscal 
year 2015 appropriations bill, NFPRHA respectfully requests that you 
make a significant investment in Title X by including $337 million to 
restore the capacity of the program to serve those in need.
    NFPRHA was disappointed to see the president's fiscal year 2015 
proposal only included $286.5 million for Title X. As more individuals 
gain access to healthcare coverage through the Affordable Care Act, the 
publicly funded family planning network will continue to play an 
essential role in our Nation's service delivery framework, setting the 
standard for and providing high-quality care to all patients--the 
insured, uninsured, under-insured as well as patients seeking 
confidential services. If the Massachusetts health reform experience 
were to prove representative of what could be expected by nationwide 
health reform, there will be a strong increase in demand for services 
within the already-strained safety net. At present, six in ten women 
describe family planning centers as their usual source of medical care. 
According to a report by the Centers for Disease Control and Prevention 
(CDC), as health reform in Massachusetts expanded coverage for most 
people living in the State, Title X family planning health centers 
continued to have high volumes of patients, both insured and uninsured, 
and remained providers of choice for many.
    The failure of States to expand Medicaid eligibility for all adults 
up to 138 percent of the Federal poverty level (an income of $16,105 a 
year for an individual in 2014)--along with new barriers to coverage 
being sought by some expansion States, such as premiums and other cost-
sharing requirements--compounds the demand being placed on the Title X 
safety net. Currently, 25 States have not expanded their Medicaid 
eligibility under the ACA. Twenty-one of these States have Medicaid 
eligibility equal to or less than 75 percent of FPL (an income of 
$8,753 a year); 14 have eligibility at or below 50 percent (an income 
of $5,835 a year). Five States have eligibility set at less than 25 
percent of FPL--that means individuals making more than $2,918 are too 
``rich'' for Medicaid.
    Similar to other publicly funded health programs, Title X has 
unfortunately suffered budget cuts despite rising patient need. Between 
fiscal year 2010-fiscal year 2013, the Title X family planning program 
was cut $39.2 million (-12.3 percent). As a result, the total number of 
Title X users shrunk from 5.22 million users to 4.76 million during 
this time period, with no indication that patients went elsewhere for 
care. Congress made incremental progress in fiscal year 2014, funding 
Title X at $286.5 million, a restoration of $8.2 million over the 
fiscal year 2013 post-sequester level. As appropriators grapple with 
how best to distribute limited Federal resources, NFPRHA encourages the 
Committees continue to prioritize investments in programs, including 
Title X, that are proven to save critical taxpayer dollars. Every $1 
invested in publicly funded family planning services saves $5.68 in 
Medicaid costs associated with unplanned births. Additionally, services 
provided in Title X-supported centers alone yielded $5.3 billion of the 
$10.5 billion in total savings for publicly funded family planning in 
2010.
    Lastly, Title X supports critical infrastructure and technology 
necessary for modern service delivery that are not reimbursable under 
Medicaid and commercial insurance. Resources for electronic health 
record implementation for safety-net providers--just as for others in 
the safety net--are necessary to help achieve the ACA goal of having a 
nationwide health information technology infrastructure and more 
coordinated models of care. Increased Title X funding is essential to 
help address the gap caused by the oversight in Federal planning that 
led to most family planning health providers' ineligibility for the 
electronic health records (EHR) incentives available under the HITECH 
Act.
    For these reasons, NFPRHA urges the Committees to make a 
significant investment in the Nation's safety-net family planning 
health services and requests funding for Title X at $337 million in 
fiscal year 2015.
    [This statement was submitted by Clare Coleman, President & CEO, 
National Family Planning & Reproductive Health Association.]
                                 ______
                                 
       Prepared Statement of the National Head Start Association
    Chairman Harkin, Ranking Member Moran, and Members of the 
Subcommittee, thank you for allowing the National Head Start 
Association (NHSA) to submit testimony on behalf of funding for Head 
Start and Early Head Start in fiscal year 2015 . For almost 50 years, 
Head Start centers have been creating opportunities for at-risk 
children and families to achieve success in life by providing critical 
early education, health, nutrition, parent engagement and family 
support services. NHSA respectfully urges the Subcommittee to continue 
its enduring bipartisan support by allocating $8,868,389,000 for Head 
Start and Early Head Start in fiscal year 2015, in line with the 
President's Budget.
    Head Start and Early Head Start directors remain appreciative of 
your leadership in ensuring that the fiscal year 2014 Omnibus 
Appropriations legislation not only restored the damaging cuts from 
sequestration, but also prioritized high quality by including 
additional funds to retain qualified staff and cope with the increased 
costs of program operation. We also sincerely appreciate the new 
investment in one of our most underserved populations--low-income 
infants and toddlers.
    Within the total amount of funding for fiscal year 2015, we urge 
the Subcommittee to continue and build on these investments. In 
particular, we propose a $150 million increase to support workforce 
quality improvements and to help offset the continued rise in energy, 
transportation, and other fixed costs related to operating a Head Start 
program. It is well known that one of the hallmarks of excellence in 
any early learning program is the caliber of its teachers. Head Start 
teachers are required to possess Bachelor's degrees in early learning 
or related fields, which enables the program to have one of the best-
trained workforces in the country. However, the average salary for 
these degreed teachers is $30,086--lower than what many schools pay 
teachers, and much lower than salaries for many other jobs with 
comparable education requirements.
    Examples of programs losing their best staff to higher paying 
schools or other providers are plentiful across the country. In New 
York, one Head Start social/emotional education mentor-coach reported 
seeing several ``gifted teachers, assistants and aides leave our 
classrooms after short stays due to the pressure to provide for their 
own families.'' Many of the staff who choose to stay with Head Start 
struggle to make ends meet--such as the Oregon teachers who have 
depended on a local food bank to help feed their own children. Others 
depend on other income supports. Focusing increased investment toward 
workforce quality improvements will help enable programs to hold on to 
dedicated teachers, and provide a solid foundation for the good of our 
students and families.
Supporting a High-Quality Birth-to-Five Pipeline:
    NHSA also urges the Subcommittee to support the continued 
development of a birth-to-five pipeline of services through expanded 
access to Early Head Start, which today is only able to serve a scant 4 
percent of eligible infants and toddlers. Continued early brain 
research tells us that with the achievement gap present as early as 18 
months, these first 2 years of life represent a critical window in 
development. Early Head Start centers are among the highest quality 
environments for children of this age. We propose that the Subcommittee 
continue to fund the new Early Head Start-Child Care Partnerships at 
$500 million. These funds should, as in fiscal year 2014, support the 
straight expansion of Early Head Start as well as partnerships with 
Child Care providers, ensuring programs designed by and solely based on 
the needs of individual communities.
    We are aware of many underserved areas with few options for 
partnerships--these communities should be given as much flexibility as 
possible to increase access to high-quality care. For example, Audubon 
Area Community Services, Inc. in Kentucky serves a 16 county area. 
However, even though there are an estimated 17,911 children in their 
service area that are eligible for Early Head Start, they are only 
funded to serve 301 Early Head Start slots. In two of those 16 
counties, there are 600 eligible children but no licensed child care 
facilities with which possibly to partner. In yet a third county, there 
is licensed child care but none of it for infants and toddlers. With 
flexibility to invest in expansion, they could find a way to serve 
those areas.
    Further, NHSA also urges the Subcommittee to allocate $100 million 
to fund the expansion of the Birth-to-Five pilot programs that the 
Office of Head Start (OHS) began last year in Detroit, Baltimore, 
Jersey City, Washington, DC, and Mississippi's Sunflower County as part 
of the first Designation Renewal System (DRS) recompetition. The grants 
are meant to encourage applicants to develop comprehensive, flexible, 
seamless Birth-to-Five programs which incorporate both Head Start and 
Early Head Start funding. We hope the Subcommittee will recognize the 
value of this approach and support expansion of these models outside of 
DRS. In particular, we suggest that the Administration utilize a 
portion of the funds to create a process that enables current grantees 
that hold both types of grants to streamline the administrative burden 
and combine these two grants into one.
    These Birth-to-Five expansion funds should also be used to assist 
Head Start grantees to add Early Head Start slots and convert existing 
Head Start slots for 3-4 year olds to Early Head Start slots; both 
actions support the goal of providing an Early Head Start slot to 
complement each Head Start slot. Across the country, as States and 
localities both expand and contract services for infants, toddlers, and 
preschoolers, Head Start programs have the necessary skills to adapt 
their services to fit the changing needs of their community. But as 
resources shift, additional funding to help transition to new or 
different types of slots would be a welcome support.
    For instance, many States have increased their investment in 
serving 4-year-olds in a variety of settings through their mixed 
delivery system, including through organizations who receive Head Start 
grants. Head Start grantees are able to tap into this funding stream to 
support and expand their current services to 4-year-olds--however many 
of those communities are now under-investing in low-income infants and 
toddlers. If that same Head Start grantee were able to apply for funds 
to help transition some of its Head Start slots to Early Head Start 
slots, the community would then be served by a more comprehensive 
birth-to-five pipeline--meeting a significant need for the working 
parents of very young children.
Ongoing Quality Improvements:
    Robust funding for Head Start and Early Head Start will ensure that 
key quality improvement initiatives are able to continue at the Office 
of Head Start. In particular, we are keen for the Office of Head Start 
to finalize an update to our rigorous performance standards as mandated 
in the 2007 Head Start Reauthorization Act. Serious and meaningful 
efforts are underway to ensure that the standards are modernized to 
reflect the needs of today's children, families, teachers, staff, and 
communities--while allowing for innovation and local adaptability. 
These standards are the heart of Head Start's model, and critical to 
future success.
    Further, we are hopeful that the Office of Head Start is able to 
continue its improvements to the Head Start Monitoring System--the 
oversight mechanism that ensures Head Start and Early Head Start 
grantees are meeting all of their high standards. We are pleased that 
the Office has instituted new initiatives that aim to work with 
programs to prevent issues before they occur. We are also appreciative 
that they are enabling iterative feedback and data collection to better 
target assistance and intervention where programs require it most. 
These are welcome changes, and we are hopeful that the Office of Head 
Start is afforded the resources to continue these improvements.
    One of the best-known provisions of the 2007 Head Start Act 
requires Head Start grantees designated as low-performing to compete 
for the continuation of their grant. Different from the Head Start 
grant termination process, this additional accountability measure, the 
Designation Renewal System (DRS) which is now in its third cycle, has 
been an enormous undertaking for the Office of Head Start and requires 
adequate resources to fully staff and execute.
    We support the Administration's request for $25 million to assist 
with grantee transition costs in the event that a grant turns over, 
though NHSA remains concerned that the Office of Head Start's timetable 
for executing these competitions is unintentionally poorly timed. 
Currently, Head Start grantees are notified in January of their 
recompetition status, but the results of those competitions are not 
determined until late in the summer. With a school year beginning 
shortly thereafter, any new grantee taking over for a low-quality 
incumbent faces a steep climb to recruit teachers, enroll children, and 
find any necessary facilities and other resources to start up their 
program. This is an avoidable strain on communities.
    Considering the opportunity that DRS provides to improve program 
quality, we must ensure that the process is done right. We hope the 
Subcommittee considers additional assistance to the Office of Head 
Start to ensure that these competitions are run effectively and 
efficiently, and that the process is accurately capturing programs that 
are of low quality.
Head Start is a High Yield Investment:
    To take a step back, NHSA believes that the budget caps now in 
place limit the opportunities to make effective investments in our 
future. President Obama proposed an additional $800 million to support 
Head Start and Early Head Start expansion. We support the President's 
focus on the need to reach the large population of underserved, at-risk 
infants, toddlers, and preschoolers, but understand that appropriations 
that exceed the fiscal year 15 budget caps are unlikely.
    Certainly, we respect the idea that our debt cannot be left for the 
very children we serve. We do hope that deficit reduction can still be 
achieved in a way that does not squander our highest-yield investments. 
Studies show that for every one dollar invested in a Head Start child, 
society earns at least $7 back through increased earnings, employment, 
and family stability; \1\ as well as decreased welfare dependency,\2\ 
healthcare costs,\3\ crime costs,\4\ grade retention,\5\ and special 
education.\6\ These are the very results taxpayers demand.
---------------------------------------------------------------------------
    \1\ Ludwig, J. and Phillips, D. (2007). The Benefits and Costs of 
Head Start. Social Policy Report. 21 (3: 4); Deming, D. (2009). Early 
childhood intervention and life-cycle skill development: Evidence from 
Head Start. American Economic Journal: Applied Economics, 1(3): 111-
134; Meier, J. (2003, June 20). Interim Report. Kindergarten Readiness 
Study: Head Start Success. Preschool Service Department, San Bernardino 
County, California; Deming, D. (2009, July). Early childhood 
intervention and life-cycle skill development: Evidence from Head 
Start, p. 112.
    \2\ Meier, J. (2003, June 20). Kindergarten Readiness Study: Head 
Start Success. Interim Report. Preschool Services Department of San 
Bernardino County.
    \3\ Frisvold, D. (2006, February). Head Start participation and 
childhood obesity. Vanderbilt University Working Paper No. 06-WG01; 
Currie, J. and Thomas, D. (1995, June). Does Head Start Make a 
Difference? The American Economic Review, 85 (3): 360; Anderson, K.H., 
Foster, J.E., & Frisvold, D.E. (2009). Investing in health: The long-
term impact of Head Start on smoking. Economic Inquiry, 48 (3), 587-
602.
    \4\ Reuters. (2009, March). Cost of locking up Americans too high: 
Pew study; Garces, E., Thomas, D. and Currie, J. (2002, September). 
Longer-term effects of Head Start. American Economic Review, 92 (4): 
999-1012.
    \5\ Barnett, W. (2002, September 13). The Battle Over Head Start: 
What the Research Shows.; Garces, E., Thomas, D. and Currie, J. (2002, 
September). Longer-Term Effects of Head Start. American Economic 
Review, 92 (4): 999-1012.
    \6\ NHSA Public Policy and Research Department analysis of data 
from a Montgomery County Public Schools evaluation. See Zhao, H. & 
Modarresi, S. (2010, April). Evaluating lasting effects of full-day 
prekindergarten program on school readiness, academic performance, and 
special education services. Office of Shared Accountability, Montgomery 
County Public Schools.
---------------------------------------------------------------------------
    Again, the Head Start community understands the pressure the 
Subcommittee faces and is grateful for the commitment shown by Congress 
and the President to keep early learning, and Head Start in particular, 
as a priority. We urge the Subcommittee to build on the investments 
made in Head Start and Early Head Start, to increase access, to improve 
accountability, and ensure the prosperity of our next generation. Thank 
you for your time and consideration.

    [This statement was submitted by Yasmina Vinci, Executive Director, 
National Head Start Association.]
                                 ______
                                 
  Prepared Statement of the National Indian Child Welfare Association
    The National Indian Child Welfare Association (NICWA) is a national 
American Indian/Alaska Native (AI/AN) nonprofit organization. NICWA has 
over 35 years of experience providing leadership in the development of 
public policy that supports tribal self-determination in child welfare 
and children's mental health systems.
Child Welfare Overview
    Tribes have an important relationship with their children and 
families: they are experts in the needs of AI/AN children, best suited 
to effectively serve those needs, and most able to improve child 
welfare outcomes for these children (NICWA & Pew Charitable Trust, 
2007). In addition, statistics show that AI/AN children face elevated 
rates of child abuse and neglect (Dept. of Health and Human Services, 
2012). The key to successful tribal child welfare is a budget that 
avoids unnecessary restraint on tribal decisionmaking and accounts for 
the elevated need. For this reason we make the following 
recommendations:
  --For programs administered by the Department of Health and Human 
        Services, Administration for Children and Families: Promoting 
        Safe and Stable Families ($75 million discretionary; $345 
        million mandatory), Child Welfare Services ($280 million), 
        Child Abuse Discretionary Activities ($35 million), Community 
        Based Child Abuse Prevention Program ($60 million), and 
        Demonstration to Address Over-Utilization of Psychotropic 
        Medications for Children in Foster Care ($250 million).
Children's Mental Health Overview
    To understand the mental health needs of AI/AN children, 
policymakers must consider the legacy of trauma that has been visited 
upon this population and left them with unresolved historical trauma 
(Yellow Horse Brave Heart and DeBruyn, 1998). Inadequate funding, 
uncoordinated health systems, cultural incompetence, and a shortage of 
mental health professionals are barriers to the development of 
successful mental health systems of care in AI/AN communities (Novins & 
Bess, 2011). Key to children's mental health programs in tribal 
communities is a budget that supports and strengthens a system of 
tribally driven children's mental health prevention, intervention, and 
treatment. For this reason we make the following recommendations:
  --For programs administered by the Department of Health and Human 
        Services, Substance Abuse Mental Health Services 
        Administration: Programs of Regional and National Significance, 
        Children and Family Programs ($6.5 million), Children's Mental 
        Health Services Program, Children's Mental Health Initiative 
        ($117 million), Tribal Behavioral Health Grants ($40 million), 
        GLS Youth Suicide Prevention Program ($35.5 million), and AI/AN 
        Suicide Prevention ($2.94 million).
                 child welfare priority recommendations
    Child Welfare Services Program recommendation: Restore funding to 
at least $280 million, to increase funding for tribal programs while 
still providing for an increase in state funding.
    This program provides funds to promote program flexibility and fill 
gaps in child welfare programming. Tribes receive an allocation based 
on a population-based formula identified within the regulations. This 
tribal allocation is then deducted from the state's allocation. Studies 
show that culturally competent programs, resources, and case management 
result in better outcomes for AI/AN children and families involved in 
the child welfare system (Red Horse, Martinez & Day, 2001). The funding 
of the Child Welfare Service Program is flexible enough for tribes to 
tailor their child welfare services to fit their communities' needs and 
culture.
    Without adequate funding AI/AN children and families in tribal 
communities cannot receive the care they need and remain at risk of 
further harm and trauma. Of the 566 federally recognized tribes 180 
depend on this funding. The median tribal grant is about $13,300 an 
insufficient amount to support all the gaps in tribal services this 
program can fill. Because of the way the formula for tribal grants has 
been created, it is essential to increase the entire appropriation of 
this program to $280 million to increase tribal amounts.
    Promoting Safe and Stable Families recommendation: Increase 
discretionary funding to $75 million to allow more tribes, who are 
currently ineligible, access to these funds. As recommended by the 
President's Budget fully fund the $345 million in mandatory funding cut 
due to sequestration.

                                     PROMOTING SAFE AND STABLE FAMILIES (SOCIAL SECURITY ACT TITLE IV-B, SUBPART 2)
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                Fiscal year
                                                                      Fiscal year   Fiscal year   Fiscal year      2015       Fiscal year
                                                                     2012 enacted     2013 *     2014 enacted    president       2015      Authorization
                                                                                      enacted                     budget      recommended
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mandatory..........................................................  $345,000,000  $327,405,500  $320,160,000  $345,000,000  $345,000,000   $345,000,000
Discretionary......................................................    63,065,000    59,671,500    59,765,000    59,765,000    75,000,000    200,000,000
Total..............................................................   408,065,000   387,077,000   379,925,000   404,765,000   420,000,000    545,000,000
Tribal Mandatory...................................................     9,149,000     8,459,200     9,604,800    10,350,000    14,100,000   3% set aside
Tribal Discretionary...............................................     1,892,000     1,790,000     1,792,950     1,792,950     2,250,000       of total
Tribal Total.......................................................    11,041,000   10,249,200   11,397,750    12,142,950    16,350,000  appropriation
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Reflects sequestration effects.

    This program is designed to provide funds to operate a coordinated 
program of family preservation, family support, reunification, and 
adoption services. Promoting Safe and Stable Families is authorized 
with both a mandatory capped entitlement ($345 million) as well as a 
discretionary appropriation ($200 million). Tribes are eligible for 
funds based on a 3 percent set-aside of the total appropriation. All 
tribes whose plan receives approval are eligible for a portion equal to 
that tribe's relative share of children compared with all tribal 
entities with approved plans. Tribes who would qualify for less than 10 
thousand dollars under the formula are not eligible to receive funding.
    Tribal child welfare programs work tirelessly to strengthen 
families and provide services that keep children safely in their homes. 
This program is an integral part of these efforts. It supports 
parenting classes, home-visiting services, respite care for caregivers 
of children, and other services that safely preserve families.
    One hundred and thirty tribes and tribal consortia depend on this 
funding. Yet because of the funding levels, many tribes are ineligible 
for these formula grant dollars as their portion of the tribal set-
aside is less than $10,000. Increasing this program's discretionary 
funding to $75 million and fully funding the $345 million in mandatory 
funding would help dozens of new tribes access this funding and 
hundreds of families obtain tribal child welfare services.
                  child welfare other recommendations
    Child Abuse Discretionary Activities, including Innovative 
Evidence-Based Community Prevention Programs recommendation: Increase 
appropriations to $35 million to account for tribes' recent eligibility 
for these funds while holding state and other grantees harmless.
    The Community Based Child Abuse Prevention Program recommendation: 
Increase funding to $60 million, so that more tribes can have access to 
these scarce child abuse prevention dollars.
    Demonstration to Address Over-Utilization of Psychotropic 
Medications for Children in Foster Care (Presidents fiscal year 2015 
Initiative) recommendation: Fund this initiative at the proposed $250 
million and ensure a tribal set-aside of 3 percent so that tribal 
communities can also participate in this important initiative to ensure 
children receive holistic mental healthcare.
department of health and human services recommendations substance abuse 
               and mental health services administration
           children's mental health priority recommendations
    Programs of Regional and National Significance: Children and Family 
Programs (Circles of Care) recommendation: Fund Circles of Care Program 
at $6.5 million as recommended by the President to ensure current 
communities can continue their important work and new tribal 
communities can have access to this program.
    The Children and Family Programs line item represents funds 
allocated to the Circles of Care Program. The Circles of Care program 
is the cornerstone of children's mental health programming in tribal 
communities. The Circles of Care program is the only SAMHSA grant 
program that is focused specifically on AI/AN children's mental health 
needs. It is also the only SAHMSA program that allows tribes and tribal 
organizations to apply without competing for funding with other 
governmental entities such as States, counties, or cities. There are 
currently seven communities receiving Circles of Care funding.
    The American Psychiatric Association has found that AI/AN children 
and youth face a "disproportionate burden" of mental health issues 
while simultaneously facing more barriers to quality mental healthcare 
(2010). Circles of Care provides communities with funding to plan and 
build culturally competent services and design integrated supports that 
meet the specific needs of their youth with behavioral health 
challenges. It is essential to the well-being of AI/AN children. It is 
imperative that funding that matches the President's Budget request of 
$6.5 million be reserved in this line item for the Circles of Care 
program. This will ensure that more tribal communities can access this 
grant and improve their children's mental healthcare systems.
    Children's Mental Health Services Program: Children's Mental Health 
Initiative (Systems of Care) recommendation: Maintain funding at $117 
million to continue support of Tribal children's mental health systems 
change efforts.
    The various Systems of Care grants funded under this line item 
support a community's efforts to plan and implement strategic 
approaches to mental health services and supports that are family 
driven; youth guided; strength based; culturally and linguistically 
competent; and meet the intellectual, emotional, cultural, and social 
needs of children and youth.
    The American Psychiatric Association (APA; 2010) has recognized 
family, culture, and traditional health practices as important 
protective factors for AI/ANs struggling with mental health challenges. 
The Systems of Care program, which foster those protective factors 
described by the APA, has been both well-received and particularly 
effective in tribal communities. Currently, 17 tribal communities are 
funded under the Children's Mental Health Initiative line item.
    The well-being of AI/AN children is dependent on the ability of 
more tribes to access these funds and create real systems change. Thus, 
funding must be maintained at $117 million as recommended by the 
President's Budget. This will ensure the current Systems of Care 
grantees can continue, and a new robust cohort of grantees can begin 
this important work.
                children's mental health recommendations
    Tribal Behavioral Health Grants recommendation: Implement 
President's Budget fiscal year 2013 recommendation to fund this new 
initiative at $40 million so that additional tribal communities can 
receive resources for children's mental health and substance abuse.
    The GLS State/Tribal Youth Suicide Prevention and Early 
Intervention Program recommendation: Keep funding at the fiscal year 
2014 appropriated level of $35.5 million to ensure that current 
grantees can complete their projects, and a similar sized cohort of 
annual grantees will have access to this program.
    AI/AN Suicide Prevention program recommendation: Fund at the 
President's Budget recommended amount of $2.94 million, to ensure that 
the epidemic of AI/AN suicide receives the attention it warrants.
    If you have any questions about this testimony please contact NICWA 
Government Affairs Associate Addie Smith at [email protected].
                                 ______
                                 
    Prepared Statement of the National Indian Education Association
    The National Indian Education Association (NIEA) was incorporated 
in 1970 and is the most representative Native education organization in 
the United States. NIEA's mission is to advance comprehensive and equal 
educational opportunities for American Indian, Alaska Native, and 
Native Hawaiian students. NIEA supports tribal sovereignty over 
education as well as strengthening traditional Native cultures and 
values that enable Native learners to become contributing members of 
their communities. As the most inclusive Native education organization, 
NIEA membership consists of tribal leaders, educators, students, 
researchers, and education stakeholders from all 50 States. From 
communities in Hawaii, to tribal reservations across the continental 
U.S., to villages in Alaska and urban communities in major cities, NIEA 
has the most reach of any Native education organization in the country.
    Tribes and Native communities have a tremendous stake in an 
improved education system, because an improved system equates to better 
services for Native people and students. As tribes work to increase 
their footprint in education, there must be support for that increased 
participation. The Federal Government must uphold its trust 
relationship with tribes. Established through treaties, Federal law, 
and U.S. Supreme Court decisions, this relationship includes a 
fiduciary obligation to provide parity in access and equal resources to 
all American Indian and Alaska Native students, regardless of where 
they attend school. National fiscal and policy concerns should not be 
addressed by decreasing funds and investment to Native students or the 
programs that serve them. Rather, Native education, including those 
programs and services under the Departments of Education (ED) and 
Health and Human Services (HHS), is one of the most effective and 
efficient investments the Federal Government can make.
    As tribes and Native communities work with Congress for parity in 
access to increase their role and responsibility in administering 
education, Federal support for tribal governments and Native education 
institutions has continued to shrink as a percentage of the Federal 
budget. Historical funding trends illustrate that the Federal 
Government is abandoning its trust responsibility by decreasing Federal 
funds to Native-serving programs by more than half in the last 30 
years. Sequestration only exacerbated those shortfalls.
    While fiscal year 2014 funding increases over sequestration levels 
were welcome, several Native-serving programs remained flat with 2013 
sequestration levels, such as Elementary and Secondary Education Act 
Title VII funding. These levels continue to be insufficient for 
effectively and equally serving Native students. Partly as a result of 
this insufficient funding, Native students continue to lag behind their 
non-Native peers. Graduation rates often hover around 50 percent in 
many States, which can lead to increased substance abuse, criminal 
acts, and extended periods of unemployment. If the 25,000 Native 
students who dropped out of the Class of 2010 had graduated, an 
additional $295 million would likely have been added to total annual 
earnings, supplementing local and regional economies.
    To provide tribes and Native communities the educational 
institutions that supplement economic growth, the Federal Government 
should fund Native education programs at the levels requested below as 
they detail the minimum appropriations needed to maintain a system that 
is already struggling and underfunded. The following funding requests 
illustrate continuing need for Native programs but do not comprise the 
full list of budget requests, which can be found in the fiscal year 
2015 NIEA Budget Document. Further, NIEA supports the budget requests 
of the National Congress of American Indians and American Indian Higher 
Education Consortium.
State-Tribal Education Partnership (STEP) Program (ED)
  --Provide $5 million. An increase of $3 million.
    Congress appropriated roughly $2 million dollars for the STEP 
program to five participating tribes under the Tribal Education 
Department appropriations. In order for this program to successfully 
achieve the original intent of the appropriation, it must receive its 
own line and authorization of appropriations in fiscal year 2015. 
Collaboration between tribal education agencies and State education 
agencies is crucial to developing the tribal capacity to assume the 
roles, responsibilities, and accountability of tribal education 
departments that increase self-governance in Native education.
Impact Aid (ED)
  --Provide $2 billion for Impact Aid, under ESEA Title VIII. An 
        increase of $711 million.
    Impact Aid provides direct payments to public school districts as 
reimbursement for the loss of traditional property taxes due to a 
Federal presence or activity, including the existence of an Indian 
reservation. With nearly 93 percent of Native students enrolled in 
public schools, Native students were disproportionately affected by the 
devastating reductions implemented under sequestration. Additional 
funds are required to cover previous Impact Aid shortfalls.
Title VII (Indian Education Formula Grants in ED)
  --Provide $198 million under ESEA Title VII, Part A. An increase of 
        $74 million.
    This grant funding is designed to supplement the regular school 
program and assist Native students so they have the opportunity to 
achieve the same educational standards as their non-Native peers. Title 
VII funding, which was maintained at 2013 sequestration levels in 
fiscal year 2014, only reaches 500,000 Native students leaving over 
100,000 without supplementary academic and cultural programs in their 
schools. As Native students continually lag behind their non-Native 
peers in educational achievement, increased funding is necessary to 
address this substantial gap.
Native Hawaiian Education Program (ED)
  --Provide $35 million under ESEA Title VII, Part B. An increase of $3 
        million.
    The Native Hawaiian Education program empowers innovative 
culturally-appropriate programs to enhance the quality of education for 
Native Hawaiians. When establishing the Native Hawaiian Education 
Program, Congress acknowledged the trust relationship between the 
Native Hawaiian people and the United States. These programs strengthen 
Native Hawaiian culture and improve educational attainment, both of 
which are correlated with positive economic outcomes.
Alaska Native Education Equity Assistance Program (ED)
  --Provide $35 million under ESEA Title VII, Part C. An increase of $5 
        million.
    This assistance program funds the development of curricula and 
education programs that address the unique educational needs of Alaska 
Native students as well as the development and operation of student 
enrichment programs in science and mathematics. Other eligible 
activities include professional development for educators, activities 
carried out through Even Start and Head Start programs, family literacy 
services, and dropout prevention programs.
Vocational Rehabilitation Services Projects for American Indians with 
        Disabilities (ED)
  --Provide $67 million to Vocational Rehabilitation Services Projects. 
        Create a line item of $5 million for providing outreach to 
        tribal recipients.
    According to the Centers for Disease Control and Prevention, 
approximately 30 percent of Native adults have a disability--the 
highest rate of any other population in the Nation. Of those, 51 
percent reported having fair or poor health. A number of issues 
contribute to this troubling reality, including high incidences of 
diabetes, heart disease, and preventable accidents. As a result, tribes 
have an extraordinary need to support their disabled citizens in 
improving their health, attaining experiential learning courses, and 
becoming self-sufficient. Tribes have limited access to funding for 
vocational rehabilitation and job training as compared to States and 
$67 million would begin to put tribes on par to support their disabled 
citizens.
Native Languages Preservation (Esther Martinez Program Grants in HHS)
  --Provide $12 million for Native language preservation with $5 
        million designated to fund the Esther Martinez Native Language 
        Programs. An increase of $3 million.
    Native language grant programs are essential to revitalizing Native 
languages and cultures, many of which are at risk of disappearing in 
the upcoming decades. In addition to protecting Native languages, these 
immersion programs promote higher academic success for participating 
students in comparison to their Native peers who do not participate. 
The Federal budget should include $12 million for Native language 
preservation activities which would include $5 million designated to 
support Esther Martinez Native Language Programs' immersion 
initiatives.
    Thank you for your consideration of this testimony. For more 
information or to attain NIEA's complete budget document with all 
fiscal year 2015 requests for the Departments of Education and Health 
and Human Services, please contact Ahniwake Rose, NIEA Executive 
Director, at [email protected].
                                 ______
                                 
          Prepared Statement of the National Kidney Foundation
    The National Kidney Foundation (NKF) is pleased to submit testimony 
for the written record in support of the Centers for Disease Control 
and Prevention Chronic Kidney Disease Program, the National Institute 
of Diabetes and Digestive and Kidney Disease, and the Health Resources 
and Services Administration Division of Transplantation. NKF is 
America's largest and oldest health organization dedicated to the 
awareness, prevention and treatment of kidney disease for hundreds of 
thousands of healthcare professionals, millions of patients and their 
families, and tens of millions of people at risk. In addition, we have 
provided universally recognized evidence-based clinical practice 
guidelines for all stages of chronic kidney disease (CKD) since 1997 
through the NKF Kidney Disease Outcomes Quality Initiative (NKF KDOQI).
    We respectfully request fiscal year 2015 funding of $2.1 million 
for the CDC Chronic Kidney Disease Program, $2.066 billion for NIDDK, 
and $24 million for the HRSA Division of Transplantation.
    In 2011, almost 616,000 Americans had End Stage Renal Disease 
(ESRD), including more than 430,000 dialysis patients and nearly 
186,000 kidney transplant recipients, with members of many minority 
populations disproportionately affected. Complicating the cost and 
human toll is the fact that it is a disease multiplier, with patients 
very likely to be diagnosed with diabetes, cardiovascular disease, or 
hypertension (40 percent of ESRD patients had a diagnosis of diabetes 
and two-thirds have diabetes or hypertension). ESRD is the only 
disease-specific coverage under Medicare regardless of age or other 
disability. In 2011, ESRD was present in 1.4 percent of Medicare 
beneficiaries but responsible for more than 7 percent of Medicare 
expenditures. (1)
    NKF recently announced an initiative to help address awareness of 
CKD by increasing communication between practitioners and patients. 
There is a misconception that once someone is diagnosed with CKD, there 
must be a referral to a nephrologist. However, there are not enough 
nephrologists to care for the 15 percent of the U.S. population with 
chronic kidney disease. NKF's CKD Primary Care Initiative will 
disseminate CKD guidelines to primary care physicians through education 
programs, symposia and practical implementation tools so they can 
provide this care to the growing numbers of Americans with CKD. Our 
initiative will help build on CDC's program, outlined below.
CDC Chronic Kidney Disease Program
    To address the social and economic impact of kidney disease, NKF 
worked with Congress to initiate a Chronic Kidney Disease Program at 
CDC in fiscal year 2006. Prior to this, no national public health 
program focusing on early detection and treatment existed. Cost-
effective treatments exist to potentially slow progression of kidney 
disease and prevent its complications, but only if individuals are 
diagnosed before the latter stages of CKD.
    The CDC program is designed to identify members of populations at 
high risk for CKD, develop community-based approaches for improving 
detection and control, and educate health professionals about best 
practices for early detection and treatment. The National Kidney 
Foundation respectfully urges the Committee to maintain $2.1 million in 
line-item funding for the Chronic Kidney Disease Program for fiscal 
year 2015. Continued support will benefit kidney patients and Americans 
who are at risk for kidney disease, advance the objectives of Healthy 
People 2020 and the National Strategy for Quality Improvement in Health 
Care, and fulfill the mandate created by Sec. 152 of the Medicare 
Improvement for Patients and Providers Act.
    It is estimated that CKD affects 26 million adult Americans (2) and 
73 million more are at risk. Furthermore, a task force of the American 
Heart Association noted that decreased kidney function has consistently 
been found to be an independent risk factor for cardiovascular disease 
(CVD) outcomes and all-cause mortality and that the increased risk is 
present with even mild reduction in kidney function. (3) Therefore 
addressing CKD is a way to achieve one of the priorities in the 
National Strategy for Quality Improvement in Health Care: Promoting the 
Most Effective Prevention and Treatment of the Leading Causes of 
Mortality, Starting with Cardiovascular Disease.
    CKD is often asymptomatic, especially in the early stages and 
therefore goes undetected without laboratory testing. Some people 
remain undiagnosed until they have reached CKD Stage 5 and must begin 
dialysis immediately. However, early identification and treatment can 
slow the progression of kidney disease, delay complications, and 
prevent or delay kidney failure. Accordingly, Healthy People 2020 
Objective CKD--2 is to ``increase the proportion of persons with 
chronic kidney disease (CKD) who know they have impaired renal 
function.''
    Screening and early detection provides the opportunity for 
interventions to foster awareness, foster adherence to medications and 
control risk factors. Additional data collection is required to 
precisely define the incremental benefits of early detection on kidney 
failure, cardiovascular events, hospitalization and mortality. 
Increasing the proportion of persons with CKD who know they are 
affected requires expanded public and professional education programs 
and screening initiatives targeted at populations who are at high risk. 
As a result of consistent congressional support, the National Center 
for Chronic Disease Prevention and Health Promotion at CDC has 
instituted a series of projects that could assist in attaining the 
Healthy People 2020 objective. However, this forward momentum will be 
stifled and CDC's investment in CKD to date jeopardized if line-item 
funding is not continued.
    As noted in CDC's Preventing Chronic Disease: April 2006, Chronic 
Kidney Disease meets the criteria to be considered a public health 
issue: (1) the condition places a large burden on society; (2) the 
burden is distributed unfairly among the overall population; (3) 
evidence exists that preventive strategies that target economic, 
political, and environmental factors could reduce the burden; and (4) 
evidence shows such preventive strategies are not yet in place.
    The Chronic Kidney Disease program has consisted of three projects 
to promote kidney health by identifying and controlling risk factors, 
raising awareness, and promoting early diagnosis and improved outcomes 
and quality of life for those living with CKD. These projects include 
(1) demonstrating approaches for identifying individuals at high risk 
for CKD through State-based screening; (2) conducting an economic 
analysis on the economic burden of CKD and the cost-effectiveness of 
interventions; and (3) establishing a surveillance system for CKD by 
analyzing and interpreting information to assist in prevention and 
health promotion efforts for kidney disease. The surveillance project 
includes a CDC website program containing information on risk factors, 
early diagnosis, and strategies to improve outcomes.
    Undetected Chronic Kidney Disease can lead to costly and 
debilitating irreversible kidney failure. However, cost-effective 
interventions are available if patients are identified in the early 
stages of CKD. With the continued support of Congress, NKF is confident 
a feasible detection, surveillance and treatment program can be 
established to slow, and possibly prevent, the progression of kidney 
disease.
NIDDK
    NKF joins multiple other kidney patient and professional 
organizations to request $2.066 billion for NIDDK in fiscal year 2015. 
Medicare spends $77 billion annually to care for patients with kidney 
disease, including nearly $35 billion for individuals with ESRD, yet 
NIH funding for kidney disease research is only about $600 million 
annually or less than $25 per patient for the 26 million adults with 
CKD. In March 2014, NKF hosted a Kidney Patient Summit that included 
participation from our advocates and those of five other kidney patient 
organizations. Increased Federal support for kidney disease research 
was one of the requests the advocates presented in meetings with their 
congressional delegations.
    We were honored to have NIDDK Director Dr. Griffin Rodgers address 
the Kidney Summit where we learned of exciting opportunities in CKD 
research. America's scientists are at the cusp of many potential 
breakthroughs in improving our understanding of CKD and providing new 
therapies to delay and treat various kidney diseases. With the unique 
status of ESRD in the Medicare program, it can be argued that 
breakthroughs in CKD have the potential to provide cost savings to the 
Federal Government like that of no other chronic disease. We urge 
Congress to continue its strong bipartisan support for NIH in fiscal 
year 2015 and to fund NIDDK at this requested level that is widely 
supported by the kidney community.
HRSA Organ Transplantation
    NKF also urges the Committee to support the President's Budget 
Request of $24 million for organ donation and transplantation programs 
run by the Health Resources and Services Administration's (HRSA) 
Division of Transplantation (DoT). This represents an increase of less 
than $500,000 over the fiscal year 2014 level and would restore funding 
to the fiscal year 2012 level.
    The national organ transplant wait list contains more than 122,000 
listings, including 100,000 people waiting for a kidney. 
Transplantation remains the treatment of choice for most patients with 
kidney failure yet few of them will be given an opportunity to receive 
a new kidney, especially if they do not have a potential living kidney 
donor. Kidney recipients often have an improved quality of life (and 
are more likely to stay in or return to the work force) and 
transplantation is tremendously cost effective. Medicare spends about 
$25,000 per year on a kidney recipient after the year of transplant, 
compared to more than $80,000 annually on a dialysis patient (these 
figures reflect all Medicare expenses and are not limited to kidney 
related care).
    The HRSA program supports the Organ Procurement and Transplantation 
Network (OPTN) which allocates donor organs to individuals on wait 
lists. Additional activities supported by DoT include initiatives to 
increase the number of donor organs; a grant program to assist living 
donors with out-of-pocket expenses that are not reimbursed by 
insurance, a health benefit program, or any other State or Federal 
program; State donor registry initiatives to enroll potential donors; 
and, activities to build upon achievements of HRSA's Breakthrough 
Collaboratives of a decade ago.
    Thank you for your consideration of our requests for fiscal year 
2015.
    (1) 2013 U.S. Renal Data System Annual Report.
    (2) Josef Coresh, et al. ``Prevalence of Chronic Kidney Disease in 
the United States,''JAMA, November 7, 2007.
    (3) Mark J. Sarnak, et al. Kidney Disease as a Risk Factor for the 
Development of Cardiovascular Disease: A Statement from the American 
Heart Association Councils on Kidney in Cardiovascular Disease, High 
Blood Pressure Research, Clinical Cardiology, and Epidemiology and 
Prevention. Circulation 2003: 108: 2154-69.
                                 ______
                                 
         Prepared Statement of the National League for Nursing
    The National League for Nursing (NLN) is the premiere organization 
dedicated to promoting excellence in nursing education to build a 
strong and diverse nursing workforce to advance the Nation's health. 
With leaders in nursing education and nurse faculty across all types of 
nursing programs in the United States--doctorate, master's, 
baccalaureate, associate degree, diploma, and licensed practical--the 
NLN has more than 1,200 nursing school and healthcare agency members, 
40,000 individual members, and 24 regional constituent leagues.
    The NLN urges the subcommittee to fund the following HRSA nursing 
programs:
  --The Title VIII Nursing Workforce Development Programs at $251 
        million in fiscal year 2015; and
  --The Title III Nurse-Managed Health Clinics at $20 million in fiscal 
        year 2015.
Nursing Education Is a Jobs Program
    According to the Bureau of Labor Statistics (BLS), the registered 
nurse (RN) workforce will grow by 19.4 percent from 2012 to 2022, 
outpacing the 11 percent average for most occupations. BLS projects 
that this growth will result in 1,052,600 job openings in the economy, 
representing one of the largest numeric job increases for all 
occupations. BLS calculates the openings from an increase of 526,800 
new RN jobs due to technological advancements fueling growth in 
treatments, preventive care being emphasized more, expanding demand 
from new health reform enrollments, and accelerating demand from the 
two million Baby Boomers aging into Medicare every year. A particularly 
disconcerting element of the probable RN job openings is a loss of 
nursing expertise owing to the replacement need of some 525,700 jobs 
vacated by RNs expected to leave the profession and/or retire from the 
labor force by 2022.
    The March 7, 2014, BLS Employment Situation Summary--February 2014 
likewise reinforces the strength of the nursing workforce in creating 
job growth. While the Nation's overall unemployment rate was little 
changed at 6.7 percent for February 2014, the employment in healthcare 
increased with the addition of 10,000 jobs at ambulatory healthcare 
services, hospitals, and nursing and residential care facilities, 
amounting to an unemployment rate of only 4.0 percent in the industry.
    BLS notes that the healthcare sector is a critically important 
industrial complex for the Nation. It is at the center of the economic 
recovery with the number of jobs climbing steadily. Growing even when 
the recession began in December 2007, healthcare jobs are up 
nationwide. Almost five million workers are in hospital settings, which 
often are the largest employer in a State. Healthcare has been a 
stimulus program generating employment and income, and nursing is the 
predominant occupation in the healthcare industry with more than 4.031 
million active, licensed RNs in the United States in 2014.
    The Nursing Workforce Development Programs provide training for 
entry-level and advanced degree nurses to improve the access to, and 
quality of, healthcare in underserved areas. The Title VIII nursing 
education programs are fundamental to the infrastructure delivering 
quality, cost-effective healthcare. The NLN applauds the subcommittee's 
bipartisan efforts to recognize that a strong nursing workforce is 
essential to a health policy that provides high-value care for every 
dollar invested in capacity building for a 21st century nurse 
workforce.
    The current Federal funding falls short of the healthcare 
inequities facing our Nation. Absent consistent support, slight boosts 
to Title VIII will not fulfill the expectation of generating quality 
health outcomes, nor will episodic increases in funding fill the gap 
generated by a 15-year nurse and nurse faculty shortage felt throughout 
the U.S. health system.
The Nurse Pipeline and Education Capacity
    Although the recession resulted in some stability in the short-term 
for the nurse workforce, policy makers must not lose sight of the long-
term growing demand for nurses in their districts and States. The NLN's 
findings from its Annual Survey of Schools of Nursing--Academic Year 
2011-2012 cast a wide net on all types of nursing programs, from 
diploma through doctoral, to determine rates of application, 
enrollment, and graduation. This data can be found at http://
www.nln.org/researchgrants/slides/index.htm. Key findings include:
  --Demand for spots in nursing education programs historically 
        outstripped supply. In 2012, 43 and 37 percent of master's and 
        doctoral nursing programs, respectively, rejected qualified 
        applicants. More dramatically, 72 percent of programs offering 
        practical nursing (PN) degrees and 84 percent offering 
        associate's degrees in [registered] nursing programs (ADN) were 
        forced to turn away qualified candidates, as did almost two-
        thirds (64 percent) of baccalaureate in science of [registered] 
        nursing (BSN) programs. The aggregate rate across all basic RN 
        programs was 28 percent of qualified applications not accepted 
        in the Fall 2012.
  --Expansion of nursing education programs impeded by shortage of 
        faculty. Deans and directors of schools providing programs that 
        did not accept all eligible applicants were asked to identify 
        the primary obstacle to expanding their program's capacity. 
        Since 2010, the percentage of those directing ADN and PN 
        programs that cited a shortage of clinical sites as the primary 
        impediment to expansion has steadily increased. For PN programs 
        in particular, the percentage jumped to 51 percent in 2012. By 
        contrast, graduate programs consistently cite a lack of faculty 
        as the primary obstacle to expansion. A strong correlation 
        exists between the shortage of nurse faculty and the inability 
        of nursing programs to keep pace with the demand for new nurse 
        faculty and new RNs. Increasing the productivity of education 
        programs is a high priority in most States, but faculty 
        recruitment is a glaring problem. Without faculty to educate 
        our future nurses, the shortage cannot be resolved.
  --Age of associate degree students rises. A substantial increase in 
        the percentage of ADN students who were over 30 years old 
        occurred, rising in 2012 to 50 percent of the student nursing 
        enrollments. Because ADN students comprise two-thirds of all 
        pre-licensure RN enrollees, this uptick in enrollments among 
        older students could reignite concerns over an aging nursing 
        workforce and the potential for future labor shortages.
Equally Pressing Is Lack of Diversity
    Our Nation is enriched by cultural diversity--37 percent of our 
population identify as racial and ethnic minorities. Yet ethnic, 
cultural, and gender diversity eludes the nursing student and nurse 
educator populations. A survey of nurse educators conducted by the NLN 
and the Carnegie Foundation's Preparation for the Professions Program 
found that only 7 percent of nurse educators were minorities compared 
with 16 percent of all U.S. faculty. The lack of faculty diversity 
limits nursing schools' ability to deliver culturally appropriate 
health professions education. In addition, the NLN survey for the 2011-
2012 academic year reported that:
  --African-American enrollment drops. The percentage of racial-ethnic 
        minority students enrolled in pre-licensure RN programs has 
        declined steadily over the past 2 years--ultimately dropping 
        from a high of 29 percent in 2009 to 24 percent in 2011 and up 
        to 26 percent in 2012. The majority of that decline stems from 
        a steep reduction in the percentage of African-American 
        students enrolled in associate degree nursing programs, which 
        dropped by almost 5 percent to 9 percent. BSN programs saw a 
        small, but not significant drop, in African-American 
        enrollment, down from 13 to 12 percent. Inversely, diploma 
        programs saw a sharp rise in African-American enrollments to 30 
        percent, but because they represent just 4 percent of all basic 
        RN programs, the impact is not great.
  --Hispanic representation, while still lagging, inches upward. 
        Hispanics remain dramatically underrepresented among nursing 
        students. Representing a mere 6 percent of associate degree and 
        baccalaureate nursing students, Hispanics were enrolled in 
        basic nursing programs at less than half the rate at which they 
        were enrolled in undergraduate programs overall. However, the 
        percentage of Hispanics enrolled in post-licensure programs has 
        nearly doubled at every level.
  --Men's enrollment at historic high. While significantly less than 
        the proportion in the U.S. population, at 15 percent, men 
        enrolled in basic RN programs (i.e., 13 percent BSN, 16 percent 
        diploma, and 16 percent ADN) remained at the historic high 
        reached at the start of the recession. Approximately 11 percent 
        of PN students, RN-to BSN students, master's, and doctoral 
        students were male in 2012.
    Besides representing an untapped talent pool to remedy the nursing 
shortage, ethnic, cultural, and gender-diverse minorities in nursing 
are essential to developing a healthcare system that understands and 
addresses the needs of our rapidly diversifying population. Workforce 
diversity is needed where research indicates that factors such as 
societal biases and stereotyping, communication barriers, limited 
cultural sensitivity and competence, and system and organizational 
determinants contribute to healthcare inequities.
Title VIII Federal Funding Reality
    Today's undersupply of appropriately prepared nurses and nurse 
faculty, as well as the projected loss of experienced nurses over the 
next decade, does not bode well for our Nation. The Title VIII Nursing 
Workforce Development Programs are a comprehensive system of capacity-
building strategies that provide students and schools of nursing with 
grants to strengthen education programs, including faculty recruitment 
and retention efforts, facility and equipment acquisition, clinical lab 
enhancements, and loans, scholarships, and services that enable 
students to overcome obstacles to completing their nursing education 
programs. A few examples of HRSA's Title VIII data below provide 
perspective on current Federal investments.
    Nurse Faculty Loan Program (NFLP)--BLS projects a need of 35 
percent more faculty members to meet the expected increase in demand. 
In addition, with 10,200 current faculty members expected to retire, 
34,200 new nursing instructors will be needed by 2022. NFLP supports 
the establishment and operation of a loan fund at participating schools 
of nursing to assist nurses in completing their graduate education to 
become qualified nurse faculty. Ongoing NFLP support for faculty 
production is critical to building the pipeline that assures the full 
capacity of the Nation's future nursing workforce. Targeting a portion 
of those funds for minority faculty preparation is fundamental to 
achieving that goal. In fiscal year 2012, NFLP grantees exceeded the 
program's performance target by 49.6 percent in providing loans to 
2,259 students pursuing faculty preparation. About one out of every 
four students receiving the NFLP loans were considered underrepresented 
minorities.
    Comprehensive Geriatric Education Program (CGEP)--CGEP provides 
support to educate individuals in providing geriatric care for the 
elderly. This goal is accomplished through curriculum development and 
dissemination, continuing education, and traineeships for individuals 
preparing for advanced nursing education degrees. In fiscal year 2012, 
CGEP grantees awarded traineeships to 74 students--the majority of whom 
(81 percent) were pursuing a Master's Degree in Nursing.
    Nurse Education, Practice, Quality, and Retention Grants (NEPQR)--
NEPQR addresses the critical nursing shortage via projects to expand 
the nursing pipeline, promote career mobility, provide continuing 
education, and support retention. Grants to support recruiting and 
retaining nursing assistants and personal and home care aides in 
occupational shortage and/or high demand areas trained 4,624 students 
during fiscal year 2012. NEPQR also supported expanding the size of BSN 
programs and supported nurse-managed health clinics.
Nurse-Managed Health Clinics (NMHC)
    NMHCs are a nurse-practice arrangement, managed by advanced 
practice registered nurses, that provides primary care or wellness 
services. NMHCs are associated with a school, college, university, or 
department of nursing, federally qualified health center, or 
independent nonprofit health or social services agency.
    NMHCs deliver comprehensive primary healthcare services, disease 
prevention, and health promotion in medically underserved areas for 
vulnerable and specialized populations (e.g., veterans and/or families 
of active military). The complexity of care for these patients presents 
significant financial barriers, heavily affecting the sustainability of 
these clinics. While providing access points in areas where primary 
care providers are in short supply, expansion of NMHCs also increases 
the number of structured clinical teaching sites available to train 
nurses and other primary care providers. In fiscal year 2012, more than 
1,600 health professions students were trained in NMHCs, where the 
majority of NMHCs and associated training sites were primarily located 
in medically underserved communities (97 percent) and served as a 
primary care setting for their local community (65 percent). 
Appropriating $20 million in fiscal year 2015 to NMHCs would increase 
access to primary care for thousands of underserved people.
    The NLN can state with authority that the deepening health 
inequities, inflated costs, and poor quality of healthcare outcomes in 
this country will not be reversed until the concurrent shortages of 
nurses and qualified nurse educators are addressed. Your support will 
help ensure that nurses exist in the future who are prepared and 
qualified to take care of you, your family, and all those who will need 
our care. Without national efforts of some magnitude to match the 
healthcare reality facing our Nation today, an under resourced nurse 
education and its adverse effect in healthcare generally will be 
difficult to avoid.
    The NLN urges the subcommittee to maintain the Title VIII Nursing 
Workforce Development Programs by funding them at a level of $251 
million in fiscal year 2015. We also recommend that the Title III 
Nurse-Managed Health Clinics be funded at $20 million in fiscal year 
2015.

    [This statement was submitted by Beverly Malone, PhD, RN, FAAN, 
Chief Executive Officer, National League for Nursing.]
                                 ______
                                 
             Prepared Statement of the National MPS Society
    The National MPS Society supports research to find cures for 
Mucopolysaccharidoses (MPS) and related diseases, and provides hope and 
support for affected individuals and their families through research, 
advocacy, and awareness of these devastating disorders. The Society 
submits this testimony to request insertion of language in the fiscal 
year 2015 Appropriations to direct the National Institutes of Health 
(NIH) to fund MPS research.
    MPS diseases are rare genetic diseases that affect both children 
and adults. They cause progressive damage to cells in the body, 
resulting in severe disability and early death. There are currently few 
treatments and no cures. There are 11 types of MPS but only 4 FDA 
approved enzyme replacement therapy treatments to slow disease 
progression. The damage from MPS results in severe problems, including 
profound intellectual disabilities, heart disease, vision loss, speech 
and hearing impairment, short stature, stiff joints, and pain, among 
others. MPS diseases are devastating for children and families, largely 
due to the progressive nature of the diseases. Babies are often born 
looking perfectly healthy. It is only later, as cell damage becomes 
worse, that parents receive the heartbreaking diagnosis. All MPS 
diseases are terminal with most affected individuals not surviving 
beyond teenage years.
    The National MPS Society is requesting the insertion of language 
specific to MPS and related diseases into the fiscal year 2015 
Appropriations Bill. This language will help focus NIH research efforts 
related to MPS and related diseases. After several years of decreased 
funding, the NIH budget for MPS research increased between 2010 through 
2013 but saw a significant decline in 2014 due to sequestration.
    Researchers focused on MPS diseases get almost all of their funding 
from the NIH. There is very little private funding for MPS and related 
diseases research. Although there are very few therapies for MPS 
diseases, the ones that are available are the result of NIH-funded 
research. Prominent researchers in the field believe that continued 
research holds the promise of effective treatments and cures for MPS 
diseases, including stem cell therapies, gene therapies, and small 
molecule therapies. Researchers are beginning to build momentum in 
their work on MPS diseases. Increased funding for MPS and related 
diseases research will ensure that this momentum translates into 
progress toward new treatments and a cure. Reduced funding stalls 
progress and prevents these critical gains.
    On behalf of the children and families impacted by MPS diseases, 
the National MPS Society respectfully requests the insertion of the 
following language into the fiscal year 2015 Appropriations Bill.
    Mucopolysaccharidoses: The Committee encourages the NINDS and NIDDK 
to expand research efforts in the development of effective treatments 
for MPS diseases. The Committee commends the National Institute of 
Neurological Disorders and Stroke (NINDS) and the Office of Rare 
Diseases Research (ORDR) and National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK) for sponsoring scientific 
conferences like the Gordon Research Conference (April 2013) focusing 
on basic science of lysosomal biology and function but with strong 
emphasis on pathogenic mechanisms of lysosomal disease. The Committee 
further acknowledges and applauds the National Institutes of Health 
ORDR, NINDS and NIDDK for their work related to the Rare Diseases 
Clinical Research Network (RDCRN) over the next 5 years to fund 
research consortia including lysosomal diseases: mucopolysaccharidosis 
(MPS), and MPS bone disease, helping to create additional opportunities 
for small research communities, such as the Lysosomal Disease Network, 
to address some of these clinical research needs.
    Mucopolysaccharidoses (MPS) are a group of genetic, progressive 
diseases that are caused by the absence or malfunctioning of certain 
enzymes needed to break down molecules called glycosaminoglycans--long 
chains of sugar carbohydrates in each of our cells. When mutations 
occur in the genes for the enzymes involved in the normal turnover of 
Mucopolysaccharidoses, excess amounts of them are stored in the body, 
causing progressive damage to a number of different organs and tissues, 
and, in most cases, early death. There are no current cures for MPS, 
although stem cell transplants and enzyme replacement therapy show 
potential for reducing symptom severity. Treatment for the skeletal 
abnormalities remains a challenge due to the difficulty of introducing 
replacement enzymes or transplanted cells into skeletal tissues. 
Although the greatest benefit is likely to be discovered through MPS 
research supported by other NIH components, ongoing research at the 
NIAMS in other areas of skeletal research may help to inform the 
science base and potentially improve the quality of life of patients 
with the disease.
    Action taken or to be taken: The Committee encourages NINDS, ORDR 
and NIDDK to continue supporting scientific conferences in the 
Mucopolysaccharidoses and other Lysosomal Disease research community, 
such as the Lysosomal Disease Network's Annual WORLD Symposium. This 
international conference gives researchers an opportunity to share 
findings in basic, translational and clinical research and to establish 
collaborations that could enable multicenter studies in natural history 
and other areas of clinical research. In addition, this Symposium 
promotes interaction among interested lay participants and medical and 
scientific experts, in addition to representatives from pharmaceutical 
industry, involved in lysosomal diseases.
    The intent of the report language is to focus and encourage the 
National Institutes of Health's efforts with respect to the direction 
of Mucopolysaccharidoses and other Lysosomal Disease related research. 
The language included annually in the LHHS report has consistently 
addressed some of the most pressing, scientific needs in this complex 
area of biomedical research. The outcome has been, and one would hope 
continue to be, the Institutes examination of the issues raised by the 
Committee so that it can make meaningful efforts to enhance NIH 
activity on these important Mucopolysaccharidoses and Lysosomal Disease 
research issues.
                                 ______
                                 
     Prepared Statement of the National Multiple Sclerosis Society
    Mr. Chairman and Members of the Subcommittee, thank you for this 
opportunity to provide testimony regarding funding of critically 
important Federal programs that impact those affected by multiple 
sclerosis. We urge the Subcommittee to provide the following in fiscal 
year 2015: $2.5 million for the Lifespan Respite Care Program; at least 
$32 billion for the National Institutes of Health (NIH); robust support 
for Medicare and Medicaid; and $12.6 billion for the Social Security 
Administration (SSA).
    Multiple sclerosis (MS) is an unpredictable, often disabling 
disease of the central nervous system that interrupts the flow of 
information within the brain, and between the brain and body. Symptoms 
range from numbness and tingling to blindness and paralysis. The 
progress, severity, and specific symptoms of MS in any one person 
cannot yet be predicted. Most people with MS are diagnosed between the 
ages of 20 and 50, with at least two to three times more women than men 
being diagnosed with the disease.
    The National MS Society sees itself as a partner to the Government 
in many critical areas. As we advocate for NIH research, we do so as an 
organization that in 2013, funded approximately $48 million in MS 
research through funds generated through the Society's fundraising 
efforts. And as we advocate for Lifespan Respite funding, we do so as 
an organization that works to provide some level of respite relief for 
caregivers. So while we're here to advocate for Federal funding, we do 
it as an organization that commits tens of millions of dollars each 
year to similar or complementary efforts as those being funded by the 
Federal Government.
Lifespan Respite Care Program
    Up to one quarter of individuals living with MS require long-term 
care services at some point during the course of the disease. Often, a 
family member steps into the role of primary caregiver. According to a 
2011 AARP report, 61.6 million family caregivers provided care at some 
point during 2009 and the value of their uncompensated services was 
approximately $450 billion per year. Family caregivers allow the person 
living with MS to remain home for as long as possible and avoid 
premature admission to costlier institutional facilities.
    Family caregiving, while essential, can be draining and stressful. 
A 2012 National Alliance for Caregiving (NAC) survey of individuals 
providing care to people living with MS shows that on average, 
caregivers spend 24 hours a week providing care. Sixty 4 percent of 
caregivers were emotionally drained, 32 percent suffered from 
depression and 22 percent have lost a job due to caregiving 
responsibilities.
    The Lifespan Respite Care Program, enacted in 2006 under President 
Bush, provides competitive grants to States to establish or enhance 
statewide lifespan respite programs that better coordinate and increase 
access to quality respite care. Respite offers professional short-term 
help to give caregivers a break from the stress of providing care and 
has been shown to provide family caregivers with the relief necessary 
to maintain their own health and bolster family stability. Perhaps the 
most critical aspect of the program for people living with MS is that 
Lifespan Respite serves families regardless of special need or age--
literally across the lifespan. Much existing respite care has age 
eligibility requirements and since MS is typically diagnosed between 
the ages of 20 and 50, Lifespan Respite programs are often the only 
open door to needed respite services.
    For these reasons, the National MS Society asks that Congress 
provide $2.5 million for the Lifespan Respite Care Program in fiscal 
year 2015.
National Institutes of Health
    As mentioned previously, the National MS Society invested $48 
million to MS research in 2013 and sees the NIH as an invaluable 
partner to stop MS in its tracks, restore function and end MS forever. 
Approximately $115 million of fiscal year 2013 was directed to MS-
related research and over the years, NIH research projects have helped 
make significant progress in understanding MS. NIH scientists were 
among the first to report the value of MRI in detecting early signs of 
MS and have enhanced knowledge about how the immune system works and 
its role in the development of MS lesions.
    Twenty years ago, there were no MS therapies or medications--now 
there are ten. The NIH provided the basic research necessary so that 
these therapies could be developed. Despite this progress, there are 
still no treatments approved for people living with progressive MS. 
Only with continued investment will the innovation momentum continue, 
allowing us to find successful treatments for those with progressive MS 
and a cure for all.
    The NIH also directly supports jobs in all 50 States and 17 of the 
30 fastest growing occupations in the U.S. are related to medical 
research or healthcare. More than 83 percent of the NIH's funding is 
awarded through almost 50,000 competitive grants to more than 325,000 
researchers at over 3,000 universities, medical schools, and other 
research institutions in every State.
    For these reasons, the Society urges Congress to provide at least 
$32 billion for the NIH in fiscal year 2015.
Centers for Medicare & Medicaid Services
    Medicare: It is estimated that over 20 percent of the MS population 
relies on Medicare as its primary insurer. The majority of these 
individuals are under the age of 65 and receive the Medicare benefit as 
a result of their disability. Of particular importance to the MS 
community are: having appropriate reimbursement levels for Medicare 
physicians, maintaining access to diagnostics and durable medical 
equipment, protecting access to needed speech, physical and 
occupational therapy services, and discouraging overly burdensome cost-
sharing for prescription drugs.
    Medicaid: Medicaid provides comprehensive health coverage to over 
eight million persons living with disabilities, plus six million 
persons with disabilities who rely on Medicaid to fill Medicare's gaps. 
The latest statistics (which are pre-recession) show that about 5-10 
percent of people with MS have Medicaid coverage. The most recently 
available data (2007) reveals that the average annual direct and 
indirect (e.g. lost wages) cost for someone with MS in the U.S. is 
approximately $69,000. After years of paying to manage their disease, 
some people with MS have spent the vast majority of their earnings and 
savings, making their financial situation so dire that Medicaid becomes 
their only option for health coverage.
    The National MS Society urges Congress to maintain funding for 
Medicaid and reject proposals to cap or block grant the program. Any of 
these proposals would merely shift costs to States, forcing States to 
shoulder a seemingly insurmountable financial burden or cut services on 
which our most vulnerable rely. The Society also urges Congress to 
protect and promote access to home- and community-based care in line 
with the 1999 U.S. Supreme Court decision Olmstead.
Social Security Administration
    Because of the unpredictable nature and sometimes serious 
impairment caused by the disease, SSA recognizes MS as a chronic 
illness or ``impairment'' that can cause disability severe enough to 
prevent an individual from working. During such periods, people living 
with MS are entitled to and rely on Social Security Disability 
Insurance (SSDI) or Supplemental Security Income (SSI) benefits to 
survive. The National MS Society urges Congress to provide $12.3 
billion for the SSA's administrative budget so that it can continue 
efforts to reduce hearings and disability backlogs, pay monthly 
benefits in a timely manner, and determine post-entitlement issues in a 
timely manner.
Conclusion
    The National MS Society thanks the Committee for the opportunity to 
provide written testimony and our recommendations for fiscal year 2015 
appropriations. The agencies and programs we have discussed are of 
vital importance to people living with MS and we look forward to 
continuing to working with the Committee to help move us closer to a 
world free of MS. Please don't hesitate to contact me with any 
questions.

    [This statement was submitted by Ted Thompson, Vice President, 
Federal Government Relations.]
                                 ______
                                 
     Prepared Statement of the National Nursing Centers Consortium
    On behalf of the National Nursing Centers Consortium (NNCC), I 
would like to thank the members of this subcommittee for the 
opportunity to submit testimony regarding the importance of 
appropriating funds to support nurse-managed health clinics. 
Specifically, NNCC and its members request an appropriation of $20 
million to support grants to nurse-managed health clinics through the 
Nurse Managed Health Clinic grant program under the Health Resources 
and Services Administration's Bureau of Primary Health Care in the 
Department of Health and Human Services.
    NNCC is a 501(c)(3) member association of nonprofit, nurse-managed 
health clinics, sometimes called nurse-managed health centers or NMHCs. 
Section 254(c)-1a(a)(2) of the Public Health Services Act defines 
``nurse-managed health clinic'' as ``a nurse practice arrangement, 
managed by advanced practice nurses, that provides primary care or 
wellness services to underserved or vulnerable populations and that is 
associated with a school, college, university or department of nursing, 
federally qualified health center (FQHC), or independent nonprofit 
health or social services agency.'' Currently, there are approximately 
250 NMHCs in operation throughout the United States. Section 254(c)-1a 
also mandates the creation of a Nurse Managed Health Clinic grant 
program and authorizes $50 million in grant funding.\1\ The NMHC grant 
program was established to provide these clinics with a stable source 
of Federal funding that would place them on footing similar to other 
safety-net providers. However, to date, funding for the grant program 
has not been appropriated.
---------------------------------------------------------------------------
    \1\ Public Health Services Act, 42 USC Sec. 254(c)-1a(e) (2014).
---------------------------------------------------------------------------
The Value of NMHCs and the Need for NMHC Grant Funding
    NMHCs Expand Primary Care Workforce Capacity.--The Nation is facing 
a primary care crisis that is about to get worse. According to the 
Association of American Medical Colleges (AAMC), by 2025 there will be 
a dearth of 130,600 physicians, which includes a shortage of 65,800 
primary care physicians.\2\ AAMC data also shows that American medical 
schools are not graduating enough doctors to meet this need.\3\ The 
Congressional Budget Office estimates the Medicaid expansion called for 
by the ACA will lead to 11 million new enrollees.\4\ As these new 
enrollees establish primary care homes, the burden on the primary care 
workforce is likely to increase dramatically. Data from Massachusetts 
shows just how bad the problem could get. A study conducted 2 years 
after expanding its public coverage found that only 52 percent of 
internists in Massachusetts were accepting new patients and one-third 
of family physicians were no longer accepting new patients.\5\
---------------------------------------------------------------------------
    \2\ American Association of Medical Colleges (AAMC). (June 2010). 
The impact of healthcare reform on the future supply and demand for 
physicians updated projections through 2025.
Retrieved from https://www.aamc.org/download/158076/data/
updated_projections_through
_2025.pdf.
    \3\ Dill, M. & Salsberg, E., AAMC Center for Workforce Studies. 
(Nov. 2008). The complexities of physician supply and demand. Retrieved 
from https://members.aamc.org/eweb/upload/
The%20Complexities%20of%20Physician%20Supply.pdf.
    \4\ Congressional Budget Office (CBO). (July 2012). Estimates for 
the insurance coverage provisions of the affordable care act updated 
for the recent supreme court decision. Retrieved from http://
www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-
CoverageEstimates.pdf.
    \5\ Massachusetts Medical Society. (2008). Physician workforce 
study: Executive summary. Retrieved from www.massmed.org/workforce.
---------------------------------------------------------------------------
    NMHCs are primarily managed by nurse practitioners, which make up 
the fastest growing segment of primary care providers in the country. 
According to the Health Resources and Services Agency, the number of 
primary care NPs is expected to grow by 30 percent, from 55,400 in 2010 
to 72,100 by 2020.\6\ Because of these growing numbers, policymakers 
across the country are calling for nurse practitioners and NMHCs to 
assume a greater role in primary care. For example, in its report, 
``The Future of Nursing, Leading Change, Advancing Health,'' the 
Institute of Medicine (IOM) states, ``advanced practice registered 
nurses should be called upon to fulfill and expand their potential as 
primary care providers across practice settings based on their 
education and competency.'' \7\ When discussing the role of NMHCs, the 
IOM report says, ``Nurse-managed health clinics offer opportunities to 
expand access; provide quality, evidence-based care; and improve 
outcomes for individuals who may not otherwise receive needed care.'' 
\8\
---------------------------------------------------------------------------
    \6\ Health Resources and Servs. Admin., Dept. of Health and Human 
Services. (November 2013). Projecting the supply and demand for primary 
care practitioners through 2020.
Retrieved from http://bhpr.hrsa.gov/healthworkforce/supplydemand/
usworkforce/primarycare/projectingprimarycare.pdf.
    \7\ Institute of Medicine (IOM). The future of nursing: Leading 
change, advancing health. p. 1-2. Washington, D.C.: National Academies 
Press.
    \8\ Institute of Medicine (IOM). The future of nursing: Leading 
change, advancing health. p. c-4. Washington, D.C.: National Academies 
Press.
---------------------------------------------------------------------------
    Along with the IOM, the National Governor's Association (NGA) and 
the National Institute for Health Care Reform (NIHCR) both released 
reports identifying the greater use of nurse practitioners as a means 
of alleviating the pressure on the primary care workforce and 
presenting NP scope of practice law and payment policy reform as 
important to ensuring comprehensive access to primary care. Most 
recently, in a 2013 study published in Health Affairs, the RAND 
Corporation projected that greater use of the nurse-managed health 
centers model could address the increased demand for primary care.\9\
---------------------------------------------------------------------------
    \9\ Auerbach, D. I. (Nov. 2013). Nurse-Managed Health Centers and 
Patient-Centered Medical Homes Could Mitigate Expected Primary Care 
Physician Shortage. Health Affairs, 32 (11), 1933--41.
---------------------------------------------------------------------------
    As safety-net providers, NMHCs offer high quality primary care to 
medically underserved patients regardless of the patient's ability to 
pay. However, NMHCs are struggling financially and often lack access to 
FQHC money available to other safety net providers. Thus, the NMHC 
grant program was created, providing NMHCs with alternative Federal 
funding to ensure their continued ability to meet the needs of their 
patients and communities. Because they already serve a high percentage 
of Medicaid patients, the clinics are positioned to not only absorb 
demand from the newly ensured but also fill gaps in care resulting from 
the fragmented application of Medicaid expansion.
    To lessen the primary care crisis and ensure the underserved can 
take full advantage of the care NMHCs offer, NNCC requests that the 
Subcommittee appropriate funding to the NMHC grant program. Evidence 
suggests that funding NMHCs will not only expand access but also lower 
the cost of care. In addition to lower labor costs, research shows that 
NMHCs decrease costs by reducing unnecessary emergency room visits and 
hospitalizations.\10\
---------------------------------------------------------------------------
    \10\ Coddington, J. A. & Sands, L. P. (2008). Cost of healthcare 
and quality outcomes of patients at nurse-managed clinics. Nurs. Econ, 
26(2), 75-83.
---------------------------------------------------------------------------
    NMHCs Help Educate the Health Professionals of Tomorrow.--FQHC 
funding is often unavailable to NMHCs, because many are affiliated with 
academic schools of nursing. Academically-affiliated NMHCs operate 
under the jurisdiction of a university, so most cannot meet FQHC 
governance requirements without breaking their academic connection and 
giving up their clinical programs. Ironically, it is these academic 
affiliations that make the NMHC model especially responsive to primary 
care shortages, since they contribute to workforce development. NMHCs 
naturally serve as community-based clinical training sites for a 
diverse group of health profession students including those training to 
be registered nurses and advance practice nurses (mostly nurse 
practitioners) as well as medical, pharmacy, dental, social work, 
public health, and other students. In post-clinical focus groups, 
students report being ``overwhelmingly satisfied'' with their 
experience in NMHC clinical rotations, crediting, in part, the 
community-based experience absent from other clinical rotations.\11\ 
The Future of Nursing report also praised NMHC clinical programs for 
their interprofessional education, which relates to both job 
satisfaction and a flexible workforce.\12\
---------------------------------------------------------------------------
    \11\ Institute for Nursing Centers. (2009). Feedback from student 
focus groups.
    \12\ Institute of Medicine (IOM). The future of nursing: Leading 
change, advancing health. p. c-4. Washington, D.C.: National Academies 
Press.
---------------------------------------------------------------------------
    In 2012, the NNCC conducted a survey of its members to measure 
their contribution to health professions education. Twenty-eight NMHCs 
in a mix of urban, rural, and suburban communities reported providing 
educational opportunities for nearly 1,500 students.\13\ The average 
number of students educated by the NMHC grant funded clinics was 80, 
while the clinics participating in the 2012 survey reported educating 
an average of 55 students. These results demonstrate that (1) NMHCs 
advance workforce development and (2) increased funding enhances the 
ability of NMHCs to offer educational opportunities.
---------------------------------------------------------------------------
    \13\ NNCC. (2012). NNCC Membership Survey.
---------------------------------------------------------------------------
    Despite the benefits of NMHC clinical programs, NMHC leaders are 
often forced to abandon this important piece of the NMHC model to 
qualify for FQHC funding. By providing an alternative source of funding 
for NMHCs, the Nurse-Managed Health Clinic grant program helps to 
preserve the contribution of NMHCs to workforce development. Given the 
country's growing need for nurses, NNCC respectfully requests that the 
subcommittee members appropriate funding to support clinical programs 
and place NMHCs on a similar footing with other safety-net providers 
through the NMHC grant program.
    In October of 2010, HRSA released $14.8 million in Prevention and 
Public Health Fund dollars to fund ten NMHC grants. In addition to 
serving over 27,000 patients and recording more than 72,000 encounters, 
the NMHC grantees have provided interdisciplinary clinical training to 
over 800 health profession students annually.\14\
---------------------------------------------------------------------------
    \14\ National Nursing Centers Consortium (NNCC). (2011). Survey of 
NMHCs.
---------------------------------------------------------------------------
    Request.--The 10 NMHC grants distributed in 2010 will expire this 
year if Congress does not move to appropriate funding to the program. 
NNCC respectfully requests an appropriation of $20 million in fiscal 
year 2015 for the Nurse-Managed Health Clinic Grant Program, as 
authorized under Title III of the Public Health Service Act.

    [This statement was submitted by Tine Hansen-Turton, CEO, National 
Nursing Centers Consortium.]
                                 ______
                                 
          Prepared Statement of the National Respite Coalition
    Mr. Chairman, I am Jill Kagan, Chair of the National Respite 
Coalition (NRC), a network of respite providers, family caregivers, 
national, State and local agencies and organizations who support 
respite. Thirty State respite coalitions are also affiliated with the 
NRC. This statement is presented on behalf of these organizations. The 
NRC also facilitates the Lifespan Respite Task Force, a coalition of 
over 100 national, State and local groups who support the Lifespan 
Respite Program and its continued funding. We are requesting that the 
Subcommittee include $2.5 million for the Lifespan Respite Care Program 
administered by ACL/AoA in the fiscal year 2015 Labor, HHS, and 
Education Appropriations bill or designate this amount from the 
Prevention and Public Health Fund as recommended in the President's 
fiscal year 2015 budget. This amount is only modestly above the current 
fiscal year 2014 level of $2.3. This will enable:
  --State replication of best practices in Lifespan Respite to allow 
        family caregivers, regardless of the care recipient's age or 
        disability, to have access to affordable respite, and to be 
        able to continue to play the significant role in long-term care 
        that they are fulfilling today, saving Medicaid billions;
  --Improvement in the quality of respite services currently available;
  --Expansion of respite capacity to serve more families by building 
        new and enhancing current respite options, including 
        recruitment and training of respite workers and volunteers; and
  --Greater consumer direction by providing family caregivers with 
        training and information on how to find, use and pay for 
        respite services.
                           who needs respite?
    A 2012 national survey from the Pew Research Center found that four 
in ten adults in the U.S. are caring for an adult or child with 
significant health issues, up from 30 percent in 2010 (Fox, S, et al, 
2013). The estimated economic value of the unpaid contributions of 
family caregivers caring for someone over the age of 18 is 
approximately $450 billion. This amount is more than total Medicaid 
spending, including both Federal and State contributions for healthcare 
and long-term services and supports. If parents caring for children 
with special needs are also considered, another $50 to $100 billion 
would be added to the economic value of family caregiving (AARP Public 
Policy Institute, 2011).
    Family caregiving is not just an aging issue, but also a lifespan 
one. While the aging population is growing rapidly, the majority of 
family caregivers are caring for someone under age 75 (56 percent); 28 
percent of family caregivers care for someone between the ages of 50-
75, and 28 percent care for someone under age 50 (National Alliance for 
Caregiving (NAC) and AARP, 2009). Many family caregivers are in the 
sandwich generation--46 percent of women who are caregivers of an aging 
family member and 40 percent of men also have children under the age of 
18 at home (Aumann, K, and Galinsky, E, 2008). And 6.7 million children 
are in the primary custody of an aging grandparent or other relative.
    Families of the wounded warriors, military personnel who returned 
from Iraq and Afghanistan with traumatic brain injuries and other 
serious chronic and debilitating conditions, don't have full access to 
respite. Even with enactment of the VA Family Caregiver Support Program 
which serves only veterans since 9/11, the need for respite will remain 
high for all veterans and their family caregivers. Caregivers whose 
veterans have PTSD are about half as likely as other caregivers to 
receive respite (11 percent vs. 20 percent) (NAC, November 2010). 
Sixty-eight percent of veterans' caregivers reported their situation as 
highly stressful compared to 31 percent of caregivers nationally, and 
three times as many say there is a high degree of physical strain (40 
percent vs. 14 percent) (NAC, 2010). Veterans' caregivers specifically 
asked for up-to-date lists of respite providers in their communities 
and help to find services, the very thing Lifespan Respite is charged 
to provide (NAC, 2010).
    National, State and local surveys have shown respite to be the most 
frequently requested service of the Nation's family caregivers (The 
Arc, 2011; National Family Caregivers Association, 2011). Other than 
financial assistance for caregiving through direct vouchers payments or 
tax credits, respite is the number one national policy related to 
service delivery that family caregivers prefer (NAC and AARP, 2009). 
Yet respite is unused, in short supply, inaccessible, or unaffordable 
to a majority of the Nation's family caregivers. The NAC 2009 survey 
found that despite the fact that among the most frequently reported 
unmet needs of family caregivers were ``finding time for myself'' (32 
percent), ``managing emotional and physical stress'' (34 percent), and 
``balancing work and family responsibilities'' (27 percent), nearly 90 
percent of family caregivers across the lifespan are not receiving 
respite services at all.
    An estimated 80 percent of all long-term care in the U.S. is 
provided at home. This percentage will only rise in the coming decades 
with greater life expectancies of individuals with disabling and 
chronic conditions living with their aging parents or other caregivers, 
the aging of the baby boom generation, and the decline in the 
percentage of the frail elderly who are entering nursing homes.
          respite barriers and the effect on family caregivers
    Barriers to accessing respite include reluctance to ask for help, 
fragmented and narrowly targeted services, cost, and the lack of 
information about respite or how to find or choose a provider. Even 
when respite is an allowable funded service, a critically short supply 
of well-trained respite providers may prohibit a family from making use 
of a service they so desperately need. Lifespan Respite is designed to 
help States eliminate these barriers through improved coordination and 
capacity building.
    While most families take great joy in helping their family members 
to live at home, it has been well documented that family caregivers 
experience physical and emotional problems directly related to their 
caregiving responsibilities. In a 2009 survey of family caregivers, a 
majority (51 percent) who are caring for someone over age 18 have 
medium or high levels of burden of care, measured by the number of 
activities of daily living with which they provide assistance, and 31 
percent were identified as ``highly stressed'' (NAC and AARP, 2009). 
Parents of children with special healthcare needs report poorer general 
health, more physical health problems, worse sleep, and increased 
depressive symptoms compared to parents of typically developing (TD) 
children (McBean, A and Schlosnagle, L, 2013).
    A family caregiver's declining health status is a risk factor for 
care recipient institutionalization. When caregivers lack effective 
coping styles or are depressed, care recipients may be at risk for 
falling, developing preventable secondary health conditions or 
limitations in functional abilities. The risk of abuse from caregivers 
among care recipients with significant needs increases when caregivers 
themselves are depressed or in poor health (American Psychological 
Association, nd).
    Supports that would ease family caregiver stress, most importantly 
respite, are too often out of reach or completely unavailable. 
Restrictive eligibility criteria also preclude many families from 
receiving services or continuing to receive services for which they 
once were eligible. Children with disabilities will age out of the 
system when they turn 21 and they will lose many of the services, such 
as respite. A survey of nearly 5000 caregivers of individuals with 
intellectual and developmental disabilities (I/DD) conducted by The Arc 
found: the vast majority of caregivers report that they are suffering 
from physical fatigue (88 percent), emotional stress (81 percent) and 
emotional upset or guilt (81 percent) some or most of the time; 1 out 
of 5 families (20 percent) report that someone in the family had to 
quit their job to stay home and support the needs of their family 
member; and more than 75 percent of family caregivers caring for adult 
children with developmental disabilities could not find respite 
services (The Arc, 2011). Respite may not exist at all in some States 
for individuals with Alzheimer's, those under age 60 with conditions 
such as ALS, MS, spinal cord or traumatic brain injuries, or children 
with serious emotional conditions.
              respite benefits families and is cost saving
    Respite has been shown to be an effective way to reduces stress and 
improve the health and well-being of family caregivers that in turn 
helps avoid or delay out-of-home placements, such as nursing homes or 
foster care, minimizes the precursors that can lead to abuse and 
neglect, and strengthens marriages and family stability. A recent study 
of parents of children with autism spectrum disorders found that 
respite care was associated with reduced stress and improved marital 
quality (Harper, Amber, et al, 2013). A U.S. Department of Health and 
Human Services report prepared by the Urban Institute found that 
reducing key stresses on caregivers, such as physical strain and 
financial hardship, through services such as respite would reduce 
nursing home entry (Spillman and Long, USDHHS, 2007). In a survey of 
caregivers of individuals with Multiple Sclerosis (MS), two-thirds said 
that respite would help keep their loved one at home. When the care 
recipient with MS also has cognitive impairment, the percentage of 
those saying respite would be helpful to avoid or delay nursing home 
placement jumps to 75 percent (NAC, 2012).
    The budgetary benefits that accrue because of respite are just as 
compelling. Delaying a nursing home placement for just one individual 
with Alzheimer's or other chronic condition for several months can save 
Medicaid and other government programs thousands of dollars. 
Researchers at the University of Pennsylvania studied the records of 
over 28,000 children with autism ages 5 to 21 who were enrolled in 
Medicaid in 2004. They concluded that for every $1,000 States spent on 
respite services in the previous 60 days, there was an 8 percent drop 
in the odds of hospitalization (Mandell, David S., et al, 2012). In the 
private sector, U.S. businesses lose from $17.1 billion to $33.6 
billion per year in lost productivity of family caregivers (MetLife 
Mature Market Institute, 2006). Higher absenteeism alone among working 
caregivers costs the U.S. economy an estimated $25.2 billion in lost 
productivity per year (Witters, D., 2011). Respite for working family 
caregivers could help improve job performance and employers could 
potentially save billions.
                lifespan respite care program will help
    The Federal Lifespan Respite program is administered by the 
Administration for Community Living (ACL), Administration on Aging 
(AoA), U.S. Department of Health and Human Services (HHS). ACL/AoA 
provides competitive grants to eligible State agencies in concert with 
Aging and Disability Resource Centers (ADRCs) working in collaboration 
with State respite coalitions or respite organizations. Congress 
appropriated $2.5 million each year from fiscal year 2009--fiscal year 
2012 and a slightly lower amount due to sequestration in fiscal year 
2013 and fiscal year 2014. Since 2009, 32 States and the District of 
Columbia each received three-year $200,000 start-up Lifespan Respite 
Grants. Nine States and DC received one-time $150,000 expansion grants 
to focus on direct services, especially for those who are unserved. In 
the last 2 years, many of the States received 17-month Integration and 
Sustainability grants to continue their important work.
    The purpose of the law is to expand and enhance respite services, 
improve coordination, and improve respite access and quality. States 
are required to establish State and local coordinated Lifespan Respite 
care systems to serve families regardless of age or special need, 
provide new planned and emergency respite services, train and recruit 
respite workers and volunteers and assist caregivers in gaining access 
to services. Those eligible would include family members, foster 
parents or other adults providing unpaid care to adults who require 
care to meet basic needs or prevent injury and to children who require 
care beyond that required by children generally to meet basic needs.
    Lifespan Respite, defined as a coordinated system of community-
based respite services, helps States use limited resources across age 
and disability groups more effectively. Provider pools can be 
recruited, trained and shared, administrative burdens reduced by 
coordinating resources, and savings used to fund new respite services 
for families who do not qualify for any Federal or State program.
          how is lifespan respite program making a difference?
    With limited funds, Lifespan Respite grantees are engaged in 
innovative activities such as:
  --In TN and RI, the Lifespan Respite program is building respite 
        capacity by expanding volunteer networks of providers by 
        recruiting University students or Senior Corps volunteers or 
        expanding the national TimeBanks model for establishing 
        voluntary family cooperative respite strategies.
  --In Texas, the Lifespan Respite program has established a statewide 
        Respite Coordination Center, and an online database.
  --In SC, the State respite coalition and the Lifespan Respite program 
        are partnering in new ways with the untapped faith community to 
        provide respite, especially in rural areas.
  --The North Carolina Lifespan Respite Program has challenged each of 
        its 100 counties to improve respite service delivery locally, 
        and has partnered with the Money Follows the Person program to 
        develop family caregiver peer-to-peer support and respite.
  --In NH, new providers have been recruited and trained through 
        partnerships with the NH National Alliance on Mental Illness, 
        New Hampshire Family Voices, and the College of Direct Support 
        with funding from the Department of Labor to expand the pool of 
        respite providers to work with teens and older individuals with 
        mental health conditions or other groups where respite is in 
        short supply.
  --The AZ Lifespan Respite program housed in Division of Aging and 
        Adult Services has partnered with their State's Children with 
        Special Health Care Needs Program to provide respite vouchers 
        to families in need across the age and disability spectrum.
  --The OK Lifespan Respite program partnered with their State's 
        Federal Transit Administration's Section 5310 transportation 
        authority to release a van no longer needed to develop mobile 
        respite to serve isolated rural areas of the State.
    Across the board, States are building respite registries and ``no 
wrong door systems'' in collaboration with State respite coalitions and 
ADRCs to help family caregivers access respite and funding sources. OK, 
AL, NV, TN and others are using Lifespan Respite grants to expand or 
implement participant-directed respite through voucher systems so that 
family caregivers have greater control over the type and quality of the 
respite they select. State grantees secure commitments from partnering 
State agencies to share information and coordinate resources to build a 
seamless Lifespan Respite system for accessing respite.
    Funding must be maintained to help sustain these innovative State 
efforts. The goal of Lifespan Respite System is to coordinate respite 
services and funding, maximize existing resources and leverage new 
dollars in both the public and private sectors to build respite 
capacity and serve the unserved, but States need more time and fiscal 
support to do so. Maintaining funding for the program in fiscal year 
2015 could allow several new States to start Lifespan Respite Programs 
and help assist at least a few of the remaining grantees to complete 
the work that they have started. As it is, given the limited funding 
for fiscal year 2014, only 1-2 new States and 5-8 of the current 
grantees are expected to be funded. States are working successfully 
with ARCH to develop comprehensive sustainability plans, but without 
Federal support, many of the grantees will be cut off before they have 
had a chance to have a lasting impact.
    No other Federal program mandates respite as its sole focus, helps 
ensure respite quality or choice, and allows funds for respite start-
up, training or coordination to address accessibility and affordability 
issues for families. With tens of millions of families affected, 
caregiving is a public health issue requiring an immediate proven 
preventive response, such as respite. We urge you to include at least 
$2.5 million in the fiscal year 2015 Labor, HHS, and Education 
appropriations bill or designate this amount in the Prevention and 
Public Health Fund. This will allow Lifespan Respite Programs to be 
replicated and sustained. Families, with access to respite, will be 
able to maintain their own health and well-being and continue to play 
the significant role that they are fulfilling today.

    [This statement was submitted by Jill Kagan, Chair, National 
Respite Coalition.]
                                 ______
                                 
      Prepared Statement of the National Rural Health Association
    The National Rural Health Association (NRHA) is pleased to provide 
the Labor, Health and Human Services, Education and Related Agencies 
Appropriations Subcommittee with a statement for the record on fiscal 
year 2015 funding levels for programs with a significant impact on the 
health of rural Americans.
    NRHA is a national nonprofit membership organization with a diverse 
collection of 21,000 individuals and organizations who share a common 
interest in rural health. The Association's mission is to improve the 
health of rural Americans and to provide leadership on rural health 
issues through advocacy, communications, education and research.
    NRHA is advocating support for a group of rural health program that 
assist rural communities in maintaining and building a strong 
healthcare delivery system into the future. Most importantly, these 
programs help increase the capacity of the rural healthcare delivery 
system and true safety net providers. Rural Americans, on average, are 
poorer, sicker and older than their urban counterparts. Programs in the 
rural health safety net increase access to healthcare, help communities 
create new health programs for those in need and train the future 
health professionals that will care for the 62 million rural Americans. 
With modest investments, these programs evaluate, study and implement 
quality improvement programs and health information technology systems.
    Important rural health programs supported by NRHA are outlined 
below.
    Rural Health Outreach and Network Grants provide capital investment 
for planning and launching innovative projects in rural communities 
that later become self-sufficient. These grants are unique in the 
Federal system as they allow the community to build a program around 
their needs. These grants award funding to develop needed formal, 
integrated networks of providers that deliver primary and acute 
services. The grants have led to projects including information 
technology networks, oral screenings, and preventative care. Due to the 
community nature of the grants and a focus on self-sustainability after 
the terms of the grant have run out--85 percent of the Outreach 
Grantees continue to deliver services 5 full years after Federal 
funding ended. Request: $62.7 million.
    Rural Health Research and Policy Grants form the Federal 
infrastructure for rural health policy. Without these funds, rural 
America has no coordinated voice in the Department of Health and Human 
Services (HHS). In addition to the expertise provided to agencies such 
as the Centers for Medicare and Medicaid Services, this line item also 
funds rural health research centers across the country. Additionally, 
we urge the Subcommittee to include in report language instructions to 
the Office of Rural Health Policy to direct additional funding to the 
State rural health associations. Request: $10.3 million.
    State Offices of Rural Health are the State counterparts to the 
Federal rural health research and policy efforts, and form the State 
infrastructure for rural health policy. They assist States in 
strengthening rural healthcare delivery systems by maintaining a focal 
point for rural health within each State and by linking small rural 
communities with State and Federal resources to develop long term 
solutions to rural health problems. Without these funds, States would 
have diminished capacity to administer many of the critical rural 
health programs. The State offices play a key role in assisting rural 
health clinics, community health centers, and small, rural hospitals 
assess community healthcare needs. This program creates a State focus 
for rural health interests, brings technical assistance to rural areas, 
and helps frontier communities tap State and national resources 
available for healthcare and economic development. In partnership with 
other State agencies, the State rural health offices have been 
essential in addressing the unique needs of rural communities. Request: 
$11.1 million.
    Rural Hospital Flexibility Grants fund quality improvement and 
emergency medical service projects for Critical Access Hospitals (CAHs) 
across the country. The BBA created this essential program to improve 
access to essential healthcare services by CAHs, rural hospital 
networks and rural emergency medical services. These grants allow 
statewide coordination and provide expertise to CAHs for quality 
improvement or information technology activities. Also funded in this 
line is the Small Hospital Improvement Program (SHIP), which provides 
grants to more than 1,500 small rural hospitals (50 beds or less) 
across the country to help improve their business operations, focus on 
quality improvement and to ensure compliance provisions related to 
health information privacy. Request: $47.7 million.
    Rural and Community Access to Emergency Devices assist communities 
in purchasing emergency devices and training potential first responders 
in their use. Defibrillators double a victim's chance of survival after 
sudden cardiac arrest, which an estimated 163,221 Americans experience 
every year. This program trains lay rescuers and first responders in 
their use and places them in public areas where sudden cardiac arrest 
is likely to occur. Request: $3.7 million.
    The Office for the Advancement of Telehealth supports distance-
provided clinical services and is designed to reduce the isolation of 
rural providers, foster integrated delivery systems through network 
development and test a range of telehealth applications. Long-term, 
telehealth promises to improve the health of millions of Americans, 
provide constant education to isolated rural providers and save money 
through reduced office visits and hospital care. The OAT leads, 
coordinates and promotes the use of telehealth technologies by 
fostering partnerships between Federal agencies, States and private 
sector groups to create telehealth projects. These approaches are still 
new and unfolding and continued investment in the infrastructure and 
development is needed. Request: $15.3 million.
    National Health Service Corps (NHSC) plays a critical role in 
providing primary healthcare services to rural underserved populations 
by placing healthcare providers in our Nation's most underserved 
communities. Investment in our healthcare workforce is absolutely vital 
to support the newly insured population resulting from health reform 
and the long-term underserved in isolated rural communities. Programs 
like the NHSC help maximize the capacity of our health system to care 
for patients. The demand for primary care providers far exceeds the 
supply, and the needs of our rural communities continue to grow. The 
NRHA supports the President's request to ensure that the NHSC has 
access to the dedicated funding through the CHC Fund.
    Frontier Community Health Integration Demonstration Program (F-
CHIP) funds development and testing of new models for the delivery of 
healthcare services in frontier areas through improving access and 
integration of the delivery of healthcare to Medicare beneficiaries.
    Frontier Extended Stay Clinic (FESC) a geographically isolated 
medical clinic designed to provide primary, emergency, and extended-
stay care 24 hours per day when hospital services are not readily 
available. The Federal Office of Rural Health Policy (ORHP) has 
provided funding for infrastructure development to four clinics in 
Alaska.
Title VII Health Professions Training Programs (with a significant 
        rural focus):
  --Area Health Education and Centers (AHECs) financially support and 
        encourage those training to become healthcare professionals to 
        practice in rural areas. Without this experience and support 
        while in medical school, far fewer professionals would make the 
        commitment to rural areas and facilities including Community 
        Health Centers, Rural Health Clinics and rural hospitals. The 
        AHEC Programs and Centers play a critical national role in 
        addressing healthcare workforce shortages, particularly those 
        in primary care through an established infrastructure. The 
        program grantees support the recruitment and retention of 
        physicians, students, faculty and other primary care providers 
        in rural and medically underserved areas by providing local, 
        community-based, interdisciplinary primary care training. 
        Educating and training rural healthcare providers ensures a 
        sound future in the delivery of rural healthcare. It has been 
        estimated that nearly half of AHECs would shut down without 
        Federal funding. Request: $75 million.
  --Rural Physician Pipeline Grants will help medical colleges develop 
        special rural training programs and recruit students from rural 
        communities, who are more likely to return to their home 
        regions to practice. This ``grow-your-own'' approach is one of 
        the best and most cost-effective ways to ensure a robust rural 
        workforce into the future. Request: $4.4 million.
  --Geriatric Programs train health professionals in geriatrics, 
        including funding for Geriatric Education Centers (GEC). There 
        are currently 47 GECs nationwide that ensure access to 
        appropriate and quality healthcare for seniors. Rural America 
        has a disproportionate share of the elderly and could see a 
        shortage of health providers without this program. Request: 
        $36.7 million.
    The National Rural Health Association appreciates the opportunity 
to provide our recommendations to the Subcommittee. These programs are 
critical to the rural health delivery system and help maintain access 
to high quality care in rural communities. We greatly appreciate the 
support of the Subcommittee and look forward to working with Members of 
the Subcommittee to continue making these important investments in 
rural health.
                                 ______
                                 
           Prepared Statement of the National Safety Council
    Chairman Harkin, Ranking Member Moran, and Members of the 
subcommittee, thank you for the opportunity to submit testimony 
regarding the National Safety Council's workplace safety appropriations 
priorities. My name is Jim Johnson, and I am Vice President of 
Workplace Safety Initiatives at the National Safety Council. We are a 
100 year-old Congressionally chartered nonprofit safety organization 
dedicated to saving lives by preventing injuries and deaths at work, in 
homes and communities, and on the roads through leadership, research, 
education, and advocacy. Our more than 14,000 member companies 
represent over 8 million employees at more than 51,000 worksites. Today 
I am seeking support for $565.01 million for the Occupational Safety 
and Health Administration (OSHA) and $332.86 million for the National 
Institute for Occupational Safety and Health (NIOSH), two organizations 
whose work is vitally important to the mission of safety.
Occupational Safety and Health Administration
    The National Safety Council believes that an effective and 
efficient OSHA is important for the safety of American workers and 
workplaces. NSC supports stable funding for OSHA that adequately funds 
all the agency's key functions, including compliance assistance and 
support to companies striving for safety excellence, the timely 
promulgation of regulations to protect America's workers, enforcement 
actions against companies that fail to comply with OSHA standards, and 
whistle blower protection for workers.
    The Council supports the top line funding level of $565.01 million 
for the agency included in the President's fiscal year 2015 budget 
request, and we strongly encourage the committee to fund the agency at 
a minimum of this funding level. While the Council is pleased that OSHA 
rulemaking and enforcement efforts in fiscal year 2014 have been 
restored to pre-sequester funding levels, we continue to have strong 
concerns about funding constraints placed on the agency's Federal 
compliance assistance efforts, which are presently funded at $69.4 
million, more than 9 percent less than fiscal year 2012 enacted levels.
    Of special concern to the Council is the impact that reduced 
compliance assistance funding has had on the agency's Voluntary 
Protection Programs (VPP). We encourage the committee to include report 
language recommending that VPP receive no less than $3 million in 
fiscal year 2015.
    VPP were created by OSHA in 1982 as a way of recognizing those 
employers who successfully implement effective safety and health 
management systems and maintain injury and illness rates below the 
national average for their industries. Under VPP, company stakeholders 
establish a relationship with OSHA based on a cooperative partnership. 
Because of this, approval into VPP is as much a proactive effort as it 
is recognition of hard work and effort put in by employers and 
employees to achieve exceptional records in occupational safety and 
health.
    The pursuit of VPP status has helped many safety professionals 
encourage their employers' leadership to improve safety management 
systems by complying with the program's criteria. Organizations with 
VPP status represent business leaders who have implemented strong 
safety management systems and demonstrated a commitment to continuous 
improvement. VPP sites have a Days Away Restricted or Transferred 
(DART) case rate of 52 percent below the industry average. The majority 
of VPP sites have less than 100 employees.
    However, despite the success of this program, recent budget 
constraints have required the agency to slow the growth in the number 
of new cooperative program participants. Following sequestration in 
fiscal year 2013, OSHA only reapproved sites that could be visited 
through local travel. As it stands, OSHA is not scheduling new VPP site 
approvals until a region's backlog of re-approvals of existing VPP 
facilities is eliminated. Minimum funding at a level of at least $3 
million will ensure that OSHA has the resources necessary to address 
the backlog of re-approvals of existing VPP facilities and to begin to 
approve new VPP sites.
National Institute for Occupational Safety and Health
    Funding NIOSH at the fiscal year 2014 program level of $332.86 
million at a minimum, and preserving the fiscal year 2014 level of $24 
million for the Institute's Agriculture, Forestry and Fishing (AgFF) 
Sector Program and $27.5 million for the Education and Research Centers 
(ERCs), is essential to ensuring that NIOSH can fulfill its mission of 
saving lives and preventing injuries.
    Finally, I would like to focus on the important role that NIOSH 
programs play in reducing workplace injuries and fatalities. NIOSH's 
primary responsibility is to conduct research and make recommendations 
for the prevention of work-related injuries and illnesses. NIOSH works 
to ensure the health and safety of the American workforce through 
research, education and training. It is not a regulatory agency, and 
can only issue recommendations for health and safety standards. The 
Council is disheartened to see the President's budget request again 
target the Institute's Agriculture, Forestry and Fishing (AgFF) Sector 
Program and Education and Research Centers (ERCs) by eliminating their 
budget.
    NIOSH established the AgFF program in 1990 in response to evidence 
that agricultural workers were suffering higher rates of injury and 
illness than other U.S. workers. The agriculture, forestry, and 
fishing, industry fatality rate is more than 8 times that of the all-
industry average. Yearly, almost 18,000 workers in this sector are 
injured seriously enough to require time away from work.\1\ Daily, an 
average of over 330 workers in this sector sustain injuries serious 
enough to require medical consultation, and nearly 2 workers die from 
an injury suffered at work.\2\ Today, the initiative includes nine 
regional centers and one national center to address children's farm 
safety. These centers conduct vital research leading to evidence-based 
standards that save lives. The AgFF Program is the only substantive 
Federal effort to meet the obligation to ensure safe conditions for 
workers in this sector, and it is effective.
---------------------------------------------------------------------------
    \1\ U.S. Bureau of Labor Statistics, U.S. Department of Labor. 
(2013). Table 2. numbers of nonfatal occupational injuries and 
illnesses by case type and ownership, selected industries, 2012. 
Retrieved February 12, 2014, from http://www.bls.gov/news.release/
osh.t02.htm.
    \2\ National Safety Council. (2013). Injury Facts, 2013 Edition.
---------------------------------------------------------------------------
    NIOSH supports education and research in occupational health 
through academic degree programs and research opportunities, primarily 
through 18 university-based ERCs located at leading universities around 
the country serving all 50 States. The mission of the ERCs is to reduce 
work-related injuries and illnesses in the U.S. by performing 
prevention research and by educating, through degree programs and 
continuing education, high-quality professionals who implement programs 
to improve occupational health and safety and minimize the dangers 
faced by workers across the country. The ERCs provide programs in a 
unique group of disciplines that benefit employers of all sizes and 
industries in every part of the country. Currently, the ERCs are 
responsible for supplying a good portion of the country's OSH graduates 
who will go on to fill professional roles. With an aging occupational 
safety and health workforce, and a shortage of qualified OSH 
professionals, ERCs are essential to educating the next generation of 
professionals.
    Thank you again for the opportunity to submit testimony for the 
record.
                                 ______
                                 
Prepared Statement of the National Technical Institute for the Deaf and 
                   Rochester Institute of Technology
    Mr. Chairman and Members of the Committee: I am pleased to present 
the fiscal year 2015 budget request for the National Technical 
Institute for the Deaf (NTID), one of nine colleges of the Rochester 
Institute of Technology (RIT), in Rochester, N.Y. Created by Congress 
by Public Law 89-36 in 1965, we provide university technical and 
professional education for students who are deaf and hard of hearing, 
leading to successful careers in high-demand fields for a sub-
population of individuals historically facing high rates of 
unemployment and under-employment. We also provide baccalaureate and 
graduate-level education for hearing students in professions serving 
deaf and hard-of-hearing individuals. NTID students live, study and 
socialize with more than 17,000 hearing students on the RIT campus.
Budget Request
    On behalf of NTID, for fiscal year 2015 I would like to request 
$66,291,000 in Operations. NTID has worked hard to manage its resources 
carefully and responsibly and as such is not requesting an increase in 
support in 2015. Over the past 2 years we have reduced our workforce by 
12 percent (70 positions) and limited our equipment expenditures. We 
also reduced our non-personnel expenditures by over 30 percent in such 
areas as building and equipment maintenance, instructional supplies, 
freelance interpreting, professional travel and student employment. 
NTID has also postponed requests for construction funding for critical 
and long overdue renovations to a 33-year old building currently 
housing three times the number of staff for which it was intended. In 
terms of non-Federal revenues, from fiscal year 2006 to fiscal year 
2014, student tuition and fees increased by 63 percent to offset the 
rising costs of providing a state-of-the-art college education. 
Likewise, from fiscal year 2006 to fiscal year 2013, NTID raised almost 
$20 million in support from individuals and organizations.
    Our fiscal year 2015 request to continue fiscal year 2014 funding 
of $66,291,000 in Operations would allow us to maintain a balanced 
budget and avoid harmful reductions. Without this funding, we would 
have to impose additional limitations in the areas of equipment 
purchasing, interpreting and captioning, scholarship support, building 
maintenance, and, most importantly, in personnel and enrollment. These 
are not the consequences a successful Federal investment should face.
Enrollment
    Truly a national program, NTID has enrolled students from all 50 
States. In Fall 2013 (fiscal year 2014), we attracted 1,432, the sixth 
straight year of more than 1,400 students. For fiscal year 2015, NTID 
hopes to maintain this high enrollment, if our operational resources 
allow us to do so. Our enrollment history over the last 8 years is 
shown below:

                                                  NTID ENROLLMENTS: FISCAL YEAR 2007--FISCAL YEAR 2014
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                      Deaf/Hard-of-Hearing Students                 Hearing Students
                                                              --------------------------------------------------------------------------------   Grand
                         Fiscal Year                                                                       Interpreting                          Total
                                                               Undergrad   Grad RIT     MSSE    Sub-Total     Program       MSSE    Sub-Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
2014.........................................................      1,195         42         18      1,255          147          30        177      1,432
2013.........................................................      1,269         37         25      1,331          167          31        198      1,529
2012.........................................................      1,281         42         31      1,354          160          33        193      1,547
2011.........................................................      1,263         40         29      1,332          147          42        189      1,521
2010.........................................................      1,237         38         32      1,307          138          29        167      1,474
2009.........................................................      1,212         48         24      1,284          135          31        166      1,450
2008.........................................................      1,103         51         31      1,185          130          28        158      1,343
2007.........................................................      1,017         47         31      1,095          130          25        155      1,250
--------------------------------------------------------------------------------------------------------------------------------------------------------

    MSSE: Master of Science in Secondary Education of Deaf/Hard of 
Hearing Students
    Grad RIT: other graduate programs at RIT
NTID Academic Programs
    NTID offers high quality, career-focused associate degree programs 
preparing students for specific well-paying technical careers. NTID 
also is expanding the number of its transfer associate degree programs 
to better serve the higher achieving segment of our student population 
seeking bachelor's and master's degrees. These transfer programs 
provide seamless transition to baccalaureate studies in the other 
colleges of RIT. In support of those deaf and hard-of-hearing students 
enrolled in the other RIT colleges, NTID provides a range of access 
services (including sign language interpreting, real-time speech-to-
text captioning, and notetaking) as well as tutoring services. One of 
NTID's greatest strengths is our outstanding track record of assisting 
high-potential students to gain admission to, and graduate from, the 
other colleges of RIT at rates comparable to their hearing peers.
    A cooperative education (co-op) component is an integral part of 
academic programming at NTID and prepares students for success in the 
job market. A co-op gives students the opportunity to experience a 
real-life job situation and focus their career choice. Students develop 
technical skills and enhance vital personal skills such as teamwork and 
communication, which will make them better candidates for full-time 
employment after graduation. Almost 300 students last year participated 
in 10-week co-op experiences that augment their academic studies, 
refine their social skills, and prepare them for the competitive 
working world.
Student Accomplishments
    For our graduates, over the past 5 years, an average of 91 percent 
have found jobs commensurate with their education level. Of our fiscal 
year 2012 graduates (the most recent class for which numbers are 
available), 93 percent were employed 1 year later, with 65 percent 
employed in business and industry, 24 percent in education/non-profits, 
and 11 percent in government.
    Graduation from NTID has a demonstrably positive effect on 
students' earnings over a lifetime, and results in a notable reduction 
in dependence on Supplemental Security Income (SSI) and Social Security 
Disability Insurance (SSDI). In fiscal year 2012, NTID, the Social 
Security Administration, and Cornell University examined earnings and 
Federal program participation data for approximately 16,000 deaf and 
hard-of-hearing individuals who applied to NTID over our entire 
history. The studies show that NTID graduates over their lifetimes are 
employed at a much higher rate, earn substantially more (therefore 
paying significantly more in taxes), and participate at a much lower 
rate in SSI and SSDI than students who withdrew from NTID.
    Using SSA data, at age 50, 78 percent of NTID deaf and hard-of-
hearing graduates with bachelor degrees and 73 percent with associate 
degrees report earnings, compared to 58 percent of NTID deaf and hard-
of-hearing students who withdrew from NTID. Equally important is the 
demonstrated impact of an NTID education on graduates' earnings. At age 
50, $58,000 is the median salary for NTID deaf and hard-of-hearing 
graduates with bachelor degrees and $41,000 for those with associate 
degrees, compared to $34,000 for deaf and hard-of-hearing students who 
withdrew from NTID. Higher earnings, of course, yield higher tax 
revenues.
    An NTID education also translates into reduced dependency on 
Federal transfer programs, such as SSI and SSDI. At age 40, less than 2 
percent of NTID deaf and hard-of-hearing associate and bachelor degree 
graduates participated in the SSI program compared to 8 percent of deaf 
and hard-of-hearing students who withdrew from NTID. Similarly, at age 
50, only 18 percent of NTID deaf and hard-of-hearing bachelor degree 
graduates and 28 percent of associate degree graduates participated in 
the SSDI program, compared to 35 percent of deaf and hard-of-hearing 
students who withdrew from NTID.
Access Services
    NTID provides an access services system to meet the needs of a 
large number of deaf and hard-of-hearing students enrolled in 
baccalaureate and graduate degree programs in RIT's other colleges as 
well as students enrolled in NTID programs who take courses in the 
other colleges of RIT. Access services also are provided for events and 
activities throughout the RIT community. Access services include sign 
language interpreting, real-time captioning, classroom notetaking 
services, captioned classroom video materials, and Assistive Listening 
Services.
    As enrollments have steadily increased, so has the demand for 
access services. In fiscal year 2013, 145,003 hours of interpreting 
were provided--an increase of 27 percent compared to fiscal year 2008. 
In fiscal year 2013, 18,263 hours of real-time captioning were provided 
to students--a 9 percent increase over fiscal year 2008. The increase 
in demand is partly a result of the increase in the number of students 
enrolled in baccalaureate programs at RIT and the number of students 
with cochlear implants. In fiscal year 2014, there were 526 deaf and 
hard-of-hearing students enrolled in baccalaureate programs at RIT, a 
19 percent increase compared to fiscal year 2008, and 360 students with 
cochlear implants, a 47 percent increase over fiscal year 2008.
Summary
    It is extremely important that our fiscal year 2015 funding request 
be granted in order that we might continue our mission to prepare deaf 
and hard-of-hearing people to excel in the workplace. NTID has shown 
through hard data that our graduates have higher salaries, pay more 
taxes, and depend less on Federal SSI/SSDI payments than their 
counterparts who do not attend NTID. Our employment rate is 91 percent 
over the past 5 years--even more remarkable given the state of the 
economy. Demand for an NTID education is higher than ever. Therefore, I 
ask that you please consider funding our fiscal year 2015 request of 
$66,291,000 for Operations.
    We are hopeful that the members of the Committee will agree that 
NTID, with its long history of successful stewardship of Federal funds 
and outstanding educational record of service with people who are deaf 
and hard of hearing, remains deserving of your support and confidence. 
Likewise, we will continue to demonstrate to Congress and the American 
people that NTID is a proven economic investment in the future of young 
deaf and hard-of-hearing citizens. Quite simply, NTID is a Federal 
program that works.

    [This statement was submitted by Dr. Gerard J. Buckley, President, 
National Technical Institute for the Deaf, and Vice President and Dean, 
Rochester Institute of Technology. ]
                                 ______
                                 
     Prepared Statement of the National Violence Prevention Network
    Thank you for this opportunity to submit testimony in support of 
increased funding for the National Violent Death Reporting System 
(NVDRS), which is administered by the National Center for Injury 
Prevention and Control at the Centers for Disease Control and 
Prevention (CDC). The National Violence Prevention Network, a broad and 
diverse alliance of health and welfare, suicide and violence 
prevention, and law enforcement advocates supports increasing the 
fiscal year 2015 funding level to $25 million to allow for nationwide 
expansion of the NVDRS program. fiscal year 2014 NVDRS funding is $11.2 
million.
                               background
    Each year, about 55,000 Americans die violent deaths. In addition, 
an average of 105 people (22 of which are military veterans) take their 
own lives each day.
    The NVDRS program makes better use of data that are already being 
collected by health, law enforcement, and social service agencies. The 
NVDRS program, in fact, does not require the collection of any new 
data. Instead it links together information that, when kept in separate 
compartments, is much less valuable as a tool to characterize and 
monitor violent deaths. With a clearer picture of why violent deaths 
occurs, law enforcement, public health officials and others can work 
together more effectively to identify those at risk and target 
effective preventive services.
    Currently, NVDRS funding levels only allow the program to operate 
in 18 States, including Alaska, Colorado, Georgia, Kentucky, Maryland, 
Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio, 
Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and 
Wisconsin. Several other States have expressed an interest in joining 
once new funding becomes available. While NVDRS is beginning to 
strengthen violence and suicide prevention efforts in the 18 
participating States, non-participating States continue to miss out on 
the benefits of this important public health surveillance program.
                            nvdrs in action
    Child abuse and other violence involving children and adolescents 
remains a problem in America, and it is only through a comprehensive 
understanding of its root causes that these needless deaths can be 
prevented. Studies suggest that between 3.3 and 10 million children 
witness some form of domestic violence annually. Additionally, 1,560 
children died as a result of abuse or neglect in 2010.
    Children are most vulnerable and most dependent on their caregivers 
during infancy and early childhood. Sadly, NVDRS data has shown that 
young children are at the greatest risk of homicide in their own homes. 
Combined NVDRS data from Alaska, Maryland, Massachusetts, New Jersey, 
Oregon, South Carolina, and Virginia determined that African American 
children aged 4 years old and under are more than four times as likely 
to be victims of homicide than Caucasian children, and that homicides 
of children aged four and under are most often committed by a parent or 
caregiver in the home. The data also shows that household items, or 
``weapons of opportunity,'' were most commonly used, suggesting that 
poor stress responses may be factors in these deaths. Knowing the 
demographics and methods of child abusers can lead to more effective, 
targeted prevention programs.
    Intimate partner violence (IPV) is another issue where NVDRS is 
proving its value. While IPV has declined along with other trends in 
crime over the past decade, thousands of Americans still fall victim to 
it every year. Intimate partner homicides accounted for 30 percent of 
the murders of women and 5 percent of the murders of men in 2006, 
according to the Bureau of Justice Statistics.
    Despite being in its early stages in several States, NVDRS is 
already providing critical information that is helping law enforcement 
and health and human service officials allocate resources and develop 
programs in ways that target those most at risk for intimate partner 
violence. For example, NVDRS data shows that while occurrences are 
rare, most murder-suicide victims are current or former intimate 
partners of the suspect, and a substantial number of victims were the 
suspect's offspring. In addition, NVDRS data indicate that women are 
about seven times more likely than men to be killed by a spouse, ex-
spouse, lover, or former lover, and most of these incidents occurred in 
the women's homes.
                          nvdrs & va suicides
    Although it is preventable, every year more than 38,000 Americans 
die by suicide and another one million Americans attempt it, costing 
more than $36 billion in lost wages and work productivity. In the 
United States today, there is no comprehensive national system to track 
suicides. However, because NVDRS includes information on all violent 
deaths--including deaths by suicide--information from the system can be 
used to develop effective suicide prevention plans at the community, 
State, and national levels.
    The central collection of this data can be of tremendous value for 
organizations such as the Department of Veterans Affairs that are 
working to improve their surveillance of suicides. For instance, CDC 
determined from national NVDRS data that veterans comprised 20 percent 
of all suicide victims. The types of data collected by NVDRS including 
gender, blood alcohol content, mental health issues and physical health 
issues can help prevention programs better identify and treat at-risk 
individuals.
                          federal role needed
    At an estimated annual cost of $25 million for full implementation, 
NVDRS is a relatively low-cost program that yields high-quality 
results. While State-specific information provides enormous value to 
local public health and law enforcement officials, data from all 50 
States, the U.S. territories and the District of Columbia must be 
obtained to complete the national picture. Aggregating this additional 
data will allow us to analyze national trends and also more quickly and 
accurately determine what factors can lead to violent death so that we 
can devise and disseminate strategies to address those factors.
         strengthening and expanding nvdrs in fiscal year 2014
    The 2014 Consolidated Appropriations Act recognized the public 
health utility of NVDRS in preventing violent deaths and increased 
NVDRS funding by roughly $8 million to facilitate continued expansion 
of the NVDRS program. With this new funding, NVDRS will expand to 
roughly two-thirds of the country. The time is now to complete the 
nation-wide expansion of NVDRS by providing an appropriation of $25 
million in fiscal year 2015.
    We thank you for the opportunity to submit this statement for the 
record. The investment in NVDRS has already begun to pay off, as the 18 
participating States are adopting effective violence prevention 
programs. We believe that national implementation of NVDRS is a wise 
public health investment that will assist State and national efforts to 
prevent deaths from domestic violence, veteran suicide, teen suicide, 
gang violence and other violence that affects communities around the 
country. We look forward to working with you secure an fiscal year 2015 
NVDRS appropriation of $25 million.
                                 ______
                                 
      Prepared Statement of the Native Hawaiian Education Council
    Aloha Chairman Harkin and members of the Senate Committee on 
Appropriations, Labor, HHS, and Education Subcommittee: Mahalo, thank 
you, for allowing us an opportunity to submit this request for 
appropriations.
    We are seeking continued funding at pre-sequestration levels for 
the Native Hawaiian Education Program (NHEP) that targets the Native 
Hawaiian student population. The NHEP is an important part of 
fulfilling the trust relationship between the U.S. and Native 
Hawaiians, and it helps to improve the educational status of Native 
Hawaiians. It is an important element in the Native community's effort 
to control its education programs and policies and to achieve 
educational parity. NHEP aims to close the education achievement gap 
between Native Hawaiians and the general population, and also functions 
to fulfill the trust relationship between the United States and Native 
Hawaiians, the indigenous people of a once sovereign nation. During the 
time of their own sovereignty in the kingdom of Hawai`i, Native 
Hawaiians had a higher rate of literacy than citizens of the United 
States. The educational achievement gap has occurred during the 
intervening years since the loss of Native Hawaiian sovereignty, so 
that today Native Hawaiians are among the most disadvantaged groups in 
the State.
The NHEP Works
    NHEP has been effective over the years in meeting the goals of the 
program. For example, NHEA has been instrumental in preserving and 
protecting the Native Hawaiian language through funding projects that 
are designed to address the use of the Native Hawaiian language in 
instruction, one of the priorities named in the NHEA. The number of 
speakers nearly doubled in 18 years from 8,872 speakers in 1990 to 
16,864 in 2008 (Source: OHA Data Book 2011 Tables 4.19 and 4.44)
    The NHEP has funded programs that incorporate culture and 
indigenous teaching practices in the classroom that leads to better 
outcomes for Native Hawaiian students. An example is the improvement in 
the graduation rates for Native Hawaiians and math and reading scores. 
Graduation rates for Native Hawaiians between 2002 and 2010 rose from 
70 percent to 72.2 percent (Sources: Kamehameha Schools' Native 
Hawaiian Education Assessment Update 2009, Fig. 9 and HI DOE 2005-06 to 
2009-10).
    Similarly, math and reading scores have risen for Native Hawaiians. 
The percent of Native Hawaiians scoring ``Proficient or Above `` from 
2007 to 2012 rose from 27 percent to 49 percent in math and from 41 
percent to 62 percent in reading (Source: Hawaii DOE Longitudinal Data 
System ).
    School attendance rates in schools with student populations that 
are over 50 percent Native Hawaiian have increased from 90.1 percent in 
the 2000-01 school year to 91.3 percent in the 2011-12 school year 
(Source: Kamehameha Schools' draft Ka Huaka`i update, p. 58)
The Need Still Exists
    In spite of the gains that Native Hawaiians have made 
educationally, the need for innovative programs to assist Native 
Hawaiians to improve their academic performance still exists, since 
Native Hawaiians have not yet attained parity with the rest of the 
students in the State.
    Timely high school graduation rates for students in the State rose 
from 77 percent to 79.6 percent in the same time period that it rose 
from 70 percent to 72.2 percent for Native Hawaiians (Sources: 
Kamehameha Schools' Native Hawaiian Education Assessment Update 2009, 
Fig. 9 and HI DOE 2005-06 to 2009-10).
    Native Hawaiians still lag behind the rest of the State in academic 
performance; however the gap between the Native Hawaiians and others is 
decreasing. From 2007 to 2012 the increase in the percentage of Native 
Hawaiians scoring ``Proficient or Above `` in math rose 22 percentage 
points, while the increase for the State during the same time period 
was 21 percentage points. The increase for Native Hawaiians in reading 
was even more dramatic during that time period, increasing 21 
percentage points compared to the State increase of only 11 percentage 
points. Unfortunately those gains were not enough to bring Native 
Hawaiians to parity. In 2012 Native Hawaiians were still 10 points 
behind the State in the percentage scoring ``Proficient or Above'' in 
math and nine points behind in the percentage scoring ``Proficient or 
Above'' in reading.

                                       Percent Scoring Proficient or Above
----------------------------------------------------------------------------------------------------------------
                                                                               2007            2012       Change
----------------------------------------------------------------------------------------------------------------
Native Hawaiians..........................  Math........................             27%             49%   22
State Totals..............................  Math........................              38              59   21
                                            Difference..................             -11             -10  ......
Native Hawaiians..........................  Reading.....................              41              62   21
State Totals..............................  Reading.....................              60              71   11
                                            Difference..................             -19              -9  ......
----------------------------------------------------------------------------------------------------------------
Source: Hawaii DOE Longitudinal Data System.

    In the area of Native Hawaiian language immersion, although the 
gains have been tremendous, the nearly 17,000 speakers in 2008 only 
represents 6 percent of the approximately 290,000 Native Hawaiians in 
Hawai`i (2010 U.S. Census).
Appropriations Request
    The pre-sequestration appropriations level for the NHEP was $34 
million. Sequestration reduced the amount by $2 million to $32 million, 
which is the amount entered into the President's budget. For such a 
small program as the NHEP, the $2 million reduction makes a significant 
negative impact on the program. We would like to continue to make gains 
in the educational achievement of Native Hawaiians, and request the 
pre-sequestration level of $34 million so that we don't lose the 
momentum of improvement.
    NHEP funds programs to help improve the educational attainment of 
Native Hawaiians in ways that are linguistically and culturally aligned 
to the needs of our Native students and communities in Hawai`i. 
Improving education, particularly for the most depressed groups, 
eventually leads to cost savings over time through decreased 
incarceration, poor health, and public assistance.(Barnett, W. S., & 
Ackerman, D. J. 2006. Costs, benefits, and the long-term effects of 
early care and education programs: Cautions and recommendations for 
community developers. Journal of the Community Development Society, 
37(2), 86-100.) Academic achievement is also correlated with positive 
economic outcomes. (Belfield, C. 2008, June. The economic investments 
of early education in Hawaii. Issue Brief. Flushing, NY: Queen's 
College, City University of New York.)
    Please help us sustain the NHEP to its pre-sequestration level in 
order to continue the educational gains that have taken this program 
years to accomplish.
                                 ______
                                 
             Prepared Statement of the Nephcure Foundation
            summary of recommendations for fiscal year 2015
_______________________________________________________________________

  --$32 billion for the National Institutes of Health (NIH)
  --Provide a corresponding increase to the National Institute of 
        Diabetes and Digestive and Kidney Diseases (NIDDK)
  --Expansion of the FSGS/NS Research Portfolio at NIDDK, the Office of 
        Rare Diseases Research (ORDR) and the National Institute on 
        Minority Health and Health Disparities (NIMHD) by funding more 
        research proposals for Primary Glomerular Disease
_______________________________________________________________________

    Thank you for the opportunity to present the views of the NephCure 
Foundation regarding research on idiopathic focal segmental 
glomerulosclerosis (FSGS) and primary nephrotic syndrome (NS). NephCure 
is the only non-profit organization exclusively devoted to fighting 
FSGS and the NS disease group. Driven by a panel of respected medical 
experts and a dedicated band of patients and families, NephCure works 
tirelessly to support kidney disease research and awareness.
    NS is a collection of signs and symptoms caused by diseases that 
attack the kidney's filtering system. These diseases include FSGS, 
Minimal Change Disease and Membranous Nephropathy. When affected, the 
kidney filters leak protein from the blood into the urine and often 
cause kidney failure, which requires dialysis or kidney 
transplantation. According to a Harvard University report, 73,000 
people in the United States have lost their kidneys as a result of 
FSGS. Unfortunately, the causes of FSGS and other filter diseases are 
poorly understood.
    FSGS is the second leading cause of NS and is especially difficult 
to treat. There is no known cure for FSGS and current treatments are 
difficult for patients to endure. These treatments include the use of 
steroids and other dangerous substances which lower the immune system 
and contribute to severe bacterial infections, high blood pressure and 
other problems in patients, particularly child patients. In addition, 
children with NS often experience growth retardation and heart disease. 
Finally, NS that is caused by FSGS, MCD or MN is idiopathic and can 
often reoccur, even after a kidney transplant.
    FSGS disproportionately affects minority populations and is five 
times more prevalent in the African American community. In a 
groundbreaking study funded by NIH, researchers found that FSGS is 
associated with two APOL1 gene variants. These variants developed as an 
evolutionary response to African sleeping sickness and are common in 
the African American patient population with FSGS/NS.
    FSGS has a large social impact in the United States. FSGS leads to 
end-stage renal disease (ESRD) which is one of the most costly chronic 
diseases to manage. In 2008, the Medicare program alone spent $26.8 
billion, 7.9 percent of its entire budget, on ESRD. In 2005, FSGS 
accounted for 12 percent of ESRD cases in the U.S., at an annual cost 
of $3 billion. It is estimated that there are currently approximately 
20,000 Americans living with ESRD due to FSGS.
    Research on FSGS could achieve tremendous savings in Federal 
healthcare costs and reduce health status disparities. For this reason, 
and on behalf of the thousands of families that are significantly 
affected by this disease, we encourage support for expanding the 
research portfolio on FSGS/NS at the NIH.
Encourage FSGS/NS Research at NIH
    There is no known cause or cure for FSGS and scientists tell us 
that much more research needs to be done on the basic science behind 
FSGS/NS. More research could lead to fewer patients undergoing ESRD and 
tremendous savings in healthcare costs in the United States.
    With collaboration from other Institutes and Centers, ORDR 
established the Rare Disease Clinical Research Network. This network 
provided an opportunity for the NephCure Foundation, the University of 
Michigan, and other university research health centers to come together 
to form the Nephrotic Syndrome Study Network (NEPTUNE). NEPTUNE is 
developing a database of NS patients who are interested in 
participating in clinical trials which would alleviate the problem 
faced by many rare disease groups of not having access to enough 
patients for research. NephCure urges the subcommittee to continue its 
support for RDCRN and NEPTUNE, which has tremendous potential to 
facilitate advancements in NS and FSGS research.
    The NephCure Foundation is also grateful to NIDDK for issuing 
program announcements (PA) that serve to initiate grant proposals on 
primary glomerular disease. Two PAs that have recently been issued 
utilize the R01 and UM1 mechanisms to award funding for primary 
glomerular disease research. NephCure recommends the subcommittee 
encourage NIDDK to continue to issue primary glomerular disease PAs.
    Due to the disproportionate burden of FSGS on minority populations, 
it is appropriate for NIMHD to develop an interest in this research. 
NephCure asks the subcommittee to encourage ORDR, NIDDK and NIMHD to 
collaborate on research that studies the incidence and cause of this 
disease among minority populations. NephCure also asks the Subcommittee 
to urge NIDDK and the NIMHD to undertake culturally appropriate efforts 
aimed at educating minority populations about primary glomerular 
disease.
    Thank you for the opportunity to present the views of the FSGS/NS 
community. Please contact the NephCure Foundation if additional 
information is required.

    [This statement was submitted by Irving Smokler, PH.D., President 
and Founder, Nephcure Foundation.]
                                 ______
                                 
          Prepared Statement of the Neurofibromatosis Network
    Thank you for the opportunity to submit testimony to the 
Subcommittee on the importance of continued funding at the National 
Institutes of Health (NIH) for research on Neurofibromatosis (NF), a 
genetic disorder closely linked to many common diseases widespread 
among the American population. We respectfully request that you include 
the following report language on NF research at the National Institutes 
of Health within your fiscal year 2015 Labor, Health and Human 
Services, Education Appropriations bill.
    Neurofibromatosis [NF]--The Committee supports efforts to increase 
funding and resources for NF research and treatment at multiple NIH 
Institutes, including NCI, NINDS, NIDCD, NHLBI, NICHD and NEI. Children 
and adults with NF are at significant risk for the development of many 
forms of cancer; the Committee encourages NCI to increase its NF 
research portfolio in fundamental basic science, translational research 
and clinical trials focused on NF. The Committee also encourages the 
NCI to support NF centers, NF clinical trials consortia, NF preclinical 
mouse models consortia and NF-associated tumor sequencing efforts. 
Because NF causes brain and nerve tumors and is associated with 
cognitive and behavioral problems, the Committee urges NINDS to 
continue to aggressively fund fundamental basic science research on NF 
relevant to nerve damage and repair, learning disabilities and 
attention deficit disorders. Since NF2 accounts for approximately 5 
percent of genetic forms of deafness, the Committee encourages NIDCD to 
expand its investment in NF2 basic and clinical research.
    On behalf of the Neurofibromatosis (NF) Network, a national 
organization of NF advocacy groups, I speak on behalf of the 100,000 
Americans who suffer from NF as well as approximately 175 million 
Americans who suffer from diseases and conditions linked to NF such as 
cancer, brain tumors, heart disease, memory loss, and learning 
disabilities. Thanks in large measure to this Subcommittee's strong 
support, scientists have made enormous progress since the discovery of 
the NF1 gene in 1990 resulting in clinical trials now being undertaken 
at NIH with broad implications for the general population.
    NF is a genetic disorder involving the uncontrolled growth of 
tumors along the nervous system which can result in terrible 
disfigurement, deformity, deafness, pain, blindness, brain tumors, 
cancer, and even death. In addition, approximately one-half of children 
with NF suffer from learning disabilities. NF is the most common 
neurological disorder caused by a single gene and is more common than 
Muscular Dystrophy and Cystic Fibrosis combined. There are three types 
of NF: NF1, which is more common, NF2, which initially involves tumors 
causing deafness and balance problems, and Schwannomatosis, the 
hallmark of which is severe pain. While not all NF patients suffer from 
the most severe symptoms, all NF patients and their families live with 
the uncertainty of not knowing whether they will be seriously affected 
because NF is a highly variable and progressive disease.
    Researchers have determined that NF is closely linked to heart 
disease, learning disabilities, memory loss, cancer, brain tumors, and 
other disorders including deafness, blindness and orthopedic disorders, 
primarily because NF regulates important pathways common to these 
disorders such as the RAS, cAMP and PAK pathways. Research on NF 
therefore stands to benefit millions of Americans:
Learning Disabilities/Behavioral and Brain Function
    Learning disabilities affect one-half of people with NF1. They 
range from mild to severe, and can impact the quality of life for those 
with NF1. In recent years, research has revealed common threads between 
NF1 learning disabilities, autism and other related disabilities. New 
drug interventions for learning disabilities are being developed and 
will be beneficial to military dependants, as well as the general 
population. Research being done in this area includes a clinical trial 
of the statin drug Lovastatin, as well as other categories of drugs.
Bone Repair
    At least a quarter of children with NF1 have abnormal bone growth 
in any part of the skeleton. In the legs, the long bones are weak, 
prone to fracture and unable to heal properly; this can require 
amputation at a young age. Adults with NF1 also have low bone mineral 
density, placing them at risk of skeletal weakness and injury. Research 
currently being done to understand bone biology and repair will pave 
the way for new strategies to enhancing bone health and facilitating 
repair.
Pain Management
    Severe pain is a central feature of Schwannomatosis, and 
significantly impacts quality of life. Understanding what causes pain, 
and how it could be treated, has been a fast-moving area of NF research 
over the past few years. Pain management is a challenging area of 
research and new approaches are highly sought after.
Nerve Regeneration
    NF often requires surgical removal of nerve tumors, which can lead 
to nerve paralysis and loss of function. Understanding the changes that 
occur in a nerve after surgery, and how it might be regenerated and 
functionally restored, will have significant quality of life value for 
affected individuals. Light-based therapy is being tested to dissect 
nerves in surgery of tumor removal. If successful it could have 
applications for treating nerve damage and scarring after injury, 
thereby aiding repair and functional restoration.
Wound Healing, Inflammation and Blood Vessel Growth
    Wound healing requires new blood vessel growth and tissue 
inflammation. Mast cells, important players in NF1 tumor growth, are 
critical mediators of inflammation, and they must be quelled and 
regulated in order to facilitate healing. Researchers have gained deep 
knowledge on how mast cells promote tumor growth, and this research has 
led to ongoing clinical trials to block this signaling, resulting in 
slower tumor growth. As researchers learn more about blocking mast cell 
signals in NF, this research can be translated to the management of 
mast cells in wound healing.
New Cancer Treatments
    NF can cause a variety of tumors to grow, which includes tumors in 
the brain, spinal cord and nerves. NF affects the RAS pathway which is 
implicated in 70 percent of all human cancers. Some of these tumor 
types are benign and some are malignant, hard to treat and often fatal. 
One of these tumor types is malignant peripheral nerve sheath tumor 
(MPNST), a very aggressive, hard to treat and often fatal cancer. 
MPNSTs are fast growing, and because the cells change as the tumor 
grows, they often become resistant to individual drugs. Clinical trials 
are underway to identify a drug treatment that can be widely used in 
MPNSTs and other hard-to-treat tumors.
    The enormous promise of NF research, and its potential to benefit 
over 175 million Americans who suffer from diseases and conditions 
linked to NF, has gained increased recognition from Congress and the 
NIH. This is evidenced by the fact that numerous institutes are 
currently supporting NF research, and NIH's total NF research portfolio 
has increased from $3 million in fiscal year 1990 to an estimated $18 
million in fiscal year 2014. Given the potential offered by NF research 
for progress against a range of diseases, we are hopeful that the NIH 
will continue to build on the successes of this program by funding this 
promising research and thereby continuing the enormous return on the 
taxpayers' investment.
    We appreciate the Subcommittee's strong support for NF research and 
will continue to work with you to ensure that opportunities for major 
advances in NF research are aggressively pursued. Thank you.
                                 ______
                                 
     Prepared Statement of the New England Educational Opportunity 
                              Association
    On behalf of the low-income, first-generation students and students 
with disabilities served by the Federal TRIO Programs (``TRIO'') across 
Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and 
Vermont, the New England Educational Opportunity Association (``NEOA'') 
respectfully requests that the Senate Subcommittee on Labor, Health and 
Human Services, and Education boost TRIO funding by $52 million in 
fiscal year 2015.
    A $52 million funding increase would allow for a total funding 
level of $890 million in fiscal year 2015 which, in turn, would allow 
TRIO's Student Support Services program to expand its reach by 10 
percent and grow to serve 20,000 additional low-income, first-
generation students at colleges and universities across the Nation 
during the 2015-2016 academic year. This funding level would also allow 
current TRIO programs to sustain the high-quality access and success 
services provided to 750,000 students across the Nation as well as 
allow for the expansion of these services to include 23,000 more who 
stand in need. Such growth is critical as TRIO programs have lost more 
than 120,000 students over the last decade. While we are tremendously 
grateful for the work of this Subcommittee to restore 95 percent of the 
funds lost to sequestration in fiscal year 2014, we would be remiss if 
we did not request additional funding so that we may continue to recoup 
from earlier losses. If the success of TRIO in New England serves as 
any indicator, it becomes clear that greater investment in TRIO is 
critical to boosting educational attainment nationally.
    More than 42,000 students ranging from middle school through 
graduate study participate in TRIO programs across New England. 
Throughout the region, stories of student success abound, with strong 
statistics to support them. For instance, both the Talent Search and 
Upward Bound programs in Rhode Island can boast of 99 percent high 
school graduation rates. Moreover, 86 percent of Rhode Island's Talent 
Search students go directly onto college as do 90 percent of the Upward 
Bound students.
    In New Hampshire, a longitudinal study of Student Support Services 
(``SSS'') participants at the University of New Hampshire demonstrated 
that, compared to eligible non-participants, SSS students exhibited 
higher graduation rates, greater improvement in grades, and lower 
academic suspension rates. Meanwhile, during fiscal year 2010, Plymouth 
State University had a 92 percent retention rate among non-graduating 
SSS participants. The SSS program at the University of Bridgeport in 
Connecticut can demonstrate similar success. During the 2013-2014 
Academic Year, 58 percent of SSS participants made the Dean's List and/
or the President's List as a result of their GPAs.
    In recent years, the Educational Opportunity Center (EOC) in 
Vermont aided 63 percent of its clients--which include out-of-work 
adults and military veterans--in enrolling in postsecondary education 
programs for the first time; a similar percentage (61 percent) of 
postsecondary ``stop-outs'' re-enrolled in postsecondary education 
programs. Similarly, the EOC program in Maine helped more than 900 
adult learners enroll in college and assisted nearly 2,000 adults in 
developing career and educational plans.
    Massachusetts also produces stellar results through its TRIO 
programs. Many notable examples are found at the University of 
Massachusetts-Boston. For instance, the institution's Veterans Upward 
Bound (VUB) program found that 81.5 percent of VUB participants who 
enrolled in postsecondary education programs persisted through to a 
second year of academic study. Meanwhile, 48 percent of students who 
participated in their Ronald E. McNair Postbaccalaureate Achievement 
program earned doctoral degrees within 10 years of receipt of their 
bachelor's degree.
    This is just a sampling of the success sparked by the supportive 
services provided by TRIO. We hope that you will strongly consider 
these examples when determining funding levels for our program in 
fiscal year 2015.
    Thank you for your consideration of this request.

    [This statement was submitted by Karen Keim, President, New England 
Educational Opportunity Association.]
                                 ______
                                 
      Prepared Statement of the New Hampshire Community Loan Fund
    Chairman Harkin, Ranking Member Moran, and distinguished Members of 
the Appropriations Subcommittee on Labor, Health and Human Services, 
Education, and Related Agencies: Helping child-care centers finance 
improvements to their facilities has been a key poverty-fighting 
strategy of the New Hampshire Community Loan Fund for the last two 
decades. We see first-hand what the experts are able to prove: that 
quality early learning provides a critical foundation for social and 
economic success.
    The Community Loan Fund wishes to endorse the testimony of the 
National Children's Facilities Network and the network's call for 
adequate Federal funding for the acquisition, construction, and 
improvement of child-care facilities. Over the last 7 years, New 
Hampshire's child-care centers have grown increasingly averse to the 
risks associated with investing in capital improvements. The recession 
heightened the typical executive director's financial anxiety and that 
anxiety persists. Now would be the perfect time for Federal action that 
would increase their confidence and encourage investments in their 
facilities.
    Please let me know if you would like additional information from 
us.

    [This statement was submitted by Richard A. Minard, Jr., Vice 
President, New Hampshire Community Loan Fund.]
                                 ______
                                 
              Prepared Statement of the Nursing Community
    The Nursing Community is a forum comprised of 60 national 
professional nursing associations that builds consensus and advocates 
on a wide spectrum of healthcare and nursing issues surrounding 
practice, education, and research. These organizations are committed to 
promoting America's health through the advancement of the nursing 
profession. Collectively, the Nursing Community represents nearly one 
million Registered Nurses (RNs), Advanced Practice Registered Nurses 
(APRNs-including certified nurse-midwives, nurse practitioners, 
clinical nurse specialists, and certified registered nurse 
anesthetists), nurse executives, nursing students, faculty, and 
researchers.
    For fiscal year 2015, our organizations respectfully request $251 
million for the Health Resources and Services Administration's (HRSA) 
Nursing Workforce Development programs (authorized under Title VIII of 
the Public Health Service Act [42 U.S.C. 296 et seq.]), $150 million 
for the National Institute of Nursing Research (NINR) within the 
National Institutes of Health (NIH), and $20 million in authorized 
funding for the Nurse-Managed Health Clinics (Title III of the Public 
Health Service Act). These investments will help ensure that our 
Nation's population receives the highest-quality nursing services 
possible.
Demand for Nurses Continues to Grow
    According to the Bureau of Labor Statistics' (BLS) Employment 
Projections for 2012-2022, the expected number of practicing nurses 
will grow from 2.71 million in 2012 to 3.24 million in 2022, an 
increase of 526,800, or 19.4 percent. The number of job openings due to 
demand for registered nursing services and replacements in the 
workforce brings the total of RNs needed to 1.053 million by 2022. In 
addition, nurse practitioners are one of the fastest growing 
occupations according to the BLS projections, noting there will be a 
33.7 percent increase in nurse practitioners between 2012-2022.
    Two primary factors contribute to this overwhelming demand. First, 
America's nursing workforce is aging. A 2013 HRSA report, The U.S. 
Nursing Workforce: Trends in Supply and Education, indicates that over 
the next 10 to 15 years, the nearly one million RNs over age 50 
(comprising approximately one-third of the current workforce), will 
reach retirement age. Secondly, America's Baby Boomer population is 
aging. This population will require a vast influx of nursing services, 
particularly in areas of primary care and chronic illness management. A 
significant investment must be made in the education of new nurses to 
provide the Nation with the nursing services it demands.
Addressing the Demand: Title VIII Nursing Workforce Development 
        Programs
    For 50 years, the Nursing Workforce Development programs, 
authorized under Title VIII of the Public Health Service Act, have 
helped to build the supply and distribution of qualified nurses to meet 
our Nation's healthcare needs. The Title VIII programs bolster nursing 
education at all levels, from entry-level preparation through graduate 
study, and provide support for institutions that educate nurses for 
practice in rural and medically underserved communities. Today, the 
Title VIII programs are essential to ensure the demand for nursing care 
is met. Between fiscal year 2005 and 2012 alone, these programs 
supported over 450,000 nurses and nursing students, as well as numerous 
academic nursing institutions and healthcare facilities.
    The American Association of Colleges of Nursing's (AACN) Title VIII 
Student Recipient Survey gathers information about Title VIII dollars 
and their impact on nursing students. The 2013-2014 survey, which 
included responses from over 800 students, indicated that the Title 
VIII programs played a critical role in funding these students' nursing 
education. The survey showed that 78 percent of the students receiving 
Title VIII funding are attending school full-time. By supporting full-
time students, the Title VIII programs are helping to ensure that 
students enter the workforce without delay.
    The Title VIII programs also address the need for more nurse 
faculty. Data from AACN's 2013-2014 enrollment and graduations survey 
show that nursing schools were forced to turn away 78,089 qualified 
applications from entry-level baccalaureate and graduate nursing 
programs in 2013, and faculty vacancy was a primary reason. The Title 
VIII Nurse Faculty Loan Program aids in increasing nursing school 
enrollment capacity by supporting students pursuing graduate education, 
provided they serve as faculty for 4 years after graduation.
  --The Nursing Community respectfully requests $251 million for the 
        Nursing Workforce Development programs in fiscal year 2015.
National Institute of Nursing Research: Foundation for Evidence-Based 
        Care
    As one of the 27 Institutes and Centers at the NIH, the NINR funds 
research that lays the groundwork for evidence-based nursing practice. 
Nurse scientists at NINR examine ways to improve care models to deliver 
safe, high-quality, and cost-effective health services to the Nation. 
Our country must look toward the prevention aspect of healthcare as the 
vehicle for saving our system from further financial burden, and the 
work of NINR embraces this endeavor through research related to care 
management of patients during illness and recovery, reduction of risks 
for disease and disability, promotion of healthy lifestyles, 
enhancement of quality of life for those with chronic illness, and care 
for individuals at the end of life.
    Moreover, NINR helps to provide needed faculty to support the 
education of future generations of nurses. Training programs at NINR 
develop future nurse researchers, many of whom also serve as faculty in 
our Nation's nursing schools.
  --The Nursing Community respectfully requests $150 million for the 
        NINR in fiscal year 2015.
Nurse-Managed Health Clinics: Expanding Access to Care
    NMHCs are healthcare delivery sites managed by APRNs and are 
staffed by an interdisciplinary health provider team which may include 
physicians, social workers, public health nurses, and therapists. These 
clinics are often associated with a school, college, university, 
department of nursing, federally qualified health center, or 
independent nonprofit healthcare agency. NMHCs serve as critical access 
points to keep patients out of the emergency room, saving the 
healthcare system millions of dollars annually.
    NMHCs provide care to patients in medically underserved regions of 
the country, including rural communities, Native American reservations, 
senior citizen centers, elementary schools, and urban housing 
developments. The populations within these communities are the most 
vulnerable to chronic illnesses that create heavy financial burdens on 
patients and the healthcare system. NMHCs aim to reduce the prevalence 
of disease and create healthier communities by providing primary care 
services and educating patients on health promotion practices. 
Furthermore, NMHCs serve as clinical education training sites for 
nursing students and other health professionals. This is crucial given 
that a lack of training sites is commonly identified as a barrier to 
nursing school enrollment.
  --The Nursing Community respectfully requests $20 million for the 
        Nurse-Managed Health Clinics authorized under Title III of the 
        Public Health Service Act in fiscal year 2015.
    Without a workforce of well-educated nurses providing evidence-
based care to those who need it most, including our growing aging 
population, the healthcare system is not sustainable. The Nursing 
Community's request of $251 million for the Title VIII Nursing 
Workforce Development programs, $150 million for the National Institute 
of Nursing Research, and $20 million for Nurse-Managed Health Clinics 
in fiscal year 2015 will help ensure continued access to quality care 
provided by America's nursing workforce.
       members of the nursing community submitting this testimony
Academy of Medical-Surgical Nurses
American Academy of Ambulatory Care Nursing
American Academy of Nursing
American Assembly for Men in Nursing
American Association of Colleges of Nursing
American Association of Critical-Care Nurses
American Association of Heart Failure Nurses
American Association of Neuroscience Nurses
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordination
American Association of Nurse Practitioners
American College of Nurse-Midwives
American Nurses Association
American Organization of Nurse Executives
American Pediatric Surgical Nurses Association
American Psychiatric Nurses Association
American Rehabilitation Nurses
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
Association of Community Health Nursing Educators
Association of Nurses in AIDS Care
Association of periOperative Registered Nurses
Association of Public Health Nurses
Association of Women's Health, Obstetric and Neonatal Nurses
Commissioned Officers Association of the U.S. Public Health Service
Dermatology Nurses' Association
Developmental Disabilities Nurses Association
Emergency Nurses Association
Gerontological Advanced Practice Nurses Association
Hospice and Palliative Nurses Association
Infusion Nurses Society
International Society of Psychiatric Nursing
National American Arab Nurses Association
National Association of Clinical Nurse Specialists
National Association of Hispanic Nurses
National Association of Pediatric Nurse Practitioners
National Association of School Nurses
National Black Nurses Association
National Forum of State Nursing Workforce Centers
National Nursing Centers Consortium
National Organization for Associate Degree Nursing
National Organization of Nurse Practitioner Faculties
Nurses Organization of Veterans Affairs
Oncology Nursing Society
Preventive Cardiovascular Nurses Association
Society of Urologic Nurses and Associates
                      
                                 ______
                                 
             Prepared Statement of the Older Americans Act
    Mr. Chairman, Ranking Member, and distinguished Members of the 
Subcommittee, Oral Health America (OHA), a leading organization 
dedicated to changing lives by connecting communities with resources to 
increase access to care, education, and advocacy for all Americans, 
especially those most vulnerable; is requesting fiscal year 2015 
funding for all programs administered under the Older Americans Act 
(OAA) be restored to fiscal year 2012 levels. Of particular interest to 
OHA is to ensure Title III-D, Disease Prevention and Health Promotion, 
is restored to at least $21,000,000 because of the cost-effectiveness 
that health education, prevention and promotion programs provide to the 
system.
    The OAA provides Federal programs that serve to meet the needs of 
millions of older Americans. We understand the United States continues 
to operate amid a challenging budgetary environment. However, OHA 
believes that proper Federal investment in the OAA is critical to keep 
pace with the rate of inflation and to meet the needs of this ever-
growing segment of the population through the multitude of services the 
OAA provides. Simply stated, proper investment in OAA saves taxpayer 
dollars. This is especially evident when it comes to health services. 
Health services the emphasize prevention and promotion will help to 
reduce disease, leading to the improvement of the overall health and 
well-being of America's older adults and resulting in the reduction of 
premature and costly medical interventions. OHA strongly contends that 
one's health and overall well-being begins with proper oral health.
Background
    The population of the United States is aging at an unprecedented 
rate. Older adults make up one of the fastest growing segments of the 
American population. In 2009, 39.6 million seniors were U.S. residents. 
This aging cohort is expected to reach 72.1 million by 2030--an 
increase of 82 percent.\1\
---------------------------------------------------------------------------
    \1\ Administration on Aging. (2013). Aging Statistics. Retrieved 
from http://www.aoa.gov/Aging_Statistics/.
---------------------------------------------------------------------------
    The oral health of older Americans is in a state of decay. The 
reasons for this are complex. Limited access to dental insurance, 
affordable dental services, community water fluoridation, and programs 
that support oral health prevention and education for older Americans 
are significant factors that contribute to the unmet dental needs and 
edentulism among older adults, particularly those most vulnerable. 
While improvements in oral health across the lifespan have been 
observed in the last half century, long term concern may be warranted 
for the 10,000 Americans retiring daily, as it is estimated that only 
9.8 percent of this ``silver tsunami''--baby boomers turning age 65--
will have access to dental insurance benefits.\2\
---------------------------------------------------------------------------
    \2\ Consumer Survey, National Association of Dental Plans. 2012.
---------------------------------------------------------------------------
    Dental Health and Disparities.--Older adults experience an 
increased risk for oral conditions such as edentulism, oral cancer, and 
periodontal disease. The reasons for this vary but are often related to 
age-associated physiologic changes, underlying chronic diseases, race, 
gender, and the use of various medications. These oral conditions 
disproportionately affect persons with low income, racial and ethnic 
minorities, and those who have limited or no access to dental 
insurance. Older adults with physical and intellectual disabilities and 
those persons who are homebound or institutionalized are also at 
greater risk for poor oral health.\3\
---------------------------------------------------------------------------
    \3\ U.S. Department of Health and Human Services. (2000). Oral 
Health in America: A Report of the Surgeon General. Retrieved from 
http://silk.nih.gov/public/[email protected].
fullrpt.pdf.
---------------------------------------------------------------------------
    As examples of these disparities, older African American adults are 
1.88 times more likely than their white counterparts to have 
periodontitis; \4\ low-income older adults suffer more than twice the 
rate of gum disease than their more affluent peers (17.49 verses 8.62 
respectively); and Americans who live in poverty are 61 percent more 
likely to have lost all of their teeth when compared to those in higher 
socioeconomic groups.
---------------------------------------------------------------------------
    \4\ Borrel, L.N., Burt, B.A., & Taylor, G.W. (2005, October). 
Prevalence and Trends in Periodontitis in the USA: from the NHANES III 
to the NHANES, 1988 to 2000. Journal of Dental Research,84(10). 
Retrieved from http://jdr.sagepub.com/content/84/10/924.abstract.
---------------------------------------------------------------------------
    Edentulism and Overall Health.--Despite these existing conditions, 
recent dental public health trends demonstrate that as the population 
at large ages, older Americans are increasingly retaining their natural 
teeth.\5\ Today, many older adults benefit from healthy aging 
associated with the retention of their natural teeth, improvements in 
their ability to chew, and the ability to enjoy a variety of food 
choices not previously experienced by earlier generations of their 
peers.
---------------------------------------------------------------------------
    \5\ Dolan, T. A., Atchison, K., & Huynh, T. N. (2005). Access to 
Dental Care Among Older Adults in the United States. Journal of Dental 
Education, 69(9), 961-974. Retrieved from http://www.jdentaled.org/
content/69/9/961.long.
---------------------------------------------------------------------------
    Oral health data reveals that many older adults experience adverse 
oral health associated with chronic and systemic health conditions. For 
example, associations between periodontitis and diabetes have emerged 
in recent years, as well as oral conditions such as xerostomia 
associated with the use of prescription drugs.\6,7\ Xerostomia, 
commonly known as dry mouth, contributes to the inception and 
progression of dental caries (cavities). For older Americans, the 
occurrence or recurrence of dental caries coupled with an inability to 
access treatment may lead to significant pain and suffering along with 
other detrimental health effects.
---------------------------------------------------------------------------
    \6\ Ira B. Lamster, DDS, MMSc, Evanthia Lalla, DDS, MS, Wenche S. 
Borgnakke, DDS, PhD and George W. Taylor, DMD, DrPH. (2008). Journal of 
the American Dental Association.
    \7\ Fox, Philip C. (2008). Xerostomia: Recognition and Management. 
Retrieved from: http://www.colgateprofessional.com.hk/LeadershipHK/
ProfessionalEducation/Articles/Resources/profed_art_access-supplement-
2008-xerostimia.pdf.
---------------------------------------------------------------------------
    Oral Care Provider Issues.--Although a growing number of older 
Americans need oral healthcare, the current workforce is challenged to 
meet the needs of older adults. The current dental workforce is aging, 
and many dental professionals will retire within the next decade.\2\ A 
lack of geriatric specialty programs complicates this problem, and few 
practitioners are choosing geriatrics as their field of choice.
    While these trends are favorable, adverse oral health consequences 
are emerging. Due to reasons stated in this report, together with 
increased demand for services, lack of access to dental benefits 
through Medicare, increased morbidity and mobility among older adults, 
and reduced income associated with aging and retirement, many older 
Americans are unable to access oral healthcare services. As a result, 
many older adults who have retained their natural teeth are now 
experiencing dental problems.
Older Adults' Oral Health in State of Decay
    OHA released State of Decay on October 8, 2013, which is a State-
by-State analysis of oral healthcare delivery and public health factors 
impacting the oral health of older adults. The report revealed more 
than half of the country received a ``fair'' or ``poor'' assessment 
when it comes to minimal standards affecting dental care access for 
older adults. The top findings of the report were:
  --Persistent lack of oral health coverage across much of the Nation. 
        Forty-two percent of States (21 States) provide either no 
        dental benefits or provide only emergency coverage through 
        adult Medicaid Dental Benefits. Nearly 70 percent of older 
        Americans lack dental insurance, and in the context of a 
        rapidly aging Nation, this percentage will only likely 
        increase.
  --Strained dental health work force. Thirty-one States (62 percent) 
        have high rates of Dental Health Provider Shortage Areas 
        (HPSAs), meeting only 40 percent or less of dental provider 
        needs.
  --Tooth loss remains a signal of suboptimal oral health. Eight States 
        had strikingly high rates of edentulism, with West Virginia 
        notably having an adult population that is 33.8 percent 
        edentate.
  --Deficiencies in preventive programs. Thirteen States (26 percent) 
        have upwards of 60 percent of their residents living in 
        communities without water fluoridation (CWF), despite 
        recognition for 68 years that this public health measure 
        markedly reduces dental caries. Hawaii (89.2 percent) and New 
        Jersey (86.5 percent) represent the highest rates of citizens 
        unprotected by fluoridation, an unnecessary public peril.
    Moreover, poor oral health has substantial financial implications. 
For example, in 2010 alone, between $867 million and $2.1 billion was 
spent on emergency dental procedures. When compared to care delivered 
in a dentist's office, hospital treatments are nearly ten times more 
expensive than the routine care that could have prevented the 
emergency. This places a costly yet avoidable burden on both the 
individual and the health institutions that must then bear the expense.
    In sum, oral health and access to preventive care significantly 
impact overall health and expenditure, yet are difficult to maintain--
particularly for older adults--in the Nation's present context of 
support systems and healthcare.
How OHA Empowers Older Adults to Meet their Oral Health Needs
    Oral Health America's Wisdom Tooth Project aims to change the 
lives of older adults especially vulnerable to oral disease. Its goal 
is to educate Americans about the oral health needs of older adults, 
connect older adults to local resources, and to advocate for policies 
that will improve the oral health of older adults. The Wisdom Tooth 
Project achieves these goals through five strategies: publications, our 
web portal, regional symposia, communications, and demonstration 
projects.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    In addition to the State of Decay report referenced above, a vital 
component of the Wisdom Tooth Project is Toothwisdom.org, which is a 
first-of-its-kind website created to connect older adults and their 
caregivers to local care and education around the oral health issues 
they face, the importance of continuing prevention as we age, and the 
overall impact of oral health on overall health.
Importance of OAA Reauthorization to Oral Health of Older Adults
    Recognizing this current State of oral health among older adults, 
Oral Health America welcomes the bipartisan-supported Older Americans 
Act reauthorization in the U.S. Senate, S.1562. The Senate's bill 
includes--for the first time--a small provision that allows the Aging 
Network to use funds they receive for disease prevention and health 
promotion activities to conduct oral health screenings. Preventive 
dental care that can be provided through oral health screenings can 
head off more expensive dental work and help prevent severe diseases. 
Unfortunately, dentists see older adults everyday living with infection 
and pain that could be easily avoided with proper care that these 
screenings could provide. Although the oral health screenings provision 
would not require new or additional funding under Title III-D, Disease 
Prevention and Health Promotion Services, restoring funding to fiscal 
year 2012 levels would greatly assist the Aging Network to conduct the 
screenings. More succinctly, the Senate's bill recognizes the 
importance of oral health and its role in disease prevention. We view 
this as a step toward improving the oral--and overall--health of older 
adults and call for the bill's passage.
                             recommendation
    It is evident the United States' healthcare system is woefully 
unprepared to meet the oral health challenges of a burgeoning 
population of older adults with special needs, chronic disease 
complications, and a growing inability to access and pay for dental 
services. However, the benefits of proper oral hygiene and routine care 
for older adults to our Nation's healthcare system and economy are also 
quite clear. Through OHA's Wisdom Tooth Project, OHA aspires to change 
the lives of older adults especially vulnerable to oral disease. OHA 
views proper funding of the Older Americans Act as a crucial Federal 
investment vehicle to advance health promotion and disease prevention. 
Therefore, OHA recommends the Subcommittee to restore fiscal year 2015 
funding for all OAA program to fiscal year 2012 levels, and moreover, 
to ensure Title III-D, Disease Prevention and Health Promotion, is 
restored to at least $21,000,000 because of the cost-effectiveness that 
health education, prevention and promotion programs provide to the 
system.
    Thank you for the opportunity to present and submit our written 
testimony before the Subcommittee.

    [This statement was submitted by Beth Truett, CEO/President, Oral 
Health America.]
                                 ______
                                 
       Prepared Statement of the Ovarian Cancer National Alliance
    The Ovarian Cancer National Alliance (the Alliance) greatly 
appreciates the opportunity to submit testimony for the record 
regarding our fiscal year 2015 funding recommendations. The fiscal year 
2015 programmatic funding levels we are advocating for will help 
advance the awareness, detection and treatment of ovarian cancer, the 
deadliest of gynecologic cancers. Specifically, the Alliance 
respectfully requests Congress provide $7.5 million for the Centers for 
Disease Control and Prevention's (CDC) Ovarian Cancer program, which 
funds critical public health research of ovarian cancer. CDC also leads 
a public gynecologic cancer (ovarian, uterine, cervical, vaginal, 
vulvar) awareness initiative, authorized by Johanna's Law, that plays 
an integral role in women's cancer education, detection and prevention. 
As such, the Alliance respectfully requests Congress appropriate $5.5 
million for Johanna's Law implementation. Furthermore, to advance and 
leverage the important ovarian cancer research funded through the 
National Cancer Institute (NCI) at the National Institutes of Health 
(NIH), the Alliance respectfully requests Congress allocate $5.26 
billion to NCI, as a portion of $32 billion appropriated to NIH in 
fiscal year 2015.
    For 17 years, the Alliance has worked to increase awareness of 
ovarian cancer and advocate on behalf of women with ovarian cancer. As 
an umbrella organization of 58 State and regional Partner Member 
organizations, the Alliance unites the efforts of survivors, caretakers 
and healthcare professionals to bring national attention to ovarian 
cancer. The Alliance advocates at a national level for greater 
investment in Federal research to support the development of an early 
detection test, improved healthcare practices and life-saving treatment 
protocols. The Alliance also educates healthcare professionals about--
and raises public awareness of--risk factors for and symptoms of 
ovarian cancer.
    Ovarian cancer is a highly deadly disease. According to the 
American Cancer Society, in 2013, an estimated 22,240 women were 
diagnosed with ovarian cancer and 14,030 women lost their lives to this 
terrible disease. A quarter of women diagnosed with ovarian cancer will 
die within 1 year of diagnosis and over half of women do not survive 5 
years after diagnosis. Unfortunately, these rates have not changed in 
nearly 40 years. These grim statistics arise from the fact that there 
is no early detection test for ovarian cancer; tragically, most cases 
of ovarian cancer are diagnosed after the disease has already begun to 
spread and are more difficult to effectively treat. However, if ovarian 
cancer is caught in the early stages, nearly ninety percent of women 
survive. As such, it is critical that women and healthcare providers be 
aware of the signs and symptoms of ovarian cancer and that valid and 
reliable early detection tests be developed.
    Few treatments for ovarian cancer have been approved by the Food 
and Drug Administration (FDA). Many FDA approved drugs are platinum-
based therapies, to which cancers readily become resistant if multiple 
rounds of chemotherapy are needed. Nearly 80 percent of ovarian cancer 
patients will have a recurrence of disease, underscoring the great need 
for new and better treatments for ovarian cancer. For these reasons, we 
respectfully urge you and your colleagues to support ovarian cancer 
research, education and awareness efforts.
     cdc division of cancer prevention and control--ovarian cancer
    The Ovarian Cancer Line (also known as the Ovarian Cancer Control 
Initiative) funds public health research of ovarian cancer to better 
identify women most at risk for developing ovarian cancer, and design 
risk-reduction and prevention-focused interventions. In fiscal year 
2014, CDC's ovarian cancer program received $4.75 million to achieve 
its mission. Some of the projects being supported by those funds 
include: the development of a Continuing Medical Education curriculum 
on hereditary breast and ovarian cancer that educates physicians about 
how to identify, screen and manage high-risk patients; the 
investigation of ways to improve follow-up care for ovarian cancer 
patients given that so many experience disease recurrence; and the 
examination of risk factors, treatment disparities and other factors 
influencing survival rates to identify ways to improve patient outcomes 
with existing tools and treatments.
    With an allocation of $7.5 million in fiscal year 2015, the CDC 
will be able to continue this important work, and expand a pilot 
initiative that promotes educating women and providers about the BRCA 
mutations, identifies women at high risk for developing breast/ovarian 
cancer and ensures appropriate referral of these at risk women for 
genetic counseling or testing. This pilot program is currently 
operational in three States, but with increased funding, similar 
programs can be established in additional States and communication 
among women and their providers about genomic risk and testing can be 
further encouraged.
    Given the shared risk between ovarian and breast cancers for 
individuals with BRCA mutations, it is imperative that we integrate 
ovarian cancer risk assessment, education and genetic testing into 
other CDC cancer-related programs, such as the EARLY Act and the 
National Breast and Cervical Cancer Early Detection Programs. Combining 
breast and ovarian cancer programs in this manner will leverage scarce 
resources, better coordinate efforts between existing Federal programs, 
create economies of scale and efficiencies with respect to CDC 
education and awareness programs and advance complementary efforts to 
reduce ovarian cancer related deaths.
      cdc division of cancer prevention and control--johanna's law
    Johanna's Law funds a CDC-led gynecologic cancer awareness 
campaign, Inside Knowledge, which educates women and healthcare 
providers about the signs and symptoms of gynecologic cancers. In 
fiscal year 2014, CDC received $4.85 million for Johanna's Law 
activities, which include supporting the ongoing creation and 
dissemination of awareness campaign materials in English and Spanish, 
and a series of print, radio and television PSAs featuring survivor 
stories. In 2012, the campaign achieved one billion views of its PSAs 
across media types.
    With $5.5 million in fiscal year 2015, CDC will be able to continue 
to raise awareness of the signs and symptoms of ovarian and other 
gynecologic cancers, undertake a targeted outreach of its messages to 
high risk women and expand its partnerships with external patient 
advocacy, health professional and other stakeholder organizations to 
leverage scarce resources and amplify their messages. Collaboration 
with these organizations, such as the Alliance, would magnify the CDC's 
efforts to raise awareness and help ensure that women, particularly 
those known to be at a higher risk, seek the healthcare they need to 
identify and treat gynecologic cancers early.
                               nci at nih
    NCI and the NIH fund the majority of ovarian cancer research in the 
United States and the world. On average, each year, NCI and NIH fund 
more than $140 million in peer-reviewed research grants to researchers 
at universities and small businesses across the United States. These 
studies are generating insights into the origins of ovarian cancer and 
disease progression that may lead to the development of early detection 
tests and better treatments for ovarian cancer. For example, NIH and 
NCI investments in basic research led to the understanding of a class 
of enzymes called PARPs implicated in ovarian cancer. Pharmaceutical 
companies have built upon these insights to develop PARP inhibitors, a 
class of drugs holding great promise for ovarian cancer patients.
    In addition to the basic research underlying future cures, NCI 
supports clinical research necessary for translating those ideas into 
treatments. NCI funding provides critical support to the ovarian cancer 
Specialized Programs of Research Excellence (SPORE), which facilitate 
collaborative research studies on the early detection and treatment of 
ovarian cancer. The Roswell Park Cancer Institute and University of 
Pittsburgh Cancer Institute Ovarian Cancer SPORE is working on reducing 
morbidity and mortality of ovarian cancer through groundbreaking 
translational research aimed at risk stratification, treatment, and 
prevention of relapse. Currently, a phase I clinical trial is being 
conducting on vaccines that induce anti-tumor immunity and several 
other clinical trials are in development. NCI's clinical trials 
enterprise plays an essential role in testing the safety and 
effectiveness of potential treatments for ovarian cancer. Robust NCI 
funding is critical to the continued excellence of the SPOREs.
    Furthermore, NCI recently launched the National Clinical Trials 
Network (NCTN), which consolidates and streamlines existing cooperative 
clinical trial groups. One of these new groups, the NRG Oncology 
Clinical Trial network, includes the Gynecologic Oncology Group (GOG), 
whose trials have been responsible for several advances in ovarian 
cancer research. Specifically, a GOG trial found that chemotherapy 
followed by maintenance use of Avastin increased progression free 
survival time of advanced ovarian cancer patients, when compared to 
chemotherapy alone. By funding important trials such as this, GOG (and 
now NRG) fills a clinical research gap left open by pharmaceutical 
companies that do not often research maintenance therapies. Due to the 
NCTN's critical importance in clinical trial design and implementation, 
robust NCI funding is necessary to accomplish these and other important 
tasks.
    Robust investment in NCI of $5.26 billion, out of a total $32 
billion for NIH in fiscal year 2015, is critical to ensuring the next 
generation of discoveries that will improve the health and well-being 
of women with--and at-risk for--ovarian cancer, as well as all 
Americans.
                                 * * *
    The Alliance maintains a long-standing commitment to working with 
Congress and other stakeholders to improve the survival rates for women 
with ovarian cancer through increased research, education and 
awareness. On behalf of our community of patients, caregivers and 
survivors, we thank you for your consideration of our fiscal year 2015 
requests and urge you to support the aforementioned Federal programs so 
vital to conquering this horrible disease.
                                 ______
                                 
             Prepared Statement of Parents of Dead Children
    Can you please address a serious health epidemic that is affecting 
families everywhere? There is a medical epidemic that no one in 
Congress seems to want to address. That is heroin addiction and proper 
ways to treat it. The government is spending way too much money in the 
wrong places and the money should go for helpful and intensive 
treatment, including a significant amount of time addressing mental 
health treatment--again, something no one wants to talk about. Addicts 
do not choose to be addicts, which seems to be the way the vast 
majority of Americans like to think about it. There are mental health 
issues that go untreated and lead to self-medication. Methadone Clinics 
are a huge failure and have little to no oversight and certainly have 
no statistics that provide meaningful data as to their success or 
failure. The money poured into those places could be better utilized. 
Also, more oversight of in patient treatment centers is desperately 
needed--these are money making ventures and they say they treat for co-
occurring disorders (such as bi-polar), it is a joke. If a patient 
meets one on one with a psychiatrist for half an hour every 2 weeks, 
how does that help?
    Read this article:The Problem with Methadone Clinics: They Are For-
Profit Businesses
    Sine Nomine, Yahoo Contributor Network
    Mar 30, 2007
    Today, many Americans go to a methadone clinic. Some do it for 
legitimate reasons, others do it just to get a high. The problem with 
these methadone clinics are that they are for-profit organizations. 
Many people do not realize that the methadone clinic is a business. 
Businesses are open to make money. Here in lies the biggest problem 
facing people who do go to these clinics. The nurses, the counselors, 
and the doctors that are there to help patients are actually there to 
keep patients coming back. Why would they want someone to quit coming 
to the clinic? If everyone decided to quit using methadone then they 
would be out of a job. I know many people who get up every morning and 
make it to the methadone clinic. Some of these people have tried to 
quit and they always go back. Most don't even last 2 days without their 
methadone. These people have ended up trading one addiction for 
another. That is what methadone is, a legal addiction. People can go 
there everyday and get a legal high.
    Besides that, regulations for methadone clinics are practically non 
existent. You can fail a drug test there and not have to worry about 
it. All that will happen to you is that they will make you come there 
everyday to get your methadone. You won't be allowed to take any home 
with you. What is even worse is they do not care if you fail a drug 
test just as long as your back there the next day to get your next 
dose. The government needs to step in and make some serious regulations 
on this business.
    As it stands, right now you can go to the methadone clinic for as 
long as you need to. There is no turning you away just as long as you 
can pay for your dose and to make that easier they will even let you 
charge a day if you don't have the money. People go to the methadone 
clinic for years even decades because they are addicted to the 
methadone. Their bodies won't let them quit. They start suffering 
withdraw symptoms within the first 48 hours. So back to the methadone 
clinic they go. No one will help you detox if they know you are on 
methadone. You have to go to a specialized institution to detox off 
methadone.
    The government can step in and ban the sell of prescription drugs, 
ban the use of marijuana, they even tell you where you can and can't 
smoke today. But what are they doing for the growing methadone problem? 
Very little. More and more people are dying every day because of 
methadone. But let me be clear it is not just the methadone that is 
killing them. These people are mixing methadone with other drugs such 
as Xanax, Valium, Percocet, OxyContin, etc. The drug tests done at 
these methadone clinics show up these other drugs. Yet nothing is done 
about the fact that these people are abusing other drugs that interact 
with methadone causing a lethal combination. The government should step 
in and implement a system for checking this so called business. A 
system that would allow them to check the drug screens of each 
individual. Those individuals that cannot pass three drug screens 
should be eliminated from the program. The government should also make 
it mandatory to drug test each individual at least twice a week. I also 
believe that a set time limit for methadone maintenance should be 
implemented. Every two weeks the patient should be made to come down a 
minimum of two milligrams of methadone. This means that a patient 
starting out at 50 mg will be completely off the methadone in a little 
under a year. By implementing this system the government would decrease 
the patients who abuse methadone and would help those who need the 
methadone without making them methadone addicts.
    Gina Haggerty, mother of a dead son who just wanted help and was 
not going to a methadone clinic because he said they were a joke. The 
deadline for submitting this testimony, May 23rd, would have been his 
25th birthday.
                                 ______
                                 
          Prepared Statement of the Parkinson's Action Network
    Dear Chairman Harkin and Ranking Member Moran: The Parkinson's 
Action Network (PAN) appreciates the opportunity to comment on the 
fiscal year 2015 appropriations for the U.S. Department of Health and 
Human Services. Our comments will focus on the importance of Federal 
investment in biomedical research at the National Institutes of Health 
(NIH) and the National Institute of Neurological Disorders and Stroke 
(NINDS), which recently adopted a series of priority research 
recommendations for Parkinson's disease. PAN supports at least $32 
billion in funding for the NIH and an increase for NINDS to support the 
research recommendations set forth by the NINDS planning strategy to 
bring us closer to better treatments and a cure for Parkinson's 
disease.
    PAN is the unified voice of the Parkinson's community advocating 
for better treatments and a cure. In partnership with other Parkinson's 
organizations and our powerful grassroots network, we educate the 
public and government leaders on better policies for research and 
improved quality of life for the estimated 500,000 to 1.5 million 
Americans living with Parkinson's, for whom there is no treatment 
available that slows, reverses, or prevents progression.
    As the second most common neurodegenerative condition after 
Alzheimer's disease, Parkinson's disease is projected to grow 
substantially over the next few decades as the size of the elderly 
population grows and will have a direct impact on the healthcare system 
and economy. A study published in Movement Disorders estimated that the 
economic burden of Parkinson's disease is at least $14.4 billion a year 
in the United States, and the prevalence of Parkinson's will more than 
double by the year 2040.\1\ In addition, the study calculated an 
additional $6.3 billion in indirect costs such as missed work or loss 
of a job for the patient or family member who is helping with care, 
long-distance travel to see a neurologist or movement disorder 
specialist, as well as costs for home modifications, adult day care, 
and personal care aides.
---------------------------------------------------------------------------
    \1\ ``The Current and Projected Economic Burden of Parkinson's 
Disease in the United States,'' Movement Disorders, Vol. 28, No. 3, 
2013.
---------------------------------------------------------------------------
    A second study also published in Movement Disorders projected that 
if Parkinson's progression were slowed by 50 percent, there would be a 
35 percent reduction in excess costs, representing a dramatic reduction 
in cost of care spread over a longer expected survival.\2\ Both studies 
highlight the enormous economic implications of this devastating 
disease, and make it abundantly clear that increased research funding 
is a wise investment on the front end to help significantly lower or 
eliminate costs on the back end.
---------------------------------------------------------------------------
    \2\ ``An Economic Model of Parkinson's Disease: Implications for 
Slowing Progression in the United States,'' Movement Disorders, Vol. 
28, No. 3, 2013.
---------------------------------------------------------------------------
    NIH has the unique role of being at the forefront of medical 
discovery in the United States. NIH supports research in all fifty 
States, with more than 80 percent of the funding going to universities, 
research institutions, and small businesses, which create thousands of 
jobs and grow local economies. In 2012, this amounted to over 402,000 
jobs nationwide and $57.8 billion in economic activity. Perhaps even 
more important than their economic contributions is the practical 
impact NIH grants have in identifying and developing a better 
understanding of and treatments for countless complex diseases and 
disorders.
    There is currently a concerted effort at NIH to better target areas 
of unmet medical need, including Parkinson's research. In January 2014, 
NINDS approved a list of 31 priority research recommendations specific 
to Parkinson's that highlight areas in which NINDS and the broader 
field should direct its resources to achieve the greatest impact in 
addressing treatments and the underlying causes of the disease. These 
recommendations were the result of an intensive planning process that 
brought together clinicians, researchers, and the patient community to 
determine the areas of greatest need to reframe how we approach the 
disease. We applaud NINDS for their leadership in this effort, which 
represents an unparalleled opportunity to coordinate critical 
initiatives to help unlock the mysteries of Parkinson's--but its 
success is dependent upon strengthening funding at NIH and NINDS to 
ensure that sufficient capacity and resources are available.
    Unfortunately, due to ongoing fiscal constraints, including 
sequestration, the NIH research budget has not kept pace with inflation 
or the growing needs of an aging population and the overall public 
health. Sequestration alone cut over $1.55 billion from NIH in fiscal 
year 2013, which is roughly equivalent to the entire budget for NINDS. 
NIH, the largest funder of Parkinson's research in the world, was also 
forced to reduce its Parkinson's-related research from a high of $154 
million in fiscal year 2012 to $135 million in fiscal year 2013, a 12 
percent decrease. Across the country, many institutions have felt the 
burden of these cuts, receiving smaller grants or no grants at all. As 
NIH continues to find high-priority areas to fund in order to advance 
Parkinson's research, we should be increasing support and not applying 
cuts that could possibly delay years of progress toward a cure for 
Parkinson's and other diseases.
    Despite some greater certainty in the current appropriations cycle 
because of the budget agreement passed in December 2013, there is still 
grave concern over the implications for medical research long-term. Dr. 
Francis Collins, director of NIH, has even noted that ``without 
sustained investment, many high-priority efforts would move at a 
substantially slower pace, and years of effectively flat funding for 
biomedical research have left scientists facing the lowest chances in 
history of having their research funded by NIH.'' \3\ Because of this 
trend, there is also the fear that the next generation of scientists 
will leave the United States or be reluctant to enter the field of 
neurological research at all because of the uncertainty in financial 
support they see and feel here at home. Innovation and new 
possibilities for medical research are at our fingertips, and we must 
be sure that we have the resources in place to fully recognize and 
cultivate their potential.
---------------------------------------------------------------------------
    \3\ ``Investing in the Nation's Health,'' Dr. Francis Collins. The 
Washington Post. Opinions. December 24, 2013.
---------------------------------------------------------------------------
    We recognize that due to spending caps put into place by the 2013 
budget agreement, the President's fiscal year 2015 budget proposal only 
requests a modest increase for NIH and many other important programs. 
But, we also understand that the final decision on how these funds 
should be allocated within those caps is the responsibility of 
Congress--and we look to you for your leadership and support. PAN urges 
the Subcommittee to prioritize biomedical research funding by 
supporting at least $32 billion for the NIH overall and increasing 
funding for NINDS to advance critical priorities designed to 
fundamentally change our understanding of Parkinson's disease. We look 
forward to working with the Subcommittee as the fiscal year 2015 
appropriations process moves forward.
                                 ______
                                 
        Prepared Statement of the Pew Children's Dental Campaign
    On behalf of the Pew Children's Dental Campaign, thank you for the 
opportunity to submit testimony regarding appropriations for fiscal 
year 2015. We appreciate the subcommittee's recognition of oral health 
as a key aspect of overall health and its continued support of programs 
that expand access to preventive and restorative services through the 
Health Resources and Services Administration (HRSA) and the Centers for 
Disease Control and Prevention (CDC).
    The Pew Children's Dental Campaign works at the State and national 
levels to ensure that more children receive dental care and benefit 
from evidence-based policies, such as community water fluoridation, 
dental sealant programs, and expansion of the dental workforce. Since 
it was established in 2008, our initiative has produced numerous 
reports evaluating access to care across the 50 States and the District 
of Columbia, and while we have made significant progress in advancing 
reforms nationally and in the States, there is still much to be done on 
this important issue.
    Tooth decay affects nearly 60 percent of the Nation's children, 
and, unsurprisingly, its consequences are concentrated 
disproportionately among low-income children.\1\ Dental disease is the 
most common chronic disease among children in the U.S.--five times more 
prevalent than asthma, and in a single year, U.S. students may miss as 
many as 51 million hours of school due to dental health problems.\2\ It 
causes pain, hampers school performance, and if left untreated can lead 
to tooth loss and abscesses that spread infection to the blood and 
brain.\3\
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services, Oral Health in 
America: A Report of the Surgeon General, DHHS, Rockville, MD, 2000.
    \2\ Ibid.
    \3\ Ibid.
---------------------------------------------------------------------------
    Lack of access to preventive services and oral healthcare also 
imposes a huge cost on States. In 2011, preventable dental conditions 
were the primary reason for 857, 712 emergency room (ER) visits in the 
U.S.\4\ In 2010, Florida spent more than $88 million on more than 
115,000 hospital ER visits for dental problems and in 2007, 60,000 
dental visits to ERs cost the State of Georgia more than $23 
million.\5,6\ Dental problems can also impact the workforce, causing an 
estimated 164 million hours of lost work time each year, and can 
inhibit a person's ability to find a job.\7\ Additionally, a 2008 study 
of the armed forces found that 52 percent of new recruits were found to 
be Class 3 in ``dental readiness,'' meaning they had oral health 
problems that needed urgent attention and would delay overseas 
deployment.\8\
---------------------------------------------------------------------------
    \4\ HCUPnet, Healthcare Cost and Utilization Project, ``Information 
on ED visits from the HCUP Nationwide Emergency Department Sample 
(NEDS),'' Agency for Healthcare Research and Quality, Rockville, MD. 
http://hcupnet.ahrq.gov/
    \5\ ``315 Patients a Day Seek Dental Treatment in Florida's 
Hospital Emergency Rooms,'' a news release by the Florida Public Health 
Institute, (December 15, 2011).
    \6\ Andy Miller, ``Fight over Georgia dental rules flares again,'' 
Georgia Health News, September 7, 2011, http://
www.georgiahealthnews.com/2011/09/fight-dental-rules-flares/.
    \7\ U.S. Department of Health and Human Services, Oral Health in 
America: A Report of the Surgeon General, DHHS, Rockville, MD, 2000.
    \8\ T. M. Leiendecker, G. C. Martin et al., ``2008 DOD Recruit Oral 
Health Survey: A Report on Clinical Findings and Treatment Need,'' Tri-
Service Center for Oral Health Studies (2008), 1.
---------------------------------------------------------------------------
    Given the enormous impact of oral health on overall health and the 
associated social and economic consequences, we respectfully request 
that the subcommittee consider the following appropriations requests 
for programs that aim to expand access to care and preventive services 
for those most in need.
Focusing on prevention
    With support from the CDC Division of Oral Health, States can 
better promote oral health and efficiently administer scarce resources, 
monitor oral health status and problems, and conduct and evaluate 
prevention programs through cooperative agreements. This funding is 
critical to a State's ability to prevent problems before they occur, 
rather than treating them when they are painful and expensive. The 
cooperative agreement program also supports State community water 
fluoridation programs and school-based dental sealant programs, and 
while funding for this program has been authorized for all 50 States, 
the Division is currently only able to support 21 States: Colorado, 
Connecticut, Georgia, Hawaii, Idaho, Iowa, Kansas, Louisiana, Maryland, 
Michigan, Minnesota, Mississippi, New Hampshire, New York, North 
Dakota, Rhode Island, South Carolina, Vermont, Virginia, West Virginia, 
and Wisconsin.
    Research shows that community water fluoridation offers one of the 
greatest returns on investment of any preventive healthcare strategy. 
For most cities, every $1 invested in water fluoridation saves $38 in 
dental treatment costs.\9\ CDC estimates that fluoridated water saves 
more than $4.6 billion annually in dental costs in the United 
States,\10\ and even more could be saved by expanding coverage to some 
of the 70 million people who still do not have it.\11\ Dental sealants 
are also cost-effective; school-based programs can efficiently prevent 
60 percent of decay in the permanent teeth most likely to become 
decayed during childhood.\12\ We recommend a funding level sufficient 
to enable all States and the District of Columbia to receive the 
critical CDC prevention funds, starting with an increase for the coming 
fiscal year to begin moving toward full funding.
---------------------------------------------------------------------------
    \9\ Centers for Disease Control and Prevention, ``Cost Savings of 
Community Water Fluoridation,'' Fact Sheet, Accessed March 27, 2014: 
http://www.cdc.gov/fluoridation/factsheets/cost.htm
    \10\ Centers for Disease Control and Prevention, ``Preventing 
Dental Caries with Community Programs,'' Fact Sheet, Accessed March 27, 
2014: http://www.cdc.gov/oralhealth/publications/factsheets/
dental_caries.htm
    \11\ Centers for Disease Control and Prevention, ``2012 Water 
Fluoridation Statistics,'' Data and Statistics, Accessed March 27, 
2014: http://www.cdc.gov/fluoridation/statistics/2012stats.htm
    \12\ Truman, B. I., Gooch, B. F., Sulemana, I., Gift, H. C., 
Horowitz, A. M., Evans, C. A., et al. (2002). Reviews of evidence on 
interventions to prevent dental caries, oral and pharyngeal cancers, 
and sports-related craniofacial injuries. American Journal of 
Preventive Medicine, 23(1 Suppl.), 21--54.
---------------------------------------------------------------------------
Funding request for fiscal year 2015: $19 million for the CDC Division 
        of Oral Health to expand cooperative agreements to additional 
        States
Addressing the dental access crisis
    Pew's 2013 brief, In Search of Dental Care, found that roughly 45 
million Americans live in dental professional shortage areas, regions 
that have a scarcity of dentists relative to the population.\13\ 
Additionally, in 2011, more than 14 million children enrolled in 
Medicaid did not receive any dental service, in part due to the low 
numbers of dentist participation in the Medicaid program.\14\ The 
supply of dentists nationally is also likely to shrink in the coming 
years. The American Dental Association projects that despite the 
addition of new dental schools and possible increase in graduates, 
between 2010 and 2030 the ratio of dentists to Americans will continue 
to fall due to high numbers of dentists approaching retirement age.\15\
---------------------------------------------------------------------------
    \13\ The Pew Charitable Trusts, ``In Search of Dental Care,'' June 
2013, http://www.pewstates.org/uploadedFiles/PCS_Assets/2013/
In_search_of_dental_care.pdf
    \14\ This figure counts children ages 1 to 18 eligible for the 
Early and Periodic Screening, Diagnostic and Treatment Benefit. See 
U.S. Department of Health and Human Services, Centers for Medicare and 
Medicaid Services, Annual EPSDT Participation Report, Form CMS-416 
(National) fiscal year: 2011, April 1, 2013. Analysis by The Pew 
Charitable Trusts; U.S. Department of Health and Human Services, 
Centers for Medicare and Medicaid Services, Early and Periodic 
Screening, Detection and Treatment Web page (accessed May 24, 2013), 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/
Benefits/Early-Periodic-Screening-Diagnosis-and- Treatment.html.
    \15\ American Dental Association, Health Policy Resources Center, 
2011 American Dental Association Workforce Model: 2009-2030 (Chicago: 
American Dental Association, 2011), 11.
---------------------------------------------------------------------------
    Many States are expanding scope of practice laws to enable a 
variety of dental care providers to expand access to care to the 
underserved, such as dental therapists in Minnesota and Alaska tribal 
lands, public health hygienists in Kentucky, Maryland, and New 
Hampshire, and community dental health coordinators in Arizona, 
California, Montana, New Mexico, Oklahoma, and Wisconsin. A Federal 
demonstration grant program authorized in 2010 but currently unfunded 
would provide training institutions, community health centers, public 
hospitals, and other organizations with funding to train these types of 
providers, all in accordance with State scope of practice laws, and 
evaluate their impact on access to care.\16\ Also eligible for funding 
through this demonstration are programs such as one in California that 
uses telehealth services to bring care to patients in Head Start 
centers and nursing homes \17\ and ER diversion programs that link 
public hospitals to federally qualified health centers.\18\
---------------------------------------------------------------------------
    \16\ Patient Protection and Affordable Care Act of 2010, Public Law 
No. 111-148, sec. 5304, 124 Stat. 119, 621-622 (2010).
    \17\ Virtual Dental Home Demonstration Project, Arthur A. Dugoni 
School of Dentistry, University of the Pacific: http://
www.dental.pacific.edu/Community_Involvement/
Pacific_Center_for_Special_Care--(PCSC)/Innovations_Center/
Virtual_Dental_Home_Demonstration_Project. html.
    \18\ Centers for Medicare and Medicaid Services, ``Emergency Room 
Diversion Grant Program,'' 2008- 2011, http://www.medicaid.gov/
Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Grant-
Programs/ER-Diversion-Grants.html.
---------------------------------------------------------------------------
    Pilot efforts to assess how new dental providers can increase 
access to care are being developed in Oregon, Michigan, Connecticut and 
Hawaii, and Maine, Kansas, New Mexico, Ohio, and Washington are among 
the States considering legislation to authorize dental therapists. 
These providers and programs can increase access at a lower cost to 
States, and numerous studies have reaffirmed the quality of the 
services being provided.\19\ These evaluations would not only benefit 
those States that have authorized alternative providers, but would also 
provide information to inform policies in the many other States that 
are struggling to find answers to the challenge of expanding access to 
the underserved.
---------------------------------------------------------------------------
    \19\ David A. Nash et al., A Review of the Global Literature on 
Dental Therapists, April 2012, W.K. Kellogg Foundation, http://
www.wkkf.org/knowledge-center/resources/2012/04/nash-dental-therapist-
literaturereview.aspx.
---------------------------------------------------------------------------
HRSA funding request for fiscal year 2015:
  --Removal of the current funding block on existing funding for the 
        Alternative Dental Health Care Provider Demonstration Grants, 
        Section 340G-1 of the Public Health Service Act, and an 
        appropriation of $10 million to initiate the program
  --$32 million for Title VII program grants to expand and educate the 
        dental workforce
    By making targeted Federal investments in effective policy 
approaches, the subcommittee can enable States to sustain programs that 
prevent the pain, missed school hours and long-term health and economic 
consequences of untreated dental disease. A handful of States are 
leading the way, but all States can and must do more to ensure access 
to dental care for those who need it most. Thank you for your 
consideration of this testimony.

    [This statement was submitted by Shelly Gehshan, Director, Pew 
Children's Dental Campaign.]
                                 ______
                                 
  Prepared Statement of the Physician Assistant Education Association
    On behalf of the 187 accredited physician assistant (PA) education 
programs in the United States, the Physician Assistant Education 
Association (PAEA) is pleased to submit these comments on the fiscal 
year 2015 appropriations for PA education programs that are authorized 
through Title VII of the Public Health Service Act. PAEA supports 
funding of at least $280 million in fiscal year 2015 for the health 
professions education programs authorized under Title VII of the Public 
Health Service Act and administered through the Health Resources and 
Services Administration (HRSA). We also request $12 million of that 
funding support PA programs operating across the country. This is the 
only designated source of Federal funding for PA education and is 
crucial to the U.S. PA education system's ability to meet the demand 
for education and to continue to produce highly skilled physician 
assistants ready to enter the healthcare workforce in an average of 26 
months. The way that PAs are educated in America--the caliber of our 
institutions and the expertise of our educators--is the gold-standard 
throughout the world and that distinction must be maintained in this 
period of unprecedented patient need and rapid growth within the PA 
profession.
Need for Increased Federal Funding
    The unmet need for primary care services in the United States is 
well documented, and only expected to grow as Baby Boomers age and the 
Affordable Care Act is fully implemented. The very parameters of access 
and healthcare quality are rapidly evolving. Yet the one constant in 
our healthcare system remains the need for qualified healthcare 
providers in numbers sufficient to meet demand, and primary care has 
been clearly identified as the critical entry point into the healthcare 
system where that access must be guaranteed. The PA profession was 
created specifically to address a shortage of primary care physicians 
almost fifty years ago, and today's PAs stand ready to help address the 
challenges our Nation faces in primary care. The effectiveness of 
physician assistants is well-documented by studies showing better 
patient access, especially for Medicaid patients, high patient 
satisfaction, more frequent patient education, and healthcare outcomes 
similar to physicians. Importantly, PAs could play an even larger role 
in high-quality, cost-effective care if offered appropriate financial 
support and through innovations in the PA education system.
    Like physicians, the PA profession also faces a shortage of 
graduates that will hinder its ability to help fully address the 
primary care issue in the United States. Without new solutions, at the 
current output of approximately 7000 graduates from PA programs per 
year, these shortages will persist, particularly in the rural and 
underserved communities where care is needed the most. Title VII is the 
only funding source that provides direct support for PA programs and 
plays a crucial role in developing and supporting the education 
system's ability to produce the next generation of these advanced 
practice clinicians.
Background on the Profession
    Since the 1960s, PAs have consistently demonstrated they are 
effective partners in healthcare, readily adaptable to the needs of an 
ever-changing delivery system. Physician assistants are licensed health 
professionals with advanced education in general medicine that practice 
medicine as members of the healthcare team. They provide a broad range 
of medical and therapeutic services to diverse populations in rural and 
urban settings, including prescriptive authority in all 50 States, the 
District of Columbia, and Guam. PAs practice medicine to the extent 
allowed by law and within the physician's scope of practice and their 
combination of medical training, advanced education, and hands-on 
experience allows PAs to practice with significant autonomy, and in 
rural and other medically underserved areas where they are often the 
only full-time medical provider. The profession is well established, 
yet nimble enough to embrace new models of care, adopt innovative 
approaches to training and education, and adapt to health system 
challenges. The PA practice model is, by design, a team-based approach 
to patient-centered care where the PA works in tandem with a physician 
and other health professionals. This PA practice approach to quality 
care is uniquely aligned with the patient-centered, collaborative, 
interprofessional and outcomes-based care models transforming the U.S. 
healthcare system.
PA Education: The Pipeline for Physician Assistants
    There are currently 187 accredited PA education programs in the 
United States--a 23 percent increase over the past 5 years; together 
these programs graduate over 7,000 PA students each year. PAs are 
educated as generalists in medicine and that training gives them the 
flexibility to practice in more than 60 medical and surgical 
specialties. More than one third of PA program graduates are working in 
a primary care specialty.
    The average PA education program is 26 months in length and 
includes one didactic year in the classroom, and another year devoted 
to clinical rotations. Most curricula include 340 hours of basic 
sciences and nearly 2,000 hours of clinical training, second only to 
physicians in time spent in clinical study.
    As of today, approximately 65 new PA programs are in the pipeline 
at various stages of development and moving toward accredited status. 
The growth rate in the applicant pool is even more pronounced. Since 
its inception in 2001 through the most recent application cycle, the 
Centralized Application Service (CASPA) used by most programs grew from 
4,669 applicants to over 20,000. As of March 2014, there were 19,968 
applicants to PA education programs, a 36 percent increase in CASPA 
applicants over the past 5 years alone.
    The PA profession is expected to continue to grow as a result of 
the projected shortages of physicians and other healthcare 
professionals, the growing demand for care driven by an aging 
population, and the continuing strong PA applicant pool. Accordingly, 
The Bureau of Labor Statistics projects a 39 percent increase in the 
number of PA jobs between 2008 and 2018. With its relatively short 
initial training time and the flexibility of generalist-trained PAs, 
the PA profession is well-positioned to help fill projected shortages 
in the numbers of healthcare professionals--if appropriate resources 
are available to support the education system behind them.
                          areas of acute need
Faculty Shortages
    Faculty development is one of the profession's critical needs and 
educators are an often overlooked element to developing an adequate 
primary care workforce. Nearly half of PA program faculty are 50 years 
or older and the PA teaching profession faces large numbers of 
retirements in the next 10-15 years. An interest in education must be 
developed early in the educational process to ensure a continuous 
stream of educators, and to do so, we must alleviate the significant 
loan burdens that prevent many physician assistants from entering 
academia. In order to attract the most highly qualified faculty, PA 
education programs must have the resources to help clinicians 
transition into education, including curriculum development, teaching 
methods, and laboratory instruction. Most educators come from clinical 
practice and these non-clinical professional skills are essential to a 
successful transition from clinical practice to a classroom setting. 
Without Federal support, we will face an impending shortage of 
educators who are prepared for and committed to the critical teaching 
role that will ensure the next generation of skilled practitioners.
Clinical Site Shortages
    Outside of the classroom, PA education faces additional challenges 
in meeting demand. A lack of clinical sites for PA education is 
hampering PA programs' ability to produce PAs at the pace needed to 
meet the demand for primary care in the U.S. This shortage is caused by 
two main factors: a shortage of medical professionals willing to teach 
students as they are cycling through their clinical rotations 
(preceptors), and a lack of sites with the physical space to teach.
    This phenomenon is experienced throughout the health professions, 
and is particularly acute in primary care. It has created unintentional 
competition for clinical sites and preceptors within and among PAs, 
physicians and advance practice nurses. Federal funding can help 
incentivize practicing clinicians to both offer their time as 
preceptors, and volunteer their clinical operations as training grounds 
for PAs and other health professionals to train together and directly 
interact with patients as a team. PAEA believes that interprofessional 
clinical training and practice are necessary for optimum patient care 
and will be a defining model of healthcare in the U.S. in the 21st 
century. We can only make that a reality if we begin to build a 
sufficient network of health professionals who are willing to teach the 
next generation of primary care professionals--that approach will 
benefit PAs as well as the future physicians, nurses and other 
clinicians that comprise the full primary care team.
Enhancing Diversity
    Workforce diversity, and practice in underserved areas are key 
priorities identified by HRSA and are consistent with those of PAEA. It 
is increasingly important for patient care quality that the health 
workforce better represents America's changing demographics, as well as 
addresses the issues of disparities in healthcare. PA programs have 
been committed to attracting students from underrepresented minority 
groups and disadvantaged backgrounds into the profession, including 
veterans who have served our country and desire to transition to 
civilian health professions. Studies have found that health 
professionals from underserved areas are three to five times more 
likely to return to underserved areas to provide care, and PA programs 
are looking for unique ways to recruit diverse individuals into the 
profession, and sustain them as leaders in the education field. If we 
can provide resources to schools that are particularly poised to 
improve their diversity recruitment efforts and replicate or create 
best practices including transition programs for our veterans, we can 
begin to address this systemic need.
    In order to leverage the efforts of PA programs through Title VII 
funding to increase workforce diversity in the PA profession, PAEA also 
supports the restoration of funding for the Health Careers Opportunity 
Program (HCOP), and increased funding for the Scholarships for 
Disadvantaged Students and National Health Service Corps. Historically, 
access to higher education has been constrained for individuals from 
disadvantaged backgrounds. These programs help to provide a clear path 
for students who might not otherwise consider a physician assistant 
career.
Title VII Funding
    Title VII funding fills a critical need for curriculum development, 
faculty development, clinical site expansion and diversification of the 
primary care workforce--areas that if appropriately supported can help 
ensure the PA profession realizes its full promise in the U.S. 
healthcare system. These funds enhance clinical training and education, 
assist PA programs with recruiting applicants from minority and 
disadvantaged backgrounds, and enable innovative programs that focus on 
educating a culturally competent workforce. Title VII funding increases 
the likelihood that PA students will practice in medically underserved 
communities with health professional shortages. The absence of this 
funding would result in the loss of care to patients with the most 
urgent need for access to care.
    Title VII support for PA programs was strengthened in 2010 when 
Congress enacted a 15 percent allocation in the Appropriations process 
specifically for PA programs working to address the health provider 
shortage. This funding has enhanced capabilities to train a growing PA 
workforce, creatively expand care to the underserved, and develop a 
more diverse PA workforce:
  --One Texas program has used its PA training grant to support the 
        program at a distant site in an underserved area. This grant 
        provides assistance to the program for recruiting, educating, 
        and training PA students in the largely Hispanic South Texas 
        and mid-Texas/Mexico border areas and supports new faculty 
        development.
  --A Utah program has used its PA training grant to promote 
        interprofessional teams. The grant allowed the program to 
        optimize its relationship with three service-learning partners, 
        develop new partnerships with three service-learning sites, and 
        create a model geriatric curriculum that includes didactic and 
        clinical education.
  --An Alabama program used its PA training grant to update and expand 
        the current health behavior educational curriculum and HIV/STD 
        training. They were also able to include PA students from other 
        programs who were interested in rural, primary care medicine 
        for a four-week comprehensive educational program in HIV 
        disease diagnosis and management.
Recommendations on fiscal year 2015 Funding
    The Physician Assistant Education Association requests the 
Appropriations Committee's support in funding for Title VII health 
professions programs at a minimum of $280 million for fiscal year 
2015.This level of funding is crucial to support the Nation's ability 
to produce and maintain highly skilled primary care practitioners, 
particularly those from diverse backgrounds and the military who will 
practice in medically underserved areas and serve vulnerable 
populations. We also ask for the continuation of the 15 percent 
allocation for PA education programs in the Primary Care cluster as 
mandated in the Affordable Care Act. The Accreditation Review 
Commission on Education for the Physician Assistant estimates that an 
additional 75 programs will be added by 2018. Therefore, we request an 
increase in funding to $12 million which will allow sufficient funding 
for the expanding number of PA programs expected to begin enrolling 
students during the next four to 5 years.
    We thank the members of the subcommittee for their support of the 
health professions and look forward to your continued commitment to 
finding solutions to the Nation's health workforce shortage. We 
appreciate the opportunity to present the Physician Assistant Education 
Association's fiscal year 2015 funding recommendation.

    [This statement was submitted by Anthony Miller, M.Ed., PA-C Chief 
Policy and Research Officer.]
                                 ______
                                 
    Prepared Statement of the Population Association of America and 
                   Association of Population Centers
Introduction
    Thank you, Mr. Chairman Harkin, Ranking Member Moran, and other 
distinguished members of the Subcommittee, for this opportunity to 
express support for the National Institutes of Health (NIH), National 
Center for Health Statistics (NCHS), and Bureau of Labor Statistics 
(BLS). These agencies are important to the members of the Population 
Association of America (PAA) and Association of Population Centers 
(APC) because they provide direct and indirect support to population 
scientists and the field of population, or demographic, research 
overall. In fiscal year 2015, we urge the Subcommittee to adopt the 
following funding recommendations: NIH, $32 billion, consistent with 
the level recommended by the Ad Hoc Group for Medical Research; NCHS, 
$182 million, consistent with the Administration's request; and BLS, 
$610 million, consistent with the Administration's request, at a 
minimum.
    The PAA and APC are two affiliated organizations that together 
represent over 3,000 social and behavioral scientists and almost 40 
population research centers nationwide that conduct research on the 
implications of population change. Our members, which include 
demographers, economists, sociologists, and statisticians, conduct 
scientific research, analyze changing demographic and socio-economic 
trends, develop policy recommendations, and train undergraduate and 
graduate students. Their research expertise covers a wide range of 
issues, including adolescent health and development, aging, health 
disparities, immigration and migration, marriage and divorce, 
education, social networks, housing, retirement, and labor.
National Institutes of Health
    Demography is the study of populations and how or why they change. 
A key component of the NIH mission is to support biomedical, social, 
and behavioral research that will improve the health of our population. 
The health of our population is fundamentally intertwined with the 
demography of our population. Recognizing the connection between health 
and demography, NIH supports extramural population research programs 
primarily through the National Institute on Aging (NIA) and the 
National Institute of Child Health and Human Development (NICHD).
National Institute on Aging
    To inform the implications of our rapidly aging population, 
policymakers need objective, reliable data about the antecedents and 
impact of changing social, demographic, economic, health and well-being 
characteristics of the older population. The NIA Division of Behavioral 
and Social Research (BSR) is the primary source of Federal support for 
basic research on these topics.
    In addition to supporting an impressive research portfolio that 
includes the prestigious Centers on the Demography and Economics of 
Aging, the NIA BSR Division also supports several large surveys that 
produce accessible data. These surveys include the National Health and 
Aging Trends Study (NHATS), which has enrolled 8,000 Medicare 
beneficiaries with the goal of studying late-life disability trends and 
dynamics. The study also includes a supplement to examine informal 
caregivers and their impact on the utilization of long-term care by 
people with chronic disabilities. Another NIA survey, the Health and 
Retirement Study (HRS), provides unique information about economic 
transitions in work, income, and wealth, allowing scientists to study 
how the domains of family, economic resources, and health interact. The 
HRS has collected data every 2 years since 1992, including most 
recently, biomarkers, from a representative sample of more than 26,000 
Americans over the age of 50. These data are accessible to researchers 
worldwide and have informed numerous scientific findings. For example, 
in 2013, researchers using the HRS published a study in the New England 
Journal of Medicine, concluding that the cost of providing dementia 
care is comparable to, if not greater than, those for heath disease and 
cancer.
Eunice Kennedy Shriver National Institute of Child Health and Human 
        Development
    Since 1968, NICHD has supported research on population processes 
and change. This research is housed in the Institute's Population 
Dynamics Branch, which supports research and training in demography, 
reproductive health, and population health and funds major national 
studies that track the health and well-being of children and their 
families from childhood through adulthood. These studies include 
Fragile Families and Child Well-Being, the first scientific study to 
track the health and development of children born to unmarried parents, 
and the National Longitudinal Study of Adolescent Health (Add Health), 
tracing the effects of childhood and adolescent exposures on later 
health.
    One of the most important population research programs that the 
NICHD supports is the Population Dynamics Centers Research 
Infrastructure Program. This program promotes innovation, supports 
interdisciplinary research, translates scientific findings into 
practice, and develops the next generation of population scientists. In 
addition, the centers provide incentives to reduce the costs and 
increase the efficiency of research by streamlining and consolidating 
research infrastructure. The population research centers generate and 
facilitate significant scientific research findings as well. For 
example, in March 2014, researchers at Johns Hopkins University 
published findings in JAMA, concluding that opening or expanding 
casinos on California tribal lands reduces poverty and the obesity rate 
of children by almost 3 percent.
National Center for Health Statistics
    The National Center for Health Statistics (NCHS) is the Nation's 
principal statistical agency. Most notably, NCHS funds and manages the 
National Vital Statistics System (NVSS), which contracts with the 
States to collect birth and death certificate information, and funds a 
number of complex large surveys, such as National Survey of Family 
Growth and National Health Interview Survey, which are an invaluable 
resource for population scientists. The Subcommittee's support of NCHS 
in recent years has enabled it to make significant progress toward 
modernizing the NVSS and expediting the release of these data to the 
user community. Yet, much work is still needed to fully modernize the 
NVSS and to support necessary expansions to the agency's core surveys 
so that these data can effectively assess Americans' health.
Bureau of Labor Statistics
    The Bureau of Labor Statistics (BLS) produces essential economic 
information for public and private decisionmaking. Its data are used 
extensively by population scientists who study and evaluate labor and 
related economic policies and programs. Given the importance and unique 
nature of BLS data, we urge the Subcommittee to support the 
Administration's request, $610 million, at a minimum, but to consider 
increasing its funding to $631 million. This additional funding is 
necessary to restore the agency's purchasing power back to fiscal year 
2010 levels and specifically to restore recent program cuts.
    Thank you for considering the importance of these agencies under 
your jurisdiction that benefit the population sciences.

    [This statement was submitted by Mary Jo Hoeksema, Director, 
Government Affairs Population Association of America/Association of 
Population Centers.]
                                 ______
                                 
                Prepared Statement of Prevent Blindness
                        funding request overview
    Prevent Blindness appreciates the opportunity to submit written 
testimony for the record regarding fiscal year 2015 funding for vision 
and eye health related programs. As the Nation's leading non-profit, 
voluntary health organization dedicated to preventing blindness and 
preserving sight, Prevent Blindness maintains a long-standing 
commitment to working with policymakers at all levels of government, 
organizations and individuals in the eye care and vision loss 
community, and other interested stakeholders to develop, advance, and 
implement policies and programs that prevent blindness and preserve 
sight. Prevent Blindness respectfully requests that the Subcommittee 
provide the following allocations in fiscal year 2015 to help promote 
eye health and prevent eye disease and vision loss:
  --Provide at least $1,000,000 to strengthen the Vision Health 
        Initiative (visual screening education) at the Centers for 
        Disease Control and Prevention (CDC).
  --Provide at least $3,319,000 to continue the Glaucoma Project at the 
        CDC.
  --Support the Maternal and Child Health Bureau's (MCHB) National 
        Center for Children's Vision and Eye Health.
  --Provide at least $639 million in to sustain programs under the 
        Maternal and Child Health (MCH) Block Grant.
  --Provide at least $730 million to the National Eye Institute (NEI).
                       introduction and overview
    Vision-related conditions affect people across the lifespan. Good 
vision is an integral component to health and well-being, affects 
virtually all activities of daily living, and impacts individuals 
physically, emotionally, socially, and financially. Loss of vision can 
have a devastating impact on individuals and their families. An 
estimated 80 million Americans have a potentially blinding eye disease, 
three million have low vision, more than one million are legally blind, 
and 200,000 are more severely visually blind. Vision impairment in 
children is a common condition that affects five to 10 percent of 
preschool age children, and is a leading cause of impaired health in 
childhood. Recent research showed that the economic burden of vision 
loss and eye disorders is $139 billion each year, $47.4 billion of 
which is Federal spending. Alarmingly, while half of all blindness can 
be prevented through education, early detection, and treatment, the NEI 
reports that ``the number of Americans with age-related eye disease and 
the vision impairment that results is expected to double within the 
next three decades.'' \1\
---------------------------------------------------------------------------
    \1\ ``Vision Problems in the U.S.: Prevalence of Adult Vision 
Impairment and Age-Related Eye Disease in America,'' Prevent Blindness 
America and the National Eye Institute, 2008.
---------------------------------------------------------------------------
    To curtail the increasing incidence of vision loss in America, and 
its accompanying economic burden, Prevent Blindness advocates sustained 
and meaningful Federal funding for programs that promote eye health and 
prevent eye disease, vision loss, and blindness; needed services and 
increased access to vision screening; and vision and eye disease 
research. In a time of significant fiscal constraints, we recognize the 
challenges facing the Subcommittee and urge you to consider the 
ramifications of decreased investment in vision and eye health. Vision 
loss is often preventable, but without continued efforts to better 
understand eye conditions, and their treatment, through research, to 
develop the public health systems and infrastructure to disseminate and 
implement good science and prevention strategies, and to protect 
children's vision, millions of Americans face the loss of independence, 
loss of health, and the loss of their livelihoods, all because of the 
loss of their vision.
 vision and eye health at the cdc: helping to save sight and save money
    The CDC serves a critical role in promoting vision and eye health. 
Since 2003, the CDC and Prevent Blindness have collaborated with other 
partners to create a more effective public health approach to vision 
loss prevention and eye health promotion. The CDC works to promote eye 
health and prevent vision loss; improve the health and lives of people 
living with vision loss by preventing complications, disabilities, and 
burden; reduce vision and eye health related disparities; and integrate 
vision health with other public health strategies. However, severely 
constrained financial resources have limited the CDC's ability to take 
the work of the Vision Health Initiative (VHI) to the next level.
    Prevent Blindness requests at least $1,000,000 in fiscal year 2015 
to strengthen vision and eye health efforts of the CDC. This funding 
level would allow the VHI to increase vision impairment and eye disease 
surveillance efforts, apply previous CDC vision and eye health research 
findings to develop effective prevention and early detection 
interventions, and begin to incorporate vision and eye health promotion 
activities into State and national public health chronic disease 
initiatives, with an initial focus on early detection of diabetic 
retinopathy
Improving Access to Eye Care for those at High Risk for Glaucoma
    An estimated 2.2 million people are affected by glaucoma. A disease 
of the aging eye, risk for glaucoma increases with age, especially 
among black, Hispanic/Latinos, and Asians. Once vision is lost to 
glaucoma, it cannot be restored, but with early diagnosis and 
appropriate treatment, it is possible to slow disease progression and 
save the remaining sight. Detection and management of glaucoma are 
challenged by difficulties in reaching high-risk populations and by the 
lack of simple, cost-effective screening plans.
    Prevent Blindness requests at least $3,319,000 in fiscal year 2015 
to continue the work of the Glaucoma Project to improve glaucoma 
screening, referral, and treatment. The program is intended to reach 
those populations experiencing the greatest disparity in access to 
glaucoma care through an integrated collaboration among private and 
public organizations.
    investing in the vision of our nation's most valuable resource--
                                children
    While the risk of eye disease increases after the age of 40, eye 
and vision problems in children are of equal concern. The visual system 
in children younger than 8 years old is in a critical developmental 
stage. Unidentified and untreated vision problems can lead to permanent 
and irreversible visual loss and/or cause problems socially, 
academically, and developmentally in this critical time of a child's 
life. Currently, only one in three children receive eye care services 
before the age of six.[1] Requirements for preventive eye care/vision 
screenings prior to or during the school years vary broadly from State 
to State. Many States have no standards and those with standards 
present with little consistency regarding type, frequency, and referral 
or follow-up requirement protocol.[i] Inclusion of vision screenings 
with a comprehensive approach to follow up treatment and an integrated 
approach to data collection as a part of the required health component 
for grant recipients will help to change disparities in vision and eye 
health for our Nation's children.
    In 2009, the MCHB established the National Center for Children's 
Vision and Eye Health (the Center), a national vision health 
collaborative effort aimed at developing the public health 
infrastructure necessary to promote eye health and ensure access to a 
continuum of eye care for young children.
    The Center is guided by an Advisory Committee comprised of the 
Nation's leaders in children's vision and public health to implement 
national guidelines for quality improvement strategies, vision 
screening and developing a continuum of children's vision and eye 
health. With this support the Center, will continue to: (1) provide 
national leadership in dissemination of best practices, infrastructure 
development, professional education, and national vision screening 
guidelines that ensure a continuum of vision and eye healthcare for 
children; (2) advance State-based performance improvement systems, 
screening guidelines, and mechanisms for uniform data collection and 
reporting; and (3) provide technical assistance to States in the 
implementation of strategies for vision screening, establishing quality 
improvement measures, and improving mechanisms for surveillance.
    Prevent Blindness also requests at least $639 million in fiscal 
year 2015 to sustain programs under the MCH Block Grant. The MCH Block 
Grant enables States to expand critical healthcare services to millions 
of pregnant women, infants and children, including those with special 
healthcare needs. In addition to direct services, the MCH Block Grant 
supports vital programs, preventive and systems building services 
needed to promote optimal health--including the National Center for 
Children's Vision and Eye Health.
            advance and expand vision research opportunities
    Prevent Blindness calls upon the Subcommittee to provide $730 
million for the NEI to enable the agency to pursue its primary 
``audacious goal'' of restoring vision by bolstering its efforts to 
identify the underlying causes of eye disease and vision loss, improve 
early detection and diagnosis of eye disease and vision loss, and 
advance prevention and treatment efforts. Research is critical to 
ensure that new treatments and interventions are developed to help 
reduce and eliminate vision problems and potentially blinding eye 
diseases facing consumers across the country. By providing additional 
funding for the NEI at the NIH, essential efforts to identify the 
underlying causes of eye disease and vision loss, improve early 
detection and diagnosis of eye disease and vision loss, and advance 
prevention, treatment efforts and health information dissemination will 
be bolstered.
                               conclusion
    On behalf of Prevent Blindness, our Board of Directors, and the 
millions of people at risk for vision loss and eye disease, we thank 
you for the opportunity to submit written testimony regarding fiscal 
year 2015 funding for the CDC's vision and eye health efforts, the 
MCHB's National Center for Children's Vision and Eye Health, and the 
NEI. Please know that Prevent Blindness stands ready to work with the 
Subcommittee and other Members of Congress to advance policies that 
will prevent blindness and preserve sight. Please feel free to contact 
us at any time; we are happy to be a resource to Subcommittee members 
and your staff. We very much appreciate the Subcommittee's attention 
to--and consideration of--our requests.

    [This statement was submitted by Hugh Parry, President & CEO, 
Prevent Blindness.]
                                 ______
                                 
            Prepared Statement of the Prostatitis Foundation
    Some young men have prostatitis before they even reach twenty years 
of age, many older men have had symptoms for many years. You do not 
hear about it as much as prostate cancer because men do not discuss 
such issues with their friends, families and acquaintances. Many 
couples assume there may be a stigma to having the annoying condition. 
Even many urologists tell them there is no cure and they will just have 
to live with it.
    Prostatitis is a family affair as it presents itself as a disabling 
pain accompanied by sexual dysfunction and infertility issues. It 
usually causes a hesitant urination and an inability to empty the 
bladder. Patients are sometimes unable to work and sometimes even 
become suicidal.
    Prostatitis is a huge financial drain as it tends to imitate 
prostate cancer symptoms. The tests and procedures needed to rule out 
prostate cancer are very expensive and often unnecessary but needed to 
reassure the patient and his family. Prostatitis has been mentioned in 
historical literature from previous times and generations ago.
    The NIH has worked to find a cause and cure for (CP/CPPS) chronic 
prostatitis/chronic pelvic pain syndrome for nearly twenty years. In 
the latest research group called the MAPP Research Network they have 
included other specialties than urologists to help find a clue to 
prostatitis which affects 10 percent of men all over the world. It is 
critical to fully fund those research efforts of the NIH and keep the 
CDC involved.

    [This statement was submitted by Mike Hennenfent, President, 
Prostatitis Foundation.]
                                 ______
                                 
      Prepared Statement of the Pulmonary Hypertension Association
    Chairman Harkin and distinguished members of the Subcommittee, 
thank you for your time and your consideration of the priorities of the 
pulmonary hypertension community as you work to craft the fiscal year 
2015 Labor, Health and Human Services Appropriations Bill.
                      about pulmonary hypertension
    Pulmonary hypertension (PH) is a disabling and often fatal 
condition simply described as high blood pressure in the lungs. It 
affects people of all ages, races and ethnic backgrounds. Although 
anyone can get PH, there are risk factors that make some people more 
susceptible.
    Treatment and prognosis vary depending on the type of PH. In one 
type, pulmonary arterial hypertension (PAH), the arteries in the lungs 
become too narrow to handle the amount of blood that must be pumped 
through the lungs. This causes several things to happen: a backup of 
blood in the veins returning blood to the heart; an increase in the 
pressure that the right side of your heart has to pump against to push 
blood through your lungs; and a strain on the right side of your heart 
due to the increased work that it has to do. If this increased pressure 
is not treated, the right side of your heart can become overworked, 
become very weak and may possibly fail. Because the blood has 
difficulty getting through the lungs to pick up oxygen, your blood 
oxygen level may be lower than normal. This can put a strain not only 
on your heart, but also decrease the amount of oxygen getting to your 
brain.
    There is currently no cure for PAH. Twelve treatment options are 
available to help patients manage their disease and feel better day to 
day but even with treatment, life expectancy with PAH is limited.
                         about the association
    From simple beginnings--four women who met around a kitchen table 
in Florida in 1990--the Pulmonary Hypertension Association has evolved 
into a community of well over 10,000 pulmonary hypertension patients, 
caregivers, family members and medical professionals.
    As we have grown, we have stayed true to our roots and the vision 
and ingenuity of our founders: We continue to work every day to end the 
isolation that PH patients face, and find a cure for pulmonary 
hypertension.
Research
    PHA provides grants to promising researchers in the field of 
pulmonary hypertension. The program fosters new leaders in the field by 
supporting their interest in PH research and providing them with 
opportunities to work with mentors and learn new skills. Researchers 
supported by PHA are looking for new methods for early detection, new 
treatments to prevent the onset of PH and ultimately a cure for this 
terrible illness. To date, PHA has leveraged more than $13 million in 
PH research funding through partnerships with the NIH and others.
Early Diagnosis Campaign
    It takes too long for pulmonary hypertension to be diagnosed. The 
median survival rate without treatment is approximately 2.8 years, 
making the need to obtain a rapid and accurate diagnosis urgent. 
Unfortunately, the median duration from symptom onset to a confirmed 
diagnosis by right heart catheterization is 1.1 years. We are reaching 
patients too late in the process. Almost three-fourths of patients have 
advanced PH by the time they are diagnosed, leading more costly 
treatments and poorer outcomes. For the most advanced cases of PH, a 
lung or heart-lung transplant may be the only treatment option. The 
goal of PHA's Early Diagnosis Campaign is to discover the disease 
sooner in the early stages. This will allow the start of a treatment 
regimen that can slow the progression of PH and secure a better life 
for the patient.
Center Accreditation
    The Pulmonary Hypertension Association's Scientific Leadership 
Council, 28 global leaders in the field of pulmonary hypertension, have 
spearheaded the PHA-Accredited PH Care Centers (PHCC) initiative. The 
goal of this initiative is to establish a program for accreditation of 
centers with special expertise in pulmonary hypertension (PH), 
particularly pulmonary arterial hypertension (PAH), to raise the 
overall quality of care and outcomes in patients with this life-
threatening disease.
                          one patient's story
    In 2011, at the age of 29, GS12 Human Terrain Analyst Jessica 
(Puglisi) Armstrong began experiencing shortness of breath and 
dizziness. She was in Afghanistan at the time. Jessica was first 
diagnosed with dehydration. Then, as is the case with many PH patients, 
she was told she had asthma and was given an inhaler. Two months later, 
she fainted for no apparent reason. An echocardiogram revealed blood 
clots in her lungs and Jessica was medically evacuated to Germany and 
then to the U.S. Six months after her fist symptoms, she was finally 
given a complete work up and diagnosed with pulmonary hypertension.
    Jessica, she had a unique form of PH due to blood clots that can be 
mitigated with a pulmonary thromboendarterectomy (PTE)--a complex 
surgery that involves opening the chest cavity and stopping circulation 
for up to twenty minutes. She describes the surgery, which she 
underwent at the University of California San Diego, as ``more painful 
than I could ever imagine.'' She notes that UCSD's PTE program did not 
begin until 1990 and even now, despite being recognized as the global 
leaders on this procedure, has only completed about 3,000 surgeries. 
The procedure that saved Jessica's was developed in her lifetime.
    Jessica was terminated from Army employment and spent $60,000 out 
of pocket on medical expenses which she has not been able to recoup. 
She was forced to begin a civilian job just two weeks after her PTE in 
order to retain health insurance. Despite this, Jessica is, in many 
ways, one of the lucky ones. I am glad to report that she is now doing 
well and serving an integral role at PHA as the coordinator of our 
Early Diagnosis Campaign.
    Over the past decade, treatment options, and the survival rate, for 
pulmonary hypertension patients have improved significantly. However, 
courageous patients of every age lose their battle with PH each day. 
There is still a long way to go on the road to a cure and biomedical 
research holds the promise of a better tomorrow.
                             sequestration
    We have heard from the medical research community that 
sequestration and deficit reduction activities have created serious 
issues for Federal funding opportunities and the career development 
pipeline. In order to ensure that the pulmonary hypertension research 
portfolio can continue to grow, and, more importantly, to ensure that 
our country is adequately preparing the next generation of young 
investigators, we urge you to avert, mitigate, or otherwise eliminate 
the specter of sequestration. The Association has anecdotal accounts of 
the harms of sequestration and the Federated American Societies for 
Experimental Biology has reported:
  --In constant dollars (adjusted for inflation), the NIH budget in 
        fiscal year 2013 was $6 billion (22.4 percent) less than it was 
        in fiscal year 2003.
  --The number of competing research project grants (RPGs) awarded by 
        NIH has also fallen sharply since fiscal year 2003. In fiscal 
        year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3 
        percent) fewer than in fiscal year 2003.
  --Awards for R01-equivalent grants, the primary mechanism for 
        supporting investigator-initiated research, suffered even 
        greater losses. The number awarded fell by 2,528 (34 percent) 
        between fiscal year 2003 and fiscal year 2013.
    The pay line for some NIH funding mechanisms has fallen from 18 
percent to 10 percent while the average age for a researcher to receive 
their first NIH-funded grant has climbed to 42. These are strong 
disincentives to choosing a career as a medical researcher. Our 
scaling-back is occurring at a time when many foreign countries are 
investing heavily in their biotechnology sectors. China alone plans to 
dedicate $300 million to medical research over the next 5 years; this 
amount is double the current NIH budget over the same period of time. 
Scientific breakthroughs will continue, but America may not benefit 
from the return-on-investment of a robust biotechnology sector. For the 
purposes of economic and national security, as well as public health, 
the Association asks that you work with your colleagues to eliminate 
sequestration and recommit to supporting this Nation's biomedical 
research enterprise.
              health resources and services administration
    Due to the serious and life-threatening nature of PH, it is common 
for patients to face drastic health interventions, including heart-lung 
transplantation. Federal organ transplantation activities are 
coordinated through HRSA. To ensure HRSA can expand its important 
mission and continue to make improvements in donor lists and donor-
matching please provide HRSA with a meaningful funding increase in 
fiscal year 2015.
               centers for disease control and prevention
    As a result of Federal investment in medical research, there are 
now twelve FDA-approved treatments for PH. The effectiveness of these 
therapies though is dependent on how early a patient can receive an 
accurate diagnosis and begin treatment. Unfortunately, two-thirds of 
patients are not diagnosed until PH has reached a late stage. In 
addition to mitigating the impact of many treatments, late diagnosis 
puts PH patients in a position to face interventions like heart-lung 
transplantation and even death. CDC and NCCDPHP have the resources to 
compliment PHA's own Sometimes its PH Early Diagnosis Campaign. 
Improving public awareness and recognition of PH will not only save 
lives, it can save the Federal healthcare system money. Please provide 
CDC with meaningful funding increases so the agency can expand its 
focus beyond winnable battles into increasingly important and cost-
effective areas.
                     national institutes of health
    NIH hosts a sizable PH research portfolio. Further, NIH and PHA 
have a strong track record of working together to advance our 
scientific understanding of PH. The twelve FDA-approved treatments, 
more than nearly every other rare disease, are evidence of the return-
on-investment from these activities. Please provide NIH with meaningful 
increases to facilitate expansion of the PH research portfolio so we 
can continue to improve diagnosis and treatment.
NCATS
    The Office of Rare Diseases Research (ORDR), located within NCATS, 
supports and coordinates rare disease research and provides information 
on rare diseases to patients, their families, healthcare providers, 
researchers and the public. In collaboration with other NIH institutes, 
ORDR funds rare diseases research primarily through the Rare Diseases 
Clinical Research Network (RDCRN), which supports clinical studies, 
investigator training, pilot projects, and access to information on 
rare diseases. The most recent funding opportunity announcement, which 
was widely broadcast and open to all rare diseases, including PAH, was 
issued in the fall of 2013 and awards are expected to be made in the 
summer of 2014
NHLBI
    The NHLBI-funded Centers for Advanced Diagnostics and Experimental 
Therapeutics in Lung Diseases Stage II program, which will begin in 
fiscal year 2014, will provide a mechanism to accelerate the 
development of therapies for lung diseases, including pulmonary 
fibrosis and pulmonary arterial hypertension.
                         additional activities
S. 1453
    Senator Robert Casey (D-PA) has introduced the Pulmonary 
Hypertension Research and Diagnosis Act (S.1453). This budget neutral 
legislation has a bipartisan companion in the House due to its emphasis 
on lowering healthcare costs by promoting efficiencies within the 
Federal Government. S. 1453 seeks to establish an HHS-wide Committee 
tasked with preparing a report on how to leverage limited resources to 
improve early diagnosis of PH. Please consider cosponsoring S. 1453 and 
working with your colleagues to advance this important legislation.
S. 2115
    PHA has written to Senators Richard Durbin (D-IL) and Barbara 
Mikulksi (D-MD) to thank them for their leadership on the American 
Cures Act (S. 2115). We hope this legislation is an indication that 
policymakers have committed themselves to supporting innovative 
proposals to bolster and advance our Nation's biomedical research 
enterprise.
                                 ______
                                 
                 Prepared Statement of Research!America
    Research!America, the Nation's largest public education and 
advocacy alliance committed to advancing medical research and 
development, appreciates your stewardship over such a critical subset 
of our Nation's discretionary funding priorities. As the subcommittee 
begins the process of prioritizing fiscal year 2015 funding, we urge 
you to consider the following thoughts on Federal agencies entrusted 
with sustaining our Nation's sophisticated public health 
infrastructure, partnering with the private sector to accelerate 
medical progress, and optimizing healthcare outcomes.
    The National Institutes of Health (NIH), the Centers for Disease 
Control and Prevention (CDC), and the Agency for Healthcare Research 
and Quality (AHRQ) play pivotal roles in combating disabling and deadly 
health conditions. Moreover, the funding, or lack of it, allocated to 
these agencies will bear on our Nation's ability to compete in key 
export markets within the global economy, foster business development 
that grows and maintains jobs across the country, meet our solemn 
obligations to wounded warriors and support troops on the ground, 
combat deadly medical errors, and protect our Nation against pandemics 
and emerging health threats. The stakes truly are that high.
NIH as a driver of innovation
    In fiscal year 2015, we urge you to provide at least $32 billion in 
NIH funding to drive us beyond the stagnation that squanders 
opportunities to advance science and strengthen our Nation. Research 
funded by the NIH at universities, academic medical centers, 
independent research institutions and small businesses across the 
country lays the foundation for new product development by the private 
sector. Since much of the research NIH supports is at the non-
commercial stages of the research pipeline, NIH funding does not 
compete with, but rather sets the stage for, critical private sector 
investment and development. These two complementary funding streams 
lead to business development, job growth and beneficial medical 
advances. Taxpayer-funded research through the NIH has helped our 
Nation make remarkable progress against such insidious health threats 
as childhood cancer, HIV-AIDS and heart disease.
    The secrets of diabetes, Alzheimer's, Parkinson's, myriad cancers 
and many other diseases can and will be unlocked by science. The 
question is not if, but when . . . unless we dismiss the significance 
of such progress and continue to allow research resources to stagnate. 
And our Nation's best weapon against spiraling healthcare costs is 
research. Ignoring growing healthcare costs is a ticket to disaster. 
Alzheimer's disease alone is projected to cost the Federal Government 
over $1 trillion during the next 20 years. Ultimately, we must prevent 
and cure disease in order to tackle the costs associated with it.
CDC as a first responder
    In fiscal year 2015, we urge you to provide a funding level that 
continues the growth in CDC budget authority that was initiated in 
fiscal year 2014. The CDC engages in research that stems deadly and 
costly pandemics, bolsters our Nation's defenses against bioterrorism, 
and helps prevent the onset of debilitating and expensive diseases. The 
CDC is the Nation's first responder to lethal viruses and infections, 
including life-threatening and costly drug-resistant infections that 
pose a particular threat to children and young adults, as well as 
investigating tragic phenomena like cancer clusters. Due to cuts in 
recent years, the CDC is functioning with one hand tied behind its 
back, even as health challenges like the obesity epidemic, autism 
epidemic and infectious disease outbreaks capture headlines and ruin 
lives. It is always more efficient and cost effective to be in front of 
an outbreak or biological attack than to take reactionary measures.
AHRQ translates medical innovation into the right care at the right 
        time
    In fiscal year 2015, we urge you to provide at least $375 million 
in funding for AHRQ. Research supported by AHRQ identifies 
inefficiencies in healthcare delivery that inflate the cost of public 
and private insurance. AHRQ-supported research also combats medical 
errors and improves the quality of care to help reduce the length and 
intensity of disability and disease. It helps patients and physicians 
make informed treatment decisions that improve outcomes and reduce 
costly ``false starts'' in the provision of healthcare services.
    Just one of many success stories is AHRQ's issuance of new 
standards of care and practices related to central line-associated 
bloodstream infections. The implementation of the guidelines resulted 
in a reduction of up to two-thirds of cases during early rollout 
studies. With an annual estimated 80,000 cases, up to 28,000 deaths and 
an average cost per patient of $45,000, this has the potential to save 
$2.3 billion annually in healthcare costs. Given the enormity of the 
challenge of inefficiency in healthcare delivery, AHRQ is severely 
underpowered.
The threat of sequestration's return
    The Ryan-Murray Bipartisan Budget Act provided America with 2 years 
of partial relief from sequestration after across the board budget cuts 
dramatically impacted medical research in March 2013. Unfortunately, 
sequestration will go back into full effect in 2016 unless Congress 
takes action, and it will be in effect for 2 years longer than 
originally established under the 2011 Budget Control Act. The return of 
sequestration's budget cuts to discretionary spending, including that 
for NIH, CDC and AHRQ, poses potentially devastating setbacks to 
medical research. Short-changing medical research is not a solution to 
the Federal deficit or debt. On the contrary, neglecting medical 
research undercuts strategies to fight chronic disease and the 
multipronged Federal costs that arise from it, while squandering 
opportunities to increase private sector and Federal revenues through 
new medical innovations.
    Research!America appreciates the difficult task facing the 
subcommittee as it seeks to simultaneously confront the budget deficit, 
strengthen the U.S. and promote the well-being of Americans. There are 
few Federal investments that confer as many benefits as medical 
research--new cures, new businesses, new jobs, new solutions to 
healthcare cost inflation, and new fuel to drive U.S. leadership in a 
global economy shaped by the ability of countries to continuously 
innovate. We firmly believe that investing in NIH, CDC and AHRQ is a 
means of advancing all three of these fundamental goals. Thank you for 
your leadership and consideration; we know that your task is 
extraordinarily difficult, and that our Nation is fortunate to have 
such pragmatic, committed and gifted leaders at the helm.
                                 ______
                                 
            Prepared Statement of the Research Working Group
    Chairman Harkin, Ranking Member Moran, and members of the 
Committee, thank you for the opportunity to provide testimony on the 
National Institutes of Health (NIH) budget overall and for AIDS 
research in fiscal year 2015. Tomorrow's scientific and medical 
breakthroughs depend on your vision, leadership, and commitment to 
robust NIH funding this year. To this end, the Research Working Group 
(RWG) urges this Committee to support a funding target of $36 billion 
in fiscal year 2015 to maintain the United States' position as the 
world leader in medical research and innovation.
    Investments in health research via the NIH have paid enormous 
dividends in the health and wellbeing of people in the U.S. and around 
the world. NIH-funded HIV and AIDS research has supported innovative 
basic science for better drug therapies, evidence-based behavioral and 
biomedical prevention interventions, and vaccines that have saved and 
improved the lives of millions, and holds great promise for 
significantly reducing HIV infection rates and providing more effective 
treatments for those living with HIV/AIDS in the coming decade.
    Despite these advances, the number of new HIV/AIDS cases continues 
to rise in the U.S. and around the world. There are 1.1 million HIV-
infected people in the U.S., the highest number in the epidemic's more 
than 30 year history; additionally over 50,000 Americans become newly 
infected every year. In 2012, 35.3 million were infected with HIV/AIDS 
worldwide, 1.6 million died from the disease and 2.3 million people 
were newly infected. With proper funding, we can capitalize on the 
ongoing scientific progress in therapeutics and prevention science, 
vaccines, and finding a cure for HIV, as well as addressing the 
comorbidity such as viral hepatitis and tuberculosis that affect 
patients living with HIV.
    Major advances over the last few years in HIV prevention 
technologies--with HIV vaccines, medical male circumcision, 
antiretroviral treatment as prevention, and pre-exposure prophylaxis 
using antiretrovirals (PrEP) --demonstrate that adequately resourced 
NIH programs can transform our lives. Because HIV disease entails many 
common co-morbidities, HIV research funding is spread across the 
Institutes and Centers--and HIV research discoveries have had broad 
benefits for many other conditions including: aging, cancer, 
immunosuppression and auto-immune disorders, heart disease, stroke, 
Alzheimer's disease, osteoporosis, viral hepatitis, and influenza, 
among others. Federal support for AIDS research has led to new 
treatments for other diseases, including cancer, heart disease, 
Alzheimer's, hepatitis, osteoporosis, and a wide range of autoimmune 
disorders.
    Over the years, the NIH has sponsored the evaluation of a host of 
vaccine candidates, some of which are advancing to efficacy trials. The 
successful iPrEx and HPTN 052 trials have shown the potential of 
antiretroviral drugs to prevent HIV infection. Moreover, increased 
funding will support the future testing of new vaccines, microbicides 
and therapeutics in the pipeline via the newly restructured, cross-
cutting NIAID clinical trials network that translates NIH-funded 
scientific innovation into critical quality-of-life gains.
    It is also essential to note that NIH-funded HIV pathogenesis and 
clinical research has contributed substantially to our understanding of 
potential curative approaches. The NIAID clinical trial networks 
comprise one of the largest groups of clinical research sites in the 
world and have been instrumental to the progress made in response to 
the HIV epidemic domestically and globally. These networks are now 
taking on the challenges of tuberculosis and hepatitis C and have 
dramatically expanded the opportunities to test new drugs and other 
critically needed interventions to advance knowledge in these leading 
infectious disease killers.
    Increased funding for the NIH in fiscal year 2015 makes good 
bipartisan economic sense, especially in shaky fiscal times. Robust 
funding for the NIH overall will enable research universities to pursue 
scientific opportunity, advance public health, and create jobs and 
economic growth. In every State across the country, the NIH supports 
research at hospitals, universities, private enterprises, and medical 
schools. This includes the creation of jobs that will be essential to 
future discovery. Sustained investment is also essential to train the 
next generation of scientists and prepare them to make tomorrow's HIV 
discoveries. NIH funding puts 350,000 scientists to work at research 
institutions across the country. According to the NIH, each of its 
research grants creates or sustains six to eight jobs, and NIH-
supported research grants and technology transfers have resulted in the 
creation of thousands of new, independent private-sector companies. 
Strong, sustained NIH funding is a critical national priority that will 
foster better health and economic revitalization.
    Since 2003, funding for the NIH has failed to keep up with our 
existing research needs--damaging the success rate of approved grants 
and leaving very little money to fund promising new research. The real 
value of the increases prior to 2003 has precipitously declined because 
of the relatively higher inflation rate for the cost of research and 
development activities undertaken by the NIH. According to the 
Biomedical Research and Development Price Index, which calculates how 
much the NIH budget must change each year to maintain purchasing power, 
between fiscal year 2003 and fiscal year 2014, the cost of NIH 
activities increased by 38.1 percent. By comparison, the overall NIH 
budget increased by 10.8 percent, over fiscal year 2003. So in real 
terms, the NIH has already sustained budget decreases of close to 30 
percent over the past decade due to inflation alone! As such, flat 
funding or cuts to the NIH will have the clear and devastating effects 
of undermining our Nation's leadership in health research and our 
scientists' ability to take advantage of the expanding opportunities to 
advance healthcare. The race to find better treatments and a cure for 
cancer, heart disease, AIDS, and other diseases, and for controlling 
global epidemics like AIDS, tuberculosis, and malaria, all depend on a 
robust long-term investment strategy for health research at NIH.
    In conclusion, the RWG calls on Congress to continue the bipartisan 
Federal commitment towards combating HIV as well as other chronic and 
life-threatening illnesses by increasing funding for the NIH to $36 
billion in fiscal year 2015. A meaningful commitment to stemming the 
epidemic and securing the well being of people with HIV cannot be met 
without prioritizing the research investment at the NIH that will lead 
to tomorrow's lifesaving vaccines, treatments, and cures. Thank you for 
the opportunity to provide these written comments.
                                 ______
                                 
             Prepared Statement of the Rotary International
    Chairman Harkin, members of the Subcommittee, Rotary International 
appreciates this opportunity to submit testimony in support of the 
polio eradication activities of the U. S. Centers for Disease Control 
and Prevention (CDC). The Global Polio Eradication Initiative (GPEI) is 
an unprecedented model of cooperation among national governments, civil 
society and UN agencies working together to reach the most vulnerable 
children through the safe, cost-effective public health intervention of 
polio immunization. We appeal to this Subcommittee for continued 
leadership to ensure we seize the opportunity to conquer polio once and 
for all. Rotary International strongly supports the President's 2015 
request of $161 million for the polio eradication activities of the CDC 
to enable full implementation of the polio eradication strategies and 
innovations outlined in the Polio Eradication and Endgame Strategic 
Plan (2013-2018).
           progress in the global program to eradicate polio
    Significant strides were made in 2013 toward stopping transmission 
of polio. Thanks to this committee's leadership in appropriating funds 
for the polio eradication activities of the CDC:
  --India was certified polio free in February 2014, following 3 years 
        with no cases of polio. The entire Southeast Asia region was 
        certified polio free on 27 March 2014.
  --Eradication efforts have led to more than a 99 percent decrease in 
        cases since the launch of the GPEI in 1988.
  --The number of polio cases in the endemic countries was 40 percent 
        lower in 2013 than in 2012 (160 vs. 217). Afghanistan and 
        Nigeria each had less than half the number of cases in 2013 
        that they had in 2012.
  --Pakistan is now considered to be the only country in the world with 
        uncontrolled transmission of wild polio and as of 20 March, 
        accounts for more than 75 percent of polio cases in 2014.
  --Outbreaks in the Horn of Africa and Syria accounted for roughly 60 
        percent of all cases in 2013. These outbreaks underscore the 
        risk to polio-free countries until the wild poliovirus has been 
        eradicated in the remaining places where it persists.
  --Incidence of type 3 polio is at historically low levels. There have 
        been no cases of type 3 polio since November 2012.
  --Lack of access to children in insecure areas continues to hamper 
        progress. In Pakistan alone, more than 50 health workers and 
        security personnel assigned to protect them have been killed in 
        targeted attacks since November of 2012. Insecurity/inability 
        to access large populations is now a key factor in all endemic 
        transmission zones and is also a factor in outbreak areas 
        (Syria, Horn of Africa).
    The Polio Eradication and Endgame Strategic Plan (2013-2018) 
launched in 2013 lays out the strategies for the certification of the 
eradication of wild poliovirus by 2018 at a total global cost of US$5.5 
billion. This new plans builds on the lessons learned from the 
successful eradication of polio to date and the substantial advances in 
technology in 2012. The timely availability of funds remains essential 
to the achievement of a polio free world. The United States has been 
the leading public sector donor to the Global Polio Eradication 
Initiative. Members of U.S. Rotary clubs appreciate the United States' 
generous support and recognize increased funding provided by Congress 
in fiscal year 2014 to ensure the GPEI can fully implement the plan. 
Rotarians are committed to continuing their own fundraising for the 
program until the world is certified polio free. Rotarians will also 
continue to advocate support from the public and other governments, 
both polio free and polio affected, to support the successful execution 
of the Strategic Plan. The ongoing support of donor countries, like the 
United States, is essential to assure the necessary human and financial 
resources are made available to polio-endemic and at risk countries to 
certify the world polio free by the end of 2018.
                    the role of rotary international
    Rotary International, a global association of more than 34,000 
Rotary clubs in more than 170 countries with a membership of over 1.2 
million business and professional leaders (more than 345,000 of which 
are in the U.S.), has been committed to battling polio since 1985. 
Rotary International has contributed more than US$1.2 billion toward a 
polio free world--representing the largest contribution by an 
international service organization to a public health initiative ever. 
Rotary also leads the United States Coalition for the Eradication of 
Polio, a group of committed child health advocates that includes the 
March of Dimes Foundation, the American Academy of Pediatrics, the Task 
Force for Global Health, the United Nations Foundation, and the U.S. 
Fund for UNICEF. These organizations join us in thanking you for your 
support of the GPEI.
    the role of the u.s. centers for disease control and prevention
    Rotary commends CDC for its leadership in the global polio 
eradication effort, and greatly appreciates the Subcommittee's 
increased support of CDC's polio eradication activities to support full 
implementation of the Strategic Plan. The United States is the leader 
among donor nations in the drive to eradicate this crippling disease. 
CDC is using the increased Congressional support provided in fiscal 
year 2014 to:
  --Build capacity in Nigeria. Increased investment in Nigeria will 
        serve to establish and broaden environmental surveillance; 
        strengthen traditional AFP surveillance, scale up the National 
        Stop Transmission of Polio Program (N-STOP) in Kano and other 
        high risk polio States to ensure broad coverage at the Local 
        Government Authority Level, trapping poliovirus in its 
        remaining reservoirs in Northern Nigeria.
  --Build capacity in Pakistan. Increased investment in Pakistan will 
        focus on training and placing local personnel to strengthen the 
        program in areas where access is possible.
  --Provide essential technical assistance in Afghanistan. The 
        investment in Afghanistan will support two staff members in 
        country.
  --Laboratory Surveillance: Investment with CDC's Polio Global 
        Reference Lab will allow the recruitment of additional staff, 
        training for country and regional labs, essential IPV research, 
        and expansion of environmental surveillance capabilities in the 
        field. CDC provides technical and programmatic assistance to 
        the global polio laboratory network through the Polio 
        Laboratory in CDC's Division of Viral Diseases. CDC's labs 
        provide critical diagnostic services and genomic sequencing of 
        polioviruses to help guide disease control efforts. CDC will 
        continue to serve as the global reference laboratory, while 
        expanding environmental surveillance in countries to serve as a 
        ``safety measure'' to detect any polioviruses circulating in 
        areas without cases.
  --Vaccine Purchase: CDC funds are being used to purchase oral polio 
        vaccine to immunize children against polio.
  --Vaccine Operations & Social Mobilization. CDC, through its 
        cooperative agreement with WHO, provides funding for 
        immunization activities in high risk and polio infected 
        countries. CDC funding is essential to supporting the 
        supplemental immunization activities that both stop existing 
        outbreaks and prevent new outbreaks. CDC collaborates closely 
        with UNICEF and provides critical support on analysis and use 
        of campaign results to identify and address reasons why 
        children are missed and address vaccine hesitancy concerns.
  --Immunization Systems Strengthening. Investment in this area will 
        allow CDC to provide scientific assistance across a range of 
        topics related to the introduction of IPV to focus countries, 
        other GAVI-eligible countries, and to non-eligible countries.
    Continued funding will allow CDC to fully capitalize on the 
resources of the Emergency Operation Center to provide direct support 
and build capacity to continue intense supplementary immunization 
activities in the remaining polio-affected countries, continue 
leadership on data management to drive evidence-based decisionmaking, 
and continue to implement strategies to increase effective management 
and accountability. These funds will also help maintain essential 
certification standard surveillance.
                     benefits of polio eradication
    Since 1988, over 10 million people who would otherwise have been 
paralyzed are walking because they have been immunized against polio. 
Tens of thousands of public health workers have been trained to manage 
massive immunization programs and investigate cases of acute flaccid 
paralysis. Cold chain, transport and communications systems for 
immunization have been strengthened. The global network of 145 
laboratories and trained personnel established by the GPEI also tracks 
measles, rubella, yellow fever, meningitis, and other deadly infectious 
diseases and will do so long after polio is eradicated.
    A study published in the November 2010 issue of the journal Vaccine 
estimates that the GPEI could provide net benefits of at least $40-50 
billion. Polio eradication is a cost-effective public health investment 
with permanent benefits. On the other hand, as many as 200,000 children 
could be paralyzed annually in the next 10 years if the world fails to 
capitalize on the more than $10 billion already invested in 
eradication. Success will ensure that the significant investment made 
by the U.S., Rotary International, and many other countries and 
entities, is protected in perpetuity.
                                 ______
                                 
    Prepared Statement of the Ryan White Medical Providers Coalition
    My name is Dr. James Raper, and I serve as the Director of the 1917 
HIV/AIDS Outpatient Clinic at the University of Alabama at Birmingham. 
I am writing to submit testimony on behalf of the Ryan White Medical 
Providers Coalition (RWMPC), which I co-chaired from 2010-2013. I 
remain a member of the RWMPC Steering Committee. Thank you for the 
opportunity to describe the lifesaving HIV/AIDS care and treatment 
provided by Ryan White Part C funded programs, including those provided 
at my own clinic.
    RWMPC is a national coalition of medical providers and 
administrators who work in clinics supported by the Ryan White HIV/AIDS 
Program funded by the HIV/AIDS Bureau (HAB) at the Health Services and 
Resources Administration (HRSA). I thank the Subcommittee for its 
support of Ryan White Part C Programs in fiscal year 2014. And while I 
am grateful for this support, and understand that times are tough, I 
request $225.1 million, or a $24 million increase for Ryan White Part C 
programs in fiscal year 2015. While I know that this is a lot of 
funding, it is in fact well below the estimated need, and Ryan White 
providers would spend those dollars identifying, engaging and treating 
persons living with HIV/AIDS--an infectious disease that can be 
effectively prevented and treated in a way that saves both lives and 
money.
    The 1917 Clinic is a dedicated, not-for profit outpatient HIV/AIDS 
medical and dental clinic established in 1988 at the University of 
Alabama at Birmingham. Ryan White Part C funding provides critical 
assistance in helping the clinic meet the needs of our patients. Today, 
35 percent of the 1917 Clinic's patients are uninsured and would be at 
risk for losing access to lifesaving services without Ryan White 
Program funding.
    The 1917 Clinic provides comprehensive outpatient HIV primary care 
services to residents of Jefferson, Walker, Winston, Cullman, Blount, 
St. Clair, and Shelby counties. Although our service area technically 
includes only these seven counties, we serve people with HIV/AIDS 
throughout Alabama and its neighboring States. In February 2013, the 
1917 Clinic absorbed 800+ new patients from the previously Ryan White 
Part C funded Cooper Green Hospital's St. Georges' Clinic, which closed 
on January 31, 2013. The 1917 Clinic is now providing care to 2,950 
adult patients--this represents approximately 24 percent of the 12,404 
known adults living with HIV/AIDS in Alabama.
    The clinic offers a range of primary care and social services 
critical to successful HIV treatment, including primary medical and 
oral healthcare; on-site case management; mental health and substance 
abuse treatment services; onsite access to clinical trials; medication 
adherence; spiritual, risk reduction, and nutrition counseling; 
infusion therapy; coordination of hospital discharge planning; and home 
healthcare/hospice referral. To avoid emergency room visits, the 1917 
Clinic provides `sick call' services five days a week. Subspecialty 
care is available at the University's Kirklin Clinic--which is located 
just two blocks from the 1917 Clinic.
    In addition to critical funding that Ryan White Part C provides 
through direct Federal grants for comprehensive medical care clinics 
like the 1917 Clinic, most Part C clinics, including the 1917 Clinic, 
also receive support from other Parts of the Ryan White Program that 
help support access to medication; additional medical care, such as 
dental services; and key support services, such as case management and 
transportation, which are essential components of the highly effective 
Ryan White HIV care model that result in excellent outcomes for our 
patients.
Ryan White Part C Programs Support Comprehensive, Expert and Effective 
        HIV Care
    Part C of the Ryan White Program funds comprehensive, expert and 
effective HIV care and treatment--services that are directly 
responsible for the dramatic decrease in AIDS-related mortality and 
morbidity over the last decade. The Ryan White Program has supported 
the development of expert HIV care and treatment programs that have 
become patient-centered medical homes for individuals living with this 
serious, chronic condition. In 2011, a ground-breaking clinical trial--
named the scientific breakthrough of the year by Science magazine--
found that HIV treatment not only saves the lives of people with HIV, 
but also reduces HIV transmission by more than 96 percent--proving that 
HIV treatment is also HIV prevention.
    The comprehensive, expert HIV care model that is supported by the 
Ryan White Program has been highly successful at achieving positive 
clinical outcomes with a complex patient population.\1\ In a 
convenience sample of eight Ryan White-funded Part C programs ranging 
from the rural South to the Bronx, retention in care rates ranged from 
87 to 97 percent. In estimates from the Centers for Disease Control and 
Prevention (CDC), only 37 percent of all people with HIV are in regular 
care nationally.\2\ Once in care, patients served at Ryan White-funded 
clinics do well-- with 75 to 90 percent having undetectable levels of 
the virus in their blood. This is much higher than the estimate from 
the CDC that just 25 percent of all people living with HIV in the U.S. 
are virally suppressed.
---------------------------------------------------------------------------
    \1\ 1 See Improvement in the Health of HIV-Infected Persons in 
Care: Reducing Disparities at http://cid.oxfordjournals.org/content/
early/2012/08/24/cid.cis654.full.pdf+html.
    \2\ See CDC's HIV in the United States: The Stages of Care http://
www.cdc.gov/nchhstp/newsroom/docs/2012/Stages-of-CareFactSheet-508.pdf.
---------------------------------------------------------------------------
Investing in Ryan White Part C Programs Saves Both Lives and Money
    Early and reliable access to HIV care and treatment both helps 
patients with HIV live relatively healthy and productive lives and is 
more cost effective. One study from the 1917 Clinic at the University 
of Alabama at Birmingham found that patients treated at the later 
stages of HIV disease required 2.6 times more healthcare dollars than 
those receiving earlier treatment meeting Federal HIV treatment 
guidelines. On average it costs $3,501 per person per year to provide 
the comprehensive outpatient care and treatment available at Part C 
funded programs. The comprehensive services provided often include lab 
work, STD/TB/Hepatitis screening, ob/gyn care, dental care, mental 
health and substance abuse treatment, and case management.
Current Challenges--Future Promise
    However, this effective and comprehensive HIV care model is not 
completely supported by Medicaid or most private insurance. While many 
Ryan White Program clients have some form of insurance coverage, 
without the Ryan White Program, they would risk falling out of care. 
Barriers include poor reimbursement rates; benefits designed for 
healthier populations that fail to cover critical services, such as 
care coordination; and inadequate coverage for other important 
services, such as extended medical visits, mental health and substance 
use treatment. Full implementation of the Affordable Care Act plus 
continuation of the Ryan White Program will dramatically improve health 
access and outcomes for many more people living with HIV disease.
Fully Funding and Maintaining Ryan White Part C Programs Is Essential
    Because of both the inadequacy of insurance coverage for people 
with complex conditions like HIV and the fact that some individuals 
will remain uncovered, even with Affordable Care Act implementation 
(particularly in the non-Medicaid expansion States), fully funding and 
maintaining the Ryan White Program is essential to providing 
comprehensive, expert and effective HIV care nationwide.
    And while RMWPC is concerned about the proposal to consolidate Ryan 
White Part D funding into Part C, it welcomes the $4 million increase 
for Part C programs proposed in the President's fiscal year 2015 
budget. RWMPC's specific concerns include:
  --Part D funding supports effective HIV care and treatment services 
        for vulnerable populations, including women and adolescents. 
        With adolescents accounting for 39 percent of new HIV 
        infections in the U.S., it is critical to target resources to 
        support comprehensive services that effectively engage and 
        retain young people in HIV care and treatment.
  --In some communities, Part D-funded programs are the main providers 
        of HIV care and treatment. It is critical to ensure that 
        implementation of any budget proposal does not leave any 
        community without adequate access to effective and 
        comprehensive HIV care and treatment. Also, for Ryan White 
        medical clinics that currently receive only Part D funding, it 
        could prove difficult to successfully compete for Part C 
        funding if there currently exists a Part C program serving that 
        community. Loss of the aforementioned Part D program would 
        reduce the community's access to HIV care and treatment.
  --It is unclear how the proposed consolidation would be implemented. 
        At this time it is unclear what the consolidation process would 
        entail and how it would practically impact grantees and access 
        to HIV care and treatment in communities. Since most Ryan White 
        medical clinics receive funding from multiple parts of the Ryan 
        White Program, reduction of funding to one part can have 
        damaging and unintended consequences to the overall services 
        provided by Ryan White medical clinics, especially now, at a 
        time when providers are working to expand access to HIV care 
        and treatment.
    At this critical time in the HIV/AIDS epidemic, when research has 
confirmed that early access to HIV care and treatment not only saves 
lives but prevents new infections by reducing the risk of transmission 
to near zero for patients who are virally suppressed, it is essential 
to maintain overall funding levels for the Ryan White Program. While 
the ACA provides important new healthcare coverage options for many 
patients, most health insurers fail to support the comprehensive care 
and treatment necessary for many patients to manage HIV infection. 
Exorbitant cost sharing, benefit gaps and limited State uptake of the 
Medicaid expansion necessitate a vital and ongoing role for the Ryan 
White Program. Increasing access to and successful engagement in 
effective, comprehensive HIV care and treatment is the only way to lead 
the Nation to an AIDS-free generation and reduce the devastating costs 
of--including lives lost to--HIV infection.
Conclusion
    Thank you very much for your consideration of RWMPC's fiscal year 
2015 request of $225.1 million for Ryan White Part C programs, a $24 
million increase over fiscal year 2014.

    [This statement was submitted by James L. Raper, PhD, CRNP, JD, 
FAANP, FAAN; Director, 1917 HIV/AIDS Outpatient Clinic; Professor of 
Medicine & Nursing.]
                                 ______
                                 
             Prepared Statement of the Safe States Alliance
    Safe States Alliance, the national membership association dedicated 
to strengthening the practice of injury and violence prevention, 
appreciates the opportunity to provide testimony in support of the 
Centers for Disease Control and Prevention (CDC). Safe States Alliance 
requests that the CDC's National Center for Injury Prevention and 
Control (Injury Center) receive $205.5M in fiscal year 15--an 
additional $29.7M for the Core Violence and Injury Prevention Program 
(VIPP), including resources to meaningfully address the epidemic of 
prescription drug misuse, abuse and overdose; and an additional $13.7M 
for the National Violent Death Reporting System (NVDRS). Safe States 
Alliances also supports continued funding of the CDC's Preventive 
Health and Health Services (PHHS) Block Grant at $180 million.
                               background
     In 1985, the Institute of Medicine (IOM) first called attention to 
the lack of recognition and funding for injury and violence prevention 
(IVP) as a public health issue in the United States.\1\ Although some 
progress has been made in subsequent years, injuries and violence 
continue to have a significant impact on the health of Americans and 
the healthcare system, as more people ages 1-44 die from injuries than 
from any other cause, including cancer, HIV, or the flu.\2\
---------------------------------------------------------------------------
    \1\ National Research Council. Injury in America: A Continuing 
Public Health Problem. Washington, DC: The National Academies Press, 
1985.
    \2\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS) [online] (2007) [accessed 2013 Feb 15]. 
Available from URL: http://www.cdc.gov/injury/wisqars.
---------------------------------------------------------------------------
    Injuries and violence are serious public health problems. Areas 
include:
Assault & Homicide
Bullying
Child Maltreatment
Child Passenger Safety
Disaster Response
Domestic & Intimate Partner Violence
Drowning
Elder Abuse
Falls
Fire & Burns
Motor Vehicle Safety
Pedestrian & Bicycle Safety
Poisoning & Prescription Drug Overdose
Sexual Assault & Rape
Suicide
Traumatic Brain Injury
Youth Violence
    In fact, more than 29 million people are treated in emergency 
departments each year, two million are hospitalized, and approximately 
180,000 people die--one person every three minutes. Every 45 minutes, 
one of those preventable deaths is a child.\2\ In a single year, 
injuries and violence will ultimately cost $406 billion in medical 
costs and lost productivity.\3\ Yet to date, there is no national 
program to support State public health IVP programs.
---------------------------------------------------------------------------
    \3\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS) [online] (2007) [accessed 2013 Feb 15]. 
Available from URL: http://www.cdc.gov/injury/wisqars
---------------------------------------------------------------------------
    At the Federal level, the CDC Injury Center serves as the focal 
point for the public health approach to IVP. The CDC Injury Center only 
receives approximately 2 percent of the CDC/Agency for Toxic Substances 
and Disease Registry budget to address the significant burden of 
injuries and violence nationwide. In fiscal year 2013, the total Injury 
Center budget was only $138.9 million.
core violence and injury prevention program (vipp) and new prescription 
              drug overdose prevention expanded component
    Given its limited budget, the CDC Injury Center currently provides 
small capacity building grants of approximately $250,000 to only 20 
State health departments (SHDs) through the Core Violence and Injury 
Prevention Program (VIPP). The Core VIPP is comprised of multiple 
components including: Basic Prevention (20 States); Regional Network 
Leaders (5 States); Surveillance Quality Improvement (4 States); Older 
Adult Falls Prevention (3 States); and Motor Vehicle/Child Injury 
Prevention (4 States). The President's 2015 Budget Request includes an 
increase of approximately $15.6M to expand the number of funded Core 
VIPP programs ($5.6M) and to allow for the development of a new 
expanded component for States to address the epidemic of prescription 
drug misuse, abuse and overdose ($10 million).
    Opioid pain relievers are now involved in more overdose deaths than 
cocaine and heroin combined. The abuse of prescription opioid pain 
relievers costs up to $72 billion annually. The CDC Injury Center 
provides leadership in enhancing drug overdose surveillance, 
identifying and evaluating effective program and policy interventions 
for preventing overdoses, improving clinical practice to reduce 
prescription drug diversion and abuse, and equipping and empowering 
States with the information and resources they need to reverse the 
epidemic. Core VIPP States would be funded to advance promising 
surveillance and prevention strategies and would complement other 
Federal agencies, such as SAMHSA's work on screening, treatment and 
community prevention activities. State health departments are well 
positioned to coordinate the necessary multi-sector responses to 
reverse the epidemic through the regulation of healthcare 
professionals, prescription drug monitoring programs, and other major 
levers for preventing prescription drug abuse.
    Ohio's Core Violence and Injury Prevention Program (VIPP) provides 
statewide leadership and funding for community-based efforts to address 
prescription drug abuse and overdose through the PHHS Block Grant from 
CDC. The OH VIPP coordinates the development and implementation of 
statewide prevention strategies, conducts surveillance, supports the 
Governor's Cabinet Opiate Action Team Prescriber Education Work Group 
including the development of opioid prescribing guidelines, and 
provides support and technical assistance to expand naloxone 
distribution programs. Examples of locally PHHS Block Grant funded 
strategies include: expanding access to naloxone distribution programs; 
facilitating healthcare system changes such as implementation of opioid 
prescribing guidelines and other pain management strategies; obtaining 
commitment of prescribers to use the Ohio prescription drug monitoring 
program; and expanding access to sustainable drug disposal options.
    With overall program funding of $29.7M, the CDC Injury Center could 
support injury and violence prevention programs in ALL States and 
territories, much as it does for other key public health issues 
including chronic and infectious diseases, as well as make significant 
strides in reversing the prescription drug overdose epidemic.
            national violent death reporting system (nvdrs)
    NVDRS is a state-based surveillance system that uses information 
from a variety of States and local agencies and sources--medical 
examiners, coroners, police, crime labs and death certificates--to form 
a more complete picture of the circumstances that surround violent 
deaths. State and local violence prevention practitioners use these 
data to guide their prevention programs, policies and practices 
including: identifying common circumstances associated with violent 
deaths of a specific type (e.g. gang violence) or a specific area (e.g. 
a cluster of suicides); assisting groups in selecting and targeting 
violence prevention efforts; supporting evaluations of violence 
prevention activities; and improving the public's access to in-depth 
information on violent deaths. CDC Injury Center currently funds 18 
States to implement NVDRS and received an approximately $7.9M increase 
in fiscal year 2014 to expand number of participating States up to 30-
35 States.
    The Oregon Older Adult Suicide Prevention Advisory Work Group and 
the Oregon Department of Human Services used NVDRS data to inform 
efforts to develop and focus suicide prevention programs for older 
adults. Almost 50 percent of men ages 65 and older who died by suicide 
were reported to have a depressed mood before death, but only a small 
proportion were receiving treatment, suggesting screening and treatment 
for depression might have saved lives. As a result, Oregon developed 
primary care recommendations in 2006 to better integrate with mental 
health services so that suicidal behavior and ideation are diagnosed 
and older adults received appropriate treatment. These recommendations 
were implemented as part of Oregon's ``Healthy Aging'' efforts. The 
recommendations include the objectives of increasing the confidence and 
competence of primary care providers and other clinicians to identify, 
assess and treat older adult suicide behavior and depression. The 
suicide rates among males ages 65 and older in Oregon decreased 
approximately 8 percent from 2007 to 2010.
Safe States Alliance supports the investment of an additional $13.7 
        million to expand NVDRS to all States and territories.
        preventive health and health services (phhs) block grant
    For more than 30 years, the PHHS Block Grant has remained an 
essential source of Federal agencies to support State solutions to 
State health problems. The PHHS Block Grant allows each State to 
respond to its own distinct health priorities and need. In fiscal year 
2011, more than 20 percent of the Prevent Block Grant was used by 
States to support IVP and emergency medical services. According to a 
2011 survey conducted by Safe States Alliance, 29 States reported 
receiving an average of $329,000 from the Prevent Block Grant for IVP 
efforts.\4\ The Prevent Block Grant is a critical source of funding for 
SHD IVP programs representing 9.4 percent of total State funding in 
2011. Safe States Alliance supports continued funding of the PHHS Block 
Grant at the $180 million level.
---------------------------------------------------------------------------
    \4\ State of the States: 2011 Report. Atlanta, GA: Safe States 
Alliance; 2013.
---------------------------------------------------------------------------
    Preventable injuries exact a heavy burden on Americans through 
premature deaths and disabilities, pain and suffering, medical and 
rehabilitation costs, disruption of quality of life for families, and 
disruption of productivity for employers. Strengthening investments in 
public health IVP programs is a critical step to keep Americans safe 
and productive for the 21st century. Safe States Alliance would like to 
thank the Committee for consideration of this testimony.

    [This statement was submitted by Amber Williams, Executive 
Director, Safe States Alliance.]
                                 ______
                                 
            Prepared Statement of the Scleroderma Foundation
    Chairman Harkin and distinguished members of the Subcommittee, 
thank you for your time and your consideration of the scleroderma 
community's priorities while working to craft the fiscal year 2015 
Labor, Health and Human Services Appropriations Bill.
                           about scleroderma
    Scleroderma, or systemic sclerosis, is a chronic connective tissue 
disease generally classified as one of the autoimmune rheumatic 
diseases.
    The word ``scleroderma'' comes from two Greek words: ``sclero'' 
meaning hard, and ``derma'' meaning skin. Hardening of the skin is one 
of the most visible manifestations of the disease. The disease has been 
called ``progressive systemic sclerosis,'' but the use of that term has 
been discouraged since it has been found that scleroderma is not 
necessarily progressive. The disease varies from patient-to-patient.
    It is estimated that about 300,000 Americans have scleroderma. 
About one third of those people have the systemic form of scleroderma. 
Since scleroderma presents with symptoms similar to other autoimmune 
diseases, diagnosis is difficult. There may be many misdiagnosed or 
undiagnosed cases.
    Localized scleroderma is more common in children, whereas systemic 
scleroderma is more common in adults. Overall, female patients 
outnumber male patients at a ratio of 4-to-1. Factors other than 
gender, such as race and ethnic background, may influence the risk of 
getting scleroderma, the age of onset, and the pattern or severity of 
internal organ involvement. The reasons for this are still unknown. 
Although scleroderma is not directly inherited, some scientists feel 
there is a slight predisposition to it in families with a history of 
rheumatic or autoimmune diseases. While, scleroderma can develop in 
every age group from infants to the elderly, its onset is most frequent 
between the ages of 25 to 55.
    Currently, there is no cure for scleroderma. Treatments are based 
on a patient's particular symptoms. For instance, heartburn can be 
controlled by medications called proton pump inhibitors or medicine to 
improve the motion of the bowel. Some treatments are directed at 
decreasing the activity of the immune system. Due to the fact that 
there is so much variation from one person to another, there is great 
variation in the treatments prescribed.
    Any chronic disease can be serious. The symptoms of scleroderma 
vary greatly for each person, and the effects of scleroderma can range 
from mild to life threatening. The seriousness will depend on which 
organ systems of the body are affected, and the extent to which they 
are affected. A mild case can become more serious if not properly 
treated. Prompt and proper diagnosis and treatment by qualified 
physicians may minimize the symptoms of scleroderma and lessen the 
chance for irreversible damage.
                          about the foundation
    The non-profit Scleroderma Foundation is the national organization 
for people with scleroderma and their families and friends. It was 
formed January 1, 1998, by a merger between the West Coast-based United 
Scleroderma Foundation and the East Coast-based Scleroderma Federation. 
The national office is headquartered in Danvers, Massachusetts. The 
Foundation has a three-fold mission of support, education, and 
research.
Support
    The Scleroderma Foundation offers the following tools and resources 
in support of people living with scleroderma and their families:
  --A nationwide network of 24 chapters and more than 150 support 
        groups
  --A toll-free helpline providing information and referrals to callers
  --Educational materials, including a quarterly magazine called 
        ``Scleroderma Voice"
  --Offer a variety of brochures, booklets and newsletters, along with 
        our informative website
    Additionally, the Foundation hosts an annual National Patient 
Education Conference. The conference offers various educational and 
networking opportunities for people living with scleroderma, their 
caregivers, family members and friends. Workshops, panel discussions 
and other educational sessions are led by the leading scleroderma 
researchers and healthcare professionals.
Education
    As part of our education mission, we not only perform all the 
functions mentioned above, we also work with our Medical Advisory Board 
of internationally known scleroderma experts to provide patient 
education programs as well as education for physician/healthcare 
professionals.
Research
    The Scleroderma Foundation budgets at least $1 million a year for 
research funding, its single largest budgeted expense. The Scleroderma 
Foundation takes its fiduciary responsibility to donors very seriously, 
especially with regard to our research grant program.
    In the case of research funds, the Foundation's Peer Research 
Review Committee, composed of medical experts on scleroderma from 
around the world, helps determine which proposals will be funded by 
reading, analyzing and ranking all proposals received. It follows a 
peer review system based on that of the National Institutes of Health.
                           one family's story
    Cheyenne Cogswell is an 8-year old third-grader living in the 
poverty-stricken town of Falmouth, Kentucky. Cheyenne was diagnosed at 
age six with a severe case of systemic scleroderma. The disease has 
caused kidney failure and significant damage to her digestive system, 
making it difficult for the body to receive the proper nutrition needed 
for a growing child. She has undergone several life-saving operations 
and numerous hospitalizations. Her skin and other internal organs, such 
as the heart and lungs, are also affected. Cheyenne's treatment first 
consisted of hospitalization and intense chemotherapy. She continues 
with daily chemotherapy injections, now given by her mother, to help 
suppress her immune system and slow the progression of the disease. 
Cheyenne is being raised by a single mother who has faced extreme 
consequences from the financial burden created by scleroderma, losing 
her job in the economic downturn, as well as the family's home. Doctors 
doubted if Cheyenne would survive beyond her seventh birthday, but she 
continues to beat the odds. Chronic diseases like scleroderma are 
unpredictable in their course, and the family--together with their 
close circle of friends--continues to fight and hope for the best. 
Their road is uncertain and illustrates why funding for NIH and its 
research programs are vital to so many people whose lives are impacted 
by chronic illness such as scleroderma.
                             sequestration
    We have heard from the medical research community that 
sequestration and deficit reduction activities have created serious 
issues for Federal funding opportunities and the career development 
pipeline. In order to ensure that the scleroderma research portfolio 
can continue to grow, and, more importantly, to ensure that our country 
is adequately preparing the next generation of young investigators, we 
urge you to avert, mitigate, or otherwise eliminate the specter of 
sequestration. While the Foundation has anecdotal accounts of the harms 
of sequestration, the Federated American Societies for Experimental 
Biology has reported:
  --In constant dollars (adjusted for inflation), the NIH budget in 
        fiscal year 2013 was $6 billion (22.4 percent) less than it was 
        in fiscal year 2003.
  --The number of competing research project grants (RPGs) awarded by 
        NIH has also fallen sharply since fiscal year 2003. In fiscal 
        year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3 
        percent) fewer than in fiscal year 2003.
  --Awards for R01-equivalent grants, the primary mechanism for 
        supporting investigator-initiated research, suffered even 
        greater losses. The number awarded fell by 2,528 (34 percent) 
        between fiscal year 2003 and fiscal year 2013.
    The pay line for some NIH funding mechanisms has fallen from 18 
percent to 10 percent while the average age for a researcher to receive 
their first NIH-funded grant has climbed to 42. These are strong 
disincentives to choosing a career as a medical researcher. Our 
scaling-back is occurring at a time when many foreign countries are 
investing heavily in their biotechnology sectors. China alone plans to 
dedicate $300 million to medical research over the next 5 years; this 
amount is double the current NIH budget over the same period of time. 
Scientific breakthroughs will continue, but America may not benefit 
from the return-on-investment of a robust biotechnology sector. For the 
purposes of economic and national security, as well as public health, 
the Foundation asks that you work with your colleagues to eliminate 
sequestration and recommit to supporting this Nation's biomedical 
research enterprise.
               centers for disease control and prevention
    Early recognition and an accurate diagnosis of scleroderma can 
improve health outcomes and save lives. CDC in general and the NCCDPHP 
specifically have programs to improve public awareness of scleroderma 
and other rare, life-threatening conditions. Unfortunately, budgetary 
challenges at CDC have pushed the agency to focus resources on 
combating a narrow set of ``winnable battles.'' Please increase funding 
for CDC and NCCDPHP so that the agency can invest in additional, 
critical education and awareness activities that have the potential to 
improve health and save lives.
                     national institutes of health
    NIH has worked with the Foundation to lead the effort to enhance 
our scientific understanding of the mechanisms of scleroderma with the 
shared-goal of improving diagnosis and treatment, and ultimately 
finding a cure. Since scleroderma impacts multiple organ systems, 
NIAMS, NHLBI, and NIDDK all play crucial roles in basic, translational, 
and clinical research efforts. Further, emerging NIH initiatives like 
the Cures Acceleration Network and the Accelerating Medicines 
Partnership are creating meaningful opportunities to advance 
scleroderma research. Please provide NIH with a significant funding 
increase to the scleroderma research portfolio can continue to expand 
and facilitate key breakthroughs.
  --NHLBI, is leading Scleroderma Lung Study II, is comparing the 
        effectiveness of two drugs in treating pulmonary fibrosis in 
        scleroderma.
  --NIAMS, is leading efforts to discover whether three gene expression 
        signatures in skin can serve as accurate biomarkers predicting 
        scleroderma, and investigations into progression and response 
        to treatment to clarify the complex interactions of T cells and 
        interleukin-31 (IL-31) in producing inflammation and fibrosis, 
        or scarring in scleroderma.
                 additional medical research activities
    In recent years, scleroderma has been listed as a condition 
eligible for study through the Department of Defense (DOD) Peer-
Reviewed Medical Research Program (PRMRP). Since fiscal year 2005, the 
opportunity for scleroderma researchers to compete for funding through 
this mechanism led to over $10 million in scleroderma research funding 
as well as the initiation of meaningful research projects. Research on 
the underlying mechanisms of scleroderma is showing relevance to all 
fibrosis, which occurs at higher rates among individuals who served in 
the military and our veterans. Further, military service-associated 
environmental triggers, particularly silica, solvent, and radiation 
exposure, are believed to be potential triggers for scleroderma in 
individuals that are genetically predisposed to it.
    Despite the connection between military service and scleroderma, 
the condition was left off the PRMRP's eligible conditions list in 
fiscal year 2014. While we appreciate that the Defense Appropriations 
Subcommittee and the Senate play important roles in crafting the annual 
eligible conditions list, the scleroderma community urges you to weigh 
in with your colleagues on the Appropriations Committee to actively 
work to see that scleroderma is re-listed as a condition eligible for 
study through the PRMRP within the Committee Report accompanying the 
fiscal year 2015 Defense Appropriations Bill.
    Thank you again for your time and your consideration of the 
scleroderma community's requests.
                                 ______
                                 
         Prepared Statement of the Senior Service America, Inc.
    This statement concerns the Administration's proposed fiscal year 
2015 appropriations of $380 million for the Department of Health and 
Human Services--Administration for Community Living's Senior Community 
Service Employment Program. We urge that funding for this program be 
increased to $600 million, returning the program to its funding levels 
prior to the Great Recession (adjusted for inflation). This investment 
would provide jobs and training for more than 30,000 additional 
unemployed older Americans than the Administration's proposal. We also 
urge that the Congress refer to the authorizing committee any proposals 
to revise the mission of the program or transfer the program from the 
Department of Labor.
    The Senior Community Service Employment Program (SCSEP) is the only 
Federal program targeted to provide jobs and training to low-income 
older adults 55 and older. According to GAO Report GAO-11-92, SCSEP is 
one of only three Federal workforce development programs that do not 
overlap with any other program. Launched in 1968, SCSEP is authorized 
by Title V of the Older Americans Act and is currently administered by 
the Department of Labor Employment and Training Administration. In the 
year ending June 30, 2013, SCSEP provided jobs and training for 67,551 
economically disadvantaged older adults, who in turn provided over 37.2 
million hours of staffing to 30,000 local private and private nonprofit 
agencies serving the community. The value of these community service 
hours was $825 million, based on hourly-wage estimates from the 
Independent Sector.
    The Administration's fiscal year 2015 budget proposes to cut 
funding for SCSEP to $380 million, $52 million less than $432 million 
in total grants awarded by the USDOL for fiscal year 2014. Senior 
Service America estimates that this cut would result in 8,600 fewer 
jobs and training nationwide for low income older adults and 4.4 
million fewer staff hours in local agencies (whose value exceeds $97 
million).
    The following facts strongly support increasing the appropriations 
for SCSEP in fiscal year 2015:
    Low-income older workers, most of whom are long-term unemployed, 
continue to suffer extremely high rates of joblessness.--As the 
following table shows, since 2000 the jobless rate of low-income older 
workers (55 years and older with annual family incomes less than $20k) 
has been 2.5 to 3 times higher than the rate among all older workers:

 
----------------------------------------------------------------------------------------------------------------
                                                                     Unemployment
                                                                     rate for low    Unemployment
                               Year                                  income older     rate of All
                                                                      workers (%)       55+ (%)
--------------------------------------------------------------------------------------------------
2000..............................................................             6.6             2.6
2001..............................................................             7.6             3.0
2002..............................................................             9.7             3.8
2003..............................................................            11.1             4.0
2004..............................................................            10.6             3.7
2005..............................................................            10.1             3.4
2006..............................................................             9.9             3.0
2007..............................................................            10.0             3.1
2008..............................................................            11.8             3.8
2009..............................................................            18.8             6.6
2010..............................................................            19.9             7.0
2011..............................................................            19.5             6.5
2012..............................................................            18.4             6.0
2013..............................................................            17.0             5.8
----------------------------------------------------------------------------------------------------------------
Source: Low-income (<$20,000) age 55+ jobless rate tabulations fromCurrent Population Survey, by the Center for
  Labor Market Studies,Northeastern University, for Senior Service America, Inc., January2014.

    SCSEP is a unique employment and training program of the Federal 
Government.--Cited in the previously mentioned 2011 GAO report as one 
of only three Federal workforce programs ``that do not overlap with 
other programs.'' It also assists a harder-to-serve segment of the 
older adult workforce: 88 percent of participants were at or below the 
poverty level; 60 percent were at least 60 years old; nearly two-thirds 
were women; and over half of the participants were from a racial/ethnic 
minority (PY2012).
    SCSEP grantees succeed in carrying out the Congressional intent for 
the program.--According to an independent national evaluation conducted 
by Mathematica Policy Research (MPR) and Social Policy Research 
Associates (SPR) in 2012 for the U.S. Department of Labor, ``SCSEP 
projects are largely successful in recruiting and enrolling older 
workers with serious barriers to employment, providing participants 
with community service assignments at host agencies, and [annually] 
placing nearly half of program exiters who are available for work into 
unsubsidized jobs.''
    Programs under the Workforce Investment Act (WIA) continue to 
underserve older workers.--Several GAO reports have cited that WIA 
performance measures may create disincentives for serving older workers 
seeking part-time work. As a result, a disproportionately small 
percentage of those served by American Job Centers are older workers. 
The 2012 MPR/SPR evaluation of SCSEP stated that ``SCSEP projects find 
it difficult to draw on the resources of American Job Centers to 
support participants in finding jobs.''
    The value of work performed by SCSEP participants in their 
community service assignments is nearly double the total amount 
appropriated for SCSEP.--In PY2012, SCSEP participants worked over 37 
million hours at minimum wage in over 30,000 host agencies (nonprofit, 
faith-based, and public), including more than 10 million hours serving 
other older persons through Meals on Wheels, area agencies on aging, 
and other organizations. Using the Independent Sector's estimated 
hourly value of volunteer work, the estimated value of this community 
service was nearly $825 million.
    The fiscal year 2015 budget proposes to cut SCSEP funding to 66 
percent of the 2008 level (in constant 2000 dollars), yet low-income 
older workers continue to suffer from extraordinarily high rates of 
unemployment.--The following graph shows the unemployment rate among 
low-income older workers since 2000 (described in the previous table on 
page 2) in contrast to the history of SCSEP funding, in both current 
dollars and constant 2000 dollars. In 2008, the average annual 
unemployment rate for low-income older adults 55 and over was 11.8 
percent and SCSEP funding was $521.6 million (unadjusted) or $417.2 
million (in constant 2000 dollars). In unadjusted dollars, the proposed 
fiscal year 2015 budget for SCSEP of $380 million represents 73 percent 
of the 2008 funding for SCSEP, but the fiscal year 2015 budget would 
cut SCSEP to only 66 percent of the 2008 funding in constant dollars--
yet the average annual unemployment rate for the SCSEP-eligible 
population is about 17 percent in 2013 compared to less than 12 percent 
in 2008.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    The following table shows the history of SCSEP funding since 2000:

------------------------------------------------------------------------
                                                         Real value of
                                          Final              annual
            Fiscal Year             appropriations in  appropriations in
                                     current dollars    constant dollars
                                        (millions)     (base year: 2000)
------------------------------------------------------------------------
2000..............................              440.2              440.2
2001..............................              440.2              428.0
2002..............................              445.1              426.1
2003..............................              442.3              413.9
2004..............................              434.0              395.7
2005..............................              436.7              385.0
2006..............................              432.3              369.3
2007..............................              483.6              401.6
2008..............................              521.6              417.2
2009..............................              691.9              558.4
2010..............................              825.4              651.8
2011..............................              449.1              343.8
2012..............................              448.3              336.2
2013..............................              424.8              313.9
2014..............................              434.4              318.6
2015 (proposed)...................              380.0        274.6 (est)
------------------------------------------------------------------------
Note: Estimation Procedure for 2015 Constant Dollar Value (base year =
  2000):
Estimated Cumulative Inflation Index (CII) for 2015 is based on
  projected annual inflation rate of 1.5 percent. OMB proposed SCSEP
  appropriation for fiscal year 2015 = $380m. fiscal year 2015 $380m =
  $278.7m in 2014 constant dollars. The CII through 2014 = $380/$278.7 =
  1.3635. Estimated CII for 2015 (based on 1.5 percent inflation rate) =
  1.3635 + (1.3635 x 0.015) = 1.3840. fiscal year 2015 proposed $380m
  appropriation = $380m/1.3840 = $274.57m in constant dollars (base year
  2000).

    The proposed fiscal year 2015 would have a damaging impact on local 
communities.--As the following table shows, cuts in SCSEP funding would 
harm small and large States:

 
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                   Total fiscal year
                                     2014 funding      Estimated funding   Cut in funding in   Cut in number of   Cut in total hours     Value of lost
                                   awarded by USDOL     in fiscal year     fiscal year 2015   SCSEP participants     of community     hours of community
                                          ($)              2015 ($)               ($)                                   service           service ($)
--------------------------------------------------------------------------------------------------------------------------------------------------------
All States and Territories......         432,285,000         380,000,000         -52,285,000              -8,630          -4,381,000          97,000,000
Alabama.........................           8,011,355           7,042,000            -969,000                -160             -87,800          -1,900,000
Illinois........................          16,502,969          14,507,000          -1,996,000                -330            -161,000          -3,600,000
Iowa............................           5,430,241           4,773,000            -657,000                -110             -57,900          -1,300,000
Kansas..........................           4,210,174           3,701,000            -509,000                 -80             -43,900          -1,000,000
Maryland........................           5,832,216           5,127,000            -705,000                -120             -62,200          -1,400,000
Mississippi.....................           5,232,771           4,600,000            -633,000                -100             -53,000          -1,200,000
Tennessee.......................           8,660,178           7,613,000          -1,047,000                -170             -93,000          -2,100,000
Washington......................           6,489,633           5,705,000            -785,000                -130             -54,900          -1,200,000
--------------------------------------------------------------------------------------------------------------------------------------------------------

    In summary, our economy continues to leave millions of low-income 
older Americans behind. These older workers help expand the capacity of 
local agencies to meet the basic needs of their communities. In an 
independent national survey of 10,000 of these agencies, 75 percent 
reported that SCSEP significantly or somewhat increased their ability 
to provide services. SCSEP is a unique program that achieves a wide 
range of outcomes and produces multiple returns on investment. 
Throughout the Nation, older Americans and communities need and depend 
on the Senior Community Service Employment Program.

    [This statement was submitted by Anthony R. Sarmiento, Executive 
Director, Senior Service America, Inc.]
                                 ______
                                 
            Prepared Statement of the Sleep Research Society
    Chairman Tom Harkin, Ranking Member Jerry Moran, and distinguished 
members of the Subcommittee, as you begin to craft the fiscal year 2015 
Labor-HHS-Education appropriations bill, the Sleep Research Society 
(SRS) is pleased to submit this statement for the record asking you to 
provide $32 billion for NIH, including a proportional increase for the 
National Heart, Lung, and Blood Institute (NHLBI), $1 million in 
funding for sleep disorders awareness and surveillance at the Centers 
for Disease Control and Prevention (CDC), full support for the National 
Center on Sleep Disorders Research (NCSDR), and implementation of the 
2011 NIH Sleep Disorders Research Plan. These actions will ensure 
increased awareness of the importance of sleep and circadian rhythms 
and further the advancements being made by sleep researchers to better 
understand the relationship between sleep and health.
                         sleep research society
    SRS was established in 1961 by a group of scientists who shared a 
common goal to foster scientific investigations on all aspects of sleep 
and sleep disorders. Since that time, SRS has grown into a professional 
society comprising over 1,100 researchers nationwide. From promising 
trainees to accomplished senior level investigators, sleep research has 
expanded into areas such as psychology, neuroanatomy, pharmacology, 
cardiology, immunology, metabolism, genomics, and healthy living. SRS 
recognizes the importance of educating the public about the connection 
between sleep and health outcomes. We promote training and education in 
sleep research, public awareness, and evidence-based policy, in 
addition to hosting forums for the exchange of scientific knowledge 
pertaining to sleep and circadian rhythms.
    According to an Institute of Medicine's report entitled, ``Sleep 
Disorder and Sleep Deprivation: An Unmet Public Health Problem'' 
(2006), chronic sleep and circadian disturbances and disorders are a 
very real and relevant issue in today's society as they affect 50-70 
million Americans across all demographic groups. Sleep deprivation is a 
major safety issue, particular in reference to drowsy driving, where it 
is a factor in 20 percent of motor vehicle injuries. The widespread 
effect of sleep disorders on every age group poses a public health 
risk, extending from the ability to learn to maintain a healthy 
lifestyle. Furthermore, it is important to recognize that sleep 
disorders and circadian disturbances are often an indicator of, or a 
precursor to other major diseases and disorders including; obesity, 
diabetes, hypertension, cardiovascular disease, stroke, depression, 
bipolar disorder, and substance abuse. Another increasingly detrimental 
condition affecting 15 percent of the population is sleep-disordered 
breathing, including obstructive sleep apnea. Sleep apnea results in 
excessive daytime somnolence, poor performance, increased frequency of 
road traffic accidents, and arterial hypertension. Studies show that 85 
percent of 725 troops returning home from Afghanistan and Iraq had a 
sleep disorder and the most common was obstructive sleep apnea (51 
percent). If left untreated, obstructive sleep apnea has significant 
negative impacts on health, including early mortality.
                     national institutes of health
    Due to the fact that sleep is a multi-disciplinary issue, many 
institutes and centers at NIH, utilize a portion of their funding to 
support sleep and circadian research. The majority of sleep research is 
coordinated by NHLBI, particularly the National Center on Sleep 
Disorders Research. An appropriation of $32 billion for NIH, and $3 
billion for NHLBI, is needed to facilitate the continued growth and 
advancement in the sleep and circadian research portfolio.
    The reason NCSDR is housed at NHLBI is due to the important link 
between sleep disorders and cardiovascular health. NCSDR supports 
research, health education, and research training related to sleep-
disordered breathing and the fundamental function of sleep and 
circadian rhythms. Furthermore, NCSDR coordinates sleep research across 
NIH and with other Federal agencies and outside organizations.
    NCSDR's coordinating role between institutes is made possible 
through adequate funding. These research activities also have far 
reaching effects, beginning with training grants targeted towards 
undergraduate students and career development opportunities attracting 
top talent in doctoral programs. Sequestration has the potential to 
disrupt the research training pipeline by reducing the amount of K, T, 
and F series awards for new investigators. It could also disrupt the 
career development pipeline designed to train future investigators who 
are pursuing research in sleep disorders and circadian rhythms. It is 
important to fund NIH at $32 billion and NHLBI at $3 billion in fiscal 
year 2015 so that we can continue these advancements in sleep and 
circadian research.
    department of veterans affairs & department of defense research 
                               activities
    It is also important to recognize that by increasing the Federal 
commitment to sleep and circadian research, we can improve the health 
of those brave Americans who have served in uniform and are suffering 
from sleep disorders. Both obstructive sleep apnea and insomnia have a 
high prevalence among active-duty U.S. Armed Forces and among Veterans. 
Post-traumatic stress disorder and/or depression are highly prevalent 
in returning Iraq and Afghanistan combat Veterans. Sleep disturbance is 
a prominent symptom in these disorders. Traumatic brain injury is 
increasingly common in modern combat, and sleep disruption in the 
aftermath of TBI may have negative effects on long-term recovery of 
normal brain function.
    The Department of Veterans Affairs (VA) and the Department of 
Defense have shown a commitment to collaborating with NIH on sleep 
research related to Post-Traumatic Stress Disorder (PTSD), Traumatic 
Brain Injury (TBI), and Gulf War Illness (GWI). This is highlighted in 
the fiscal year 2014 president's budget request detailing research 
initiatives in PTSD and TBI. The ``Longitudinal Health Study of Gulf 
War Era Veterans'' is one of the largest scientific research studies on 
chronic diseases and multi-symptom illnesses, including Gulf War 
Illness. Researchers found that prazosin, an inexpensive drug already 
used by millions of Americans for hypertension and prostate problems, 
improves sleep and reduces nightmares for veterans with PTSD. They 
continue to pursue activities such as the difference between female and 
male veterans with PTSD and possible intervention strategies to help 
veterans with TBI return to daily activities. One study described in 
the Veteran's Health Administration report State of VA Research 2012, 
found that 96 percent of veterans with chronic multi-symptom illnesses 
experienced sleep disordered breathing. By using continuous positive 
airway pressure (CPAP) these veterans reported reductions in pain and 
fatigue and improvements in cognitive function.
    Sleep disruption, especially insomnia, is a contributing risk 
factor to the onset and severity of major mental health problems such 
as depression, bipolar disorder, substance abuse, PTSD, TBI, and 
suicide among the veteran population. It is important to continue 
supporting the sleep research endeavors of the VA through robust 
funding for the Medical and Prosthetic Research Program at $589 
million.
               centers for disease control and prevention
    CDC gathers important data on sleep disorders through their 
surveillance efforts under the Chronic Disease Prevention and Health 
Promotion program. Most notably, CDC hosts a National Sleep Awareness 
Roundtable (NSART) by promoting the importance of sleep through the 
production of State fact sheets, updating the CDC website, and 
disseminating information on sleep related topics. CDC also promotes 
awareness of sleep disorders and the dangers associated with sleep 
deprivation for the benefit of millions of Americans. Currently 
population-based data on the prevalence of circadian disruption and its 
relationship to disease risk is relatively limited. Please fund CDC at 
$7.8 billion including an allocation of $1 million solely for sleep 
awareness and surveillance activities within the Chronic Disease 
Prevention and Health Promotion program and within NSART, so that 
progress can continue in the areas of sleep disorders and disturbances, 
sleep awareness, and education to the public community.
                   nih sleep disorders research plan
    NCSDR published the NIH Sleep Disorders Research Plan in November 
of 2011 highlighting the implementation of pertinent sleep research 
goals to enable further advancements in the realm of sleep and 
circadian rhythm disorders. A Joint Task Force between the two leading 
organizations representing the sleep medicine and research community, 
Sleep Research Society (SRS) and American Academy of Sleep Medicine 
(AASM), has identified research opportunities that will have the 
highest impact on health within the plan.
    The Plan recommends implementation of the following sleep research 
goals which will help us understand the function of sleep and inform 
individuals on healthier lifestyle choices:
  --Advance the understanding of sleep and circadian functions and of 
        basic sleep and circadian mechanisms, in both the brain and the 
        body, across the lifespan.
  --Identify genetic, pathophysiological, environmental, cultural, 
        lifestyle factors, and sex and gender differences contributing 
        to the risk of sleep and circadian disorders and disturbances, 
        and their role in the development and pathogenesis of co-morbid 
        diseases and disability.
  --Improve prevention, diagnosis, and treatment of sleep and circadian 
        disorders, chronic sleep deficiency, and circadian disruption, 
        and evaluate the resulting impact on human health.
  --Enhance the translation and dissemination of sleep and circadian 
        research findings and concepts to improve healthcare, inform 
        public policy, and increase community awareness to enhance 
        human health.
  --Enable sleep and circadian research training to inform science in 
        cross-cutting domains, accelerate the pace of discovery, and 
        the translation of enhanced therapies from bench to bedside to 
        community.
    Research activities and stakeholders addressed by the plan benefit 
from the encompassing range of NIH research, training, and outreach 
programs. Over the past 2 years, steps have been taken to implement 
portions of this research plan, but additional work needs to be done. 
SRS encourages you to recommend that this research plan continue to be 
implemented during fiscal year 2015.
    Thank you for the opportunity to submit the views of the sleep 
research community. Please do not hesitate to contact us should you 
have any questions or require additional information.

    [This statement was submitted by Dr. Janet Mullington, Ph.D., 
President, Sleep Research Society.]
                                 ______
                                 
   Prepared Statement of The Society for Healthcare Epidemiology of 
America and the Association for Professionals in Infection Control and 
                              Epidemiology
    The Society for Healthcare Epidemiology of America (SHEA) and the 
Association for Professionals in Infection Control and Epidemiology 
(APIC) thank you for this opportunity to submit testimony on Federal 
efforts to detect dangerous infectious diseases, protect the American 
public from preventable healthcare-associated infections (HAIs) and 
address the rapidly growing threat of antibiotic resistance (AR). We 
ask that you support the following programs: First, under the Centers 
for Disease Control and Prevention National Center for Emerging and 
Zoonotic Infectious Diseases: $250 million for Core Infectious Diseases 
including $30 million for the new Detect and Protect Against Antibiotic 
Resistance (AR) Initiative, $32 million for the National Healthcare 
Safety Network (NHSN), and $30 million for the Advanced Molecular 
Detection (AMD) Initiative. Additionally, we request $34 million for 
HAI research activity conducted by the Agency for Healthcare Research 
and Quality (AHRQ) and $4.58 billion for the National Institutes of 
Health/National Institute of Allergy and Infectious Diseases (NIAID).
    HAIs are among the leading causes of preventable death in the 
United States. In hospitals alone, CDC estimates that one in 25 
patients has an HAI, totaling approximately 722,000 infections in 2011. 
According to the CDC, every day, more than 200 Americans with HAIs will 
die during their hospital stay. Further, AR is one of the most critical 
public health and patient safety threats facing us today, causing an 
estimated two million illnesses and approximately 23,000 deaths 
annually. It is estimated that as much as half of antibiotic 
prescribing in hospitals is not necessary. Antibiotics, created to save 
lives, are now contributing to patient's deaths by promoting the 
emergence of highly resistant bacteria and leading to deadly adverse 
events.
Centers for Disease Control and Prevention (CDC)
    We urge you to support the CDC Coalition's request for $7.8 billion 
in fiscal year 2015 for the CDC's ``core programs.'' We are concerned 
that the President's fiscal year 2015 budget proposal would reduce the 
CDC's budget authority by $243 million when compared with fiscal year 
2014. This total is, in fact, lower than 2003 levels. We urge Congress 
to prioritize funding for the activities and programs supported by CDC 
that are essential to protect the health of the American people and 
reduce healthcare costs.
    We especially want to highlight our support for the $30 million in 
the President's budget for the Detect and Protect Against Antibiotic 
Resistance (AR) Initiative. This initiative will establish a robust 
network of five regional labs that will detect the deadliest AR threats 
and protect patients and communities through the rapid identification 
of outbreaks, saving lives and reducing healthcare costs. It will 
prioritize healthcare prevention collaboratives focused on improving 
antibiotic use and preventing deadly infections caused by Clostridium 
difficile (C. diff), carbapenem-resistant Enterobacteriaceae (CRE), 
Pseudomonas, and methicillin-resistant Staphylococcus aureus (MRSA). 
Most importantly, the initiative will invest in direct action by 
implementing proven evidence-based interventions that reduce the 
emergence and spread of AR pathogens and improve antibiotic use. It is 
critical that Congress prioritize this rapidly growing threat to public 
health and patient safety in our Nation and around the world. Moreover, 
we strongly support CDC's focus on the implementation of antimicrobial 
stewardship programs in all healthcare settings.
    We urge you to support the $32 million in the President's budget 
for the CDC's National Healthcare Safety Network (NHSN). The 
President's request represents a $14 million increase over the fiscal 
year 2014 enacted level for the NHSN to extend HAI prevention efforts 
to more than 3,000 ambulatory surgery centers and other non-hospital 
settings. This will enable CDC to conduct applied research on 
interventions for infection prevention and continue to provide data for 
national HAI elimination and targeted HAI prevention intervention. This 
funding level will also allow for the extension and implementation of 
the NHSN Antimicrobial Use and Resistance Components to enable rapid 
detection of highly resistant pathogens and track antibiotic use in 
healthcare settings.
    The NHSN serves as the foundation for the development of 
innovative, evidence-based HAI prevention strategies through high-
quality monitoring of HAI prevalence as well as antibiotic usage in the 
US. It is a critical tool used by healthcare facilities to monitor and 
prevent HAIs. The NHSN provides medical facilities, states, regions, 
and the Nation with data collection and reporting capabilities needed 
to comply with state and Federal public reporting mandates, including 
the Centers for Medicare & Medicaid Services' Value-Based Purchasing 
Program. Consistent, scientifically sound and validated data are 
necessary to be reported at the state and Federal levels to ensure that 
accurate data are available to evaluate progress related to the HHS 
National Action Plan to Prevent HAIs as well as to support transparency 
to the public, allowing for fair comparisons between facilities.
    By August 2013, over 12,400 healthcare facilities, including nearly 
all U.S. hospitals, participated in NHSN for quality improvement. The 
number of acute care hospitals reporting multi-drug resistant organisms 
(such as C.diff and MRSA) through NHSN more than doubled to 4,000 in 
fiscal year 2013. Since 2008, the cumulative impact of CDC data 
systems, guidelines and programs has contributed to significant 
reductions of HAIs in healthcare settings, including a 44 percent 
reduction in central line-associated bloodstream infections, a 31 
percent reduction in healthcare-associated invasive MRSA infections, 
and a 20 percent reduction in surgical site infections.
    We strongly support the CDC Prevention Epicenters Program. Funded 
through the NHSN, this program is a collaboration between CDC and 
academic medical centers that conduct innovative infection control and 
prevention research to address important scientific questions regarding 
the prevention of HAIs, antibiotic resistance and other adverse 
healthcare events. The Epicenters Program has provided a unique forum 
in which academic leaders in healthcare epidemiology can partner 
directly with each other and with CDC subject matter experts. The 
resultant emphasis on multicenter collaborative research projects, 
through which investigators work together as a group, allows for 
research that in many cases, would not have been possible for a single 
academic center. Going forward, the Prevention Epicenters will continue 
to address gaps and pilot innovative ways to prevent HAIs and 
antimicrobial resistance.
    We urge your continued support of the President's $30 million 
request for the Advanced Molecular Detection (AMD) Initiative in 
bioinformatics and genomics, which allows CDC to more quickly determine 
where emerging diseases come from, whether microbes are resistant, and 
how microbes are moving through a population. This Initiative is 
critical because it strengthens CDC's epidemiologic and laboratory 
expertise to effectively guide public health action.
    We strongly support the critical work conducted through the 
Emerging Infections Program (EIP), which engages a network of state 
health departments and their academic medical center partners to help 
answer important questions about emerging HAI threats, advanced 
infection tracking methods and antibiotic resistance in the U.S.
Agency for Healthcare Research and Quality
    We request your support of the proposed investment of $34 million 
for AHRQ's HAI research activity, the level of enacted support in 
fiscal year 2014. Building on the successes of fiscal year 2013 and 
2014, these funds will support a portfolio of grant- and contract-
funded projects seeking to advance our knowledge about effective 
approaches to reducing HAIs while promoting the implementation of 
proven methods for preventing HAIs. These grants ($13.9 million) and 
contracts ($20.1 million) will investigate methods of controlling HAIs 
in diverse healthcare settings and will address the major types of 
HAIs. In addition, contracts funded by the HAI budget will accelerate 
the nationwide implementation of the Comprehensive Unit-based Safety 
Program (CUSP). To date, widespread adoption of this evidence-based 
checklist of safety practices to over 1,000 intensive care units has 
reduced the incidence of central line-associated bloodstream infections 
(CLABSIs) by 41 percent. Our organizations are pleased to participate 
in the On the CUSP: Stop CAUTI initiative, which aims to reduce mean 
rates of CAUTI in U.S. hospitals by 25 percent by working with state 
organizations and hospitals across the country to implement the CUSP 
and catheter-associated urinary tract infection (CAUTI) reduction 
practices in hospital units. In spite of notable progress, there 
remains work to be done toward the goal of HAI elimination.
National Institutes of Health (NIH)/National Institute of Allergy and 
        Infectious Diseases (NIAID)
    Within NIH, we believe that the National Institute of Allergy and 
Infectious Diseases (NIAID) should be funded at least at the $4.58 
billion requested by the Administration in the fiscal year 2014 budget 
request. Nearly flat-funding NIAID limits investment in new research 
and serves as a disincentive for young people to pursue infectious 
disease research careers so critical to the discovery of new therapies, 
new diagnostic approaches, and new preventive strategies.
    In 2013, the NIAID began funding a new clinical trials network 
focused on antibiotic-resistant bacterial infections. With sufficient 
funding, the new research network/infrastructure will conduct studies 
to address antibiotic resistance as well as begin to answer questions 
that will help fill the nearly empty antibiotic research and 
development pipeline. Severe economic disincentives have caused a mass 
exodus of private companies from the antibiotics market, making 
federally funded research in this area more critical than ever. We 
applaud NIAID's initiative in launching the new network. We recommend 
increased investment in this area.
    We thank you for the opportunity to submit testimony and greatly 
appreciate your leadership in the effort to eliminate preventable HAIs 
and combat antibiotic resistance.
    Please forward questions to:
    Melanie Young, Policy & Strategic Initiatives Director, SHEA, 
[email protected] and Lisa Tomlinson, Senior Director, Government 
Affairs, APIC, [email protected].
                                 ______
                                 
           Prepared Statement of the Society for Neuroscience
    Mr. Chairman and members of the Subcommittee, my name is Carol Ann 
Mason, Ph.D. I am a professor of pathology and cell biology, 
neuroscience, and ophthalmic science at Columbia University. I study 
the development of visual pathways in mammalian brains, with a focus on 
how neurons in the eye are encoded to project to the correct side of 
the brain, setting up the circuit for binocular vision. This statement 
is in support of increased funding for NIH for fiscal year 2015.
    I am pleased to submit this testimony in my capacity as president 
of the Society for Neuroscience (SfN). On behalf of the nearly 40,000 
members of SfN, thank you for your past support of neuroscience 
research at NIH. SfN's mission is to advance the understanding of the 
brain and nervous system; provide professional development activities, 
information and educational resources; promote public information and 
general education; and inform legislators and other policymakers.
    The Society stands with others in the research community in 
requesting at least $32 billion for NIH for fiscal year 2015. 
Sequestration is taking an enormous toll on biomedical research, coming 
on top of recent years when funding has failed to keep pace with the 
cost of research--let alone the scientific opportunities that are 
available. SfN urges Congress to reverse the current course and find 
ways to invest more in biomedical research. Let's work to put 
biomedical research on a trajectory of sustained growth that recognizes 
its promise and opportunity as a tool for economic growth and, more 
importantly, for advancing the health of Americans.
Neuroscience: An Investment in Our Future
    Even in the face of the difficult funding situation, the last 
several years have been a tremendously exciting and productive time for 
neuroscience discoveries. Major research advances on brain development, 
imaging, genomics, circuits, computational neuroscience, neural 
engineering, and many other disciplines are leading to new tools, new 
knowledge, and greater understanding that were unimaginable even a few 
years ago. Sustained investment to fuel and speed these discoveries is 
essential to American health and economic well-being for many reasons.
    First, major investment in basic and translational neuroscience is 
not only fueling an enduring and vital scientific endeavor; it is the 
essential foundation for understanding and treating diseases that 
strike nearly 1 billion people worldwide. All told, there are more than 
1,000 debilitating neurological and psychiatric diseases that strike 
over 100 million Americans each year, producing inestimable hardship 
for millions of America families and costing the U.S., in a 
conservative estimate, at least $760 billion a year, with expenses in 
the trillions looming for conditions such as Alzheimer's disease. 
Advances made possible by publicly-funded basic research will help 
better understand and treat traumatic brain injury, Alzheimer's, 
Parkinson's disease, Down syndrome, schizophrenia, epilepsy, and post-
traumatic stress disorder, to name just a few. With so much promising 
research, now, more than ever, it is time to fan the flames of research 
in order to ensure lifesaving breakthroughs continue.
    Additionally, NIH funding is an investment in America's current 
economic strength. Funding for research supports quality jobs and 
increases economic activity. NIH supports approximately 400,000 jobs 
and $58 billion in economic output nationwide. Eighty-five percent of 
the NIH budget fund extramural research in communities located in every 
State.
    Finally, without robust, sustained investment, America's status as 
the preeminent leader in biomedical research is at risk. Other 
countries are investing heavily in biomedical research to take 
advantage of new possibilities. Even with the growing philanthropic 
support, private sector cannot be expected to close the gap. The lag 
time between discovery and profitability means that the pharmaceutical, 
biotechnology, and medical device industries need federally-funded 
basic (also known as fundamental) research to develop products and 
treatments. The foundation that basic research provides is at risk if 
federally-funded research declines.
The BRAIN Initiative
    SfN appreciates that both Congress and the administration recognize 
brain science as one of the great scientific challenges of our time. 
The Brain Research through Application of Innovative Neurotechnologies 
(BRAIN) Initiative--announced by the President last April--will enable 
NIH and other Federal agencies to develop tools and plans that will 
help accelerate fundamental discoveries and improve the health and 
quality of life for millions of Americans. An eminent group of 
neuroscientists with diverse research interests is helping to formulate 
a scientifically-driven direction for the initiative, and SfN thanks 
public leaders for their interest and early support for a truly 
transformative scientific grand challenge that would need major 
financial emphasis in future years.
    The overarching goal of the BRAIN Initiative is to map the circuits 
of the brain and the activity within those circuits to understand our 
unique cognitive and behavioral capabilities. The Initiative has a 
strong focus on developing technologies which has the potential to 
benefit all of neuroscience and even non-neuroscience research. BRAIN, 
like other major brain-related initiatives around the world, 
demonstrates the global interest in tackling the mysteries of the 
brain. But BRAIN--as with all the neuroscience research that takes 
place with Federal support--can only be successful if it is part of a 
broad neuroscience commitment across Congress and the Administration. 
Such an investment will also help ensure the U.S. remains a global 
leader, as other nations and regions are now rapidly ramping up their 
investments in neuroscience research.
Cross-Disciplinary Neuroscience and the Promise of Brain Circuits
    NIH-funded basic research continues to be essential for discoveries 
that will inspire scientific and medical progress for generations. Past 
NIH-supported projects have helped neuroscientists make tremendous 
strides in diagnosing and treating neurological and psychiatric 
disorders.
    A prime example of the importance of funding research at levels 
from the most basic to translational is the current focus on 
understanding brain circuits. Circuits in the brain underlie every 
thought, emotion, and action we take. Current knowledge about the 
intricate patterns connecting brain cells is extremely limited. 
Identifying these patterns is essential to understand healthy brain 
function and dysfunction in injury or disease. Research suggests that 
some brain disorders, like autism and schizophrenia, may result from 
errors in neural circuit development. Elucidating brain circuit 
structure and function is an enormously challenging endeavor; the brain 
consists of billions of cells, and each cell contacts thousands of 
others. These cells communicate with precisely-timed signals, which 
then activate a multitude of biochemical pathways that influence every 
process in the cell. However, scientists are beginning to map the 
functions of brain circuits with previously unheard-of specificity 
using cutting-edge technologies, and learning how these circuits 
produce behaviors.
    The following examples are just a few of the many basic research 
success stories in the science of brain circuitry emerging now thanks 
to interdisciplinary research funded by a strong historic investment in 
NIH and other research agencies.
Optogenetics
    Optogenetics is a technique which uses light to activate specific 
populations of neurons with millisecond precision. It is difficult to 
overstate how revolutionary optogenetics is for neuroscience research. 
With optogenetics, flashes of light are used to activate neurons that 
have been genetically modified to contain a light-sensing protein. This 
precise control over specific populations of neurons at specific times 
was impossible until a confluence of basic research in marine biology, 
genetic engineering, cellular biology, and fiber optic technology 
facilitated its development; together these developments created an 
approach that enables the proteins to be used as ``on switches'' for 
cells. Introduced a decade ago, optogenetics is now used by hundreds of 
labs; it is one of the many neurotechnologies that today is 
transforming the field's ability to understand brain function, and is 
being used to study brain circuits in both normal function and disease, 
including Parkinson's disease, as described below. The development of 
this technology also perfectly demonstrates the often serendipitous 
nature of scientific discovery and the need to fund both research on 
all levels, from basic to translational to clinical.
Understanding the Development of Vision
    My own area of research is the development of the circuits 
underlying vision. For binocular vision to function, the brain must 
receive information from both eyes. Nerve fibers from each retina grow 
to the `optic chiasm,' at the midline of the bottom of the brain. Here, 
nerve fibers from each eye cross to the other side of the brain. Other 
axons, however, are repelled at the midline and project to the same 
side of the brain. These connections underlie binocular vision which 
enables animals, including humans, to calculate how far objects lie in 
the distance. One area of my research focuses on this question and the 
molecular mechanisms that prompt some growing nerve fibers to ``stop in 
their tracks'' and reroute to the same side. These two groups of cells 
in the eye, each taking different routes, are endowed with distinct 
genes that direct their time of birth and their growth to the regions 
where they make their synaptic connections. Understanding their genetic 
``signatures'' and growth helps us to learn how to encourage stem cells 
to be integrated into the diseased eye and injured nerve fibers to 
regrow in the correct circuits. We also investigate how the retinal 
pigment epithelium (RPE) surrounding the eye, directs retinal 
development. Perturbations in the RPE occur in albinism and in juvenile 
forms of macular degeneration, the latter leading to blindness, and our 
gene identification efforts are important for gene therapy at early 
stages of the disease. Moreover, understanding how tracts are laid down 
is essential for unraveling the basis of defects in fiber pathways and 
synapse formation in neurodevelopmental disorders such as autism. This 
research is made possible with support primarily from NIH, especially 
the National Eye Institute and with a team of innovative and 
collaborative scientists and trainees in my lab and in our community, 
and provides a foundation for future discovery and new understanding 
about diseases of the eye and other neurodevelopmental conditions.
Deep Brain Stimulation
    Deep brain stimulation (DBS) is a tool that emerged as a result of 
advances in health research. DBS involves a surgical procedure in which 
a neurostimulator device--similar to a heart pacemaker--is implanted to 
deliver electrical stimulation to targeted areas in the brain. While 
both DBS and optogenetics have emerged as instrumental methods to 
influence circuits, DBS has also been developed into a revolutionary 
therapy for the treatment of neurological disease. The electrical 
pulses delivered through the electrodes can transiently disrupt 
abnormal activity that occurs in localized circuits of diseased brains, 
such as in Parkinson's patients.
    DBS has created a new way to approach the treatment of Parkinson's 
disease. Many patients experience pronounced relief from symptoms that 
include tremor, stiffness, slowed movement, and walking problems. 
Moreover, DBS can allow patients to reduce the dosage of their 
medication, providing relief from debilitating motor side-effects. 
Additionally, advances in materials science to create more flexible 
electrodes and in imaging research to produce higher resolution images 
of the brain will improve the precision and outcome of this 
intervention.
    At this time, how and why DBS works is unknown. Insight into its 
mechanism of action came from optogenetic studies in rodents of the 
brain circuits that control movement. By systematically manipulating 
precise areas of the circuit affected by this disease, scientists were 
able to implicate the connection between two areas of the brain as the 
most effective target for DBS. These studies will also inform the 
design of other interventions in Parkinson's, and establish a model for 
study of basic brain circuitry to inform DBS treatment.
    DBS has also had success in treating both intractable depression 
and epilepsy, and has the potential to improve therapies for a whole 
host of brain diseases and disorders--as long as the correct target is 
identified. Because stimulating adjacent regions in the brain can have 
vastly different effects, researchers are attempting to better 
understand the complex brain circuits that control our normal functions 
(e.g., movement, emotion) and how they can go wrong (e.g., addiction). 
They also are tweaking the physical devices used, as well as the 
frequency and strength of the electrical pulses delivered. As we 
understand more about language of the brain through the research made 
possible by NIH funding, new applications of DBS will be possible.
The Future of American Science
    As the subcommittee considers this year's funding levels, please 
consider that significant advancements in the biomedical sciences often 
come from young investigators. As a director of the PhD training 
program of a leading neuroscience department, I see firsthand that the 
current funding environment is taking a toll on the energy and 
resilience of these young people and their career choice. America's 
scientific enterprise--and its global leadership--has been built over 
generations. Without sustained, consistent investment, we will quickly 
lose that leadership. Dramatic swings in funding have stifling and 
irreversible impacts on progress; a closed laboratory can't simply open 
again when funding is restored. The culture of entrepreneurship and 
curiosity-driven research could be hindered for decades.
    We live at a time of extraordinary opportunity in neuroscience. A 
myriad of questions once impossible to consider are now within reach 
because of new technologies, an ever-expanding knowledge base, and a 
willingness to embrace many disciplines. To take advantage of the 
opportunities in neuroscience we need an NIH appropriation that allows 
for sustained, reliable growth. That, in turn, will lead to improved 
health for the American public and will help maintain American 
leadership in science worldwide. Thank you for this opportunity to 
testify.

    [This statement was submitted by Carol Ann Mason, Ph.D., President, 
Society for Neuroscience.]
                                 ______
                                 
     Prepared Statement of The Society for Public Health Education
    I am pleased to submit this testimony on behalf of The Society for 
Public Health Education (SOPHE), a 501 (c)(3) professional organization 
founded in 1950 to provide global leadership to the profession of 
health education and health promotion. SOPHE's 4,000 national and 
chapter members work in universities, medical/healthcare settings, 
businesses, voluntary health agencies, international organizations, and 
all branches of Federal/State/local government. Members include 
behavioral scientists, faculty, practitioners, and students engaged in 
disease prevention and health promotion in both the public and private 
sectors. The Society contributes to the health of all people and the 
elimination of health disparities through advances in health education 
theory and research; excellence in professional preparation and 
practice; and advocacy for public policies conducive to health. SOPHE 
is the only independent professional organization devoted exclusively 
to health education and health promotion. SOPHE's two scientific peer-
reviewed journals, electronic newsletters, listservs, websites, new 
Center for Online Education (CORE), as well as its national conference 
help ensure that vital public health activities and programs in various 
regions are expeditiously disseminated. There are currently 20 SOPHE 
chapters covering more than 30 States and regions across the country.
    SOPHE's vision of a healthy world through health education compels 
us to advocate for increased resources targeted at the most pressing 
public health issues. For the fiscal year 2015 funding cycle, SOPHE 
encourages the Labor, Health and Human Services, Education and Related 
Agencies (Labor-HHS) Subcommittee to increase funding for public health 
programs that focus on preventing chronic disease and other illnesses 
in adults as well as youth, and eliminating health disparities. In 
particular, SOPHE requests the following fiscal year 2015 funding 
levels for Labor-HHS programs:
  --$7.8 billion for the U.S. Centers for Disease Control and 
        Prevention (CDC)
    -- $1.1 billion for the CDC National Center for Chronic Disease 
            Prevention and Health Promotion (NCCDPHP)
      -- $25 million for CDC's National Chronic Disease Prevention and 
            Health Promotion's Division of Population Health School 
            Health Program
    -- $1 billion for the Prevention and Public Health Fund
      -- $80 million for Community Prevention Grants
      -- $50 million for Racial and Ethnic Approaches to Community 
            Health
    The discipline of health education and health promotion, which is 
some 100 years old, uses sound science to plan, implement, and evaluate 
interventions that enable individuals, groups, and communities to 
achieve personal, environmental and population health. Beyond 
supporting individual behavior change, health education focuses on 
policy, systems, and environmental changes to support a healthy 
lifestyle. There is a robust, scientific evidence-base documenting not 
only that health education specialists and their various health 
education interventions work, but that they are also cost-effective. 
These principles serve as the basis for our support for the programs 
outlined below and can help ensure our Nation's resources are targeted 
for the best return on investment. Our profession is the first to 
recruit and train community health workers in terms of cost-effective 
program interventions.
    SOPHE is requesting a fiscal year 2015 funding level $7.8 billion 
for CDC in order to prevent chronic diseases and other illnesses, 
promote health, prevent injury and disability, and ensure preparedness 
against health threats. Unfortunately, President Obama's fiscal year 
2015 budget request of $6.6 billion for CDC represents a decrease of 
some $243 million when compared with fiscal year 2014. CDC is at the 
forefront of U.S. efforts to monitor health, detect and investigate 
health problems, conduct research to enhance prevention, develop sound 
public health policies, and foster safe and healthful environments. 
More than 80 percent of all CDC funds go back to States to address 
State and local health issues. Measured investments now in community-
led, evidence-based innovative programs will help to increase our 
Nation's productivity and performance in the global market; help ensure 
military readiness; decrease costly deaths due to infant low birth 
weight and adult onset of cancer, cardiovascular disease, diabetes, and 
HIV/AIDS, and; increase pediatric and adult immunization rates. 
Moroever, cuts to CDC's budget are not sustainable and will reduce the 
ability to investigate and respond to public health emergencies as well 
as foodborne and infectious disease outbreaks.
Preventing Chronic Disease
    The data are clear: chronic diseases are the Nation's leading 
causes of morbidity and mortality and account for 75 percent of every 
dollar spent on healthcare in the U.S. Collectively, they account for 
70 percent of all deaths nationwide. Healthcare accounts for 18 percent 
of GDP, and it is expected to account for 19.6 percent by 2021. Yet 
evidence shows that investing just $1 in preventing chronic disease 
will yield a $5 return on investment.
    SOPHE requests an appropriation of $1.1 billion for the CDC's 
National Center for Chronic Disease Prevention and Health Promotion 
(NCCDPHP). For example, heart conditions cost the Nation more than $107 
billion annually in healthcare costs, and nearly $95 billion in lost 
economic productivity. Studies show that spending as little as $10 per 
person on proven preventive interventions could save the country over 
$16 billion in just 5 years. The public overwhelmingly supports 
increased funding for disease prevention and health promotion programs.
    Among the many vital programs in CDC's NCCDPHP, SOPHE is requesting 
a fiscal year 2015 funding level of $25 million to the CDC Division of 
Population Health's School Health Branch (SHB). The increase in funding 
will allow the SHB to create a coordinated, national response to school 
health and chronic disease, which will maximize program effectiveness 
and accelerate health improvements. School health activities supported 
through the SHB include: supporting healthier nutrition environments in 
schools; providing comprehensive school physical activity programs and 
multi-component physical education policies; and improving capacity to 
manage chronic conditions. Almost 80 percent of young people do not eat 
the recommended five servings of fruits and vegetables each day. Daily 
participation in high school physical education classes dropped from 42 
percent in 1991 to 32 percent in 2001. Health and fitness are linked to 
improved academic achievement and grades, cognitive ability, and 
behavior as well as reduced truancy.
    Since fiscal year 2012, funding for CDC's school health activities 
to prevent chronic diseases has essentially been level funded at $14.9 
million. DPH provides a basic level of funding for school health 
activities in all 50 States (about $75,000 per State). This small 
amount of funding allows States to only conduct a minimum of school-
based health activities. The School Health Branch also provides an 
enhanced level of funding on a competitive basis to a smaller number of 
States. Increasing resources for the SHB will enable all 50 States and 
DC to engage in enhanced school health activities that improve the 
school nutrition environment and increase the quality and quantity of 
physical education and physical activity opportunities. States would 
also be strongly encouraged to fund a school health position at the 
State education agency to coordinate efforts with the State health 
department. CDC's Coordinated School Health Programs are cost-effective 
in improving children's health, their behavior, and their academic 
success. This funding builds bridges between State education and public 
health departments to coordinate health education, nutritious meals, 
physical education, mental health counseling, health services, healthy 
school environments, and parent and community involvement. The 2013 IOM 
report Educating the Student Body: Taking Physical Activity and 
Physical Education to School, stated that the school environment is key 
in encouraging and providing opportunities for children and adolescents 
to be active. The lack of physically fit and health-literate graduates 
has become a national security issue--being overweight or obese has 
become the leading medical reason why applicants fail to qualify for 
military service.
An Avenue to Future Health Savings
    SOPHE is requesting a fiscal year 2015 funding level of $1 billion 
for the Prevention and Public Health Fund. We applaud Congress for 
appropriating the Fund for the first time, as was intended by the law 
since the Fund's inception, in the fiscal year 2014 omnibus bill. We 
strongly encourage Congress to continue to appropriate the Fund at this 
level in fiscal year 2015 to sustain essential core public health 
infrastructure, the workforce, and our capacity to improve health in 
our communities. This fund provides the agility for innovation and 
meeting the needs of communities at the State and local levels.
    Specifically, the Prevention Fund helps States tackle the leading 
causes of death and root causes of costly, preventable chronic disease; 
detect and respond rapidly to health security threats; and prevent 
accidents and injuries. With this investment, the Fund helps States and 
the Nation as a whole focus on fighting disease and illness before they 
happen. The evidence is overwhelming: investing in prevention saves 
lives and money. A 2011 Urban Institute study concluded that it is in 
the Nation's best interest from both a health and economic standpoint 
to maintain funding for evidence-based, public health programs that 
save lives and bring down costs; a July 2011 study published in the 
journal Health Affairs found that increased spending by local public 
health departments can save lives currently lost to preventable 
illnesses; and a follow up to that study in 2013 found that low-income 
communities experience the largest health and economic gains with 
respect to increases in local public health spending. In addition, 
lower death rates and healthcare costs were seen especially in 
communities that allocated their public health funding across a broader 
mix of preventive services.
    SOPHE supports the new Community Prevention Grant program that will 
be funded at $80 million to help communities build multi-sector 
partnerships to strengthen multisector partnerships aimed at better 
health. Although SOPHE is disappointed that the Community 
Transformation Grant (CTG) program was discontinued in the fiscal year 
2014 omnibus, we look forward to a new stream of funding that will 
support communities to implement evidence-based chronic disease 
prevention strategies. SOPHE has met with key stakeholders in both 
Congress and the Administration and looks forward to realizing the 
vision of forthcoming funding opportunity announcements.
    As part of the Prevention Fund, SOPHE strongly supports the 
increase in funding CDC's Racial and Ethnic Approaches to Community 
Health Across the U.S. (REACH U.S.) program, which addresses health 
risk behaviors in both children and adults. Chronic diseases account 
for the largest health gap among populations and increase health 
disparities among racial and ethnic minority groups. As the U.S. 
population becomes increasingly diverse, the Nation's health status 
will be heavily influenced by the morbidity of racial and ethnic 
minority communities. With additional funding from the Prevention and 
Public Health Fund, the REACH program will address strategies in the 
areas of tobacco-free living, active living and healthy eating, 
clinical and other preventive services, social and emotional wellness, 
and healthy and safe physical environments--with a primary focus on 
African-American/Black, Hispanic/Latino, Asian, Native Hawaiian/Pacific 
Islander, and American Indian/Alaskan Native populations. These 
culturally sensitive, population specific programs, often led by health 
education specialists in tandem with community health workers, are 
aimed at disease risk reduction and preventing costly hospital re-
admission rates.
    Thank you for this opportunity to present our views to the 
Subcommittee. We understand there will be difficult choices to make in 
this fiscal environment, and join you in seriously evaluating how our 
Nation's scarce resources can provide maximum return on investment. 
Public health funding gets the job done at the State and local levels 
and only represents 1.5 percent of Federal budget; lack of full funding 
would only be ``penny wise and pound foolish''.
    SOPHE shares the Subcommittee's goals to support the Nation's 
efforts to thrive and grow through sound investments in labor, 
education and health. This can only be accomplished with a healthy 
population contributing to a skilled, healthy and productive workforce. 
We look forward to working with you to prevent chronic illness, improve 
the quality of lives, and save billions of dollars in healthcare 
spending.

    [This statement was submitted by M. Elaine Auld, MPH, MCHES, Chief 
Executive Officer, Society for Public Health Education.]
                                 ______
                                 
     Prepared Statement of the Society for Public Health Education
    The Society for Public Health Education (SOPHE) is a 501 (c)(3) 
professional organization founded in 1950 to provide global leadership 
to the profession of health education and health promotion. SOPHE 
contributes to the health of all people and the elimination of health 
disparities through advances in health education theory and research; 
excellence in professional preparation and practice; and advocacy for 
public policies conducive to health. SOPHE is the only independent 
professional organization devoted exclusively to health education and 
health promotion. SOPHE's two scientific peer-reviewed journals, 
electronic newsletters, listservs, websites, new Center for Online 
Education (CORE), as well as its national conference help ensure that 
vital public health activities and programs in various regions are 
expeditiously disseminated. Members include behavioral scientists, 
faculty, practitioners, and students engaged in disease prevention and 
health promotion in both the public and private sectors. Collectively, 
SOPHE's 4,000 national and chapter members work in universities, 
medical/healthcare settings, businesses, voluntary health agencies, 
international organizations, and all branches of Federal/State/local 
government. There are currently 20 SOPHE chapters covering more than 30 
States and regions across the country.
    SOPHE's vision of a healthy world through health education compels 
us to advocate for increased resources targeted at the most pressing 
public health issues. For the fiscal year 2015 funding cycle, SOPHE 
encourages the Labor, Health and Human Services, Education and Related 
Agencies (Labor-HHS) Subcommittee to increase funding for public health 
programs that focus on preventing chronic disease and other illnesses 
in adults as well as youth, and eliminating health disparities. In 
particular, SOPHE requests the following fiscal year 2015 funding 
levels for Labor-HHS programs:
  --$7.8 billion for the Centers for Disease Control and Prevention 
        (CDC)
  --$1 billion for the Prevention and Public Health Fund
  --$50 million for Racial and Ethnic Approaches to Community Health
  --$80 million for Community Prevention Grants
  --$25 million for CDC's Division of Population Health School Health 
        Program
    The discipline of health education and health promotion, which is 
some 100 years old, uses sound science to plan, implement, and evaluate 
interventions that enable individuals, groups, and communities to 
achieve personal, environmental and population health. There is a 
robust, scientific evidence-base documenting not only that various 
health education interventions work but that they are also cost-
effective. These principles serve as the basis for our support for the 
programs outlined below and can help ensure our Nation's resources are 
targeted for the best return on investment.
Preventing Chronic Disease
    The data are clear: chronic diseases are the Nation's leading 
causes of morbidity and mortality and account for 75 percent of every 
dollar spent on healthcare in the U.S. Collectively, they account for 
70 percent of all deaths nationwide. Healthcare now accounts for 18 
percent of GDP, and it's expected to account for 19.6 percent by 2021. 
Yet evidence shows that investing just $1 in preventing disease will 
yield a $5 return on investment.
    SOPHE is requesting a fiscal year 2015 funding level $7.8 billion 
for CDC in order to prevent chronic diseases and other illnesses, 
promote health, prevent injury and disability, and ensure preparedness 
against health threats. Unfortunately President Obama's fiscal year 
2015 budget request of $6.6 billion for CDC represents a nearly $243 
million reduction when compared with fiscal year 2014. CDC is at the 
forefront of U.S. efforts to monitor health, detect and investigate 
health problems, conduct research to enhance prevention, develop sound 
public health policies, and foster safe and healthful environments. 
More than 80 percent of all CDC funds go back to States to address 
State and local health issues. Studies show that spending as little as 
$10 per person on proven preventive interventions could save the 
country over $16 billion in just 5 years. The public overwhelmingly 
supports increased funding for disease prevention and health promotion 
programs. Small investments now in community-led, innovative programs 
will help to increase our Nation's productivity and performance in the 
global market; help ensure military readiness; decrease rates of infant 
mortality, deaths due to cancer, cardiovascular disease, diabetes, and 
HIV/AIDS, and; increase immunization rates. Cuts to CDC's budget are 
not sustainable and will reduce the ability to investigate and respond 
to public health emergencies as well as foodborne and infectious 
disease outbreaks.
    SOPHE is requesting a fiscal year 2015 funding level of $1 billion 
for the Prevention and Public Health Fund. We applaud Congress for 
appropriating the Fund for the first time, as was intended by the law 
since the Fund's inception, in the fiscal year 2014 omnibus bill. We 
strongly encourage Congress to continue to appropriate the Fund at this 
level in fiscal year 2015 to sustain essential core public health 
infrastructure, the workforce, and our capacity to improve health in 
our communities. The Prevention Fund helps States tackle the leading 
causes of death and root causes of costly, preventable chronic disease; 
detect and respond rapidly to health security threats; and prevent 
accidents and injuries. With this investment, the Fund helps States and 
the Nation as a whole focus on fighting disease and illness before they 
happen. The evidence is overwhelming: investing in prevention saves 
lives and money. A 2011 Urban Institute study concluded that it is in 
the Nation's best interest from both a health and economic standpoint 
to maintain funding for evidence-based, public health programs that 
save lives and bring down costs; a July 2011 study published in the 
journal Health Affairs found that increased spending by local public 
health departments can save lives currently lost to preventable 
illnesses; and a follow up to that study in 2013 found that low-income 
communities experience the largest health and economic gains with 
respect to increases in local public health spending. In addition, 
lower death rates and healthcare costs were seen especially in 
communities that allocated their public health funding across a broader 
mix of preventive services.
    SOPHE strongly supports the increase in funding CDC's Racial and 
Ethnic Approaches to Community Health Across the U.S. (REACH U.S.) 
program, which addresses health risk behaviors in both children and 
adults. Chronic diseases account for the largest health gap among 
populations and increase health disparities among racial and ethnic 
minority groups. As the U.S. population becomes increasingly diverse, 
the Nation's health status will be heavily influenced by the morbidity 
of racial and ethnic minority communities. With additional funding from 
the Prevention and Public Health Fund, the REACH program will address 
strategies in the areas of tobacco-free living, active living and 
healthy eating, clinical and other preventive services, social and 
emotional wellness, and healthy and safe physical environments--with a 
primary focus on African-American/Black, Hispanic/Latino, Asian, Native 
Hawaiian/Pacific Islander, and American Indian/Alaskan Native 
populations.
    SOPHE supports the new Community Prevention Grant program that will 
be funded at $80 million to help communities build multi-sector 
partnerships around better health. While SOPHE is disappointed that the 
Community Transformation Grant (CTG) program was discontinued in the 
fiscal year 2014 omnibus, we look forward to a new stream of funding 
that will support communities to implement evidence-based chronic 
disease prevention strategies. SOPHE looks forward to working with the 
Administration on forthcoming funding opportunity announcements.
    SOPHE is requesting a fiscal year 2015 funding level of $25 million 
to CDC's Division of Population Health's School Health Branch (SHB). 
The increase in funding will allow the SHB to create a coordinated, 
national response to school health and chronic disease, maximizing 
program effectiveness, and accelerating health improvements. School 
health activities supported through the SHB include: supporting 
healthier nutrition environments in schools; providing comprehensive 
school physical activity programs and multi-component physical 
education policies; and improving capacity to manage chronic 
conditions. Almost 80 percent of young people do not eat the 
recommended five servings of fruits and vegetables each day. Daily 
participation in high school physical education classes dropped from 42 
percent in 1991 to 32 percent in 2001. Health and fitness are linked to 
improved academic achievement and grades, cognitive ability, and 
behavior as well as reduced truancy.
    Since fiscal year 2012, funding for CDC's school health activities 
to prevent chronic diseases has essentially been level funded at $14.9 
million. DPH provides a basic level of funding for school health 
activities in all 50 States (about $75,000 per State). This small 
amount of funding allows States to only conduct a minimum of school-
based health activities. The School Health Branch also provides an 
enhanced level of funding on a competitive basis to a smaller number of 
States. Increasing resources for the SHB will enable all 50 States and 
DC to engage in enhanced school health activities that improve the 
school nutrition environment and increase the quality and quantity of 
physical education and physical activity opportunities. States would 
also be strongly encouraged to fund a school health position at the 
State education agency to coordinate efforts with the State health 
department. CDC's Coordinated School Health Programs have been shown to 
be cost-effective in improving children's health, their behavior, and 
their academic success. This funding builds bridges between State 
education and public health departments to coordinate health education, 
nutritious meals, physical education, mental health counseling, health 
services, healthy school environments, and parent and community 
involvement.
    Thank you for this opportunity to present our views to the 
Subcommittee. We understand there will be tough choices to make in this 
fiscal environment. However, public health funding only makes up 1.5 
percent of Federal budget, and yields a much a greater return on 
investment. We look forward to working with you to prevent chronic 
illness, improve the quality of lives, and save billions of dollars in 
healthcare spending.

    [This statement was submitted by Elaine Auld, Chief Executive 
Officer, Society for Public Health Education.]
                                 ______
                                 
     Prepared Statement of the Society for Women's Health Research
    The Society for Women's Health Research (SWHR) is pleased to have 
the opportunity to submit the following testimony urging renewed 
investment in scientific and medical research within the Department of 
Health and Human Services (HHS). For almost 25 years, our organization 
has been considered the thought leader in research on biological 
differences in disease and is dedicated to transforming women's health 
through science, advocacy, and education. We believe that a robust 
Federal research agenda that is inclusive of women's health research is 
critical for the U.S. to meet the needs and expectations of its 
citizens. We request that for fiscal year 2015, Congress fund the 
following agencies and programs at the following levels:
  --Agency for Healthcare and Research Quality-$471 million
  --Centers for Disease Control and Prevention-$6.904 billion
  --Health Resources Services Administration-$6.113 billion
  --National Institutes of Health-$32 billion
  --Substance Abuse and Mental Health Services Administration-$3.6 
        billion
  --Office of Research on Women's Health at NIH-$42 million
  --HHS Office of Women's Health-$35 million
    SWHR remains concerned with the ramifications of the Budget Control 
Act and sequestration. Funding levels for Department of Health and 
Human Services (HHS), were significantly cut and those agencies that 
fall underneath the umbrella of HHS; The Agency for Healthcare Research 
and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), 
Health Resources Services Administration (HRSA), National Institutes of 
Health (NIH), Substance Abuse and Mental Health Services Administration 
(SAMHSA), all play vital roles in improving and protecting the health 
of Americans but are forced to do more with less funding. Continued 
cuts to public health agencies decrease public health emergency 
preparedness and response capabilities, reducing funding for States to 
monitor air quality and offer mental health services, and increasing 
the risk for infectious disease outbreaks. These are essential public 
health services that save lives and protect our health. Currently, 
healthcare spending is the largest driver of the Federal deficit. By 
2021, estimates indicate that this spending will account for nearly 
one-fifth of the U.S. economy. Proper and sustained Congressional 
investment in medical and scientific research can ultimately save 
valuable healthcare dollars that are wasted on inappropriate and 
ineffective treatment. We realize that the current budgetary 
environment limits the amount of monies available for a substantial 
increase; however, the benefit from every dollar invested in medical 
research outweighs the cost many times over and is, perhaps, the single 
most cost effective strategy in reducing our Federal deficit. Past 
investments in medical research have allowed scientists to begin 
unraveling the biologic and genetic underpinning of disease. This 
research has shown that biological sex impacts every organ of the body, 
and plays an important role in disease susceptibility, prevalence, time 
of onset and severity. Sex differences are evident in all major disease 
categories, including cancer, obesity, and heart disease. These 
differences are also evident in drug absorption, distribution, 
metabolism and elimination. The medical community has now begun to 
tailor treatments to meet the needs of individual patients, taking the 
first step towards truly personalized medicine.
    National Institutes of Health-NIH serves as the America's premier 
medical research agency and is the largest source of funding for 
biomedical and behavioral research in the world. Many of the medical 
advances in recent decades are direct results from investments in the 
agency. Unfortunately, years of flat-funding, without controlling for 
rising inflation, has meant that NIH's overall budget has decreased by 
10 percent between 2004 and 2014, and its purchasing power has 
decreased by 22 percent. This number does not just impact NIH's campus 
in Maryland. Approximately 85 percent of NIH funding is spent in 
communities across the country, creating jobs at more than 3,000 
universities, medical schools, teaching hospitals, and research 
institutions. In 2013, NIH funded 750 fewer grants than in 2012 and 
grant funding fell to an all-time low of 20 percent. A shrinking number 
of available grants put scientists out of work. With limited 
opportunities for research funding, scientists have little choice than 
to pursue opportunities outside of academic research in the U.S., 
resulting in the loss of skilled bench scientists and researchers to 
Asia, the European Union and the United Kingdom, who continue to 
heavily invest in research. Unfortunately, the Administration's request 
of a 0.7 percent increase doesn't make much headway in reversing the 
$1.5 billion cut the agency sustained under sequestration in fiscal 
year 2013, nor does it keep up with biomedical inflation rate, 
projected by the HHS's Biomedical Research and Development Price Index, 
to be 2.2 percent. Once that inflation rate is taken into account, the 
Administration's budget request results in another cut to the Agency. 
SWHR recommends that Congress set, at a minimum, a budget of $32 
billion for NIH for fiscal year 2015. Further we recommend that 
Congress expand NIH's mandate on the inclusion of women in basic 
research to include women in all phases of basic, clinical and medical 
research. Current practice only mandates sufficient female subjects 
only in Phase III research, and researchers often miss out on the 
chance to look for variability by sex in the early phases of research, 
safety and effectiveness is determined.
    Federal offices of women's health-The offices of women's health 
within the Federal health agencies do critical work, both individually 
and in collaboration with other offices and Federal agencies, to ensure 
that women receive the appropriate care and treatments in a variety of 
different areas. Under HHS, the agencies currently with offices, 
advisors or coordinators for women's health or women's health research 
include the AHRQ, CDC, FDA, HRSA, Indian Health Service (INS), and 
SAMHSA. These offices do important work, both individually and in 
collaboration with other offices and Federal agencies to ensure that 
women receive the appropriate care and treatments in a variety of 
different areas. In a time of limited budgetary dollars, Congress 
should invest in these offices that promote working in collaboration 
with other agencies, which shares much needed expertise while avoiding 
unnecessary duplication. SWHR recommends that these offices be 
sufficiently funded to ensure that these programs can continue to 
provide much needed services to women and their families in fiscal year 
2015.
    Office of Research on Women's Health--ORWH is the focal point for 
coordinating women's health and sex differences research at NIH, and 
supports innovative interdisciplinary initiatives that focus on women's 
health and sex differences research. ORWH promotes opportunities for 
and support of recruitment, retention, re-entry and advancement of 
women in biomedical careers. The Building Interdisciplinary Research 
Careers in Women's Health (BIRCWH) is an innovative, trans-NIH career 
development program that pairs junior faculty with senior investigators 
in a mentored environment. Approximately 500 scholars, the majority of 
them female, have been trained at 39 centers and have produced 
approximately 5,000 publications. ORWH's administrative supplements for 
research on sex and fender differences, a trans-NIH initiative to 
broaden the field of sex and gender differences research, adds new 
dimensions to on-going studies. The specialized centers of research on 
sex and gender factors affecting women's health (SCOR) are designed to 
integrate basic and clinical approaches to sex and gender research 
across scientific disciplines and has resulted in over 650 articles, 
reviews, abstracts, book chapters and other publications. To allow 
ORWH's programs and research grants to continue make their impact on 
the research community, Congress must direct that NIH continue its 
support of ORWH and provide it with a $1 million dollar budget 
increase, bringing its fiscal year 2015 total to $42 million.
    Health and Human Services' Office of Women's Health-The HHS OWH is 
the government's champion and focal point for women's health issues. It 
works to address inequities in research, healthcare services, and 
public education gaps, which have historically placed the health of 
women at risk. Without OWH's actions, the task of translating research 
into practice would be only more difficult and delayed. Considering the 
impact of women's health programs from OWH on the public, we urge 
Congress to provide an increase of $1 million for this office, a total 
of $35.7 million for fiscal year 2015.
    In conclusion, Mr. Chairman, we thank you and this Committee for 
its support for medical and health services research and its commitment 
to the health of the Nation. We look forward to continuing to work with 
you to build a healthier future for all Americans.
    [This statement was submitted by Leslie Ritter, Director of 
Government Affairs, Society for Women's Health Research.]
                                 ______
                                 
             Prepared Statement of the Squaxin Island Tribe
    On behalf of the Tribal Leadership and members of the Squaxin 
Island Tribe, I am honored to submit our recommendation to this 
Subcommittee for appropriations to address the un-funded needs of 
American Indian and Alaska Native Treatment (AI/AN) Centers. The 
alarming statistics of increased alcohol and substance abuse use in the 
AI/AN communities speaks volumes to the need for improved and 
additional facilities to provide treatment and recovery opportunities 
to our citizens, our youths, our future leaders and the next seven 
generations. Although SAMHSA has limited discretionary funding and even 
less resources for residential care facilities, the Indian Health 
Service cannot keep pace with the growing need for these treatment 
centers. The only funding opportunity available in SAMHSA is the 
Treatment for Pregnant and Postpartum Women. In 2015, we respectfully 
request the Subcommittee:
  --$10 million--Expand access to residential care facility 
        appropriations to include Treatment Centers and increase the 
        annual appropriations to supplement inadequate funding for 
        these centers from the Indian Health Service of which the NWITC 
        will receive $1.5 million;
  --$50 million--SAMHSA's Behavioral Health Tribal Prevention Grant 
        Program; and,
  --$15 million--SAMHSA for Behavioral Health
    The Squaxin Island Tribe has been operating the Northwest Indian 
Treatment Center (NWITC) since 1994. Ingenious in creativity, the 
center offers a wide variety of cultural activities and traditional/
religious ceremonies, making it a natural place to heal--body, mind and 
soul. Fittingly, the center was given the spiritual name ``D3WXbi 
Palil'' meaning ``Returning from the Dark, Deep Waters to the Light.'' 
NWITC is a residential chemical dependency treatment facility designed 
to serve American Indians from Tribes located in Oregon, Washington and 
Idaho who have chronic relapse patterns related to unresolved grief and 
trauma. NWITC is unique in its integration of Tribal cultural values 
into a therapeutic environment for co-occurring substance abuse and 
mental health disorders. It is a 28 bed, 30-60 day residential 
facility.
    Welcomed and hailed by Tribal Leaders who felt the urgent need for 
such a facility, NWITC is centrally located in Grays Harbor County 
between Olympia and Aberdeen, on 2.5 acres in the small rural town of 
Elma, Washington. NWITC accepts patients that are referred through 
outpatient treatment programs, parole and probation services, 
hospitals, assessment centers and child and family service centers. 
Medical care is provided through local Indian Health Service clinics 
and other medical service providers. NWITC has responded with an 
overwhelming success rate of nearly 65 percent.
    Since the original Congressional set-aside in 1993, NWITC has not 
received an adequate increase in the base Indian Health Service budget. 
It is critical to increase the NWITC's annual base in order to sustain 
the current services to the Tribes of the Northwest. An increase of 
$1.5 million would restore lost purchasing power and meet the need to 
add mental health and psychiatric components to the treatment program. 
This increase would allow NWITC to continue its effective treatment of 
Native Americans.
    In 2011, the NWITC served 225 patients from 28 Tribes and added 
intensive case management and crisis support to alumni in order to 
continue to promote positive outcomes for clients. Despite funding 
challenges, NWITC has continued to develop and deliver innovative, 
culturally appropriate services to meet increasingly complex demands.
    The Treatment Center's traditional foods and medicines program is 
supported through a partnership with the Northwest Indian College and 
is funded through grants from the Washington Health Foundation, the 
National Institute of Food and Agriculture, The Potlatch Fund and 
several Tribes. Weekly hands-on classes focus on traditional foods and 
medicines, including methods for growing, harvesting, processing, and 
preparation. Twice a month, Tribal elders, storytellers, and cultural 
specialists speak as part of the program. A monthly family class allows 
patients to share what they are learning with their loved ones. 
Patients gain hands-on experience by working in three on-site teaching 
gardens. This program serves as a model for other Tribal communities.
$50 million--SAMHSA Behavioral Health Tribal Prevention Grant Program
    The Behavioral Health Tribal Prevention Grant will support 
behavioral health services that promote overall mental and emotional 
health, specifically substance abuse prevention and suicide prevention 
services. If funded, the grant program would be the only source for 
Federal substance abuse and suicide prevention funding exclusively 
available to Tribes.
$15 million--SAMHSA for Behavioral Health
    This SAMHSA grant program has been authorized to award grants to 
Indian health programs to provide prevention or treatment of drug use 
or alcohol abuse, promotion of mental health, or treatment services for 
mental illness. To date, these funds have never been appropriated. An 
appropriation of $15 million would provide support to Indian health 
programs to meet the critical substance abuse and mental health needs 
of our citizens.
Self-Governance--An Efficient and Effective Use of Federal Funds (Title 
        VI of the ISDEAA)
    Self-Governance is the most successful policy in the history of 
Tribal--Federal relations and it inspires efficient and effective 
government spending. Through Self-Governance, Tribes are empowered, as 
sovereign nations, to exercise self-determination and to design 
facilities, manage programs and funds, and provide services that are 
responsive to the needs of our communities and Tribal citizens. Tribes 
participating in Self-Governance have become successful in the business 
of healthcare and perform several key roles, serving as, governments, 
employers, healthcare providers and patients.
    Self-Governance Tribes have made every attempt to be innovative to 
operate successful health programs given the budget constraints and 
cuts Tribal programs have incurred the past two decades. For more than 
a decade we have made every effort to expand Self-Governance to other 
programs and our efforts to seek expansion of the program will continue 
until we achieve our goal. We request that this Committee recognizes 
the success of Self-Governance and encourage HHS to work with Tribes to 
make the most efficient and effective use of Federal appropriations to 
fund Tribal programs.
    Thank you for this opportunity to submit written testimony.

    [This statement was submitted by Dave Lopeman, Chairman, Squaxin 
Island Tribe.]
                                 ______
                                 
          Prepared Statement of the Treatment Advocacy Center
    The Treatment Advocacy Center is grateful for the opportunity to 
submit this testimony in support of the Department of Health and Human 
Services' Assisted Outpatient Treatment (AOT) Grant Program (AOT Grant 
Program) for Individuals with Serious Mental Illness. The Treatment 
Advocacy Center supports full funding of the AOT Grant Program at 
$15,000,000 for each of the fiscal years 2015 through 2018.
    The Treatment Advocacy Center (Organization) is a national 
nonprofit organization dedicated to eliminating barriers to the timely 
and effective treatment of severe mental illness. The Organization 
promotes laws, policies and practices for the delivery of psychiatric 
care and supports the development of innovative treatments for and 
research into the causes of severe and persistent psychiatric 
illnesses, such as schizophrenia and bipolar disorder. The Treatment 
Advocacy Center is funded by a host of individual donors, foundations 
and grants and does not accept funding from companies or entities 
involved in the sale, marketing, or distribution of pharmaceutical 
products.
    In far too many communities across the country, individuals whose 
severe mental illness impairs their ability to seek and voluntarily 
comply with treatment become caught up in a revolving door of 
hospitalization, incarceration, homelessness and repeated 
victimization. This small segment of the total population of 
individuals with a severe mental illness consumes a disproportionate 
percentage of their communities' limited mental health resources, 
without a concurrent benefit. AOT is a lifeline that can break this 
cycle, allowing this otherwise highly vulnerable population to survive 
and thrive safely in the community. AOT achieves this by providing 
medically prescribed mental health treatment under court order.
    Unfortunately, local communities are sometimes unable to realize 
AOT's benefits due to the initial start-up costs of moving away from 
their current flawed approach to one that effectively utilizes AOT. The 
AOT Grant Program will help to address this concern by providing 
communities with resources they can leverage to implement these proven 
programs. Studies show that AOT benefits not only those who receive 
court-ordered treatment, but also, ``those who will be served in a more 
efficient public behavioral healthcare system . . .  with greater 
capacity that produces better outcomes for a broader population in 
need.'' \1\ For example, an analysis of New York's Kendra's Law found 
that, ``In the long run . . . overall service capacity was increased, 
and the focus on enhanced services for AOT participants appears to have 
led to greater access to enhanced services for both voluntary and 
involuntary recipients'' \2\
---------------------------------------------------------------------------
    \1\ Swanson, Jeffrey W., Van Dorn, Richard A., Swartz, Marvin S., 
Robbins, Pamela Clark, Steadman, Henry J., McGuire, Thomas G., and John 
Monahan. 2013. ``The Cost of Assisted Outpatient Treatment: Can It Save 
States Money?'' American Journal of Psychiatry 170:1423-1432.
    \2\ Swanson, Jeffrey W., Van Dorn, Richard A., Swartz, Marvin S., 
Cislo, Andrew M., Wilder, Christine M., Moser, Lorna L., Gilbert, 
Allison R., and Thomas McGuire. 2010. ``Robbing Peter to Pay Paul: Did 
New York State's Outpatient Commitment Program.
    Crowd Out Voluntary Service Recipients?'' Psychiatric Services 61: 
1-10.
---------------------------------------------------------------------------
AOT is a Proven Means of Assisting Those Most in Need
    AOT is proven to help address the revolving door that traps far too 
many individuals with severe mental illness. In 2012, the Department of 
Justice deemed AOT to be an effective, evidence-based program for 
reducing crime and violence.\3\
---------------------------------------------------------------------------
    \3\ Assisted Outpatient Treatment. Department of Justice Office of 
Justice Programs. Retrieved from http://www.crimesolutions.gov/
ProgramDetails.aspx?ID=228.
---------------------------------------------------------------------------
AOT Reduces Hospitalization
    Researchers in 2009 conducted an independent evaluation of New 
York's court-ordered outpatient treatment law (Kendra's Law) and 
documented a striking decline in the rate of hospitalization among 
participants. During a 6-month study period, AOT recipients were 
hospitalized at less than half the rate they were hospitalized in the 6 
months prior to receiving AOT. Among those admitted, hospital stays 
were shorter: average length of hospitalization dropped from 18 days 
prior to AOT to 11 days during the first 6 months of AOT and 10 days 
for the seventh through twelfth months of AOT.\4\
---------------------------------------------------------------------------
    \4\ Swartz, Marvin S., Swanson, Jeffrey W., Steadman, Henry J., 
Robbins, Pamela Clark, and John Monahan. 2009. New York State Assisted 
Outpatient Treatment Program Evaluation. Duke University School of 
Medicine.
---------------------------------------------------------------------------
    A randomized controlled study in North Carolina (Duke Study) in 
1999 demonstrated that intensive routine outpatient services alone, 
without a court order, did not reduce hospital admission. However, when 
the same level of services (at least three outpatient visits per month, 
with a median of 7.5 visits per month) were combined with long-term AOT 
(6 months or more), hospital admissions were reduced 57 percent, and 
length of hospital stay was reduced by 20 days compared to individuals 
receiving the services alone. The results were even more dramatic for 
the subset of individuals with schizophrenia and other psychotic 
disorders--long-term AOT reduced hospital admissions by 72 percent and 
length of hospital stay by 28 days compared with services alone. The 
participants in the North Carolina study were from both urban and rural 
communities and ``generally did not view themselves as mentally ill or 
in need of treatment.'' \5\
---------------------------------------------------------------------------
    \5\ Swartz, Marvin S., Swanson, Jeffrey W., Wagner, H. Ryan, Burns, 
Barbara J., Hiday, Virginia A., and Randy Borum. ``Can Involuntary 
Outpatient Commitment Reduce Hospital Recidivism?: Findings from a 
Randomized Trial With Severely Mentally Ill Individuals.'' American 
Journal of Psychiatry 156: 1968-1975.
---------------------------------------------------------------------------
    A Washington State study of 115 patients found that AOT decreased 
hospitalization by 30 percent over 2 years. The savings in hospital 
costs for these 115 patients alone was $1.3 million.\6\ In an AOT 
program in Florida, AOT reduced hospital days from 64 to 37 days per 
patient over 18 months, a 43 percent decrease. The savings in hospital 
costs averaged $14,463 per patient.\7\
---------------------------------------------------------------------------
    \6\ Zanni, Guido and Paul F. Stavis. 2007. ``The Effectiveness and 
Ethical Justification of Psychiatric Outpatient Commitment.'' American 
Journal of Bioethics 7: 31-41.
    \7\ Esposito, Rosanna, Westhead, Valerie, and Jim Berko. 2008. 
``Florida's Outpatient Commitment Law: Effective but Underused'' 
(letter). Psychiatric Services 59: 328.
---------------------------------------------------------------------------
AOT Reduces Arrests and Incarceration
    A study of Kendra's Law published in 2010 concluded that the ``odds 
of arrest in any given month for participants who were currently 
receiving AOT were nearly two-thirds lower'' than those not receiving 
AOT.\8\ According to a 2005 New York State Office of Mental Health 
report on Kendra's Law, arrests for AOT participants were reduced by 83 
percent, from 30 percent prior to the onset of a court order to only 5 
percent after participating in the program.\9\
---------------------------------------------------------------------------
    \8\ Gilbert, Allison R., Moser, Lorna L., Van Dorn, Richard A., 
Swanson, Jeffrey W., Wilder, Christine M., Robbins, Pamela Clark, 
Keator, Karli J., Steadman, Henry J., and Marvin S. Swartz. 2010. 
``Reductions in Arrest Under Assisted Outpatient Treatment in New 
York.'' Psychiatric Services 61: 996-999.
    \9\ New York State Office of Mental Health. 2005. Kendra's Law: 
Final Report on the Status of Assisted Outpatient Treatment.
---------------------------------------------------------------------------
    A Florida report found AOT reduced days spent in jail among 
participants from 16.1 to 4.5 days, a 72 percent reduction.\10\ 
Similarly, the Duke Study found that, for individuals who had a history 
of multiple hospital admissions combined with arrests and/or violence 
in the prior year, long-term AOT reduced the risk of arrest by 74 
percent. The arrest rate for participants in long-term AOT was 12 
percent, compared with 47 percent for those who had services without a 
court order.\11\
---------------------------------------------------------------------------
    \10\ Esposito, Rosanna, Westhead, Valerie, and Jim Berko. 2008. 
``Florida's Outpatient Commitment Law: Effective but Underused'' 
(letter). Psychiatric Services 59: 328.
    \11\ Swanson, Jeffrey W., Borum, Randy, Swartz, Marvin S., Hiday, 
Virginia A., Wagner, H. Ryan, and Barbara J. Burns. 2001a. ``Can 
Involuntary Outpatient Commitment Reduce Arrests Among Persons with 
Severe Mental Illness?'' Criminal Justice and Behavior 28: 156-189.
---------------------------------------------------------------------------
AOT Reduces Violence, Crime, and Victimization.
    The New York State Office of Mental Health report also found that 
Kendra's Law resulted in dramatic reductions in harmful behaviors for 
AOT. Among AOT recipients at 6 months of assisted outpatient treatment 
compared to a similar period of time prior to the court order: 55 
percent fewer recipients engaged in suicide attempts or physical harm 
to self; 47 percent fewer physically harmed others; 46 percent fewer 
damaged or destroyed property; and 43 percent fewer threatened physical 
harm to others. Overall, the average decrease in harmful behaviors was 
44 percent.\12\
---------------------------------------------------------------------------
    \12\ New York State Office of Mental Health. 2005. Kendra's Law: 
Final Report on the Status of Assisted Outpatient Treatment.
---------------------------------------------------------------------------
    A 2010 study by Columbia University's Mailman School of Public 
Health reached equally striking findings about the impact of Kendra's 
Law on the incidence of violent criminal behavior. When AOT recipients 
in New York City and a control group of other mentally ill outpatients 
were tracked and compared, the AOT patients--despite having more 
violent histories--were found four times less likely to perpetrate 
serious violence after undergoing treatment.\13\
---------------------------------------------------------------------------
    \13\ Phelan, Jo C., Sinkewicz, Marilyn, Castille, Dorothy, Huz, 
Steven, and Bruce G. Link. 2010. ``Effectiveness and Outcome of 
Assisted Outpatient Treatment in New York State.'' Psychiatric Services 
61: 137-143.
---------------------------------------------------------------------------
    The Duke Study found that long-term AOT combined with intensive 
routine outpatient services was significantly more effective in 
reducing violence and improving outcomes for severely mentally ill 
individuals than the same level of outpatient care without a court 
order. Among a group of individuals characterized as ``seriously 
violent,'' 63.3 percent of those not in long-term AOT repeated violent 
acts, while only 37.5 percent of those in long-term AOT did so. Long-
term AOT combined with routine outpatient services reduced the 
predicted probability of violence by 50 percent.\14\
---------------------------------------------------------------------------
    \14\ Swanson, Jeffrey W., Swartz, Marvin S., Borum, Randy, Hiday, 
Virginia A., Wagner, H. Ryan, and Barbara J. Burns. 2001. ``Involuntary 
Outpatient Commitment and Reduction of Violent Behaviour in Persons 
with Severe Mental Illness.'' British Journal of Psychiatry 176: 224-
231.
---------------------------------------------------------------------------
    The Duke Study further demonstrated that individuals with severe 
psychiatric illnesses who were not on AOT ``were almost twice as likely 
to be victimized as were outpatient commitment subjects.'' 24 percent 
of those on AOT were victimized, compared with 42 percent of those not 
on AOT.\15\
---------------------------------------------------------------------------
    \15\ Hiday, Virginia A., Swartz, Marvin S., Swanson, Jeffrey W., 
Borum, Randy, and H. Ryan Wagner. 2002. ``Impact of Outpatient 
Commitment on Victimization of People with Severe Mental Illness.'' 
American Journal of Psychiatry 159: 1403-1411.
---------------------------------------------------------------------------
AOT Improves Treatment Compliance
    AOT has also been shown to be effective in increasing treatment 
compliance. In New York, AOT led to a 51 percent increase in 
recipients' exhibition of good service engagement, and more than 
doubled the exhibition of ``good'' adherence to medication.\16\
---------------------------------------------------------------------------
    \16\ New York State Office of Mental Health. 2005. Kendra's Law: 
Final Report on the Status of Assisted Outpatient Treatment.
---------------------------------------------------------------------------
    In North Carolina, only 30 percent of AOT patients refused 
medication during a 6-month period, compared to 66 percent of patients 
not under AOT.\17\ In Ohio, AOT increased attendance to outpatient 
psychiatric appointments from 5.7 to 13.0 per year; it also increased 
attendance at day treatment sessions from 23 to 60 per year.\18\
---------------------------------------------------------------------------
    \17\ Hiday, Virginia A. and Teresa L. Scheid-Cook. 1987. ``The 
North Carolina Experience with Outpatient Commitment: A Critical 
Appraisal.'' International Journal of Law and Psychiatry 10: 215-232.
    \18\ Munetz, Mark R., Grande, Thomas, Kleist, Jeffrey, and Gregory 
A. Peterson. 1996. ``The Effectiveness of Outpatient Civil 
Commitment.'' Psychiatric Services 47: 1251-1253.
---------------------------------------------------------------------------
    AOT also promotes long-term voluntary treatment compliance. In 
Arizona, ``71 percent [of AOT patients] . . . voluntarily maintained 
treatment contacts 6 months after their orders expired'' compared with 
``almost no patients'' who were not court-ordered to outpatient 
treatment.\19\ In Iowa, ``it appears as though outpatient commitment 
promotes treatment compliance in about 80 percent of patients while 
they are on outpatient commitment. After commitment is terminated, 
about three-quarters of that group remained in treatment on a voluntary 
basis.'' \20\
---------------------------------------------------------------------------
    \19\ Van Putten, Robert A., Santiago, Jose M., and Michael R. 
Berren. 1988. ``Involuntary Outpatient Commitment in Arizona: A 
Retrospective Study.'' Hospital and Community Psychiatry 39: 953-958.
    \20\ Rohland, Barbara M. 1998. The Role of Outpatient Commitment in 
the Management of Persons with Schizophrenia. Iowa City: Iowa 
Consortium for Mental Health, Services, Training, and Research.
---------------------------------------------------------------------------
    The New York Independent Evaluation also yielded interesting 
findings on the likelihood of voluntary compliance after AOT is allowed 
to expire. For individuals who received AOT for periods of 6 months or 
less, the researchers found that post-AOT sustainability of 
improvements in medication adherence depended on whether intensive 
outpatient services were continued on a voluntary basis. Those who 
continued with intensive services maintained their substantial increase 
in medication adherence relative to the pre-AOT period (from 37 to 45 
percent); those who discontinued such assistance dropped back to near 
the pre-AOT levels (33 percent). Patients who received AOT for more 
than 6 months, however, experienced increased medication adherence 
whether or not intensive services were continued. The medication 
adherence rate was higher for those who continued intensive services 
than for those who did not (50 percent vs. 43 percent), but both groups 
maintained substantial improvements from the pre-AOT rate (37 
percent).\21\
---------------------------------------------------------------------------
    \21\ Swartz, Marvin S., Swanson, Jeffrey W., Steadman, Henry J., 
Robbins, Pamela Clark, and John Monahan. 2009. New York State Assisted 
Outpatient Treatment Program Evaluation. Duke University School of 
Medicine.
---------------------------------------------------------------------------
    The Treatment Advocacy Center reemphasizes it support for full 
funding of the AOT Grant Program at $15,000,000 for each of the fiscal 
years 2015 through 2018. Should you have any questions, please feel 
free to contact John Snook, Deputy Executive Director, Treatment 
Advocacy Center at (703) 294-6006 or 
[email protected].
                                 ______
                                 
                Prepared Statement of the Trevor Project
    Dear Chairman Harkin and Senator Moran: The Trevor Project 
appreciates the opportunity to submit a statement on the critical and 
timely issue of funding for children's suicide prevention and mental 
health initiatives. We encourage you to support our Nation's most 
vulnerable youth by funding these vital programs:

                                              [Dollars in millions]
----------------------------------------------------------------------------------------------------------------
                                                                            President's        Fiscal year 2015
                     Program                         Fiscal year 2014     proposed fiscal       trevor project
                                                         enacted          year 2015 budget      recommendation
----------------------------------------------------------------------------------------------------------------
SAMHSA--Suicide Prevention Programs..............                 51                   40.1                 61
HHS/ACF--Runaway and Homeless Youth Act Funding..                114.1                114                  152.5
NIMH--Suicide Prevention Research................  ...................  ...................                 40
CDC--National Violent Death Reporting System.....                 11.3                 23.5                 25
SAMHSA Project AWARE.............................                 55                   55                   60
----------------------------------------------------------------------------------------------------------------

    The Trevor Project is the leading national organization providing 
crisis intervention and suicide prevention services to lesbian, gay, 
bisexual, transgender and questioning (LGBTQ) young people under 24. 
Among young people ages 10 to 24, suicide is the second leading cause 
of death.\1\ According to the National Survey of Children's Health, up 
to 20 percent of young people have a diagnosable mental illness, but 
only 60 percent of those in need of mental healthcare receive the 
treatment they require.\2\ In fact, half of all individuals with mental 
illness experience onset of the disorder by age 14, but do not seek 
treatment, on average, until the age of 24.\3\ For youth, the 
consequences of untreated mental illness vary and include increased 
suicide risk, school failure, involvement in the criminal justice 
system, unemployment, substance abuse, and homelessness. Among 
stigmatized populations such as LGBTQ young people, these negative 
outcomes can be exacerbated by prejudice, fear, and hate experienced in 
homes, schools, and communities.
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control, Web-based Injury Statistics Query and 
Reporting System (WISQARS), available at http://www.cdc.gov/ncipc/
wisqars (last visited Mar. 14, 2013).
    \2\ 2007 National Survey of Children's Health, Data Resource Center 
for Child & Adolescent Health, Child and Adolescent Health Measurement 
Initiative, http://www.nschdata.org (last visited May 2009).
    \3\ Ronald C. Kessler et al., Lifetime Prevalence and Age-of-Onset 
Distributions of DSM-IV Disorders in the National Co-morbidity Survey 
Replication (NCSR), 62 GENERAL PSYCHIATRY 593 (2005); and Philip S. 
Wang et al., Failure and Delay in Initial Treatment Contact After First 
Onset of Mental Disorders in the National Co-morbidity Survey 
Replication (NCS-R), 62 GENERAL PSYCHIATRY 603 (2005).
---------------------------------------------------------------------------
    Suicidality is closely associated with mental illness; more than 90 
percent of those who die by suicide have a diagnosable mental 
disorder.\4\ Therefore suicide prevention is an essential component of 
a comprehensive mental health system.
---------------------------------------------------------------------------
    \4\ Suicide in the U.S.: Statistics and Prevention, National 
Institute of Mental Health, available at http://www.nimh.nih.gov/
health/publications/suicide-in-the-us-statistics-and-prevention/index.
shtml#Moscicki-Epi (last visited Mar. 14, 2013).
---------------------------------------------------------------------------
    We thank the Committee for your ongoing support for suicide 
prevention and mental health initiatives, and we hope that this letter 
will identify the critical programs that exist to protect our most 
vulnerable youth.
    The Trevor Project recommends the following fiscal year 2015 
appropriations to improve access to effective mental healthcare and 
reduce suicide risk for young people:
  garrett lee smith memorial act suicide prevention programs (samhsa)
    The Garrett Lee Smith Memorial Act provides the largest dedicated 
source of Federal funding for youth suicide prevention efforts, which 
are a life-saving and effective means to address the daunting issue of 
youth suicide. We can help avoid tragedy by appropriately funding 
programs that focus on extreme harming behaviors and mental illness in 
young people. To date, Garrett Lee Smith funding has supported suicide 
prevention programs in 49 States, 48 tribes, and 138 colleges. Fully 
appropriating these programs would ensure that the Suicide Prevention 
Resource Center continues to provide technical assistance to 
organizations nationwide; and it would allow for the expansion of 
State, tribal, and campus grants. Also encompassed within our funding 
recommendations for these programs is the National Strategy for Suicide 
Prevention, which works towards a unified approach to suicide 
prevention through collaboration between public and private sectors; 
and the National Suicide Prevention Lifeline, which answers more than 
94,000 calls a month, including calls from veterans, active duty 
members and their families, as well as the general public.
       runaway and homeless youth act (health and human services)
    An estimated 40 percent of all homeless youth are LGBTQ-identified, 
often because they are thrown out of their homes or face family 
rejection.\5\ Nearly 2/3 of these young people are likely to attempt 
suicide at least once.\6\
---------------------------------------------------------------------------
    \5\ Durso, L. E. & Gates, G. J. (2012). Serving our youth: Findings 
from a national survey of service providers working with lesbian, gay, 
bisexual, and transgender youth who are homeless or at risk of becoming 
homeless. Los Angeles, CA: The Williams Institute with True Colors Fund 
and The Palette Fund.
    \6\ Van Leeuwen, J. M., Boyle, S., Salomonsen-Sautel, S., Baker, D. 
N., Garcia, J. T., Hoffman, A. & Hopfer, C. J. (2006). Lesbian, gay, 
bisexual homeless youth: An eight-city public health perspective. Child 
Welfare 85(2), 151-170.
---------------------------------------------------------------------------
    HUDs last Point in Time Count counted over 46,000 homeless youth, 
but less than 5,000 beds. Less than 10 percent of our homeless youth 
are receiving services, but funding for the RHYA has not significantly 
increased since 2008, despite a growing population desperately in need 
of the services provided by this Act. In order to meet the 
Administration's goal of ending youth homelessness by 2020, funding for 
runaway and homeless youth services needs to significantly increase. 
Through the RHYA, Congress ensures funding for community outreach 
programs, transitional housing and support services, and counseling and 
reunification guidance for families to be reconnected. Congress should 
appropriate $152.5 million to help keep our vulnerable youth safe and 
healthy as part of a nationwide commitment to ending youth homelessness 
by 2020.
                   suicide prevention research (nimh)
    There is a strong correlation between research funding and 
morbidity rates associated with diseases and disorders. Between 2009 
and 2012, $165 million has been spent on suicide prevention research, 
and yet in the last decade, suicide rates have increased by 31 percent. 
Conversely, over 5 billion dollars has been spent on heart disease 
research, and rates in the past decade have decreased by 16 percent.
    We encourage you to include an additional $40 million for the 
National Institute of Mental Health to conduct suicide prevention and 
brain research, a recommendation that reflects current legislation in 
the Senate and House (S. 2305/H.R. 7045), the Suicide Prevention 
Research INnovaTion Act (the SPRINT Act). The SPRINT Act aims to reduce 
the risk of self-harm, suicide, and interpersonal violence, especially 
in rural communities with a shortage of mental health services.
                        project aware--(samhsa)
    The President's Now is the Time plan is an important step forward 
to effectively address school safety and youth mental health. These 
programs must be adequately funded in order to fulfill the promise of 
making our schools and communities safe for all young people. Through 
piloting Mental Health First Aid training with $20 million , Project 
AWARE would support innovative, State-based strategies for improving 
mental health training and responsiveness to mental health emergencies; 
and would be particularly effective in rural communities, where 
community mental health services are less frequently available. 
Additionally, through $40 million in State grants, Project AWARE would 
put more trained teachers and mental health professionals on the 
ground; help school districts make sure students get the referrals they 
needs; and would underscore the importance of prevention by offering 
students mental health services for trauma or anxiety, conflict 
resolution programs, and other school-based violence prevention 
strategies.
         national violent death reporting system (nvrds) (cdc)
    The NVDRS serves as a clearinghouse for the details and 
circumstances surrounding suicides completed in the jurisdictions in 
which it operates. This valuable information informs suicide prevention 
and crisis intervention efforts, but it is currently only collected in 
18 States. Proposals to expand this system have received broad 
bipartisan support, and the NVDRS expansion was included in the Mental 
Health Awareness and Improvement Act (S. 689), which passed nearly 
unanimously in the Senate as an amendment to S. 649. Fully funding the 
NVRDS with $25 million would allow nationwide collection of this data 
to further public health research on suicide prevention.
Conclusion
    We thank the Committee for taking the time to fully assess our 
Nation's mental healthcare system, and we appreciate the opportunity to 
provide a written statement. We strongly support efforts to increase 
access to suicide prevention and mental healthcare for young people, 
and we urge the Committee to fully fund these critical programs.

    [This statement was submitted by Abbe Land, Executive Director & 
CEO, Trevor Project.]
                                 ______
                                 
           Prepared Statement of the Tri-Council for Nursing
    The Tri-Council for Nursing, comprising the American Association of 
Colleges of Nursing (AACN), the American Nurses Association, the 
American Organization of Nurse Executives, and the National League for 
Nursing, respectfully requests $251 million for the Nursing Workforce 
Development programs authorized under Title VIII of the Public Health 
Service Act (42 U.S.C. 296 et seq.) and administered by the Health 
Resources and Services Administration in fiscal year 2015.
    The Tri-Council is a long-standing nursing alliance focused on 
leadership and excellence in the nursing profession. The members of 
these respective organizations are acutely aware of the demand for 
nursing services due to a growing aging population, an increased focus 
on preventative care, and skyrocketing rates of individuals with 
multiple chronic conditions. In fact, according to the U.S. Bureau of 
Labor Statistics (BLS) Employment Projections for 2012-2022, the 
profession of registered nurses (RN) will grow by 19 percent for the 
10-year timeframe between 2012 and 2022. The number of job openings due 
to both the increasing demand for nursing services and the large number 
of retiring RNs, brings the total of RNs needed to 1.053 million by 
2022. A 2013 HRSA report, The U.S. Nursing Workforce: Trends in Supply 
and Education, indicates that over the next 10 to 15 years, the nearly 
one million RNs over age 50 (comprising approximately one-third of the 
current workforce), will reach retirement age.
    Moreover, the acute nurse faculty shortage is one significant 
reason why schools of nursing across the country turn away tens of 
thousands of qualified applications each year. The demand for nurses 
and the faculty who educate them is a serious impediment to improving 
the Nation's healthcare needs. Nurses continue to be the largest group 
of healthcare providers whose services are directly linked to quality 
and cost-effectiveness. The Tri-Council is grateful to the Subcommittee 
for your past commitment to Title VIII funding and respectfully asks 
that you continue to make the long-term investment that will build the 
nursing workforce necessary to deliver the quality, affordable care 
envisioned in health reform.
    A Proven Solution: Nursing Workforce Development Programs
    The Nursing Workforce Development programs, authorized under Title 
VIII of the Public Health Service Act, have helped build the supply and 
distribution of qualified nurses to meet our Nation's healthcare needs 
since 1964. Over these past 50 years, the original programs, newly 
added, and expanded programs have addressed all aspects of supporting 
the workforce--education, practice, retention, and recruitment. They 
have bolstered nursing education at all levels--from entry-level 
preparation through graduate study--and have provided support for 
institutions that educate nurses who practice in rural and medically 
underserved communities. A description of the Title VIII programs and 
their impact are included below.
    Advanced Nursing Education (ANE) Programs (Sec. 811) fund a number 
of grant activities--including several traineeships--that aim to 
increase the size and quality of the advanced nursing workforce. 
Supporting the preparation of RNs in master's and doctoral nursing 
programs, the ANE grants help prepare our Nation's nurse practitioners, 
clinical nurse specialists, nurse midwives, nurse anesthetists, nurse 
educators, nurse administrators, nurses in executive practice, public 
health nurses, and other nursing specialists requiring advanced nursing 
education. In fiscal year 2012, these grants supported the education of 
15,986 students. Under the ANE program are two critical traineeship 
programs that are particularly relevant as the demand for primary and 
acute care services rise.
    Advanced Education Nursing (AEN) Traineeships assist graduate 
nursing students by providing full or partial reimbursement for the 
costs of tuition, books, program fees, and reasonable living expenses. 
Funding for the AEN Traineeships supports the education of future nurse 
practitioners, clinical nurse specialists, nurse midwives, nurse 
anesthetists, nurse educators, nurse administrators, public health 
nurses, and other nurse specialists requiring advanced education.
    Nurse Anesthetist Traineeships (NAT) support the education of 
students in nurse anesthetist programs. In some States, certified 
registered nurse anesthetists are the sole anesthesia providers in 
almost 100 percent of rural hospitals.
    In fiscal year 2012, the AEN Traineeship and the NAT supported 
5,545 nursing students.
    Nursing Workforce Diversity (NWD) Grants (Sec. 821) prepare 
students from disadvantaged backgrounds to become nurses, producing a 
more diverse nursing workforce. This outcome will help meet the 
increasing need for culturally aligned, quality healthcare for the 
Nation's rapidly diversifying population and help close the gap in 
health disparities. This program awards grants and contract 
opportunities to schools of nursing for a variety of clinical training 
facilities to address nursing educational needs, not only for 
disadvantaged students, but also or racial and ethnic minorities 
underrepresented in the nursing profession. In fiscal year 2012, the 
program supported 12,077 students.
    Nurse Education, Practice, Quality and Retention (NEPQR) Grants 
(Sec. 831) help schools of nursing, academic health centers, nurse-
managed health clinics, as well as State and local governments 
strengthen nursing education programs, thereby increasing the size and 
quality of the nursing workforce. The purposes of the NEPQR grants are 
broad and flexible, allowing the program to address emerging needs in 
nursing workforce development. For example, projects have been funded 
to develop and disseminate collaborative practice models that 
incorporate the full range of healthcare workers in team-based care are 
of certain interest. NEPQR supports infrastructure development to 
enhance the coordination and capacity building of interprofessional 
practice and education among health professions across the United 
States, and particularly in medically underserved areas.
    For other interests, a number of grant activities have been funded 
to support several legislative purposes such as expanding the size of 
academic programs that are able to confer a baccalaureate degree of 
science in nursing (BSN); recruiting and educating individuals as 
qualified personal and home care aides in occupational shortage and/or 
high demand areas; training qualified nursing assistants and home 
health aides to meet the growing healthcare needs of the aging 
population; and/or supporting nurse-managed health clinics that serve 
as primary care access points in areas where primary care providers are 
in short supply.
    NURSE Corps (formerly known as the Nursing Education Loan Repayment 
and Scholarship Program) (Sec. 846) provides monies to students by 
paying up to 85 percent of a student's loan in return for at least 3 
years of service in a designated health shortage area or in an 
accredited school of nursing. The NURSE Corps Loan Repayment Program 
(LRP) is a financial incentive program under which individual RNs and 
advanced practice registered nurses enter into a contractual agreement 
with the Federal Government to work full-time in a healthcare facility 
with a critical shortage of nurses, in return for repayment of 
qualifying nursing educational loans. In fiscal year 2013, the Nursing 
Education Loan Repayment Program supported 1,446 nurses working in 
these facilities. However, given the current climate, the HRSA 2015 
Congressional Budget Justification anticipates that they will only be 
able to support 1,296 in fiscal year 2014.
    Nurse Faculty Loan Program (NFLP) (Sec. 846 A) increases the number 
of qualified nurse faculty by creating a student loan fund within 
individual schools of nursing. Students agree to teach at a school of 
nursing in exchange for cancellation of up to 85 percent of their 
educational loans, plus interest, over a 4-year period. In fiscal year 
2012, these grants supported the education of 2,259 future nurse 
educators.
    Comprehensive Geriatric Education Program (CGEP) Grants (Sec. 855) 
provide support to nursing students specializing in care for the 
elderly. These grants may be used to educate RNs who will provide 
direct care to older Americans, develop and disseminate geriatric 
curriculum, prepare faculty members, and provide continuing education. 
They may also fund traineeships for individuals who are preparing for 
advanced education nursing degrees in geriatric nursing, long-term 
care, gero-psychiatric nursing or other nursing areas that specialize 
in the care of the elderly population. In fiscal year 2012, there were 
11,600 trainees supported by these grants.
    Our Nation is faced with a growing healthcare crisis that must be 
addressed on many fronts. Nurses are an important part of the solution 
to the crisis of cost, burden of disease, and access to quality care. 
To meet this challenge, funding of proven Federal programs such as 
Title VIII will help ease the demand for RNs. The Tri-Council 
respectfully requests your support for $251 million for the Title VIII 
Nursing Workforce Development Programs in fiscal year 2015. If our 
organizations can be of assistance, please contact AACN's Director of 
Government Affairs and Health Policy, Dr. Suzanne Miyamoto, at 
[email protected].
    Sincerly,
             Eileen Breslin, PhD, RN, FAAN, President, Geraldine 
            ``Polly'' Bednash, PhD, RN, FAAN, Chief Executive Officer, 
            American Association of Colleges of Nursing; Linda Knodel, 
            MHA, MSN, RN, NE-BC CPHQ, FACHE, President, Pamela A. 
            Thompson, MS, RN, CENP, FAAN , Chief Executive Officer and 
            Sr. Vice President, American Organization of Nurse 
            Executives; Karen Daley, PhD, MPH, RN, FAAN,President,Marla 
            J. Weston, PhD, RN, FAAN, Chief Executive Officer, American 
            Nurses Association, Marsha Howell Adams, PhD, RN, CNE, 
            ANEF, President,Beverly Malone, PhD, RN, FAAN, Chief 
            Executive Officer, National League for Nursing.
                                 ______
                                 
          Prepared Statement of the Trust for America's Health
    Trust for America's Health (TFAH), a nonprofit, nonpartisan 
organization dedicated to saving lives by working to make disease 
prevention a national priority, is pleased for this opportunity to 
provide written testimony on the State of public health funding. As 
this subcommittee works to develop a fiscal year 2015 Labor, Health & 
Human Services, Education and Related Agencies (LHHS) appropriations 
bill, I urge you to ensure adequate funding for public health 
prevention and preparedness programs at the Centers for Disease Control 
and Prevention (CDC) and other public health agencies.
    After several years of cuts, Congress included a significant 
increase to CDC in the fiscal year 2014 Consolidated Appropriations 
Act, and we thank you for recognizing the importance of public health. 
Eighty-five percent of the CDC's annual budget flows to your States and 
districts in the form of grants and contracts to State and local public 
health departments, and community partners, to conduct critical public 
health and prevention activities that every American relies on, such as 
protecting us from infectious disease by combating healthcare-
associated infections, delivering immunizations, ensuring preparedness, 
and conducting nonstop surveillance.
    The CDC and its grantees across the country are working to help 
give Americans the information they need to adopt the healthy 
lifestyles that will reduce the chronic disease burden on our 
healthcare system. In 2012, we spent roughly 75 percent of our Nation's 
annual $2.8 trillion healthcare bill on treating preventable chronic 
diseases. Long-term healthcare spending at these levels is 
unsustainable for our economy and our Federal budget.
    There is a growing evidence base that demonstrates that the 
majority of chronic disease is preventable by addressing common risk 
factors. We have begun to see signs of success, with childhood obesity 
rates declining in cities and States that were among the first to adopt 
a comprehensive approach to obesity prevention. We must bring that 
knowledge to scale, so that Americans across the country have the 
opportunity to lead healthier lives. We were pleased that last year 
Congress made important new investments in community prevention that 
will help continue our efforts to transform our healthcare system to 
one that values prevention and wellness, and we urge the Committee to 
build on those investments in the fiscal year 2015 bill.
    The recently released Robert Wood Johnson Foundation 2014 County 
Health Rankings serve as another sobering reminder that an American's 
zip code is a strong predictor of whether or not they have the 
opportunity to lead a healthy life. Meeting these twin challenges of 
protecting the American people from natural and man-made threats and 
preventing disease can only occur with continued support for CDC.
Centers for Disease Control and Prevention (CDC)
    From fiscal year 2010 to 2013, the CDC saw its budget authority cut 
by 18 percent. We were pleased that the fiscal year 2014 Omnibus 
Appropriations measure provided CDC with an increase of more than $550 
million, including $373 million from the Prevention and Public Health 
Fund, resulting in a nearly $175 million increase for chronic disease 
programs. For perspective, however, that increase simply brought CDC 
funding back to fiscal year 2013 levels. Scarce resources means CDC 
will be forced to make extremely difficult, sometimes life and death 
choices. We urge the Committee to maintain adequate CDC funding levels 
in fiscal year 2015.
The Prevention and Public Health Fund (PPHF)
    TFAH was pleased to see Congress exercise its authority to allocate 
the Prevention and Public Health Fund in fiscal year 2014, and we urge 
this committee to do so again in the fiscal year 2015 appropriations 
bill. To date, the Fund had made investments in every State to support 
State and local efforts to transform and revitalize communities, build 
epidemiology and laboratory capacity to track and respond to disease 
outbreaks, address healthcare associated infections, train the Nation's 
public health and health workforce, prevent the spread of HIV, expand 
access to vaccines, reduce tobacco use, and help control the obesity 
epidemic.
National Center for Chronic Disease Prevention and Health Promotion 
        (NCCDPHP)
    Our Nation's doctors and hospitals are our trusted front line when 
illness appears, but we must continue to engage not only health systems 
but sectors such as education, housing, business and planning to 
transform communities to make the healthy choice the easy choice and 
prevent illness in the first place. The Chronic Disease Center has made 
progress in moving away from the traditional categorical approach to 
funding disease prevention and toward more coordinated, cross-cutting 
strategies. While we were disappointed at the premature termination of 
the Community Transformation Grants program, TFAH appreciates the new 
investments in community prevention made in fiscal year 2014. We hope 
the Committee restores funding for the Chronic Disease Center to fiscal 
year 2010 levels ($1.167 billion), building upon fiscal year 2014 
investments in diabetes, heart disease and stroke, the Partnerships to 
Improve Community Health initiative, the Racial and Ethnic Approaches 
to Community Health program and the Preventive Health and Health 
Services Block Grant program. For the block grant, TFAH calls upon the 
Committee to promote its use to modernize our public health system by 
supporting health department accreditation and other efforts to ensure 
the Nation's health departments can deliver foundational public health 
capabilities to all Americans.
National Center for Environmental Health (NCEH)
    Critical programs conducted at the CDC National Center for 
Environmental Health support our chronic disease prevention and public 
health preparedness efforts. Yet it remains one of the most critically 
underfunded parts of CDC. We recommended that you fund NCEH at fiscal 
year 2010 levels ($181.004 million) in fiscal year 2015 to continue to 
rebuild the lead control program, grow our National Environmental 
Public Health Tracking Network, and pursue other priorities.
Public Health Emergency Preparedness Grants
    The Public Health Emergency Preparedness (PHEP) Grants, 
administered by CDC, is the only Federal program that supports the work 
of health departments to prepare for all types of disasters, including 
bioterror attacks, natural disasters, and infectious disease outbreaks. 
The grants fund nearly 4,000 State and local public health staff 
positions, and support 15 core capabilities including public health 
laboratory testing, surveillance and epidemiology, community 
resilience, countermeasures and mitigation, and more. These funds are 
used for everyday preparedness activities, such as monitoring public 
health threats, and have been integral in expanding to respond to full-
scale disasters such as Hurricane Sandy, the fungal meningitis 
outbreak, and the West Nile Virus outbreak in Texas. TFAH recommends 
$670 million for the Public Health Emergency Preparedness Cooperative 
Agreements in fiscal year 2015 to help States and localities restore 
some of the core capabilities lost due to significant cuts to the 
program.
Hospital Preparedness Program
    The Hospital Preparedness Program (HPP), administered by the 
Assistant Secretary for Preparedness and Response (ASPR), provides 
funding and technical assistance to prepare the health system to 
respond to and recover from a disaster. The program, which began in 
response to 9/11, has evolved from one focused on equipment and 
supplies held by individual hospitals in response to a terrorist event, 
to a system-wide, all-hazards approach. The new HPP is building the 
capacity of healthcare coalitions--regional collaborations between 
healthcare organizations, providers, emergency managers, public sector 
agencies, and other private partners--to meet the disaster healthcare 
needs of communities. Through the coalition planning process, 
facilities are learning to leverage resources, such as developing 
interoperable communications systems, tracking beds, and writing 
contracts to share assets.
    HPP helped a prepared healthcare system save lives during recent 
events, including the Boston Marathon bombings and tornadoes in 
Kentucky and Joplin, MO. HPP appropriations have decreased from $426 
million in fiscal year 10 to $255 million in fiscal year 2014, 
including a one third cut in the fiscal year 2014 omnibus. TFAH 
recommends $300 million for fiscal year 2015 for HPP, an incremental 
step to rebuild the program. The significant reduction in fiscal year 
14 will likely result in fewer staff, fewer coalitions and less of the 
Nation prepared for disasters.
Combatting Prescription Drug Abuse
    Prescription drug abuse is a growing public health crisis. Overdose 
deaths involving prescription painkillers have quadrupled since 1999 
and now outnumber deaths from all illicit drugs, including heroin and 
cocaine, combined. This is a multi-faceted problem, and the CDC, 
SAMHSA, NIH and a range of other agencies have a role to play in 
finding a solution. TFAH recommends a $15.6 million increase to the CDC 
Injury Center's Injury Prevention Activities line to enable the CDC to 
work with additional States with a high burden of prescription drug 
abuse to help address the main drivers of the epidemic of prescription 
drug overdoses, and also urge you to provide the funding to ensure that 
patients with prescription drug addiction have access to the treatment 
they need to turn their lives around.
Conclusion
    Investing in disease prevention is the most effective, common-sense 
way to improve health and address our long-term deficit. Hundreds of 
billions of dollars are spent each year to pay for healthcare services 
once patients develop an acute illness, injury, or chronic disease. A 
sustained investment in public health and prevention is essential to 
reduce high rates of disease and improve health in the United States.

    [This statement was submitted by Jeffrey Levi, Executive Director, 
Trust for America's Health.]
                                 ______
                                 
   Prepared Statement of Rebecca Underwood, Parent/Guardian/Advocate
    Thank you for this opportunity to provide outside witness testimony 
for the record to the Senate Appropriations Subcommittee on Labor, 
Health and Human Services, Education and Related Agencies. I strongly 
object to the use of United States Department of Health and Human 
Services (DHHS) appropriations to develop coercive and subversive 
methods of deinstitutionalization resulting in the eviction of the most 
vulnerable individuals with intellectual/developmental disabilities 
from DHHS Medicaid licensed and funded facilities including 
intermediate care facilities for individuals with intellectual 
disabilities (ICFs/IID). I submit this testimony as a request that 
Congress prohibit Federal funds be allocated to Federal programs which 
are currently using their public funds to achieve dangerous public 
policies of forced deinstitutionalization, resulting in the eviction of 
eligible individuals with severe, profound and extreme intellectual and 
developmental disabilities (I/DD) from their HHS-licensed and funded 
homes, without regard to individual choice.
    I am the mother and co-guardian of an adult son, aged 34 who, as 
the result of brain and pulmonary hemorrhaging occurring during a 
premature birth, functions at the level of a 4-12 week old infant with 
chronic and complex medical issues. After providing his 24/7 care in 
our home for several years, we accepted the reality that our son would 
benefit from the extended care available in a highly specialized 
intermediate care facility for individuals with intellectual 
disabilities. Our son has benefitted tremendously from the highly 
specialized medical services provided in this setting as evidenced by 
his continued survival beyond any one's expectations.
    Our parenting decisions, our son's continued residence in his 
current DHHS funded facility and receipt of the services uniquely 
suited to meet his extensive and complex physical and medical needs, 
which have proven beneficial for his survival, are under attack. A 
number of DHHS funded programs are targeting forced displacement of our 
most fragile constituency without regard to individual choice, need and 
safety.
    Examples of how government dollars, through DHHS appropriations, 
are being misused in a cruel and absurd method by DHHS funded programs 
and policies to affect the downsizing and closure of DHSS licensed and 
funded facilities include:
  --Administration on Intellectual and Developmental Disabilities 
        (AIDD) administers programs and grants created under Public Law 
        106-402, Developmental Disabilities Assistance and Bill of 
        Rights Act of 2000 (DD Act). The DD Act was last reauthorized 
        in 2000. Authorizations for DD Act appropriations expired in 
        2007; however Congress continues to fund these programs. DD Act 
        programs, including Protection and Advocacy (P&A) and DD 
        Councils, operate in every State. AIDD, now under the umbrella 
        of the Administration for Community Living within DHHS, 
        administers the DD Act programs. In 2011 AIDD's (f/k/a ADD) 
        proposed recommendations included ``[d]evelop and implement 
        plans to close public and private institutions''. There have 
        been no hearings or recourse for families to address concerns 
        as to the way in which programs, including AIDD, use/misuse 
        Federal funds. DHHS has been unresponsive to complaints from 
        families of persons with severe, profound and extreme forms of 
        developmental disabilities about AIDD policies. DHHS has turned 
        a blind eye to the tragic, but predictable, results for many 
        individuals when they are forced from their specialized, 
        Medicaid certified and funded congregate care settings. 
        Independent oversight of Federal AIDD and DD Act programs is 
        desperately needed. How long will Congress and society continue 
        to ignore the increasing rate of tragic outcomes due to a 
        misguided ideological agenda of forced deinstitutionalization 
        of our most vulnerable citizens from their safe environments?
  --National Council on Disability (NCD) is an independent Federal 
        agency funded through DHHS appropriations. In October 2012 the 
        NCD released a 110 page policy document and an accompanying 201 
        page ``tool-kit'' to assist opponents of congregate care to 
        accomplish the closure of Medicaid-certified specialized homes 
        of 4 or more beds in which individuals with severe and profound 
        cognitive and other developmental disabilities receive supports 
        and services. Families and guardians of these affected 
        individuals are universally opposed to such closures and are 
        united in their opposition to NCD's misuse of their authority 
        as an independent Federal agency and their Federal funding. NCD 
        has been called upon by these families to reject their stance 
        on forced deinstitutionalization. The NCD has thus far ignored, 
        and failed to respond to, the request of these most important 
        stakeholders. Despite extensive documentation of widespread 
        abuse in community settings, along with a nationwide crisis of 
        understaffed, underpaid, and poorly trained direct care workers 
        resulting in tragic outcomes, the NCD continues pressing 
        forward with their position that ALL individuals with 
        intellectual/developmental disabilities, even those who 
        experience profound and complex medical, physical and/or 
        behavioral challenges, be forced from their safe homes if that 
        safe home is 4 or more beds. As an ``independent Federal agency 
        charged with advising the President, Congress, and other 
        Federal agencies regarding policies, programs, practices and 
        procedures that affect people with disabilities'' NCD should 
        not be taking any position which tramples on the rights of a 
        portion of the disability community.
  --DHHS Incentive grants (increase in FMAP funds) to encourage States 
        to move away from providing institutional care.
    --Money Follows the Person is a Federal ``reward'' for cash 
            strapped States to move away from providing institutional 
            care. Money Follows the Person (MFP) grants provide 
            increased FMAP (Federal Medical Assistance Percentage) 
            funds to States as a reward for each institutionalized 
            person in the target population who transitions to an 
            eligible non-institutional setting. Money Follows the 
            Person grants ($4 Billion) have been acknowledged to 
            disproportionately target individuals with developmental 
            disabilities for transition.\1\ MFP has also been 
            acknowledged as a way for States to transition individuals 
            ``out the back door'' of institutions while ``closing the 
            front door'' to new admissions in an effort to close 
            facilities.
---------------------------------------------------------------------------
    \1\ Audra T. Wenzlow and Debra J. Lipson, ``Transitioning Medicaid 
Enrollees from Institutions to the Community: Number of People Eligible 
and Number of Transitions Targeted Under MFP'', Reports from the Field, 
Number 1, January 2009, Mathematica Policy Research,
pg 6, http://www.mathematica-mpr.com/publications/PDFs/health/
MFPfieldrpt1.pdf (accessed 20 March 2014).
---------------------------------------------------------------------------
    --Balancing Incentive Program (BIP) is another Federal incentive in 
            the amount of $3 billion to cash strapped States to divert 
            eligible individuals from institutional settings, 
            disregarding choice and need.
    Combined total of $7 Billion in Federal funds through these 
Incentive grants, in addition to States' regular Federal Medical 
Assistance Percentage (FMAP), to encourage States to abandon 
institutional settings. Federal funds should not be utilized to favor 
one service setting over another, particularly as clarified in the 
Supreme Court's Olmstead ruling: ``We emphasize that nothing in the ADA 
or its implementing regulations condones termination of institutional 
settings for persons unable to handle or benefit from community 
settings...Nor is there any Federal requirement that community-based 
treatment be imposed on patients who do not desire it.'' Olmstead, 119 
S. Ct. 2176, 2187 (1999) (majority).
    It will be a travesty if the Federal Government is successful in 
pigeon-holing disability policy into a one-size-fits-all, eliminating 
choice, while continuing to ignore Supreme Court clarifications within 
Olmstead regarding the care of those with the most severe forms of 
developmental disabilities. We need an increasing array of viable 
options for services and supports for our most vulnerable, not less.
    How long will Congress and society continue to ignore the 
increasing rate of tragic outcomes (abuse, neglect, unnecessary & 
preventable deaths) of a misguided ideological agenda of forced 
deinstitutionalization of our most vulnerable citizens from their safe 
environments?
    In conclusion I call upon Congress to prohibit the Department of 
Health and Human Services' use of appropriations for 
deinstitutionalization activities that result in the eviction of 
eligible individuals with intellectual and other developmental 
disabilities from DHHS licensed and funded facilities.
                                 ______
                                 
          Prepared Statement of the United Negro College Fund
Introduction
    I am Dr. Beverly Daniel Tatum, President of Spelman College in 
Atlanta, Georgia. Founded in 1881, Spelman College is a global leader 
in the education of women of African descent and a Historically Black 
College. Since 2008 Spelman College has averaged a 6-year graduation 
rate of 77 percent--one of the highest of the 105 Historically Black 
Colleges and Universities and substantially above the national average 
of 59 percent.
    Spelman College is one of the 37 private Historically Black 
Colleges and Universities (HBCUs) that are members of the United Negro 
College Fund (UNCF), which I am representing. UNCF is the Nation's 
largest higher education organization serving students of color, 
perhaps best known by the iconic motto--``A mind is a terrible thing to 
waste.''
    In its 70-year history, UNCF has raised more than $4 billion in 
scholarship aid to help more than 400,000 students of color attend 
HBCUs and 900 other colleges and universities across the country to 
obtain the education they need to excel in the 21st century economy. 
UNCF's largest scholarship is the Gates Millennium Scholarship offered 
to high-achieving, low-income African American, American Indian/Alaska 
Native, Asian Pacific Islander and Hispanic American students. UNCF has 
awarded $179 million in Gates Millennium Scholarships to help 3,200 
students from the States the Labor-Health and Human Services-Education 
Subcommittee represents earn college degrees.
HBCU Value Proposition
    UNCF's core mission, however, remains its partnership with the 
Nation's 37 private HBCUs. The money raised by UNCF has become even 
more important today as HBCUs have suffered from a ``perfect storm'' of 
Federal disinvestments since 2011. Limitations on Pell Grant 
eligibility requirements, sequestration cuts to the Title III HBCU 
Program and Parent PLUS Loan reductions have resulted in a loss of more 
than $250 million in Federal support. Despite these challenges, HBCUs 
provide enormous value for students and the Nation. HBCUs represent 
approximately 4 percent of all 4-year colleges and universities; enroll 
9 percent of all African American college students; confer 16 percent 
of bachelor's degrees awarded to African Americans; and generate 27 
percent of the STEM bachelor's degrees awarded to African Americans. 
Moreover, HBCUs accomplish this while serving students with greater 
need: more than 70 percent of students who attend HBCUs are low-income 
students who depend on Federal Pell Grants for their education, a 
substantially greater share than the 43 percent of students at all 
other 4-year colleges and universities. At the same time, total cost of 
attendance at HBCUs is 30 percent lower, on average, than other 4-year 
institutions.
Fiscal year 2014 Appropriations
    I would like to thank the Subcommittee and, in particular, Chairman 
Harkin and Ranking Member Moran for playing leadership roles in 
restoring some of the vital Federal resources to HBCUs and the students 
we serve in the fiscal year 2014 budget. UNCF appreciates you providing 
a maximum Pell award of $5,730, restoring sequestration cuts to other 
student aid programs, and restoring two-thirds of the sequestration 
cuts to the Title III HBCU Program.
Fiscal year 2015 Appropriations Priorities
    Looking to fiscal year 2015, a national strategy to produce more 
college graduates, boost our economy and enhance global competitiveness 
must include greater investment in HBCUs. On behalf of the UNCF 
institutions and all HBCUs, I urge the Subcommittee to support our 
highest priority programs listed below:
  --I urge you to appropriate $267 million in discretionary dollars and 
        $85 million in mandatory dollars for the Title III, Part B--
        Strengthening Historically Black Colleges and Universities 
        Program. These are formula funds awarded to HBCUs for 
        operational support and essential academic services. Let me 
        note that during the 2007-2012 grant cycle, Spelman College 
        received and expended more than $11 million in Title III 
        funding. Spelman has enhanced its campus infrastructure to 
        include upgrades in technology to facilities, classrooms, labs 
        and centers. Title III assisted with the establishment of the 
        SpelBots (Spelman's Robotic Team) a winning robotics 
        initiative. Additional examples of the achievements that 
        critical Title III funding has supported at Spelman are 
        included as an attachment to my testimony. Please reinvest in 
        this program and restore the $43 million cut from the program 
        since fiscal year 2010.
  --The HBCU Capital Financing Program finances low-risk Federal loans 
        to help HBCUs, especially private institutions, improve 
        facilities, infrastructure and technology. Investing in capital 
        projects not only enhances the educational environment for 
        students but also reinvigorates our communities and provides 
        much needed jobs. I urge you to increase the appropriation for 
        loan subsidies to $25 million, which would leverage $390 
        million in annual loans to meet the infrastructure needs of our 
        institutions.
  --Without Pell Grants, most HBCU students could not pay for the 
        college education that is essential in today's economy. I urge 
        you to fund a $5,830 maximum Pell award to help our students 
        persist and complete college. In addition, I encourage you to 
        reinstate ``summer'' Pell Grants so students can earn their 
        college degrees faster and at a lower cost.
  --UNCF also strongly supports the President's fiscal year 2015 
        request of $75 Million for College Success Grants for Minority-
        Serving Institutions. These competitive grants would help 
        Minority-Serving Institutions launch new innovations and best 
        practices to improve student outcomes. I urge you to fully fund 
        this important initiative.
  --I urge you to approve the proposed College Opportunity and 
        Graduation Bonuses, which would reward institutions that enroll 
        and graduate large numbers of low-income students. UNCF 
        recommends that this proposal be amended to take into 
        consideration both the numbers and percentages of low-income 
        students graduating from institutions, given that some HBCUs 
        have smaller enrollments.
  --Finally, I urge you to restore the Health Professions Training for 
        Diversity programs to fiscal year 2012 levels and ask that you 
        expand the National Institute on Minority Health and Health 
        Disparities to $283 million to improve diversity in the 
        workforce and research funding for minority populations.
    Chairman Harkin and Ranking Member Moran and members of this 
Subcommittee--you have the power to increase Federal resources for 
operating support, student assistance, best practices and innovations 
so that HBCUs can thrive in years to come. Or, you can adhere to the 
status quo and allow our institutions to merely survive.
    UNCF does not accept the status quo. We are accelerating our 
fundraising efforts, investing in capacity building at our member 
institutions, building new partnerships and leveraging our resources to 
enhance educational opportunities for minority students. In fact, UNCF 
has updated its motto to recognize education is an investment in better 
futures for everyone. We believe that, ``A mind is a terrible thing to 
waste, but a wonderful thing to invest in.'' Please help us invest in 
our youth, in our HBCUs, and most importantly, in our country so that 
millions more low-income, minority students can graduate from college 
and lead our country to heights we have yet to imagine. Thank you for 
the opportunity to submit written testimony.

    [This statement was submitted by Dr. Beverly Daniel Tatum, 
President, Spelman College.]

Attachments:

  --HBCU Coalition fiscal year 2015 Appropriations Priorities
  --Spelman College Title III Accomplishments
                                 ______
                                 
                              Attachments
              Historically Black Colleges and Universities
    $267 Million Discretionary/$85 Million Mandatory for Strengthening 
Historically Black Colleges and Universities Program--Title III, Part 
B, supports critical investments in HBCUs such as student academic 
services, infrastructure and teacher education programs needed to 
enhance educational opportunities for our students. This critical 
investment helps HBCUs to continue delivering services to our Nation's 
neediest students. The HBCU Coalition respectfully requests $267 
million discretionary funding, which would restore this program to its 
fiscal year 2010 level, and $85 million mandatory funding for fiscal 
year 2015.
    $61 Million for Strengthening Historically Black Graduate 
Institutions Program--This program provides financial assistance to 
Historically Black Graduate Institutions to establish or strengthen 
physical buildings and supports graduate students with scholarships and 
fellowships. This aid allows the next generation of scientists, 
mathematicians and graduate students to complete professional degrees 
in underrepresented fields of study. The HBCU Coalition requests $61 
million funding, which would restore this program to its fiscal year 
2010 funding level.
    $11 Million Discretionary/$15 Million Mandatory for Strengthening 
Predominantly Black Institutions--This program provides Predominantly 
Black Institutions with funds to develop and implement programs to 
educate more low-income, African American college and secondary 
students. The HBCU Coalition requests $11 million discretionary and $15 
million mandatory funding, which would restore this program to its 
fiscal year 2010 funding level.
    $25 Million for the HBCU Capital Financing Program and Remove the 
Loan Guarantee Cap--The HBCU Capital Financing program provides low-
cost capital to finance physical improvements on HBCU campuses by 
guaranteeing and administering loans. In fiscal year 2013 and fiscal 
year 2014, demand is expected to exceed $800 million. We urge Congress 
to increase loan subsidies by $5.5 million to $25 million. This 
increase would support $86 million in new loans to approximately 2--8 
additional institutions for a total annual loan volume of $390 million. 
At a minimum, we recommend restoring the loan subsidy to its pre-
sequester level of $20.5 million. We support the appropriations 
language recommended by the Education Department to remove the $1.1 
billion loan guarantee statutory cap.
    $5,830 for the Pell Grant Maximum Award and Reinstate ``Summer'' 
Pell Grants--Pell Grants provide low- to moderate- income students with 
the financial assistance to go to and through college. The HBCU 
Coalition requests funding for the maximum Pell award at its authorized 
fiscal year 2015 level (currently estimated by OMB to be $5,830). In 
addition, we request reinstatement of the ``summer'' Pell Grant to 
allow students to accelerate their paths to graduation and lower their 
overall college costs.
    $75 Million for College Success Grants for Minority-Serving 
Institutions--The President's fiscal year 2015 budget proposes to 
initiate new College Success Grants for Minority-Serving Institutions 
(MSIs) to assist MSIs in developing sustainable strategies to reduce 
costs and improve student outcomes. Funded activities could include 
partnering with school districts and schools to provide college 
recruitment, awareness, and preparation activities; establishing high-
quality dual-enrollment programs that allow students to earn college 
credit while still in high school; providing comprehensive student 
support services; and reducing the need for remedial education. The 
HBCU Coalition supports the President's request of $75 million for this 
program.
    $647 Million for a College Opportunity and Graduation Bonus 
Program--President Obama's fiscal year 2015 budget proposes a College 
Opportunity and Graduation Bonus program that will reward colleges that 
successfully enroll and graduate a significant number of low- and 
moderate-income students on time. Grants would fund key investments and 
best practices such as providing need-based financial aid, enhancing 
academic and student supports and other innovative strategies to 
improve low-income student outcomes. The HBCU Coalition supports the 
President's request but also encourages Congress to modify the proposal 
to recognize institutions that enroll and graduate significant numbers 
or percentages of Pell-eligible students, accounting for the many HBCUs 
that have small enrollments.
    $50 Million for a National Five Fifths Agenda for America 
Initiative--To support the Administration's My Brother's Keeper 
initiative, the HBCU Coalition proposes $50 million for a new program 
called the Five Fifths Agenda for America to expand educational 
outcomes for African American males. The objective of this program is 
to demonstrate how colleges and universities, especially HBCUs, and K-
12 schools can forge partnerships to help African-American males 
prepare for, get to and through college by implementing research-based 
best practices.
    $250 Million Authorization for a HBCU Innovation Fund--To support 
the Administration's efforts to drive change in higher education 
policies and practices that improves college access, affordability, 
completion and quality, the HBCU Coalition proposes that additional 
financial resources be provided to HBCUs through an Innovation 
initiative under the Higher Education Act. An Innovation Fund would 
incentivize HBCUs to address performance goals in certain categories, 
such as student retention and completion, STEM, use of technology and 
new educational delivery methods that can speed time to degree and 
lower costs. All public and private HBCUs, or consortia of these HBCUs, 
other institutions and nonprofit organizations, would be eligible to 
receive planning and implementation grants.
                                 ______
                                 
                            Spelman College
  highlights: title iii, part b, sec. 323--strengthening historically 
                black colleges and universities program
    Spelman College is the oldest historically black college for women. 
Located in Atlanta, Georgia, Spelman was founded in 1881 as the Atlanta 
Baptist Female Seminary. The College maintains a student population of 
approximately 2,000 from 45 U.S. States and 13 countries, and since 
2008 has had an average 6-year graduation rate of 77 percent.
    Title III--Strengthening Historically Black Colleges and 
Universities funding plays a critical role in obtaining resources that 
provide students and faculty with unparalleled opportunities for 
educational enrichment and advancement. In the 2007-2012 grant cycle, 
Spelman College expended more than $11 million in Title III funds. 
Those resources were expended on a number or projects with wide-ranging 
effects on student life, faculty engagement, and facility improvement.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


  --Title III funding supports and enhances institutional efforts in 
        four critical areas: Academic Quality, Student Services 
        Outcomes, Institutional Management and Fiscal Stability. Our 
        advancements in these key areas are reflected in key indicators 
        related to enrollment, retention, graduation and fiscal 
        stability.
  --Title III funding undergirds 100 percent of the Foundational 
        Priorities of the College's Strategic Plan, enhancing academic 
        rigor in new student orientation, freshman-year and sophomore-
        year experiences.
  --The College's retention rate is 90 percent. The average 5-year 
        (2007-2011) second-year retention rate is 87 percent. Title III 
        funds continue to assist the institution with providing 
        supportive programs that ensure Spelman's first and second year 
        students successfully progress to junior status.
  --The College's 6-year graduation rate has ranged from a high of 83 
        percent to a low of 73 percent. The average 6-year (2001-2006) 
        cohort rate is 77 percent.
  --Forty-nine Global STEM students have conducted STEM research abroad 
        since 2011.
  --48 labs and 22 classrooms upgraded with state-of-the-art 
        technology.
  --Between 2008-2012, Spelman had 722 students who were admitted to 
        and attended graduate or professional degree programs in 
        disciplines in which African Americans are underrepresented.
Select Examples of Title III Activities that Support our Success
  --A campus classroom was transformed into a data analysis hub, with 
        16 new workstations installed. More than 90 percent of students 
        reported that their interest in and skills related to data 
        analysis improved as a result of their work in this facility.
  --The College implemented DegreeWorks, an online auditing and 
        advising system that aids students in proactively creating and 
        fulfilling their individual academic plans and assists faculty 
        advisors in providing effective support.
  --Spelman's Education Studies Program enlarged its interdisciplinary 
        course offerings through the addition of a new course entitled 
        ``History and Philosophy of African American Education.''
  --Creation and implementation of the Student Success Center, which 
        provides a centralized location for student support services.
  --Spelman's Department of Computer and Information Science (CIS) 
        achieved international recognition for the accomplishments of 
        its graduates and for its award-winning robotics initiative. 
        The SpelBots participated in the NSF Education Technology 
        Senate showcase in November 2009.
    These accomplishments serve as evidence of the important role that 
resources from the Strengthening Historically Black Colleges and 
Universities program play at Spelman and on HBCU campuses across the 
Nation.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
       Prepared Statement of the United Tribes Technical College
    For 45 years, United Tribes Technical College (UTTC) has provided 
postsecondary career and technical education, job training and family 
services to some of the most impoverished, high risk Indian students 
from throughout the Nation. We are governed by the five tribes located 
wholly or in part in North Dakota. We are not part of the North Dakota 
State college system and do not have a tax base or State-appropriated 
funds on which to rely. We have consistently had excellent retention 
and placement rates and are a fully accredited institution. Section 117 
Carl Perkins Act funds represent a significant portion of our operating 
budget and provides for our core instructional programs. The request of 
the UTTC Board for fiscal year 2015 is:
  --$10 million for base funding authorized under Section 117 of the 
        Carl Perkins Act for the Tribally Controlled Postsecondary 
        Career and Technical Institutions program (20 U.S.C. Section 
        2327). This is $2.3 million above the fiscal year 2014 level 
        and the fiscal year 2013 post-sequestration level. These funds 
        are awarded competitively and distributed via formula. We are 
        seeking a change to the formula which is not so reliant on 
        Indian Student Count in order to avoid dramatic swings in 
        annual awards.
  --Forward Funding. We ask that the Section 117 Perkins funds, like 
        the other funds under the Carl Perkins Career and Technical 
        Education Act, be put on a forward funded basis.
  --$30 million as requested by the American Indian Higher Education 
        Consortium for Title III-A (Section 316) of the Higher 
        Education Act, $5 million above the fiscal year 2014 level.
  --Maintain Pell Grants at the $5,830 maximum award level.
    We are disappointed that the fiscal year 2014 Appropriations Act 
did not restore the fiscal year 2013 Section 117 sequestration even 
though funding for the overall Perkins Act was restored. Perhaps 
Section 117 was overlooked as a source of job training as it is in the 
Higher Education portion of the budget. We all realize the urgent need 
to better prepare a workforce to meet industry and other emerging 
needs. We are part of that undertaking, but need more resources to come 
closer to our potential.
    We don't know if Congress will reauthorize the Carl Perkins Act 
this session, but point out that the Administration's Blueprint for 
Perkins reauthorization specifically states support for the Tribally 
Controlled Postsecondary Career and Technical Education program and 
includes some national recommendations that UTTC is already 
implementing including:
  --Training that is industry certified and provision of postsecondary 
        certificates and degrees.
  --Alignment with labor market needs--the ramifications of the North 
        Dakota Bakken oil boom are seen throughout the State. We saw 
        the need for more certified welders in relation to the oil boom 
        and so expanded our certified welding program for these good- 
        paying, in-demand jobs. Similarly, our online medical 
        transcription program was designed to meet the growing need for 
        certified medical support staff. Other courses reflect new 
        emphasis on energy auditing and GIS Technology.
  --Articulation agreements between UTTC and junior and senior high 
        schools.
  --A broad range of services for our students to help ensure their 
        success.
Additional Information about UTTC. We have:
  --Renewed unrestricted accreditation from the North Central 
        Association of Colleges and Schools for July 2011 through 2021, 
        with authority to offer all of our full programs on-line. We 
        have 26 Associate, 20 Certificate and three Bachelor degree 
        programs.
  --Services including a Child Development Center, family literacy 
        program, wellness center, area transportation, K-8 elementary 
        school, tutoring, counseling and housing.
  --A semester retention rate of 85 percent and a graduate placement 
        rate of 77 percent. Over 45 percent of our graduates move on to 
        4-year or advanced degree institutions.
  --Students from 75-88 tribes; 85 percent of our undergraduate 
        students receive Pell Grants.
  --An unduplicated count of undergraduate degree-seeking students and 
        continuing education students of 1391.
  --A critical role in the regional economy. Our presence brings at 
        least $34 million annually to the economy of the Bismarck 
        region. A 2005 study showed a projected return on Federal 
        investment of 20-1.
  --We have recently opened a distance learning center in Rapid City, 
        SD, where there are some 16,000 American Indians in the area. 
        We are also working toward the establishment of an American 
        Indian Specialized Health Care Training Clinic.
    Section 117 Perkins Base Funding. Funds are needed to: 1) maintain 
100-year-old education buildings and 50-year-old housing stock for 
students; 2) upgrade technology capabilities; 3) provide adequate 
salaries for faculty and staff who are in the bottom quartile of salary 
for comparable positions elsewhere; and 4) fund program and curriculum 
improvements.
    Perkins funds are central to the viability of our core 
postsecondary education programs. Very little of the other funds we 
receive may be used for core career and technical educational programs; 
they are competitive, often one-time targeted supplemental funds. Our 
Perkins funding provides a base level of support while allowing the 
college to compete for desperately needed discretionary funds.
    Forward Funding. We ask that the Appropriations Committees provide 
one-time funding for Section 117 Perkins to put it on a forward funded 
basis. We do not know why it is not already forward funded, given that 
the rest of the Perkins is forward funded. A number of years ago 
Section 117 was moved to the Higher Education portion of the budget 
even though it is authorized through the Perkins Act. Perhaps that has 
something to do with it, although we point out that many education 
programs are forward funded. Forward funding provides for vital 
education programs before the start of each school year, which is 
critically important when appropriations are delayed and the Government 
is funded via Continuing Resolutions.
    Title III-A (Section 316) Strengthening Institutions. Among the 
Title III-A statutorily allowable uses is facility construction and 
maintenance. We are constantly in need of additional student housing, 
including family housing. With the completion of a Science, Math and 
Technology building on our South Campus on land acquired with a private 
grant, we urgently need housing for up to 150 students, many of whom 
have families.
    While we have constructed three housing facilities using a variety 
of sources in the past 20 years, approximately 50 percent of students 
are housed in the 100-year-old buildings of what was Fort Abraham 
Lincoln, as well as housing that was donated by the Federal Government 
along with the land and Fort buildings in 1973. These buildings require 
major rehabilitation. New buildings are actually cheaper than 
rehabilitating the old buildings that now house students.
    Pell Grants. We support maintaining the Pell Grant maximum to at 
least a level of $5,830. This resource makes all the difference in 
whether most of our students can attend college.
    Government Accountability Office (GAO) Report. As you know, in 
March 2011 the GAO issued two reports regarding Federal programs which 
may have similar or overlapping services or objectives (GAO-11-318SP of 
March 1 and GAO-11-474R of March 18). Funding from the Bureau of Indian 
Education (BIE) and the Perkins Act for Tribally Controlled 
Postsecondary Career and Technical Institutions were among the programs 
listed in the supplemental report of March 18, 2011. The GAO did not 
recommend defunding these or other programs; in some cases 
consolidation or better coordination of programs was recommended to 
save administrative costs. We are not in disagreement about possible 
consolidation or coordination of the administration of these funding 
sources so long as funds are not reduced.
    Perkins funds supplement, but do not duplicate, our BIE funds. It 
takes both sources of funding to frugally maintain the institution. 
Even these combined sources do not provide the resources necessary to 
operate and maintain the college and we actively seeks alternative 
funding to assist with curricula, deferred maintenance, and scholarship 
assistance. The need for postsecondary career and technical education 
in Indian Country is so great and the funding so small, that there is 
little chance for duplicative funding. There are only two institutions 
targeting American Indian/Alaska Native career and technical education 
at the postsecondary level--UTTC and Navajo Technical University. 
Combined, these institutions received less than $15 million in fiscal 
year 2014 Federal operational funds ($7.7 million from Perkins; $7 
million from BIE), a very modest amount for two campus-based 
institutions which offer a wide and expanding array of training 
opportunities.
                                 * * *
    UTTC offers services catered to the needs of our students, many of 
whom are first generation college attendees and many of whom come to us 
needing remedial education and services. Although BIE and Section 117 
Perkins funds do not pay for remedial education, we make this 
investment through other sources to ensure our students succeed at the 
postsecondary level.
    Thank you for your consideration of our requests.

    [This statement was submitted by David M. Gipp, Chancellor, United 
Tribes Technical College.]
                                 ______
                                 
     Prepared Statement of the University of Kansas Medical Center
    Mr. Chairman and Members of the Subcommittee; thank you for the 
opportunity to submit this statement regarding fiscal year 2015 funding 
for the National Institutes of Health's Institutional Development Award 
or ``IDeA'' Program. The IDeA program is funded by NIH's National 
Institute of General Medical Sciences (NIGMS), and was authorized by 
the 1993 NIH Revitalization Act (Public Law 103-43). I submit this 
testimony on behalf of the Coalition of EPSCoR/IDeA States,\1\ the 
Kansas IDeA program, and the University of Kansas Medical Center. The 
Coalition of EPSCoR/IDeA States respectfully requests that the 
Subcommittee provide $310 million for the IDeA program in fiscal year 
2015.
---------------------------------------------------------------------------
    \1\ Alabama, Alaska, Arkansas, Delaware, Guam, Hawaii, Idaho, Iowa, 
Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, 
Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oklahoma, 
Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, 
Utah, Vermont, Virgin Islands, West Virginia, and Wyoming
---------------------------------------------------------------------------
    I would first like to provide some basic information about the IDeA 
program. The IDeA program increases our Nation's biomedical research 
capability by improving research in States that have historically been 
less successful in obtaining biomedical research funds. Twenty-three 
States and Puerto Rico are eligible. The program funds only merit-
based, peer-reviewed research that meets NIH's biomedical research 
objectives. While IDeA was authorized by the 1993 NIH Revitalization 
Act (Public Law 103-43), sizable increases in funding only began in 
fiscal year 2000. The IDeA program then grew rapidly, due in large part 
to the thoughtful actions of this Subcommittee. This initial funding 
permitted the launch of two program elements: the COBRE and BRIN/INBRE 
programs.
    The first was the COBRE program or ``Centers of Biomedical Research 
Excellence,'' which are research clusters targeting specific biomedical 
research problems. The second IDeA program was BRIN or ``Biomedical 
Research Infrastructure Networks,'' which targeted key areas such as 
bioinformatics and genomics, and facilitated the development of 
cooperative networks between research-intensive universities and 
primarily undergraduate colleges. The BRIN grants underwent competitive 
renewals in 2004 and were funded under the new name of ``IDeA Networks 
of Biomedical Research Excellence,'' or INBRE.
    The COBRE program is designed to increase the pool of well-trained 
investigators in the IDeA States by expanding research facilities, 
equipping laboratories with the latest research equipment, providing 
mentoring for promising candidates, and developing research faculty 
through support of a targeted multi-disciplinary center, led by an 
established, senior investigator with expertise in the research focus 
area of the center.
    The INBRE program is designed to increase the pipeline of 
outstanding students and enhances the quality of science faculty in the 
IDeA States by research-intensive networking with undergraduate 
institutions. The INBRE program supports research infrastructure and 
mentoring of young investigators, and prepares students for graduate 
and professional schools as well as careers in the biomedical sciences 
at participating institutions. As you can see, these two programs play 
complementary roles in developing research capability and human capital 
in biomedical fields in the IDeA States.
Impact of the IDeA Program on Kansas
    Since the year 2000, Kansas has received more than $190 million in 
awards from the IDeA program. Those IDeA investments have enabled our 
investigators to secure National Institutes of Health grants and more 
than double the amount of funding coming into Kansas. The IDeA program 
has resulted in funding of 570 biomedical research grants, supported 71 
core biomedical research core facilities, and has resulted in 1,152 new 
research related jobs.
    The Kansas INBRE (K-INBRE) program consists of three research-
intensive universities and seven primarily undergraduate universities. 
Over its 13-year history, the K-INBRE has provided significant benefits 
to the State of Kansas, including training a skilled workforce and 
helping to drive scientific commercialization potential. Over $45.1 
million from the NIH, numerous Kansas Universities, as well as 
philanthropies and industry support to the K-INBRE has benefitted 
Kansas Universities by significantly aiding Kansas's faculty to 
increase NIH funding from $50.3M (2000) to $82.8M (2013). The K-INBRE 
has significantly improved in the dissemination of knowledge throughout 
Kansas via videoconferencing, symposia and increased intra- and inter-
State collaborations.
    The K-INBRE has been successful in establishing the first 
bioinformatics facility in Kansas (three campus cores) and been 
instrumental in preparing for new advances in increased medical 
informatics and translational research. The K-INBRE has also assisted 
with building the Kansas biomedical science industry by facilitating 
industry collaborations. This is critical, as the growth of the Kansas 
bioscience sector is climbing at more than twice the national rate.
    Finally, the K-INBRE has contributed to building a skilled 
workforce for Kansas by assisting with the building of the biomedical 
workforce in Kansas by supporting research training for over 800 
undergraduates, numerous post-docs and new faculty investigators. 
Importantly, the K-INBRE has helped broaden student research 
participation of under-represented groups (rural and ethnic). In 2013 
alone, approximately 160 graduate and undergraduate students throughout 
the State of Kansas were supported by K-INBRE funds. More importantly, 
these funds have broadened research participation by under-represented 
rural and ethnic groups, and NIH-level research infrastructure has been 
initiated in seven of ten campuses within the K-INBRE network.
    Overall, the implementation of the K-INBRE program facilitates the 
generation of new strengths in Cell and Developmental Biology in the 
State of Kansas, and ultimately contributes importantly to the 
development of new tools and strategies for improving human health.
    Kansas researchers are currently involved in six active COBRE 
awards. Three of these COBREs are located at University of Kansas 
Medical Center in Kansas City. The Molecular Regulation of Cell 
Development and Differentiation COBRE has established a thriving 
multidisciplinary research group focused on the molecular regulation of 
cell development. This COBRE has been highly successful in helping 
young faculty obtain NIH funding. The purpose of the Nuclear Receptors 
in Liver Health and Disease COBRE has been to establish a recognized 
center to study liver function in health and disease. This COBRE has 
also been very successful at aiding young faculty in obtaining NIH 
funding. Importantly, it has also created a valuable ``liver bank'' 
from many strains of inbred mice. The objective of the Novel Approaches 
for Control of Microbial Pathogens COBRE is to promote and enhance the 
research capabilities of tenure track junior faculty members of 
participating institutions in the State of Kansas with an emphasis on 
inhibiting microbial pathogens. This COBRE has been critical in 
enabling Kansas faculty to obtain $52 million in NIH funding and has 
established a highly utilized flow cytometry core facility at the 
University of Kansas Medical Center
    The remaining three COBRE programs reside in Lawrence, Kansas at 
the University of Kansas. The Center of Biomedical Research Excellence 
in Protein Structure and Function conducts important basic research in 
health-related protein structure and function. By better understanding 
the structure, function, and interaction of proteins present in human 
cells, researchers are gaining a deeper understanding of how proteins 
carry out critical functions within cells. This COBRE has helped 13 
faculty establish independent NIH funding and two faculty supported by 
this COBRE have gone on to receive national recognition for their 
research.
    The Center for Molecular Analysis of Disease Pathways (CMADP) COBRE 
brings together junior and senior faculty from the physical, 
biological, and pharmaceutical sciences at the University of Kansas and 
other academic institutions in Kansas to conduct multidisciplinary 
research to develop and implement cutting-edge technologies for 
elucidating the genetic, chemical, and physical mechanisms of 
biological processes involved in disease. This COBRE has established a 
much needed Genome Sequence Core that provides state of the art 
sequencing capabilities for researchers in Kansas.
    Finally, the Center for Cancer Experimental Therapeutics (CCET) 
COBRE brings together researchers from the University of Kansas 
Lawrence campus, Kansas State University and the University of Kansas 
Medical Center. The Center combines the resources and faculty of 
Kansas' institutions to create the infrastructure needed to pursue 
cancer-related research and experimentation at the interface between 
chemistry and biology. This is the oldest of the COBRE programs in 
Kansas and the CCET works to identify novel bioactive compounds that 
will be useful basic biomedical research tools and potential 
therapeutic agents. Scientists from the participating schools fight 
cancer through research projects focusing on specific types of cancer 
and the discovery of new anti-cancer drugs and therapies. This COBRE 
has established two important research cores associated with medicinal 
chemistry and high throughput screening, two key services that are 
important for drug discovery. The CCET was also instrumental in 
establishing a National Cancer Institute Designated Cancer Center at 
the University of Kansas Medical Center in 2012.
Conclusion
    Despite these successes, our task is far from complete. Funding 
disparities between the States remain and may have a detrimental impact 
on our national self-interest. Together, the 23 States and Puerto Rico 
that comprise the IDeA community secured just 5 percent of the total 
NIH budget in fiscal year 2011. With over 22 percent of the Nation's 
population living in the EPSCoR/IDeA States, this figure clearly 
indicates the critical need for further research development and the 
importance of a strong IDeA program. In fiscal year 1999, the year 
before COBRE grants were initiated, the 23 IDeA States and Puerto Rico 
received a total of $596 million from NIH. In fiscal year 2013 total 
NIH funding to the IDeA community has risen to $1.5 billion. This is 
evidence that the program is working and that the IDeA States are 
moving in the right direction. To put the value of the IDeA investment 
into perspective, the overall fiscal year 2014 IDeA budget, $273.325 
million, for 23 States and Puerto Rico, pales in comparison to the 
$606.8 million in NIH funding that one institution in one single non-
IDeA State received in fiscal year 2012. In fiscal year 2012, the top 
seven States with NIH funding received over a $1 billion each, and 
California alone received over $3.5 billion.
    We request that this committee recommend the program to be funded 
in fiscal year 2015 at $310 million. As you know, the EPSCoR/IDeA 
Coalition has maintained that IDeA program should constitute at least 1 
percent of the total NIH budget. This level of funding would restore 
and continue funding for COBRE and INBRE, provide funding for the IDeA 
Program Infrastructure for Clinical and Translational Research (IDeA-
CTR) program, and provide co-funding which would allow researchers and 
institutions to merge with the overall national biomedical research 
community.
    On behalf of the University of Kansas Medical Center, I express 
gratitude to this Subcommittee for the efforts it has made over the 
years to provide increased funding for IDeA, in particular this 
committee's work to ensure the successful inclusion of a $50 million 
increase for the program in fiscal year 2012. I hope that you will 
continue to invest in this biomedical research program, which is so 
important to almost half of the States in the Union. Every region of 
the country has talent and expertise to contribute to our Nation's 
biomedical research efforts--and every region of the country must 
participate if we are to increase our Nation's biomedical research 
capacity substantially. On behalf of the EPSCoR/IDeA Coalition, the 
University of Kansas Medical Center and our partner institutions across 
Kansas, I thank the Subcommittee for the opportunity to submit this 
testimony.

    [This statement was submitted by Douglas Wright, Ph.D., Professor 
and Vice Chair Principal Investigator, Kansas INBRE, Department of 
Anatomy and Cell Biology, University of Kansas Medical Center.]
                                 ______
                                 
 Prepared Statement of the University of North Dakota and North Dakota 
                            State University
    On behalf of the University of North Dakota and North Dakota State 
University, thank you for the opportunity to submit our written 
testimony regarding the fiscal year 2015 funding for the National 
Institutes of Health (NIH) Institutional Development Award (IDeA) 
program. We respectfully request your support of no less than $310.0 
million for this critically important program. We further request that 
the Subcommittee gives serious consideration to legislative language 
which would direct that future NIH budgets include funding for the IDeA 
program that reaches no less than 1 percent of the total NIH budget. 
IDeA was authorized by the 1993 NIH Revitalization Act (Public Law 103-
43) and funds only merit-based, peer reviewed research that meets NIH 
research objectives in the 23 IDeA States and Puerto Rico.
    The States eligible for IDeA funding are defined as ``all States/
commonwealths with a success rate for obtaining NIH grant awards of 
less than 20 percent over the period of 2001-2005 or received less than 
an average of $120 million per year during that time period.'' 
Currently this includes 23 States and Puerto Rico--nearly half of the 
States. Funding from this critical capacity-building program has been a 
key part of the growth in research capacity and impact at the two North 
Dakota research universities in recent years.
    Funding for the IDeA program in fiscal year 2014 was $273.325 
million. The total budget for NIH in fiscal year 2014 was $30.2 
billion; thus in fiscal year 2014, the IDeA program--funding 
competitively awarded biomedical research in nearly half the Nation--
comprised only 0.89 percent of the entire NIH budget. The IDeA program 
exists because the 23 eligible States overall receive less than 20 
percent of NIH's extramural funding. The President's proposed fiscal 
year 2015 budget request of $30.4 billion represents only a 0.7 percent 
increase to the NIH, and the proposed increase of $31 million for the 
entire National Institute for General Medical Sciences, which houses 
the IDeA program is even less, only 0.3 percent. The President's 
proposed fiscal year 2015 budget request does not include a recommended 
increase for the IDeA program. The IDeA program is designed to aid 
small, rural States; it is small in the overall scheme of things at 
NIH, but huge for the States that compete for these funds. Our 
requested funding level of $310.0 million represents only 1 percent of 
the President's total fiscal year 2015 budget request for NIH.
    Our State, North Dakota, has benefited immensely from the 
competitive funding available through the IDeA program in the form of 
COBRE (Center for Biomedical Research Excellence) and INBRE (IDeA 
Networks of Biomedical Research Excellence) grants.
    At the University of North Dakota, we have been awarded funding for 
three phases of a COBRE grant supporting research on neurodegenerative 
diseases. North Dakota has one of the largest populations of the 
extremely old in the Nation (second only to Rhode Island in the 
percentage of its citizens over 85 years of age), and high rates of 
neurodegenerative diseases such as Alzheimer's, Parkinson's, and 
multiple sclerosis. As an example of the impact of this funding and the 
research capacity it has built, externally funded research at the 
University of North Dakota's School of Medicine and Health Sciences has 
grown substantially. Prior to COBRE funding, in fiscal year 2002, the 
SMHS received about $12.0 million in external funding; by fiscal year 
2013, this had increased to $27.1 million, an increase of 126 percent. 
In 2010, when UND developed a new strategic plan for research, 
neuroscience was identified as an existing strength on which to build 
further.
    Thus, the neurobiology COBRE grant is achieving its intended 
purpose of expanding our research capacity and our ability to compete 
for Federal funding. That research is directed at problems of direct 
interest not only to our citizenry, but also to the rest of the United 
States.
    The University of North Dakota has also received an additional 
COBRE grant on the topic of epigenetics. Epigenetics is the study of 
how environmental factors influence the expression of our genes; in 
many cases these changes in gene expression can then be inherited by 
the next generation. This $12.0 million grant was awarded early in 
fiscal year 2014, and will serve to carry out research on environmental 
factors that affect disease resistance while developing critical 
research capacity in the State.
    At North Dakota State University, the Center for Protease Research, 
a COBRE supported center, provides fundamental information on how 
proteases, key biological players, impact several diseases, including 
cancer, arthritis, autoimmune diseases, diabetes, and asthma. These 
studies have the potential to provide novel therapeutics that can treat 
these deadly and debilitating diseases. The multidisciplinary program 
has established two central Core Facilities in biology and synthesis 
that have had a significant impact on research programs in the 
university and throughout North Dakota. The $24.0 million Center has 
initiated several outreach activities such as workshops for North 
Dakota University System faculty and students and a summer research 
program for undergraduates.
    The Center for Visual and Cognitive Neuroscience established in 
2004 at North Dakota State University is devoted to increasing our 
understanding of the ways that information is perceived and processed 
by the brain. Center investigators are involved in the study of visual 
and cognitive processing. Core laboratory infrastructure has been 
developed allowing faculty and students to fruitfully explore the 
relationships between the nervous system and the behavior that it 
governs.
    Another critically important IDeA program is INBRE, which provides 
funding to build the biomedical workforce through activities ranging 
from outreach to elementary school children to creating opportunities 
for undergraduates to engage in research. This program has provided 
support for undergraduate students at 2- and 4-year colleges in North 
Dakota to participate in research during the summer at their home 
institutions. This program includes two tribal colleges and serves 
between 70 and 100 students each year. Another program at the 
University of North Dakota serves about 60 undergraduates per year and 
applications routinely exceed the number of slots that are available. 
These programs are critical for keeping students in the pipeline for 
the STEM (science, technology, engineering, and math) workforce. 
Studies have repeatedly shown that engaging undergraduates in original 
research is a powerful tool for retaining students in college so that 
they graduate in a timely way.
    A major emphasis has been on outreach programs to Native American 
students, the minority group that is most under-represented in the 
fields of science, engineering, and math. Between 25 and 35 Native 
American students in grades 7-12 participate each year in a program 
that uses traditional Native American tools to teach science. As many 
as 40 students from tribal colleges are funded each year to visit UND 
and learn about opportunities to transfer to the university and 
complete their 4-year degrees. INBRE provides support for transfer 
students from tribal colleges through the Pathway program, a 6-week 
summer program that prepares participants for advanced coursework in 
science. Pathway students can also receive tuition waivers from the 
university. INBRE funding is also provided to support the American 
Indian Health Research Forum on the UND campus each year; this forum 
attracts attendees from across the Nation.
    North Dakota, with an estimated 2013 population of 723,393, is the 
smallest of all the IDeA States. Yet, our School of Medicine and Health 
Sciences graduates a disproportionately large number of primary care 
physicians who practice in rural areas, and 20 percent of all Native 
American physicians in the U.S. are graduates of the University of 
North Dakota. The School recently was recognized by the American 
Academy of Family Physicians for having the largest percentage of its 
graduates enter the field of family medicine of all medical schools in 
the United States. The medical school clearly is making important 
contributions to healthcare for underserved populations. Like all 
medical schools, it must have a healthy research program underpinning 
its training of physicians, and funding from the IDeA program is 
critical to the health of that program and to building research 
capacity for the future.
    The IDeA States produce STEM graduates at the same per capita rate 
as States with larger populations and larger research portfolios. The 
students from IDeA States need and deserve the same exposure to 
research as students in larger States. If fiscal year 2015 funding 
levels for the IDeA program are not at least maintained at the current 
level, and preferably increased to $310.0 million, North Dakota and 
other small, mostly rural States, will receive a major setback in their 
efforts to increase their capacity to undertake biomedical research and 
to train the next generation of scientists who are critical for the 
health of our Nation and our economy.
    The IDeA program is absolutely critical not only for North Dakota's 
two research universities, but also for the biomedical research 
capacity and capability of research institutions nationwide. We 
sincerely appreciate the Subcommittee's ongoing support of the IDeA 
program and request that you give full consideration to our 
recommendations and fiscal year 2015 request of no less than $310.0 
million for the National Institutes of Health IDeA program. We further 
request that the Subcommittee considers legislative language directing 
that future NIH budgets include funding for the IDeA program that 
reaches no less than 1 percent of the total NIH budget.
                                 ______
                                 
       Prepared Statement of US Hereditary Angioedema Association
              summary of fiscal year 2015 recommendations
_______________________________________________________________________

  --$32 Billion for the National Institutes of Health (NIH) at an 
        increase of $1 billion over fiscal year 2014.
  --Continued focus on Hereditary Angioedema Research and Education at 
        NIH
  --Funding to create and support the Centers for Disease Control and 
        Prevention's (CDC) to Increase Awareness Efforts for Hereditary 
        Angioedema at CDC
_______________________________________________________________________

    Thank you for the opportunity to present the views of the US 
Hereditary Angioedema Association (US HAEA) regarding the importance of 
Hereditary Angioedema (HAE) public awareness activities and research.
    The US HAEA is a non-profit patient advocacy organization founded 
in 1999 to help those suffering with HAE and their families to live 
healthy lives. The Association's goals were, and remain, to provide 
patient support, advance HAE research and find a cure. The US HAEA 
provides patient services that include referrals to HAE knowledgeable 
healthcare providers, disease information and peer-to-peer support. US 
HAEA also provides research funding to scientific investigators to 
increase the HAE knowledge base and maintains an HAE patient registry 
to support ground-breaking research efforts. Additionally, US HAEA 
provides disease information materials and hosts forums to educate 
patients and their families, healthcare providers, and the general 
public on HAE.
    HAE is a rare and potentially life-threatening inherited disease 
with symptoms of severe, recurring, debilitating attacks of edema 
(swelling). HAE patients have a defect in the gene that controls a 
blood protein called C1-inhibitor, so it is also more specifically 
referred to as C1-inhibitor deficiency. This genetic defect results in 
production of either inadequate or nonfunctioning C1-inhibitor protein. 
Because the defective C1-inhibitor does not adequately perform its 
regulatory function, a biochemical imbalance can occur and produce an 
unwanted peptide--called bradykinin--that induces the capillaries to 
release fluids into surrounding tissues, thereby causing swelling.
    People with HAE experience attacks of severe swelling that affect 
various body parts including the hands, feet, face, airway (throat) and 
intestinal wall. Swelling of the throat is the most life-threatening 
aspect of HAE, because the airway can close and cause death by 
suffocation. Studies reveal that more than 50 percent of patients will 
experience at least one throat attack in their lifetime.
    HAE swelling is disfiguring, extremely painful and debilitating. 
Attacks of abdominal swelling involve severe and excruciating pain, 
vomiting, and diarrhea. Because abdominal attacks mimic a surgical 
emergency, approximately one third of patients with undiagnosed HAE 
undergo unnecessary surgery. Untreated, an average HAE attack lasts 
between 24 and 72 hours, but some attacks may last longer and be 
accompanied by prolonged fatigue.
    The majority of HAE patients experience their first attack during 
childhood or adolescence. Most attacks occur spontaneously with no 
apparent reason, but anxiety, stress, minor trauma, medical, surgical, 
and dental procedures, and illnesses such as colds and flu have been 
cited as common triggers. ACE Inhibitors (a blood pressure control 
medication) and estrogen-derived medications (birth control pills and 
hormone replacement drugs) have also been shown to exacerbate HAE 
attacks.
    HAE's genetic defect can be passed on in families. A child has a 50 
percent chance of inheriting the disease from a parent with HAE. 
However, the absence of family history does not rule out the HAE 
diagnosis; scientists report that as many as 25 percent of HAE cases 
today result from patients who had a spontaneous mutation of the C1-
inhibitor gene at conception. These patients can also pass the 
defective gene to their offspring. Worldwide, it is estimated that this 
condition affects between 1 in 10,000 and 1 in 30,000 people.
   public awareness at the centers for disease control and prevention
    HAE patients often suffer for many years and may be subject to 
unnecessary medical procedures and surgery prior to receiving an 
accurate diagnosis. Raising awareness about HAE among healthcare 
providers and the general public will help reduce delays in diagnosis 
and limit the amount of time that patients must spend without treatment 
for a condition that could, at any moment, end their lives.
    Once diagnosed, many individuals are able to piece together a 
family history of mysterious deaths and episodes of swelling that 
previously had no name. In some families, over many years, this 
condition has come to be accepted as something that must simply be 
endured. Increased public awareness is crucial so that these patients 
understand that HAE often requires emergency treatment and disabling 
attacks no longer need to be passively accepted. While HAE cannot yet 
be cured, intelligent use of available treatments can help patients 
lead a productive life.
    In order to prevent deaths, eliminate unnecessary surgeries, and 
improve patients' quality of life, it is critical that CDC pursue 
programs to educate the public and medical professionals about HAE in 
fiscal year 2015.
           research through the national institutes of health
    In years past, HAE research was conducted at the National 
Institutes of Health (NIH) through the National Institute of Allergy 
and Infectious Diseases, the National Institute of Neurological 
Disorders and Stroke, the National Heart Lung and Blood Institute, the 
National Institute of Child Health and Human Development, National 
Center for Research Resources, and the National Institute on Diabetes 
and Digestive and Kidney Diseases. However, NIH has not engaged in HAE-
specific research since 2009, and there is no longer any Federal 
research as it relates to HAE.
    As it may provide greater opportunities for HAE research, we 
applaud the recent establishment of the National Center for Advancing 
Translational Sciences (NCATS) at NIH. Housing translational research 
activities at a single Center at NIH will allow these programs to 
achieve new levels of success. Initiatives like the Cures Acceleration 
Network are critical to overhauling the translational research process 
and overcoming the challenges that plague treatment development. In 
addition, new efforts like taking the lead on drug repurposing have the 
potential to speed access to new treatments, particularly to patients 
who struggle with rare or neglected diseases. As a rare disease 
community, HAE patients may also benefit from the Therapeutics for Rare 
and Neglected Diseases (TRND) program, housed at NCATS, as well 
coordination with the Office of Rare Diseases Research (ORDR). We ask 
that you support NCATS and provide adequate resources for the Center in 
fiscal year 2014.
    In order to reinvigorate HAE research at NIH, it is vital that NIH 
receive increased support in fiscal year 2015. US HAEA recommends an 
overall funding level of $32 billion for NIH in fiscal year 2015 and 
the inclusion of recommendations emphasizing the importance of HAE 
research to learn more about this rare disease and new pathways for 
appropriate treatment.
    Thank you for the opportunity to present the views of the HAE 
community.

    [This statement was submitted by Janet Long, Executive Vice 
President, US Hereditary Angioedema Association.]
                                 ______
                                 
                       Prepared Statement of VOR
I. Introduction
    VOR is a national organization that advocates for high quality care 
and human rights for all people with intellectual and developmental 
disabilities (I/DD). VOR calls on the U.S. Senate to prohibit the use 
of U.S. Department of Health and Human Services' (HHS) appropriations 
in support of deinstitutionalization activities which evict eligible 
individuals with I/DD from their HHS-licensed and funded Medicaid 
homes, in violation of Federal law.
    Deinstitutionalization activities, including advocacy, lobbying, 
class action lawsuits, and other tactics by some HHS-funded agencies 
(discussed below) resulting in the downsizing and closure of HHS-
licensed homes are a cruel and absurd use of Federal funding. These 
closures often lead to human tragedy. Medicaid-licensed facility homes, 
including Intermediate Care Facilities for Individuals with 
Intellectual Disabilities (ICFs/IID) and other specialized nursing 
facilities, are uniquely suited to meet the residents' profound 
support, healthcare and behavioral needs. Tragedies are widespread and 
predictable when fragile citizens are removed from specialized care. 
The legally-protected rights of families and legal guardians to serve 
as primary decision-makers are routinely ignored.
II. Using HHS Funds to Eliminate HHS-Supported Homes: The 
        Administration on Intellectual and Developmental Disabilities 
        (AIDD) and its State-based Developmental Disabilities 
        Assistance and Bill of Rights Act (DD Act) Programs
    It has been 14 years since Congress last reauthorized the DD Act. 
Authorizations for DD Act appropriations expired in 2007; however, 
Congress continues to fund these programs. DD Act programs, including 
Protection & Advocacy (P&A), DD Councils, and University Programs, 
operate in every State. AIDD, within HHS, administers the DD Act 
programs.
    Independent oversight of Federal AIDD and DD Act programs is nearly 
non-existent.\1\ DD Act programs are using their public funds to 
achieve dangerous deinstitutionalization, evicting vulnerable people 
with I/DD from Medicaid-certified homes, disregarding individual choice 
and the legal right to appropriate services, as required by the 
Americans With Disabilities Act (ADA) (as interpreted by the Olmstead 
decision) and Medicaid law, both discussed below.
---------------------------------------------------------------------------
    \1\ See, VOR Federal Comments Urging Objective Performance--Not 
More Self-Reporting--of DD Act Programs (January 25, 2012) (vor.net/
images/VORCommentDDActEvaluation
Jan2012.pdf).
---------------------------------------------------------------------------
    The DD Act programs' own authorizing statute supports residential 
choice and recognizes that individuals and their families are in the 
best position to make care decisions:

      ``Individuals with developmental disabilities and their families 
        are the primary decisionmakers regarding the services and 
        supports such individuals and their families receive, including 
        regarding choosing where the individuals live from available 
        options, and play decisionmaking roles in policies and programs 
        that affect the lives of such individuals and their families.'' 
        DD Act, 42 U.S.C. 15001(c)(3)(2000); see also, H. Rep. 103-442 
        (March 21, 1994) (``[T]he goals expressed in this Act to 
        promote the greatest possible integration and independence for 
        some individuals with developmental disabilities may not be 
        read as a Federal policy supporting the closure of residential 
        institutions'').

    Yet, AIDD persists in its support for DD Act programs' 
deinstitutionalization activities and even proposed a recommendation to 
``[d]evelop and implement plans to close public and private 
institutions,'' and ``[k]eep people with disabilities out of congregate 
institutions,'' in collaboration with DOJ and The Arc (2011). Hundreds 
of families and others objected; the recommendation has not yet been 
finalized. Likewise, the national organizations for the three DD Act 
programs have referred to families who select HHS-licensed homes (ICFs/
IID) as ``clueless'' and ``unaware,'' \2\ a view not shared by the 
Supreme Court (see, Heller v. Doe, 509 U.S. 312, 329 (1993) (``. . . 
close relatives and guardians, both of whom likely have intimate 
knowledge of a mentally retarded person's abilities and experiences, 
have valuable insights which should be considered during the 
involuntary commitment process.'')).
---------------------------------------------------------------------------
    \2\ June 14, 2010 and July 30, 2007 letters to Congress referring 
to families as ``unaware'' and ``clueless,'' respectively.
---------------------------------------------------------------------------
    With AIDD directive, State-level DD Act program 
deinstitutionalization activities continue, exacting great harm on the 
very people Congress entrusted these HHS-entities to protect. Since 
1996, more than fifteen (15) P&A class action lawsuits for closure (not 
relating to conditions of care) and other deinstitutionalization 
tactics have been pursued over the objection of residents and their 
families. The P&A class action lawsuits are a particularly egregious 
use of Federal funds; they equate HHS suing itself because the targets 
of these HHS-funded lawsuits are HHS/Medicaid-licensed ICFs/IID.
    AIDD and its State-based programs persist in their ideological 
devotion to community placement despite reports of 1,200 ``unnatural 
and unknown'' deaths in New York, a risk of mortality in community 
settings of up to 88 percent in California, more than 100 deaths in 
Connecticut, 53 deaths in Illinois, 114 deaths in the District of 
Columbia, plus many more reports of abuse, neglect and death across the 
majority of all States (see e.g, Widespread Abuse, Neglect and Death in 
Small Settings Serving People with Intellectual Disabilities (VOR, 
2014)).
III. Using HHS Funds to Eliminate HHS-Supported Homes: National Council 
        on Disability
    The National Council on Disability (NCD) is an HHS-funded, 
independent Federal agency that advises the President, Congress, and 
other Federal agencies on issues affecting people with disabilities.
    On October 23, 2012, NCD released a 300-page policy paper and 
related toolkit calling for the closure of residential homes for people 
with I/DD, arbitrarily targeting residential homes for four or more 
people. NCD spent nearly $150,000 in Federal funds to prepare and 
publish ``Deinstitutionalization: Unfinished Business,'' calling on the 
broader advocacy community to engage in advocacy efforts and lawsuits 
to evict people with I/DD from their homes. NCD did not consult with 
the individuals who could be evicted from their homes, nor their 
families and legal guardians. Instead, NCD accuses these caring 
families and guardians of violating their family members' civil rights 
for choosing a care setting of four or more people. NCD has since 
received more than 350 letters from families opposing forced 
deinstitutionalization.
    Like AAID, NCD cites the landmark Supreme Court decision of 
Olmstead v L.C. (1999) as justification for its position to close HHS 
homes. Like many organizations that support deinstitutionalization, 
AAID and NCD misread and misapply the Olmstead decision's requirements. 
The Supreme Court is clear in its holding that the ADA requires 
individual choice before community placement can be imposed and 
recognizes the need for specialized care:

      ``We emphasize that nothing in the ADA or its implementing 
        regulations condones termination of institutional settings for 
        persons unable to handle or benefit from community 
        settings...Nor is there any Federal requirement that community-
        based treatment be imposed on patients who do not desire it.'' 
        Olmstead, 119 S. Ct. 2176, 2187 (1999) (majority).
      ``As already observed [by the majority], the ADA is not 
        reasonably read to impel States to phase out institutions, 
        placing patients in need of close care at risk ...`Each 
        disabled person is entitled to treatment in the most integrated 
        setting possible for that person--recognizing on a case-by-case 
        basis, that setting may be an institution'[quoting VOR's Amici 
        Curiae brief].'' Id. at 2189 (plurality).
    Likewise, Medicaid law and regulation requires that ICF/IID 
residents be ``[g]iven the choice of either institutional or home and 
community-based services.'' 42 C.F.R. Sec. 441.302(d)(2); see also, 42 
U.S.C. Sec. 1396n(c)(2)(C) and 42 C.F.R. Sec. 441.303.
    NCD's support for deinstitutionalization is contrary to Federal law 
and reckless. ICFs/IID have an array of services not often available 
elsewhere (e.g., on-site medical care, dental care, other specialties, 
and involvement in their broader communities). As discussed above, 
tragedies are predictable when residents are separated from life-
sustaining supports.
IV. Solution and Conclusion
    HHS-funded agencies should not be allowed to advance an ideological 
agenda in support of evicting eligible people from HHS-licensed homes, 
contrary to the DD Act, Medicaid law, and the ADA/Olmstead. Such 
actions are a cruel and absurd use of Federal funding that is exacting 
great harm on our nation's most vulnerable citizens, and contrary to 
societal values which respect individual and family decisionmaking.
    Please support language to prohibit the use of HHS appropriations 
in support of deinstitutionalization activities which evict eligible 
individuals with I/DD from HHS-licensed and funded homes. No Federal 
agency should define ``choice'' so narrowly and illegally as to 
disenfranchise the most vulnerable segment of our disabled population.
                                 ______
                                 
       Prepared Statement of the Workforce Data Quality Campaign
    Workforce Data Quality Campaign (WDQC)--a nonprofit initiative that 
advocates for inclusive, aligned and market-relevant data systems--
urges Congress to support programs that provide crucial data needed to 
ensure that our Nation is educating its students and workers to succeed 
in the 21st century economy.
    Federal investments in State data systems, labor market information 
and statistical programs have real impacts for:
  --Students and workers trying to figure out which colleges and 
        training programs are best at helping people land a job, 
        continue their studies or advance in the labor market.
  --Policymakers who need to know whether education and workforce 
        programs are preparing people for good jobs.
  --Business leaders wondering whether education and training programs 
        are preparing enough prospective employees to meet their 
        companies' needs.
  --Educators who want to know the long-term education and employment 
        outcomes of their graduates, so they can continually improve 
        their courses and curricula.
    Despite their profound impact on education and workforce 
development, a number of data-related programs and services have faced 
stagnant or declining funding in recent years. As Congress deliberates 
on fiscal year 2015 appropriations, we recommend halting this downward 
trend and increasing funding for the following programs.
    State longitudinal data system grants.--The State Longitudinal Data 
System grants provided by the Department of Education (ED) and the 
Workforce Data Quality Initiative grants from Department of Labor (DOL) 
have propelled the successful development, implementation and expansion 
of longitudinal data systems. Continued Federal support will 
incentivize the State interagency cooperation necessary to build and 
utilize systems that can hold education and workforce programs 
accountable for their results. Funding for these grants has been 
decreasing over the past several years, gradually eroding this 
important source of support for State data systems. The last grant 
competition was in fiscal year 2012. Additional funding is important to 
help more States improve their data infrastructure and conduct a new 
grant competition that focuses States on using data to improve policy 
and practice, as well as incorporating longitudinal data from 
postsecondary and workforce programs into their systems to allow more 
analysis of varied education and career pathways.
    Recommendation.--Double the fiscal year 2014 funding level, as 
requested by the President's Budget, to support about 20 grants and 
national activities designed to promote data coordination, quality, and 
use. Include report language directing ED and DOL to collaborate on 
providing technical assistance to grantees to ensure inclusive and 
aligned data systems.
    Workforce Information Grants/Electronic Tools. DOL awards grants to 
help States conduct research on local and regional labor markets, 
including shifts in industrial and occupational demand and its impact 
on the skills needed by the workforce. This information is critical to 
align education and training programs with employer needs, and help the 
workforce system guide students and workers to programs that will 
prepare them for high-demand occupations. Funding for these grants--
included in the Workforce Information/Electronic Tools/System Building 
line item in the State Unemployment Insurance and Employment Service 
Operations Account--has not increased for over a decade, even as demand 
for labor market information has grown. This line item also funds 
important national data activities, including the dissemination of 
information on different types of credentials and O*NET, which collects 
and disseminates information about occupations including associated 
skills, knowledge and abilities. O*NET is used as the foundation for 
variety of tools to help workers explore careers, such as a new Skills 
to Work tool from Texas that helps veterans translate their military 
experience into skills appropriate for civilian resumes and match their 
skills to job openings.
    Recommendation.--Increase funding by $10 million to support an $8 
million increase in grants to States and a $2 million increase for 
O*NET.
    National Center for Education Statistics. This office at ED 
provides a number of important services, including labor market-
relevant data products and tools on secondary and postsecondary 
enrollments, completions and credential attainment.
    Recommendation.--Increase funding to match fiscal year 2012 (pre-
sequester) levels.
    Bureau of Labor Statistics. This DOL agency produces an array of 
important data, including employment and unemployment of individuals, 
jobs and earnings by industry and occupation, job openings and labor 
turnover, mass layoffs and occupational projections. As the Nation 
continues to face high unemployment, this data is vital to help align 
human capital policies with the needs of employers.
    Recommendation.--Increase funding by $23 million to support the 
following efforts.
  --Restore Current Employment Survey funding to 2010 levels (+$7 
        million) to provide resources to enhance data quality and 
        reduce employer response burden by encouraging businesses to 
        voluntarily provide information through electronic data 
        interchange. This survey is used by local leaders to provide a 
        near real-time summary of employment conditions and to rapidly 
        spot key trends in major industries.
  --Expand Current Population Survey supplements (+$4 million), which 
        monitor labor market changes that can help State and local 
        leaders understand the education and training needs in their 
        communities.
  --Develop new cost-effective approaches for Occupational Employment 
        Statistics and the National Compensation Survey (+$2 million) 
        that allow data users to see occupational trends over time by 
        locality.
  --Increase funding for cooperative agreements with States (+$10 
        million) to enable State partners to produce a variety of labor 
        market information that is critical for workers, educators and 
        employers. Funding for these agreements has not risen in over a 
        decade.

                    SUMMARY OF RECOMMENDED INCREASES
                         [Dollars in thousands]
------------------------------------------------------------------------
                                    2014          2015
      Department of Labor         Enacted    Recommendation    Increase
------------------------------------------------------------------------
Workforce Data Quality                6,000           6,463          463
 Initiative...................
Workforce Information/E-Tools/       60,153          70,153       10,000
 System Building..............
Bureau of Labor Statistics....      592,212         615,212       23,000
    Total Increase............  ...........  ..............       33,463
Department of Education--
 Institute of Education
 Sciences
Statewide Longitudinal Data          34,539          70,000       35,461
 Systems......................
Statistics....................      103,060         108,748        5,688
    Total Increase............  ...........  ..............       41,149
------------------------------------------------------------------------

    Thank you for the opportunity to comment.

    [This statement was submitted by Rachel Zinn, Director, Workforce 
Data Quality Campaign.]
                                 ______
                                 







       LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                              ----------                              
                                                                   Page

Academy of Nutrition and Dietetics, Prepared Statement of the....   330
AcademyHealth, Prepared Statement of.............................   331
Ad Hoc Group for Medical Research, Prepared Statement of the.....   333
AIDS Alliance for Women, Infants, Children, Youth & Families, 
  Prepared Statement of the......................................   335
AIDS Institute, Prepared Statement of the........................   337
AIDS United, Prepared Statement of the...........................   339
Alexander, Senator Lamar, U.S. Senator From Tennessee, Questions 
  Submitted by.................................................160, 227
Alzheimer's:
    Association, Prepared Statement of the.......................   342
    Foundation of America, Prepared Statement of the.............   344
America Achieves, Prepared Statement of the......................   346
American Academy of:
    Family Physicians, Prepared Statement of the.................   348
    Pediatrics, Prepared Statement of the........................   350
    Physician Assistants, Prepared Statement of the..............   352
American Alliance of Museums, Prepared Statement of the..........   355
American Association for Dental Research, Prepared Statement of 
  the............................................................   357
American Association of:
    Colleges of Nursing, Prepared Statement of the...............   359
    Colleges of Osteopathic Medicine, Prepared Statement of the..   361
    Immunologists, Prepared Statement of the.....................   363
    Nurse Anesthetists, Prepared Statement of the................   365
    Nurse Practitioners, Prepared Statement of the...............   367
American College of:
    Physicians, Prepared Statement of the........................   370
    Preventive Medicine, Prepared Statement of the...............   372
    Radiology, Prepared Statement of the.........................   374
American Congress of Obstetricians and Gynecologists, Prepared 
  Statement of the...............................................   368
American Dental Education Association, Prepared Statement of the.   375
American Dental Hygienists' Association, Prepared Statement of 
  the............................................................   377
American Foundation for Suicide Prevention, Prepared Statement of 
  the............................................................   379
American Geriatrics Society, Prepared Statement of the...........   381
American Heart Association, Prepared Statement of the............   383
American Indian Higher Education Consortium, Prepared Statement 
  of the.........................................................   385
American Physiological Society, Prepared Statement of the........   387
American Psychological Association, Prepared Statement of the....   389
American Public Health Association, Prepared Statement of the....   391
American Society for:
    Clinical Oncology, Prepared Statement of the.................   401
    Hematology, Prepared Statement of the........................   404
    Microbiology, Prepared Statement of the....................393, 396
    Nephrology, Prepared Statement of the........................   405
    Nutrition, Prepared Statement of the.........................   398
    Plant Biologists, Prepared Statement of the..................   406
    Pharmacology & Experimental Therapeutics, Prepared Statement 
      of the.....................................................   399
American Thoracic Society, Prepared Statement of the.............   408
Americans for Nursing Shortage Relief, Prepared Statement of the.   411
Animal Protection of New Mexico and Animal Protection Voters, 
  Prepared Statement of the......................................   413
Association of:
    American Cancer Institutes, Prepared Statement of the........   415
    American Medical Colleges, Prepared Statement of the.........   417
    Independent Research Institutes, Prepared Statement of the...   419
    Public Television Stations and the Public Broadcasting 
      Service, Prepared Statement of the.........................   321
    University Programs in Occupational Health and Safety, 
      Prepared Statement of the..................................   421
    Zoos and Aquariums, Prepared Statement of the................   423
Austin, Christopher P., M.D., Director, National Center for 
  Advancing Translational Sciences...............................     1
    Prepared Statement of........................................    30

Birnbaum, Linda S., Ph.D., D.A.B.T., A.T.S., Director, National 
  Institute of Environmental Health Sciences, Prepared Statement 
  of.............................................................    32
Boozman, Senator John, U.S. Senator From Arkansas, Questions 
  Submitted by.................................................233, 285
Brain Injury Association of America, Prepared Statement of the...   424
Briggs, Josephine P., M.D., Director, National Center for 
  Complementary and Alternative Medicine, Prepared Statement of..    35

California Association of:
    Psychiatric Technicians, Prepared Statement of the...........   425
    State Hospital Parent Councils for the Retarded, Prepared 
      Statement of the...........................................   427
Centers for Disease Control and Prevention Coalition, Prepared 
  Statement of the...............................................   427
Children's Environmental Health Network, Prepared Statement of 
  the............................................................   429
Children's Hospital Association, Prepared Statement of the.......   431
Coalition for:
    Clinical and Translational Science, Prepared Statement of the   433
    Usher Syndrome Research, Prepared Statement of the...........   435
Coalition of Northeastern Governors, Prepared Statement of the...   437
Cochran, Senator Thad, U.S. Senator From Mississippi, Question 
  Submitted by............................................110, 155, 223
College on Problems of Drug Dependence, Prepared Statement of the   438
Collins, Francis S., M.D., Ph.D., Director, National Institutes 
  of Health, Department of Health and Human Services.............     1
    Prepared Statement of........................................    20
    Summary Statement of.........................................     5
Consortium of Social Science Associations, Prepared Statement of 
  the............................................................   440
Corporation for Public Broadcasting, Prepared Statement of the...   442
Council of Academic Family Medicine, Prepared Statement of.......   444
Council on Social Work Education, Prepared Statement of the......   446
Crohn's and Colitis Foundation of America, Prepared Statement of 
  the............................................................   449
Cystic Fibrosis Foundation, Prepared Statement of the............   450

Digestive Disease National Coalition, Prepared Statement of the..   452
Duncan, Hon. Arne, Secretary, Office of the Secretary, Department 
  of Education...................................................   165
    Prepared Statement of........................................   174
    Summary Statement of.........................................   169
Durbin, Senator Richard J., U.S. Senator From Illinois, Questions 
  Submitted by...................................99, 279, 288, 292, 310
Dystonia Medical Research Foundation, Prepared Statement of......   454

Elder Justice Coalition, Prepared Statement of the...............   456
Eldercare Workforce Alliance, Prepared Statement of the..........   457
Emergency Nurses Association, Prepared Statement of the..........   459
Endocrine Society, Prepared Statement of the.....................   461
Entomological Society of America, Prepared Statement of the......   464

Families & Friends of Care Facility Residents, Prepared Statement 
  of.............................................................   465
Fauci, Anthony S., M.D., Director, National Institute of Allergy 
  and Infectious Diseases........................................     1
    Prepared Statement of........................................    22
Federation of American Societies for Experimental Biology, 
  Prepared Statement of the......................................   468
Felak, Cheryl, Prepared Statement of.............................   469
Frieden, Hon. Thomas R., M.D., M.P.H., Director Centers for 
  Disease Control and Prevention.................................   249
    Prepared Statement of........................................   251
    Questions Submitted to.......................................   291
Friends of the Health Resources and Services Administration, 
  Prepared Statement of the......................................   470
Friends of the National Institute of:
    Child Health and Human Development, Prepared Statement of....   472
    Dental and Craniofacial Research, Prepared Statement of the..   474
    Drug Abuse, Prepared Statement of the........................   477
FSH Society, Inc., Prepared Statement of the.....................   479

GBS/CIDP Foundation International, Prepared Statement of the.....   483
Gibbons, Gary H., M.D., Director, National Heart, Lung and Blood 
  Institute......................................................     1
Girl Scouts of the USA, Prepared Statement of....................   485
Glass, Roger I., M.D., Ph.D., Director, Fogarty International 
  Center, Prepared Statement of..................................    37
Global Health Technologies Coalition, Prepared Statement of......   488
Government Relations Easter Seals, Inc., Prepared Statement of 
  the............................................................   490
Grady, Patricia A., Ph.D., RN, FAAN, Director, National Institute 
  of Nursing Research, Prepared Statement of.....................    38
Graham, Senator Lindsey, U.S. Senator From South Carolina, 
  Questions Submitted by.......................................112, 302
Green, Eric, M.D., Ph.D, Director, National Human Genome Research 
  Institute, Prepared Statement of...............................    40
Greenberg, Mark H., Esq., Acting Assistant Secretary, 
  Administration for Children and Families.......................   246
    Prepared Statement of........................................   247
    Questions Submitted to.......................................   288
Guttmacher, Alan E., M.D., Director, ``Eunice Kennedy Shriver'' 
  National Institute of Child Health and Human Development, 
  Prepared Statement of..........................................    42

Harkin, Chairman Tom, U.S. Senator From Iowa:
    Opening Statements of.............................1, 115, 165, 237,
    Prepared Statement of........................................   166
    Questions Submitted by..................94, 142, 193, 277, 291, 308
Harm Reduction Coalition, Prepared Statement of the..............   492
Health Professions and Nursing Education Coalition, Prepared 
  Statement of the...............................................   493
HIV Medicine Association, Prepared Statement of the..............   496
Hodes, Richard J., M.D., Director, National Institute on Aging, 
  Prepared Statement of..........................................    44
Humane Society of the United States and the Humane Society 
  Legislative Fund, Prepared Statement of the....................   498

Infectious Diseases Society of America's, Prepared Statement of 
  the............................................................   500
Inspector General, Railroad Retirement Board, Prepared Statement 
  of the.........................................................   328
International Foundation for Functional Gastrointestinal 
  Disorders, Prepared Statement of the...........................   502
Interstate Mining Compact Commission, Prepared Statement of the..   504
Interstitial Cystitis Association, Prepared Statement of the.....   511

Jamestown S'Klallam Tribe, Prepared Statement of the.............   513
Johanns, Senator Mike, U.S. Senator From Nebraska, Questions 
  Submitted by...................................................   161

Katz, Stephen I., M.D., Ph.D., Director, National Institute of 
  Arthritis and Musculoskeletal and Skin Diseases, Prepared 
  Statement of...................................................    46
Kirk, Senator Mark, U.S. Senator From Illinois, Questions 
  Submitted by.................................................231, 303
Klurfeld, Michael, Prepared Statement of.........................   516
KNI Parent Guardian Group, Prepared Statement of the.............   518
Koob, George, Ph.D., Director, National Institute on Alcohol 
  Abuse and alcoholism, Prepared Statement of....................    47
Komen, Susan G., Prepared Statement of...........................   520

Landis, Story C., PH.D., Director, National Institute of 
  Neurological Disorders and Stroke..............................     1
    Prepared Statement of........................................    29
Landrieu, Senator Mary L., U.S. Senator From Louisana, Questions 
  Submitted by.................................................198, 278
Lenders Coalition for Community Health Centers, Prepared 
  Statement of the...............................................   522
Lindberg, Donald A.B., M.D., Director, National Library of 
  Medicine, Prepared Statement of................................    49
Local Initiatives Support Corporation, Prepared Statement of the.   524
Lorsch, Jon R., PH.D., Director, National Institute of General 
  Medical Sciences, Prepared Statement of........................    51
Love, Timothy, Chief Operating Officer, Centers for Medicare and 
  Medicaid Services..............................................   237
    Prepared Statement of........................................   244
    Questions Submitted to.......................................   277
    Summary Statement of.........................................   242

Maddox, Yvonne T., Ph.D., Director, National Institute on 
  Minority Health and Health Disparities, Prepared Statement of..    53
March of Dimes Foundation, Prepared Statement of the.............   528
Marfan Foundation, Prepared Statement of the.....................   530
Meals On Wheels Association of America, Prepared Statement of the   534
Medical Library Association and Association of Academic Health 
  Sciences Libraries, Prepared Statement of the..................   536
Members of the Nursing Community Submitting this Testimony.......   612
Mesothelioma Applied Research Foundation, Prepared Statement of 
  the............................................................   538
Mikulski, Barbara A., U.S. Senator From Maryland, Prepared 
  Statement of...................................................   239
Moran, Senator Jerry, U.S. Senator From Kansas:
    Questions Submitted by............106, 146, 213, 281, 288, 299, 315
    Statements of......................................4, 116, 167, 240
Murray, Senator Patty, U.S. Senator From Washington, Questions 
  Submitted by...................................................   195

National AHEC Organization, Prepared Statement of the............   540
National Alliance:
    for Eye and Vision Research, Prepared Statement of the.......   541
    on Mental Illness, Prepared Statement of the.................   543
    to End Sexual Violence, Prepared Statement of the............   546
National Alopecia Areata Foundation, Prepared Statement of the...   548
National Association for:
    Geriatric Education, Prepared Statement of the...............   550
    State Community Services Programs, Prepared Statement of the.   551
National Association of:
    Chain Drug Stores, Prepared Statement of the.................   553
    Community Health Centers, Prepared Statement of the..........   555
    County and City Health Officials, Prepared Statement of the..   556
National Association of State:
    Directors of Career and Technical Education Consortium, 
      Prepared Statement of the..................................   558
    Head Injury Administrators, Prepared Statement of the........   559
    Long-Term Care Ombudsman Programs, Prepared Statement of the.   561
    National Association of States United for Aging and 
      Disabilities, Prepared Statement of the....................   563
National Blood Clot Alliance, Prepared Statement of the..........   564
National Center for Learning Disabilities, Prepared Statement of 
  the............................................................   565
National Children's Facilities Network, Prepared Statement of the   567
National Congress of American Indians, Prepared Statement of the.   568
National Council of Social Security Management Associations, 
  Prepared Statement of..........................................   571
National Energy Assistance Directors' Association, Prepared 
  Statement of the...............................................   573
National Family Planning & Reproductive Health Association, 
  Prepared Statement of the......................................   575
National Head Start Association, Prepared Statement of the.......   576
National Indian Child Welfare Association, Prepared Statement of 
  the............................................................   578
National Indian Education Association, Prepared Statement of the.   581
National Kidney Foundation, Prepared Statement of the............   583
National League for Nursing, Prepared Statement of the...........   585
National MPS Society, Prepared Statement of the..................   588
National Multiple Sclerosis Society, Prepared Statement of the...   590
National Nursing Centers Consortium, Prepared Statement of the...   591
National Public Radio, Prepared Statement of the.................   324
National Respite Coalition, Prepared Statement of the............   594
National Rural Health Association, Prepared Statement of the.....   597
National Safety Council, Prepared Statement of the...............   599
National Technical Institute for the Deaf and Rochester Institute 
  of Technology, Prepared Statement of the.......................   601
National Violence Prevention Network, Prepared Statement of the..   603
Native Hawaiian Education Council, Prepared Statement of the.....   605
Nephcure Foundation, Prepared Statement of the...................   606
Neurofibromatosis Network, Prepared Statement of the.............   607
New England Educational Opportunity Association, Prepared 
  Statement of the...............................................   609
New Hampshire Community Loan Fund, Prepared Statement of the.....   610
Nursing Community, Prepared Statement of the.....................   610

Older Americans Act, Prepared Statement of the...................   613
Ovarian Cancer National Alliance, Prepared Statement of the......   616

Parents of Dead Children, Prepared Statement of..................   618
Parkinson's Action Network, Prepared Statement of the............   619
Perez, Hon. Thomas E., Secretary, Office of the Secretary, 
  Department of Labor............................................   115
    Prepared Statement of........................................   121
    Summary Statement of.........................................   118
Pettigrew, Roderic I., Ph.D., M.D., Director, National Institute 
  of Biomedical Imaging and Bioengineering, Prepared Statement of    55
Pew Children's Dental Campaign, Prepared Statement of the........   621
Physician Assistant Education Association, Prepared Statement of 
  the............................................................   623
Population Association of America and Association of Population 
  Centers, Prepared Statement of the.............................   626
Prevent Blindness, Prepared Statement of.........................   628
Prostatitis Foundation, Prepared Statement of the................   630
Pryor, Senator Mark, U.S. Senator From Arkansas, Questions 
  Submitted by...................................................   205
Pulmonary Hypertension Association, Prepared Statement of the....   630

Railroad Retirement Board, Prepared Statement of the.............   326
Research Working Group, Prepared Statement of the................   634
Research!America, Prepared Statement of..........................   633
Reed, Senator Jack, U.S. Senator From Rhode Island, Questions 
  Submitted by.................................................144, 202
Rodgers, Griffin P., M.D., M.A.C.P., Director, National Institute 
  of Diabetes and Digestive and Kidney Diseases, Prepared 
  Statement of...................................................    56
Rotary International, Prepared Statement of the..................   636
Ryan White Medical Providers Coalition, Prepared Statement of the   638

Safe States Alliance, Prepared Statement of the..................   640
Scleroderma Foundation, Prepared Statement of the................   642
Senior Service America, Inc., Prepared Statement of the..........   645
Shaheen, Senator Jeanne, U.S. Senator From New Hampshire, 
  Questions Submitted by........................103, 205, 280, 296, 313
Shelby, Senator Richard C., U.S. Senator From Alabama, Questions 
  Submitted by........................110, 156, 223, 284, 289, 301, 319
Sieving, Paul A., M.D., Ph.D., Director, National Eye Institute, 
  Prepared Statement of..........................................    58
Skelly, Thomas P., Director, Budget Service, Department of 
  Education......................................................   165
Sleep Research Society, Prepared Statement of the................   650
Society for:
    Healthcare Epidemiology of America and the Association for 
      Professionals in Infection Control and Epidemiology, 
      Prepared Statement of the..................................   652
    Neuroscience, Prepared Statement of the......................   654
    Public Health Education, Prepared Statement of the.........657, 660
    Women's Health Research, Prepared Statement of the...........   662
Somerman, Martha, D.D.S., Ph.D., Director, National Institute of 
  Dental and Craniofacial Research, Prepared Statement of........    60
Squaxin Island Tribe, Prepared Statement of the..................   664

Tabak, Lawrence A., D.D.S., Ph.D., Office of Director, Prepared 
  Statement of...................................................    62
Treatment Advocacy Center, Prepared Statement of the.............   665
Trevor Project, Prepared Statement of the........................   668
Tri-Council for Nursing, Prepared Statement of the...............   671
Trust for America's Health, Prepared Statement of the............   673

Underwood, Rebecca, Parent/Guardian/Advocate, Prepared Statement 
  of.............................................................   675
United Negro College Fund, Prepared Statement of the.............   677
United Tribes Technical College, Prepared Statement of the.......   681
University of Kansas Medical Center, Prepared Statement of the...   683
University of North Dakota and North Dakota State University, 
  Prepared Statement of the......................................   686
US Hereditary Angioedema Association, Prepared Statement of......   688

Varmus, Harold E., M.D., Director, National Cancer Institute.....     1
Vitale, Mary A., Guardian/Sibling/Advocate, Prepared Statement of   533
VOR, Prepared Statement of.......................................   689
Volkow, Nora D., M.D., Director, National Institute on Drug 
  Abuse, Prepared Statement of...................................    64

Wakefield, Hon. Mary K., Ph.D., R.N., Administrator, Health 
  Resources and Services Administration..........................   253
    Prepared Statement of........................................   255
    Questions Submitted to.......................................   308
Whitescarver, Jack, Ph.D., Director, Office of AIDS Research, 
  Prepared Statement of..........................................    66
Workforce Data Quality Campaign, Prepared Statement of the.......   691




                             SUBJECT INDEX

                              ----------                              

                   CORPORATION OF PUBLIC BROADCASTING

Corporation for Public Broadcasting..............................   321
    Request for Appropriations...................................   321

                        DEPARTMENT OF EDUCATION

                        Office of the Secretary

Ability of Rural Schools to Compete for Grant Funds..............   189
Access to:
    Early Learning...............................................   170
    Effective Library Programs...................................   203
    Postsecondary Education......................................   200
Additional Committee Questions...................................   193
Affordability and Quality in Postsecondary Education.............   175
All Year School Study Act (S. 2029)............................190, 191
Alternate Funding Sources for College Ratings System.............   215
American Printing House Resources With Enhanced Accessibility for 
  Learning Plan..................................................   196
Assessing the Impact of Formula Versus Competitive Grant Programs   212
Bipartisan Support Needed to Close Opportunity Gaps..............   169
Budget:
    Goal--Closing Opportunity Gaps, Fiscal Year 2015.............   173
    Request:
        Department of Education Fiscal Year 2015.................   165
        President Obama's 2015...................................   175
Career and Technical Education Funding...........................   217
Chairman's Closing Remarks.......................................   193
Changing Special Education to Outcomes...........................   178
Charter School:
    Access to School Turnaround Funds............................   186
    Program......................................................   184
Charter Schools as Means for Turning Around Schools..............   186
Chief Information Officer Role in Information Technology 
  Investments....................................................   220
College Access Challenge Grants..................................   203
College Opportunity and Graduation Bonus Grants..................   179
College Ratings System:
    Costs to Date................................................   215
    Criteria.....................................................   179
    Development Funds............................................   215
    in the Fiscal Year 2015 Budget Request.......................   215
Committed to Development of College Ratings System...............   181
Competitive Grant:
    Awards and Recipients in Fiscal Years 2013 and 2014..........   206
    Programs as Percentage of Education Funds....................   187
    Versus Formula Allocation Programs...........................   186
Competitive Programs and:
    Competitive Ability of Small, Rural States...................   205
    Equity and Opportunity Gaps..................................   234
    the Reduction of Achievement and Opportunity Gaps............   216
Congressional Provisions for School Improvement Grants Program 
  Flexibility....................................................   230
Connect ED and:
    Common Core Assessments......................................   197
    Teacher Evaluation Systems...................................   197
Considerations in Developing Ratings Criteria....................   180
Cost to Impact Aid Program of Reduced Department of Defense 
  Funding of Domestic Defense Schools............................   218
Costs Associated With Gainful Employment Regulation..............   227
Data Collection on Online Learning Programs......................   205
Department of Education Fiscal Year 2015 Budget Request..........   165
Department Outreach for Innovative Approaches to Literacy Grant 
  Applications...................................................   202
Department Technology Applications--Cloudfirst and Sharefirst 
  Initiatives....................................................   221
Departmental Central Processing System and FAFSA-on-the-Web......   222
Development, Modernization, and Enhancement Funding..............   221
Disbursement of Federal Student Aid--Debit and Prepaid Cards.....   227
Distribution of FSA GE Obligations in Fiscal Years 2011-2012.....   228
Education Investment in Higher Education.........................   181
Education Research and Development...............................   219
Educational Innovation and Improvement...........................   176
Effective Teachers and Leaders State Grants......................   212
Elementary and Secondary Education Act Waivers and Student 
  Protections....................................................   195
Ensuring:
    Privacy of Student Data Under Connect ED.....................   198
    Timely Access to Printed Text for Blind and Disabled.........   196
    Widespread Benefits From Competitive Programs................   233
Entrepreneurship.................................................   218
Equity and:
    Competitive Programs.........................................   216
    Opportunity..................................................   175
Estimated Costs Associated With Implementation of Gainful 
  Employment Regulation..........................................   228
Estimated Gainful Employment Regulation Implementation Costs.....   229
Expanding High-Quality Preschool.................................   175
FAFSA-on-the-Web Management......................................   223
First in the World in College Completion.........................   179
Fiscal Year:
    2013 New Discretionary Grant Awards to States and Local 
      Educational Agencies.......................................   206
    2014 Omnibus Appropriations Bill.............................   166
    2015:
        Budget Goal--Closing Opportunity Gaps....................   173
        Department of Education, Budget Request..................   165
Foreign Language Immersion Programs and Investing in Innovation 
  Funding........................................................   232
Funding for:
    Charter School Program.......................................   198
    High School Equivalency Program and College Acceptance 
      Migrant Program............................................   196
    Historically Black Colleges and Universities.................   199
Funding of:
    Competitive Versus Formula Grant Programs....................   168
    Demonstration, Modernization, and Enhancement of IT Systems..   221
Funds for Charter Schools and School Improvement Grants..........   185
Gainful Employment:
    Institutional Accountability Metrics.........................   229
    Calculation of Debt-To-Earnings Ratios.......................   229
    Privacy Protections..........................................   229
Gap in Access to High-Speed Broadband............................   172
Good and Bad News for Education..................................   169
Grant Periods of Competitive Grant Programs......................   212
Guidance Provided on Use of Title I Funds for Homeless Students..   195
Harkin, Leadership Contributions of Chairman Tom.................   174
High:
    Cost of Postsecondary Education..............................   187
    Quality Early Learning.......................................   193
    School Graduation Initiative.................................   194
Higher Education Services for Disadvantaged Students.............   219
Impact Aid Payments for Federal Property.........................   217
Impact of Innovation Fund Set-Aside on Career and Technical 
  Education State Funding Levels and Students....................   217
Improving School Safety and Climate..............................   176
Incorporating Nontraditional Science, Technology, Engineering, 
  and Math Activities in After-School Programs...................   213
Innovation in Evaluation of Teacher Preparation Programs.........   231
Innovative Approaches to Literacy Grant Application..............   202
Institutional Access to Debt-to-Earnings Metrics.................   230
Introduction of Secretary of Education...........................   168
Investment in Career and Technical Education.....................   233
Kirk, From the Office of Senator Mark............................   191
Lack of Access to the Full Range of Math and Science Courses.....   171
Leadership Contributions of Chairman Tom Harkin..................   174
Learning From Previous Innovative Approaches to Literacy Grant 
  Competition....................................................   202
Mandatory Funding--Teacher and Principal Effectiveness...........   220
Maximizing Impact With Limited Funds.............................   190
Measuring the Success of Programs Providing Access to 
  Postsecondary Education........................................   200
Need for Focus on Completion as well as Access...................   181
New Discretionary Grant Awards to States and Local Educational 
  Agencies, Fiscal Year 2013.....................................   206
No Child Left Behind Waiver Authority............................   182
No Federal Role or Involvement in Curriculum.....................   183
Nondefense Discretionary Spending Cap............................   166
Omnibus Appropriations Bill, Fiscal Year 2014....................   166
Opportunity Gap in Access to Postsecondary Education.............   172
Opportunity, Growth, and Security Initiative.....................   177
Oregon's Pay It Forward Program..................................   187
Other Program Support for Year-Round Schooling...................   232
Overview of Implementation of School Improvement Grants..........   201
Participation Rate of States and Seas in Competitive Programs....   206
Pell Grants......................................................   225
Percentage of U.S. Schools With Broadband Access.................   173
Postsecondary Education Veterans' Resource Centers...............   224
Postsecondary Support Programs...................................   204
Preschool Development Grants.....................................   213
    Comprehensive Services.......................................   214
    Encouraging State and Community Cooperation..................   214
    Family Engagement............................................   214
    Funding Subgrants............................................   214
    Programs Requirements and Student Outcomes...................   213
    Students With Disabilities...................................   214
Preschool Education:
    Funds in Fiscal Year 2015 Budget.............................   170
    Leadership and Support.......................................   177
    Opportunity Gap..............................................   169
President Obama's 2015 Budget Request............................   175
Prioritizing and Funding STEM Initiatives Within Competitions of 
  Existing Federal Programs......................................   224
Professional Development Through the Connected Initiative........   197
Race to the Top--Equity and Opportunity...................200, 215, 225
Regulated Banks and Non-Bank Campus Financial Service Providers..   226
Regulations Affecting Management and Disbursement of Federal 
  Student Aid....................................................   226
Regulatory Cost-Benefit Analysis.................................   226
Requirements to Obtain No Child Left Behind Waiver...............   182
Results Driven Accountability Incentive Grants...................   178
Ryan Budget Impact on Education..................................   173
School Improvement Grants Funds..................................   186
Science, Technology, Engineering and Mathematics Competitive 
  Programs.......................................................   223
Selected Department of Education Shared Services.................   222
Special Education in Fiscal Year 2015 Budget Request.............   177
Special Education--Results Driven Accountability Incentive Grants   216
Student:
    Impact of Elimination of Payments for Federal Property.......   218
    Outcomes and 21st Century Workforce Needs....................   194
    Performance-Based Teacher Evaluation.........................   181
Students Benefiting From Race to the Top and Elementary and 
  Secondary School Act, Title I Services.........................   216
Successful and Effective i3 Program Models.......................   233
Successful School Turnaround Projects............................   201
Support for:
    High-Quality Early Learning..................................   170
    Successful Charter School Programs...........................   234
    Teachers and School Leaders..................................   175
    Year-Round School Programs--i3 and Promise Neighborhoods.....   231
Sustaining Preschool Development Grants..........................   214
Teacher Evaluation and Federally Granted Waivers.................   183
Teacher Quality Partnership Grants Application...................   204
    Priorities...................................................   204
Teachers Express Desire for More Classroom Technology............   173
Title II Funding:
    and the Supporting Effective Educator Development Grant 
      Program....................................................   223
    for SEED Program.............................................   199
Topic Areas Funded by the Investing in Innovation Fund...........   233
Transparency and Consumer Choice in Provision of Federal Student 
  Aid............................................................   227
TRIO Funding.....................................................   234
U.S. Lags Behind in Education....................................   191
Use of:
    Maintenance of Effort Standard...............................   203
    Performance and Outcome Information To Inform Policy and 
      Improvement................................................   199
    Title II National Activities Funds...........................   220
    i3 Program Funding...........................................   232
Using Performance Information to Turn Around Lowest Performing 
  Schools........................................................   202
Value of Early Learning..........................................   167
    Programs.....................................................   171
Veterans' Education..............................................   224
Year-Round:
    School Programs Research.....................................   232
    Schooling....................................................   192
    Schools and Student Achievement Outcomes.....................   232

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                     National Institutes of Health

Accelerating Medicines Partnership.................10, 11, 12, 106, 111
Additional Committee Questions...................................    93
Addressing Dual Burdens of Disease and Harnessing the Information 
  and Communication Technology Revolution for Global Health 
  Research, The Path Forward.....................................    38
Advancing Health Through Discovery...............................    52
Advancing Research on Natural Products...........................    36
AIDS Pandemic, The...............................................    67
AIDS Research Priorities and Opportunities.......................    67
Alzheimer's Disease..............................................    70
    Funding......................................................   109
American Cures Act...............................................    99
An Implantable Artificial Kidney Holds Promise for Patients on 
  Dialysis.......................................................    56
Animal Research..................................................    86
Asthma...........................................................   105
Autoimmune Diseases..............................................    76
Back to Basics...................................................    51
Better Pain Management: A Major Goal of Addiction Research.......    65
Big Data to Knowledge............................................    88
Big Opportunities in Big Data....................................    64
Biomedical and Health Information Services.......................    50
BRAIN Initiative.................................................14, 68
Brain Research through Application of Innovative 
  Neurotechnologies..............................................   108
Breast Cancer....................................................    33
    Screening....................................................   112
Budget Challenges................................................     7
Building Momentum Against Alzheimer's Disease....................    45
Burden of Neurological Disorders.................................    29
Cancer:
    and Distress.................................................    98
    Detection From a Routine Blood Sample........................    56
    Immunotherapy................................................    17
Chimpanzee Retirement............................................    94
Clinical and Translational Science Awards..................84, 107, 111
Clinical Science and Precision Medicine..........................    57
Collaborative Research Framework.................................    53
Community Engagement.............................................    54
Complementary and Integrative Health Care........................    35
Congenital Heart Disease.........................................   102
Coordinated Trans-NIH AIDS Research Program......................    67
Cures Acceleration Network.......................................    32
Cystic Fibrosis..................................................    77
DARPA-Like Program...............................................   106
Development and Regeneration.....................................    60
Diabetes.........................................................   103
Disease:
    Funding Prioritization.......................................    82
    Prevention...................................................    95
    Specific Funding.............................................    71
Division of Program Coordination, Planning, and Strategic 
  Initiatives (DPCPSI)...........................................    62
Economic Impact of Biomedical Research...........................    75
Embracing Research Opportunities.................................    43
Emergency Care...................................................   104
Emily's Story....................................................18, 19
Empowering the Next Generation of Researchers in Aging...........    45
Enhancing End-of-Life and Palliative Care........................    39
Environment and:
    Autoimmunity.................................................    33
    Neurological Disorders.......................................    33
Extraordinary Opportunities......................................    29
Focus on Rare Diseases...........................................    32
Fundamentals of Health Disparities...............................    53
Funding History and Success Rates................................    79
Future of:
    Biomedical Research..........................................     9
    Cancer Research..............................................    69
Grant Success Rates..............................................     8
Health Consequences of Marijuana Use.............................    65
Health Information for the Public................................    50
Immunoengineering to Modifiscal Year Immune System Responses.....    55
Impact of Funding on U.S. Innovation.............................    84
Impact on Public Health..........................................    35
Improving the Health and Well-Being of Older Americans...........    44
Individuals With Special Needs...................................    43
Infectious Diseases Research.....................................    22
Innovation in Treating Spinal Cord Injury: New Hope for Those 
  With Paralysis.................................................    55
Integrating Science-Based Information Into Practice..............    58
Jackson Heart Study..............................................   110
John Porter Memorial.............................................    78
Late Stage Drug Development Failures: Years of Work and Millions 
  of Dollars Lost................................................    10
Loan Repayment and Scholarship Programs..........................    64
Looking Toward the Future: Nurse Scientists......................    40
Medication in Pregnancy..........................................    97
Medications Development..........................................    66
Mission Into Action..............................................    31
National Cancer Institute Community Programs.....................    83
National Eye Institute (NEI):
    Audacious Goal Initiative....................................    58
    Regenerative Medicine Program................................    59
National Institutes of Health:
    AIDS Research Accomplishments................................    66
    Funding..................................................74, 79, 89
    Impact on U.S. Health and Medicine...........................     7
    Mission......................................................     6
    Program Level in Nominal Dollars and Constant 1998 Dollars...    90
National Institute on Alcohol Abuse and Alcoholism Research 
  (NIAAA)........................................................    48
New Areas of Emphasis............................................    59
Nurturing Talent and Innovation..............................37, 58, 65
Office of:
    AIDS Research (OAR)..........................................    62
    Behavioral and Social Sciences Research (OBSSR)..............    63
    Disease Prevention (ODP).....................................    63
    Research Infrastructure Programs (ORIP)......................    62
    Research on Women's Health (ORWH)............................    63
    Strategic Coordination (OSC) and the Common Fund.............    63
OppNet...........................................................   103
Opportunities in Cancer:
    Research.....................................................    15
    Therapeutics: Targeted therapy of mestastatic melanoma.......    15
Oral Cancer and Human Papillomavirus (HPV).......................    61
Oral Infections, Immunity and the Microbiome.....................    60
Overview of NCI Research Priorities..............................    24
Pediatric and Adolescent Development.............................    42
Planning Carefully for the Future................................    52
Potential Care for AIDS..........................................    91
Preempting and Preventing Chronic Disease........................    27
Preferred Method of Funding......................................    74
Pregnancy and Birth Outcomes.....................................    42
Programs and Priorities..........................................    30
Progress for Patients and Families...............................    29
Providing Useful Information to the Public.......................    36
Reducing Pain and Improving Symptom Management...................    35
Rehabilitation:
    Research.....................................................    96
    Standards....................................................    78
Research:
    on Immunology and Immune-Mediated Disorders..................    24
    Training and Infrastructure..................................    54
    Update on Endocrine Disruptors...............................    34
    Update on Gulf Oil Spill.....................................    34
Retirement of Chimpanzees........................................    81
Science Education Partnership Awards (SEPA)......................    62
Science, Technology, Engineering, and Mathematics................   110
Scientific Opportunities.........................................     9
Scope of the Problem.............................................    48
Self-Management of Chronic Illness...............................    39
Sequestration and Government Shutdown............................   100
Smart Homes for Healthy Independent Living at All Ages...........    56
Standards for Electronic Health Records..........................    50
Supporting a Diversity of Ideas..................................    52
Symptom Science: Promoting Personalized Health Strategies........    39
Temporomandibular Joint Disorders................................    61
The AIDS Pandemic................................................    67
The Office of:
    AIDS Research (OAR)..........................................    62
    Behavioral and Social Sciences Research (OBSSR)..............    63
    Disease Prevention (ODP).....................................    63
    Research on Women's Health (ORWH)............................    63
    Strategic Coordination (OSC) and the Common Fund.............    63
The Path Forward: Addressing Dual Burdens of Disease and 
  Harnessing the Information and Communication Technology 
  Revolution for Global Health Research..........................    38
Today's Basic Science for Tomorrow's Breakthroughs...........37, 57, 64
Translating Discoveries Into Public Health Impact................    28
Translational Research...........................................    31
    Spectrum.....................................................    31
Understanding Aging at Its Most Basic Level......................    44
Universal Flu Vaccine............................................12, 13
Unprecedented Scientific Opportunities...........................    27
Use of Complementary and Integrative Health Care.................    35
Wellness: Promoting Health and Preventing Illness................    39
Women's Health...................................................43, 85

                        Office of the Secretary

340 B Drug Discount Program, The.................................   309
Achieve Health Equity............................................   256
Additional Committee Questions...................................   277
Addressing the Over-Prescription of Psychotropic Drugs for 
  Children in Foster Care........................................   248
Administration for Children and Families' Fiscal Year 2015 Budget 
  Request........................................................   261
Affordable Care Act Funding......................................   276
Alzheimer's Disease Research.....................................   299
Antibiotic Resistance............................................   275
Area Health Education Centers....................................   319
Biomedical Research..............................................   292
Bolster Primary Care Infrastructure..............................   255
Budget, Fiscal Year 2015.........................................   247
Children's Hospital Graduate Medical Education & New Workforce 
  Initiative.....................................................   289
Community Health Centers..................................272, 284, 308
Critical Access Hospitals........................................   283
Duplication......................................................   301
Early Childhood Development......................................   247
Early Head Start-Child Care Partnerships.........................   256
Evaluation Tap...................................................   289
Exchange Cost....................................................   282
Exchange Enrollment..............................................   282
Fighting Antibiotic Resistance...................................   252
Fiscal Year 2015 Budget..........................................   247
Global Health Security...........................................   257
    Initiatives..................................................   275
Head Start.......................................................   288
Healthcare Fraud and Abuse.......................................   274
    Control Program..............................................   277
Healthy Homes and Lead Poisoning Prevention......................   265
Heathcare.gov Backend Systems....................................   284
Home Visiting and Lead Exposure..................................   266
Implementation of the Affordable Care Act........................   268
Improving the Efficiency of Medicare and Medicaid................   245
Information Technology...........................................   316
Keeping America and the World Safe Through Global Health Security   251
Linkages with Clinical Care......................................   291
Low-Income Home Energy assistance Program......................264, 268
Meaningful Use Stage 2...........................................   279
Medicaid Institutions for Mental Diseases........................   279
Mental Health....................................................   310
Navigators.......................................................   285
NonRecurring Expenses Fund.......................................   315
Oral Health......................................................   311
Packaging Rule...................................................   280
PostPartum Depression............................................   312
Prescription Drug:
    Abuse........................................................   269
    Overdose...................................................291, 299
Prevention and Public Health Fund................................   315
Private Insurance and the Marketplaces...........................   244
Program Integrity................................................   245
Program Management...............................................   244
Provider Non-discrimination (Section 2706).......................   278
Rate Stabilization Programs......................................   281
Recovery Audit Contractors.......................................   283
Reversing the Prescription Drug Overdose Epidemic................   252
Ryan White HIV/AIDS Program......................................   308
State-Based Exchange Replacement Costs...........................   283
Strategic National Stockpile.....................................   301
Strengthen HealthCare Workforce..................................   255
The 340 B Drug Discount Program..................................   309
Tobacco and E-Cigarettes.........................................   294
Unaccompanied Alien Children.....................................   248
    Program......................................................   288
Working to Provide Health Security 24/7..........................   251

                          DEPARTMENT OF LABOR

                        Office of the Secretary

Additional Committee Questions...................................   141
Additional Priorities............................................   126
Application of the Occupational Safety and Health Act to Farming 
  Operations With Less Than 10 Employees.........................   129
Bureau of International Labor Affairs (ILAB).....................   157
    Efforts To Combat Child Labor Abuses Abroad..................   142
Closing Statements...............................................   141
Combating Long-Term Unemployment.................................   120
Community Service Employment for Older Americans Program.........   150
Converting the Experimental Consumer Price Index for the Elderly 
  Into an Official Published Index...............................   136
Family Farm Exemption Under the Occupational Safety and Health 
  Act............................................................   136
Farm Safety for Just Kids Organization...........................   138
Fiscal Year 2015 President's Budget..............................   118
Governor's Set-Aside...........................................154, 157
Gulfport, Mississippi Job Corps Center...........................   155
H-1B Visa Program................................................   151
H-2B Rules.......................................................   156
Identifying and Combating Employee Misclassification.............   139
Implementing Reasonable Break Time for Nursing Mothers Provision 
  of Affordable Care Act.........................................   135
Improving Employment Opportunities for:
    People With Disabilities.....................................   127
    for Veterans.................................................   140
Inspector General's Report/Corrective Actions For Job Corps......   146
Investing in a Competitive Workforce.............................   123
Job Corps:
    Center Closures..............................................   147
    New On-Board Strength Model..................................   148
    Program Year 2012 Surplus....................................   144
Job-Driven Training for Workers Presidential Memorandum..........   149
New WHD Rule and Elimination of Companionship Exemption..........   161
Occupational Safety and Health Administration's (OSHA):
    Inspection of Family Farms...................................   162
    Regional Emphasis Program....................................   158
Opportunity, Growth and Security Initiative....................120, 122
President's Budget, Fiscal Year 2015.............................   118
Prohibiting Workplace Discrimination on the Basis of Sexual 
  Orientation or Gender Identity.................................   134
Proposed Silica Rule.............................................   160
Protecting America's Workers and Their Income and Retirement 
  Security.......................................................   124
Protecting Employee Wages, Safety, and Retirement Security.......   121
Rates for the auto supply industry, both nationally and in 
  Alabama........................................................   159
Redefining Fiduciary Under Employee Retirement Income Security 
  Act............................................................   162
Reemployment Eligibility Assessments.............................   143
Review of the Nation's Training Programs.........................   119
Revision of Program Requirements Handbook for Job Corps..........   145
Rewriting the Rule Defining Fiduciary Under Employee Retirement 
  Income Security Act............................................   130
Sector Strategies................................................   148
Strategies for Rewriting the Definition of a Fiduciary...........   132
Union Presence During OSHA Inspections...........................   162
Updating Regulations on Overtime.................................   133
Wage and Hour Division Plans To Prevent Abuses of Workers With 
  Disabilities...................................................   142
Wage Determinations on Military Bases............................   160
Workforce Innovation Fund........................................   158
Working With the Business Community To Employ People With 
  Disabilities...................................................   128

                       RAILROAD RETIREMENT BOARD

Agency Staffing..................................................   326
Financial Status of the Trust Funds..............................   327
Information Technology Improvements..............................   327
Other Requested Funding..........................................   327
Proposed Funding For Agency Administration.......................   326

                      Office of Inspector General

Budget Request...................................................   328
Office of:
    Audit........................................................   328
    Investigations...............................................   329
Operational Components...........................................   328

                                 [all]