[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





 
                  DEPARTMENTS OF LABOR, HEALTH AND HUMAN
                SERVICES, EDUCATION, AND RELATED AGENCIES
                         APPROPRIATIONS FOR 2017

_______________________________________________________________________

                                 HEARINGS

                                 BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FOURTEENTH CONGRESS

                              SECOND SESSION

                     ___________________________________

  SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
                    EDUCATION, AND RELATED AGENCIES

                       TOM COLE, Oklahoma, Chairman

  MICHAEL K. SIMPSON, Idaho                      ROSA L. DeLAURO, Connecticut
  STEVE WOMACK, Arkansas                         LUCILLE ROYBAL-ALLARD, California
  CHARLES J. FLEISCHMANN, Tennessee              BARBARA LEE, California
  ANDY HARRIS, Maryland                          CHAKA FATTAH, Pennsylvania
  MARTHA ROBY, Alabama
  CHARLES W. DENT, Pennsylvania
  E. SCOTT RIGELL, Virginia

 
  NOTE: Under Committee Rules, Mr. Rogers, as Chairman of the Full Committee, and Mrs. Lowey, as Ranking
 Minority Member of the Full Committee, are authorized to sit as Members of all Subcommittees.

                           Susan Ross, John Bartrum, Jennifer Cama,
                       Justin Gibbons, Kathryn Salmon, and Lori Bias,
                                 Subcommittee Staff
  
                     ___________________________________

                                  PART 6

                                                                   Page
  National Institutes of Health................................       1
                                                                      
  Department of Education......................................     167
                                                                    
  Centers for Disease Control and Prevention ..................     215
  
  

                                                                    

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]      



                      ___________________________________

          Printed for the use of the Committee on Appropriations

                     ___________________________________

                    U.S. GOVERNMENT PUBLISHING OFFICE

  21-343                    WASHINGTON: 2016

                            



                      COMMITTEE ON APPROPRIATIONS

                                ----------                              
                   HAROLD ROGERS, Kentucky, Chairman


  RODNEY P. FRELINGHUYSEN, New Jersey                   NITA M. LOWEY, New York
  ROBERT B. ADERHOLT, Alabama                           MARCY KAPTUR, Ohio
  KAY GRANGER, Texas                                    PETER J. VISCLOSKY, Indiana
  MICHAEL K. SIMPSON, Idaho                             JOSE E. SERRANO, New York
  JOHN ABNEY CULBERSON, Texas                           ROSA L. DeLAURO, Connecticut
  ANDER CRENSHAW, Florida                               DAVID E. PRICE, North Carolina
  JOHN R. CARTER, Texas                                 LUCILLE ROYBAL-ALLARD, California
  KEN CALVERT, California                               SAM FARR, California
  TOM COLE, Oklahoma                                    CHAKA FATTAH, Pennsylvania
  MARIO DIAZ-BALART, Florida                            SANFORD D. BISHOP, Jr., Georgia
  CHARLES W. DENT, Pennsylvania                         BARBARA LEE, California
  TOM GRAVES, Georgia                                   MICHAEL M. HONDA, California
  KEVIN YODER, Kansas                                   BETTY McCOLLUM, Minnesota
  STEVE WOMACK, Arkansas                                STEVE ISRAEL, New York
  JEFF FORTENBERRY, Nebraska                            TIM RYAN, Ohio
  THOMAS J. ROONEY, Florida                             C. A. DUTCH RUPPERSBERGER, Maryland
  CHARLES J. FLEISCHMANN, Tennessee                     DEBBIE WASSERMAN SCHULTZ, Florida
  JAIME HERRERA BEUTLER, Washington                     HENRY CUELLAR, Texas
  DAVID P. JOYCE, Ohio                                  CHELLIE PINGREE, Maine
  DAVID G. VALADAO, California                          MIKE QUIGLEY, Illinois
  ANDY HARRIS, Maryland                                 DEREK KILMER, Washington
  MARTHA ROBY, Alabama
  MARK E. AMODEI, Nevada
  CHRIS STEWART, Utah
  E. SCOTT RIGELL, Virginia
  DAVID W. JOLLY, Florida
  DAVID YOUNG, Iowa
  EVAN H. JENKINS, West Virginia
  STEVEN M. PALAZZO, Mississippi

  
                William E. Smith, Clerk and Staff Director

                                   (ii)
                                   
                                   
                                   


DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2017

                             _______________________                            


                                         Wednesday, March 16, 2016.

                     NATIONAL INSTITUTES OF HEALTH

                               WITNESSES

HON. FRANCIS S. COLLINS, DIRECTOR, NATIONAL INSTITUTES OF HEALTH
DOUGLAS LOWY, M.D., ACTING DIRECTOR, NATIONAL CANCER INSTITUTE
ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY AND 
    INFECTIOUS DISEASES
RICHARD J. HODES, M.D., DIRECTOR, NATIONAL INSTITUTE ON AGING
NORA D. VOLKOW, M.D., DIRECTOR, NATIONAL INSTITUTE ON DRUG ABUSE
    Mr. Cole. Good morning. It is my pleasure to welcome you to 
the Subcommittee on Labor, Health and Human Services, and 
Education to discuss the fiscal year 2017 National Institutes 
of Health budget request. We are looking forward to hearing the 
testimony of Dr. Collins, and his colleagues, I know, will be 
brought in for questions along the way.
    I would like to publicly thank Dr. Collins and the staff at 
the NIH for hosting me and other subcommittee members for a 
briefing and a tour at the NIH campus a few weeks ago, the 
second of what I hope becomes an annual trek out to NIH by this 
committee. We all left NIH with a deeper appreciation of the 
exciting work your staff do every day to find ways to save 
lives.
    I am proud that last year this Congress was able to 
increase NIH funding by $2,000,000,000, and I am confident that 
through these efforts, one day we will find cures for diseases 
like cancer and Alzheimer's. I was, therefore, especially 
disappointed to see the proposed budget cut to the National 
Institutes of Health this year by the administration.
    A proposal to divert $1,000,000,000 of biomedical research 
funds to the mandatory side of the budget ledger and rely on 
new and possibly unlikely authorizations to continue the 
advances that we have made in increasing the research funding 
is disheartening. Frankly, I do not plan to let the 
$1,000,000,000 cut stand. We need to ensure a sufficient basic 
biomedical research base is sustained to pave the way for these 
long-term advancements.
    Proposing new one-time mandatory spending that may never 
materialize is not the path to do this. I look forward to 
discussing the effects of the President's proposed 
discretionary budget cuts on your research this morning.
    I also want to stress how important it is to ensure that we 
continue to focus on the next generation of investigators. We 
know how long it takes for a new drug or treatment to make it 
from the lab to the patient. So without a pipeline of young 
researchers committed to following the process, we won't be 
able to find the cures we seek.
    I will be asking some questions this morning about a 
variety of issues like Institutional Development Awards, 
Alzheimer's disease, and the Cancer Moonshot. I hope to learn 
more this morning on how the increases we provided for the NIH 
this year are being used to move us forward toward cures of 
these diseases that cause so much suffering in our Nation.
    So without much further ado, I want to welcome Dr. Francis 
Collins, the NIH Director, to the subcommittee. Dr. Collins is 
accompanied by four of his institute directors who can assist 
in answering specific Member questions. They are Dr. Anthony 
Fauci, the Director of the National Institute of Allergy and 
Infectious Diseases; Dr. Richard Hodes, the Director of the 
National Institute of Aging; Dr. Doug Lowy, the Acting Director 
of the National Cancer Institute; and Dr. Nora Volkow, the 
Director of the Institute on Drug Abuse.
    As a reminder to the subcommittee and our witnesses, we 
will abide by the 5-minute rule. But before we begin, we have 
been joined by both the big chairman, as we like to call him, 
and our ranking member. And so I am going to defer first to the 
chairman for any remarks he would like to make.
    Then I am going to move to Mrs. Lowey, and then I will move 
to my good friend and ranking member, Ms. DeLauro. And then we 
will move to the testimony.
    So, Mr. Chairman.
    Mr. Rogers. Mr. Chairman, thank you.
    Mr. Cole. And may I add, the 5-minute clock does not apply 
to you. [Laughter.]
    Mr. Rogers. That means I have got to keep it under 1 
minute.
    Well, welcome, all of you, to this hearing, and thank you, 
Mr. Chairman, for the courtesy.
    Through all of our work together, Dr. Collins, you have 
exhibited the highest level of professionalism and dedication. 
And during a time of so much groundbreaking research in 
addiction science, Alzheimer's, cancer, NIH surely has the 
right man at the helm, I think, to meet the challenges that we 
face.
    The emergence of the Zika virus throughout the Western 
Hemisphere, one of those challenges that you are undertaking, 
underscores the importance of NIH's mission to gain and apply 
knowledge to enhance health, lengthen life, and to reduce 
illness and disability. Since most of its recent emergence in 
Brazil 10 months ago, Zika, of course, has spread to dozens of 
countries. And although CDC does not anticipate any widespread 
outbreak in the U.S., we have had 193 travel-associated cases 
reported thus far.
    The chairman and I and others just returned from a visit to 
South America night before last. We met leaders, health 
officials about--talking about the virus. We are interested to 
hear your thoughts on the role NIH can play and are playing to 
develop vaccines and therapeutics based on existing and future 
research to limit Americans' exposure going forward.
    We met with various officials on that trip, particularly in 
Brazil, and explored what they are doing to try to tamp out the 
exposure--and others in the region.
    Given the importance of NIH research, I am proud that we 
were able to work in a bipartisan fashion to increase your 
budget in fiscal 2016 by $2,000,000,000 to fund more 
groundbreaking medical research. This year, the NIH budget 
request prioritizes basic foundational research, precision 
medicine, and applying big data to improve health outcomes.
    In addition to the public health benefits that accompany 
your work, the economic impact of medical research should not 
be underestimated. NIH research dollars not only impact 
research facilities and researchers, but they also help get new 
drugs and devices to the marketplace.
    Through these funds, we have established a strong 
relationship between NIH and Kentucky, the Markey Cancer 
Center, a National Cancer Institute designated cancer center at 
the University of Kentucky, and the UK Center for Clinical and 
Translational Science, that continue to perform transformative 
research benefiting the entire region and country. We look 
forward to continuing our work together to bring an end to 
these devastating diseases.
    That being said, funding toward that goal must come through 
regular discretionary channels that allow us to respond to 
needs as they arise. I am disappointed to see the request cuts 
NIH discretionary funding by $1,000,000,000, including 
$57,000,000 from the National Institute on Drug Abuse, NIDA, 
and then backfills the hole with over $1,800,000,000 in 
mandatory money.
    However, I look forward to meeting your requirements 
through the regular appropriations process. We don't like 
mandatory spending. It has grown completely out of control. We 
have had to cut discretionary spending the last 5 years by some 
almost $200,000,000,000 in real cuts. In the meantime, the 
mandatory entitlement side of the budget is soaring out of 
control.
    When I came to Congress, we appropriated two-thirds of 
Federal spending. Now it is one-third. Entitlements were one-
third. Now they are two-thirds and growing. And unless we deal 
with it, we can't even pay the interest on the debt with 
discretionary funds.
    So that is why we are so dead set against mandatory 
increases. We need to keep control of the spending that takes 
place. It is the only accountable way under the Constitution.
    I am pleased to see Dr. Nora Volkow with us again this 
year. She has been a champion for advancing the science of drug 
abuse and addiction as the Director of the National Institute 
on Drug Abuse for 13 years now. Beyond her personal expertise 
in cutting-edge brain imaging, she has been with us since the 
beginning of our battle against drug abuse in southern and 
eastern Kentucky, where it really got its start.
    I am anxious to hear about your recent efforts regarding 
the abuse of prescription medications. As you well know, this 
epidemic now runs rampant across our Nation. I hope you will 
update the committee on your work with pharmaceutical companies 
to evaluate the risks associated with the long-term use of 
opioids and what NIH is doing to research abuse-deterrent 
medications and opioid alternatives.
    I am also pleased that you have both once again committed 
to sharing these insights at the National Prescription Summit 
in Atlanta in a few weeks, and we are excited about your being 
there for this one. And we are hopeful the chairman and others 
on the subcommittee will be able to make that fifth annual 
summit as well.
    Secondly, I look forward to hearing from you today about 
your pursuit of the Adolescent Brain Cognitive Development 
Study. I believe collecting extensive data on the effects of 
marijuana and other drugs on a young person's brain will help 
us finally appreciate the harm these substances can do over 
time.
    Federal law is clear. Yet States continue to rush to 
decriminalize or legalize marijuana, despite the lack of 
sufficient scientific data about its use. This study will help 
close that gap and, hopefully, shift public perception back to 
reality.
    We appreciate this very esteemed panel being with us today. 
We look forward to working with you during the year to make 
sure that you are doing what the country expects of us.
    Thank you, Mr. Chairman.
    Mr. Cole. Thank you, Mr. Chairman.
    We want to move next to our ranking member of the full 
committee, the distinguished lady from New York, Mrs. Lowey.
    Mrs. Lowey. And I thank you, my distinguished chair. And 
thank you for holding this very important hearing. Pleasure to 
be with you and Ranking Member DeLauro.
    This is one of the most exciting hearings I attend every, 
every appropriations session, and I would like to welcome Dr. 
Lowy, Dr. Fauci, Dr. Hodes, Dr. Volkow, and of course, Dr. 
Collins. I would also like to thank each of you for your 
service, and it is because of your vision and your dedication 
the National Institutes of Health are providing a bright future 
for millions of Americans suffering from illness and disease.
    I am very pleased you are here to discuss important 
investments in biomedical research and the health of our 
Nation. Thank you.
    And I must say I was thrilled, as I always am, to meet with 
many of you at the NIH 2 weeks ago. During our meetings, I saw 
firsthand the lifesaving breakthroughs you are leading, 
including gene therapies to treat patients with advanced 
cancer; ultra high field MRI machines to get the clearest look 
at an aging brain to date, allowing for advances in Alzheimer's 
and other brain diseases; and clinical studies that are 
improving mental health and reducing suicides and so much more.
    These breakthroughs and the need for additional research 
into hundreds of other diseases is why this committee fought to 
increase funding for the NIH by $2,000,000,000 in the fiscal 
year 2016 omnibus spending bill. NIH has the world's best 
physicians, researchers, technology at our disposal, and I 
worry that even a $2,000,000,000 investment will not go far 
enough to ensure that the NIH can compete against foreign 
research initiatives. It does not serve our national interests 
if there are not enough grants to support young researchers or 
if researchers are lured away to foreign countries to develop 
medical breakthroughs abroad.
    That is why last year, although I was pleased with the 
$2,000,000,000 increase, I called on this committee to once 
again commit to doubling funding for the NIH. I was here when 
that bipartisan effort was made, and I do call on my 
colleagues, both sides of the aisle, to double the funding for 
the NIH.
    We can't afford to let some of these brilliant researchers 
not get the support they need. Your fiscal 2017 budget request 
would be a positive step toward that end. Your budget includes 
targeted investments, such as the Cancer Moonshot, increases in 
the Precision Medicine Initiative, the BRAIN Initiative. In 
addition, it would result in 600 additional research project 
grants.
    These investments not only fund research that eases 
suffering, they would greatly reduce ballooning costs 
associated with treatment down the line. By the way, I must say 
I had the opportunity to visit Watson, the IBM research center 
in my district, just last week. And in fact, I am not sure I 
understood everything they were explaining to me, but what I 
paid particular attention to was the coordinative efforts 
between Watson and other research facilities and your precision 
brain initiative.
    It is so amazing to me that precision medicine and the 
research that is being done at the NIH is coordinating with 
many facilities. And I understand in my follow-up Watson isn't 
the only place. So, Dr. Collins, I would love if you would 
touch on that as well, the coordination that is going on and 
the amazing work to think that someone could get their cancer 
analyzed at the NIH and all the facilities out there in a 
machine such as Watson that could certainly help lead us to new 
discoveries and new cures.
    Let me say, however, while representing a net increase of 
$825,000,000, your budget will result in a $1,000,000,000 cut 
in discretionary funding for NIH. And I assure you that this 
chair and ranking member and the big chair, who I think is 
still over there, and I will just not let that happen. As an 
appropriator, the department's request for substantial sums in 
mandatory funding is of concern.
    Finally, in addition--and if you can get it, good luck to 
you. I mean, that would really be great.
    Finally, in addition to your budget request, the NIH is 
also awaiting congressional action on the emergency supplement 
to combat Zika. The world is looking to the United States to 
lead, and I am concerned that delaying consideration of the 
emergency supplemental is leaving the American public, 
particularly women who are pregnant or could soon be pregnant, 
at severe risk.
    And I know you are doing additional research, Dr. Fauci. I 
still am not satisfied that only pregnant women can suffer from 
Zika. So I know we have touched on that in our discussions.
    But the bottom line is we are already behind. We must act. 
I urge this committee and Congress as a whole to meet this need 
without delay.
    And thank you, Mr. Chairman.
    Mr. Cole. Thank you.
    We now to go to my good friend, the ranking member of the 
subcommittee, the gentlelady from Connecticut.
    Ms. DeLauro. Thank you very much, Mr. Chairman.
    And if there are any Yankee fans in this audience, you will 
know the term ``murderers' row,'' which was Babe Ruth, Tony 
Lazzeri, Lou Gehrig, and others. I want to look at this group 
this morning as ``survivors' row'' and Volkow, Lowy, Collins, 
Hodes, and Fauci. And you are, indeed, allowing people to 
survive.
    As I have said many times in the past, you give the gift of 
life, and we are so honored really to have you here this 
morning and to listen to you and have the opportunity to have a 
discussion.
    So, Mr. Chairman, again, I want to welcome everyone. And as 
we discuss the budget, the NIH is the leading biomedical 
research entity in the world. And with each scientific 
discovery, each medical breakthrough, its research advances 
human knowledge to improve the quality of our life and saves 
lives.
    Funding this research has the power to do more good for 
more people than almost anything else within the purview of our 
Government, and last year we were able to provide a significant 
increase of $2,000,000,000 for the NIH. I want to say a thank 
you to Chairman Cole, and to all of the members of the 
subcommittee, for their bipartisan work to support NIH 
research. The additional funds are helping NIH accelerate 
research to find cures for cancer, Alzheimer's, and help them 
move forward with exciting new programs like the Precision 
Medicine Initiative and the BRAIN Initiative.
    However, I was disappointed to learn that funding for HIV/
AIDS research is not increasing in fiscal year 2016. In its 
2016 budget request, NIH had proposed an additional 
$100,000,000 for HIV/AIDS research in order to advance its work 
on a universal vaccine to prevent HIV infection. I think it is 
a mistake to change course, and I hope to see NIH support that 
research this year, and it is something that I will advocate 
for.
    NIH plays an integral role in responding to emergency 
public health threats. In 2014, as Ebola raged in West Africa, 
NIH accelerated its work to create an Ebola vaccine. More 
recently, NIH has been working to develop a vaccine to address 
the looming Zika crisis, which poses an urgent and serious 
threat, as my colleague Mrs. Lowey said, to pregnant women and 
their babies.
    If you take a look at yesterday's New York Times, 
``Pregnancies Shadowed by Fears of Zika.'' This is real in the 
minds of men and women, and women particularly.
    I look forward to hearing from Dr. Fauci about the current 
status of Ebola vaccine candidates, as well as progress on 
moving Zika vaccine candidates toward clinical trials. Some of 
my colleagues have expressed a desire to shift unobligated 
funds that Congress provided for Ebola to respond to Zika. I 
strongly oppose that idea.
    I would be anxious to know what activities we would have to 
forego if we shift funds away from Ebola to Zika. We need to be 
able to respond to multiple public health threats at the same 
time, which is why in this Congress and the last Congress I 
proposed funding a public health emergency fund that mirrors 
the Disaster Relief Fund, which would enable the Federal 
Government to immediately respond to public health threats.
    I would also urge the NIH to use its statutory authority to 
respond to the rising cost of prescription drugs. As you know, 
when taxpayer-funded Federal research results in a drug patent, 
NIH may require the patent holder to license the resulting 
intellectual property to third parties, resulting in 
competition that drives down drug prices.
    It is outrageous that drugs invented under taxpayer-funded 
grants can cost sick Americans hundreds of thousands of dollars 
over the course of a year. The public pays at the front end, 
and they pay at the back end.
    I must note that while NIH is now funded at 
$32,100,000,000, thanks to the $2,000,000,000 increase, that 
funding has not kept pace with the rising cost of biomedical 
research. NIH's fiscal year 2016 funding level remains 
$7,500,000,000 below the 2003 level, adjusted for biomedical 
inflation.
    Fifteen years ago, NIH funded about one in three 
meritorious research grants. Today, the rate has fallen to 
about one in five, a slight improvement over recent years, but 
still low by historical standards. We are missing opportunities 
to work toward cures for life-altering diseases affecting far 
too many people.
    That brings us to today's topic and today's discussion, the 
2017 budget request. So much good in the proposal, and I 
applaud the ambitious proposal to increase cancer research by 
$680,000,000 in 2017. As a 30-year survivor of ovarian cancer, 
you have heard me say it before, I am alive because of the 
grace of God and biomedical research.
    I am pleased to see proposed increases of $100,000,000 and 
$45,000,000 for the Precision Medicine Initiative and the BRAIN 
Initiative. These initiatives have the potential to 
revolutionize our understanding of a disease, as well as our 
understanding of long-term physical and mental health.
    I think we can do better. This budget is clearly 
constrained by sequestration and arbitrarily low budget caps. 
As I said earlier, I think we need to boost funding for HIV/
AIDS research and not relent until we have developed a 
universal vaccine. This would save countless lives, as well as 
save billions of dollars in treatment costs in future years.
    We need to continue to develop new antibiotics or risk the 
devastating consequences of antibiotic-resistant bacteria to 
our public health and our entire public healthcare system. I 
want to note my concern over mandatory funding for NIH in this 
budget. It is the responsibility of this committee to fund the 
NIH.
    An increase to this subcommittee's allocation is the 
straightforward and responsible way to support NIH research, 
rather than to rely on mandatory funding that will not 
materialize. We should also continue to uphold the longstanding 
tradition of scientific independence in setting Federal 
research agendas rather than override scientific judgment with 
congressional preferences. That ability to allow scientific 
independence has been a hallmark of this subcommittee.
    I had the opportunity to introduce a bill last year that 
would enable our committee to increase NIH funding by 50 
percent over 5 years by providing a cap adjustment. Just like 
what we do in a cap adjustment for program integrity funding, 
we have a model. We do it there. We ought to be able to do this 
for the NIH. That would ensure proper funding for research 
without robbing other vital programs to do so.
    Thank you again for everything that you do. Biomedical 
research is one of the most important investments that we can 
make as a Nation. As I said, it gives the gift of life.
    Thank you. I look forward to your testimony and to our 
discussion.
    Mr. Cole. Thank you.

                      Dr. Collins Opening Remarks

    And now, Dr. Collins, we will go to your opening statement.
    Dr. Collins. Well, good morning, Chairman Cole, Ranking 
Member DeLauro, Chairman--from the full committee--Rogers, and 
ranking member of the full committee, Mrs. Lowey.
    My colleagues and I are delighted to appear before you 
today, and we were honored very much to host you at NIH with 
several of your committee members. And by all means, let us do 
it again next year. I think that was extremely helpful for us 
to have you on our campus.
    In this hearing on the last budget proposal of this 
administration, I plan to reflect more broadly in my opening 
statement here than usual on NIH's contribution to the Nation's 
health. So I am going to break with tradition and make some 
predictions.

                       PROGRESS 10 YEARS FROM NOW

    Ten areas in which I believe we can expect to see major 
progress 10 years from now, given a sustained commitment of 
resources for NIH. So this is 10 for 10. So here we go.
    First, the long arc of scientific discovery must begin with 
basic science. Experiments that are going on, excuse me, right 
now in labs across this Nation contain the seeds of 
breakthrough discoveries that will transform medicine.

                ONE: ANALYSIS OF INDIVIDUAL HUMAN CELLS

    Let us fast forward to 2026 and the first of these 10 
breakthroughs, and I think that will be advances in analysis of 
individual human cells. Cells are the unit of life. Cells are 
for biology like atoms are for chemistry.
    And yet during the long history of medical research, we 
haven't really had the technical ability to study individual 
cells. We have had to deal with millions of cells, maybe 
billions. With new technologies just invented in the last 
couple of years, that is all changing.
    As just one example, we can now decode the process by which 
individual immune cells attack and destroy healthy tissue in 
autoimmune disorders and transform the ways that we approach 
lupus, rheumatoid arthritis, multiple sclerosis, and many other 
diseases.

                         TWO: BRAIN INITIATIVE

    On to breakthrough number two. In 10 years' time, tools 
developed through the BRAIN Initiative will have identified 
hundreds of different types of brain cells and, more than that, 
major circuits responsible for motor function, vision, memory, 
and emotion, all functioning at the speed of thought.
    As a result, we will be able to diagnose conditions earlier 
and more precisely, and we will have new targets to explore for 
prevention and treatment of conditions like autism, 
prescription drug addiction, traumatic brain injury, 
schizophrenia, Parkinson's disease.

             THREE: NEW IMAGING TECHNIQUES AND DISCOVERIES

    Number three, aided by the BRAIN Initiative's new imaging 
techniques and discoveries made with our private sector 
collaborators, I believe we will be able to identify 
individuals at high risk for Alzheimer's disease even before 
any symptoms appear and provide them with effective therapies 
aimed at slowing or preventing the disease. Personal and family 
tragedies will be delayed or averted, and the economic savings 
from this alone will add up to hundreds of billions of dollars.

                FOUR: TREATMENT FOR SPINAL CORD INJURIES

    Number four, I predict that 10 years from now, we will have 
developed an effective treatment for spinal cord injuries. 
Already, groundbreaking NIH research has allowed four young men 
paralyzed from the waist down to walk by the use of electrical 
stimulation that bypasses the severed cord.
    If resources are available to follow up this proof of 
concept study, we can give freedom of movement back to victims 
of car accidents, sports injuries, and other spinal trauma.

              FIVE: SAFE AND EFFECTIVE ARTIFICIAL PANCREAS

    Number five, we will see the introduction of a safe and 
effective artificial pancreas. For those with diabetes, such a 
device will continually track changes in blood glucose levels 
and provide precise doses of insulin, significantly improving 
the management of their disease and preventing countless 
complications.

              SIX: OPPORTUNITIES FOR ORGAN TRANSPLANTATION

    Number six, hope is also on the horizon for heart failure, 
a major cause of death in this country. The development of 
induced pluripotent stem cells, iPS cells, derived from a skin 
biopsy, has opened up profound new opportunities for organ 
replacement. Early experiments suggest that a patient's heart 
could even be rebuilt using his or her own iPS cells. This 
personalized rebuilt heart would make transplant waiting lists 
and anti-rejection drugs obsolete.

                          SEVEN: NEW VACCINES

    Number seven, new vaccines will be readily available. 
Universal flu vaccines will protect against all strains of the 
virus, preventing a worldwide pandemic, saving millions of 
lives and eliminating the need for an annual flu shot. Early 
clinical trials are already underway, and we are in active 
collaboration with industry.
    I am also optimistic that an effective vaccine for HIV/AIDS 
will be available by 2026, giving us the opportunity to, at 
long last, bring an end to this most frightening and costly 
global epidemic.

                       EIGHT: TREATMENT FOR PAIN

    Number eight, genomics, neuroscience, and structural 
biology will unveil entirely new targets for the treatment of 
pain, allowing researchers in the public and private sectors to 
develop highly effective, non-addictive medications for pain 
management, turning around the current alarming trend of 
massive numbers of Americans becoming addicted to opiates.

                  NINE: TAILORED APPROACH TO MEDICINE

    Number nine, we will have tailored approaches to medicine 
that acknowledge not all people are the same, thanks in large 
part to the Precision Medicine Initiative and the more than 1 
million volunteers in the national research cohort that we aim 
to enroll by 2019. The willingness of these participants to 
share a wide variety of their health-related information will 
ensure that major new insights emerge and Americans from all 
walks of life will be healthier than ever 10 years from now.

      TEN: PREVENTIVE STRATEGIES AND TARGETED THERAPIES FOR CANCER

    And last, but certainly not least, I predict that a decade 
from now, hundreds of thousands of individuals will be thriving 
who without NIH's research efforts would have succumbed to 
cancer. Powerful new prevention strategies and targeted 
therapies will arise from research, accelerated by the Vice 
President's Cancer Moonshot proposal.
    If that sounds bold, consider what is happening right now. 
Seven months after President Jimmy Carter revealed that 
melanoma had spread to his brain and that he was beginning a 
course of therapy to boost his immune system's ability to 
destroy his cancer cells, last week he announced he is cancer 
free and no longer needs treatment.
    Our Nation needs a lot more stories like this. With the 
sustained efforts of this subcommittee, I think it is possible. 
With a strong, stable trajectory for support of NIH research, 
the world can look forward to a healthier and happier future, 
whether 10, 50, or even 100 years from now.
    Thank you, Mr. Chairman. My colleagues and I welcome your 
questions.
    [The information follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]        
    
    
    
    Mr. Cole. Thank you very much, Dr. Collins.

                          ORDER OF QUESTIONING

    Just for informational purposes for the Committee, I am 
going to ask my questions. Then we are going to go to the 
chairman of the full committee and the ranking member of the 
full committee, and then my good friend, the ranking member of 
the subcommittee. And then we will proceed in questions in 
order of arrival.

                 IMPACT OF $1 BILLION CUT TO NIH BUDGET

    As I mentioned, Dr. Collins, in my opening statement, 
although the administration budget appears to request an 
increase, that increase is sought through the mandatory side of 
the budget, which is, of course, outside our jurisdiction as a 
committee. The administration's request before this committee 
actually proposes a $1,000,000,000 cut in the area that we 
actually have jurisdiction over, discretionary spending.
    If we were to appropriate exactly what the administration 
has requested in your budget on the discretionary side, again a 
$1,000,000,000 cut below current levels, what would the impact 
on biomedical research in general be and on research into 
diseases like Alzheimer's and cancer specifically?
    Dr. Collins. Thank you for the question. And obviously a 
very sobering scenario that you portray and one that we very 
much hope will not happen.
    Certainly, the impact would be severe. It would be felt 
across every aspect of what NIH supports. All of my colleagues 
here and the other 23 Institute and Center directors would have 
to cut severely back in their programs. New initiatives would 
not be able to get started. Whether you are talking about 
cancer or diabetes or heart disease or Alzheimer's disease, 
this would represent a very significant slowdown.
    Again, I am just a simple doctor to the country. So the 
idea of how you divide up appropriations between discretion and 
mandatory is a little over my head. We are certainly pleased in 
the President's budget proposal for an increase and very 
gratified by your words, Mr. Chairman, and by others of the 
intention of this Committee to figure out how to maintain the 
trajectory that you started this year with the $2,000,000,000 
increase.
    I can't tell you what a shot in the arm it has been for our 
biomedical research community. The morale, the enthusiasm, the 
willingness to take risks and start new projects, which had 
been pretty much at a slowdown for about a decade, is back. And 
we want to be able to see that continue and appreciate your 
support for that.

                     NIH'S USE OF ADDITIONAL FUNDS

    Mr. Cole. Great. Let me ask you a sunnier, more upside of a 
question now that we have gotten that out of the way because I 
can assure you--and I have talked, obviously, to the Chairman 
of the Full Committee, and the Ranking Member certainly made 
her feelings known--this Committee is not going to cut 
$1,000,000,000 of discretionary funding from the NIH. Just not 
going to happen.
    So in that sense, you don't need to worry about that in 
front of you. But let us say last year the President proposed a 
$1,000,000,000 increase, which was very welcome. This committee 
actually, working in a bipartisan fashion, was able to double 
that.
    Dr. Collins. Yes.
    Mr. Cole. Let us assume that we were able to go beyond what 
the President asked for, beyond the $32,800,000,000, roughly. 
If we were able to give you extra money, where would you direct 
it? What do you think the most promising use of additional 
funds might be if we were able to do it?
    Dr. Collins. What a wonderful question. Certainly, in my 
professional judgment, there are a lot of areas that are ripe 
for expansion, and the opportunity to be able to go even faster 
on those would be welcome, indeed.
    As you know, a great deal of the research that we support 
are ideas that come to us from investigators all over the 
country. It is their bright brains that push forward the 
envelope, and we would want to be sure to do something to 
encourage even more of those grants to be fundable. As you 
know, we are still under 20 percent for that success rate.
    And that would have effects across the board. Antimicrobial 
resistance would have more resources. Alzheimer's research 
could move faster with additional resources. Cancer research--
even beyond the Moonshot, so many things are possible now. 
Opioid abuse and other issues of drug abuse, and I could go on. 
Diabetes, autism, all of these conditions, which right now are 
scientifically poised for rapid advances, all of them would 
have their opportunities lifted by the kind of wonderful 
scenario that you portray.

                   THE STATE OF ALZHEIMER'S RESEARCH

    Mr. Cole. Well, that is wonderful. Let me move to another 
area of particular interest to the committee and certainly to 
me. I saw a recent Time magazine article on Alzheimer's that 
highlighted some of the early stage clinical trials based on 
what I understand to be NIH-supported basic research.
    In my visit at NIH a few weeks ago, it was very interesting 
to learn how increased support from Congress over the last 3 
years has expanded peer review science on Alzheimer's disease 
and other dementia and has helped move the ball further. So if 
you could, and this will probably go to Dr. Hodes, I am sure, 
right away--and I don't have a lot of time--but sort of tell us 
where you are at and what you see the prospects are in 
Alzheimer's and other dementia.
    Dr. Hodes. Well, thank you for the question. And first of 
all, thank you very much for the increased funding this year, 
which has made an enormous difference.
    Fortunately, the good news is that the scientific 
opportunities, what we are learning about the brain and 
Alzheimer's disease, have expanded enormously so that resources 
are really applicable to research that is well thought out, 
well prioritized. In preparation, for example, in particular 
for the bypass budget that we submitted for the first time last 
year at congressional direction, we underwent a very extensive 
planning process in which national and international experts 
came together to identify priorities.
    These got translated into milestones, i.e., what we had to 
achieve to accelerate goals such as the establishment of an 
effective intervention in the nearest possible terms. This 
meant that with the additional funds, we were poised to act on 
this full spectrum of well-defined priorities and milestones.
    And for example, the initiatives that this year we were 
able to embark upon include a spectrum: from looking at the 
most basic biology and genetics to understanding new targets 
for intervention, new clinical trials that take advantage of 
the most promising of those interventions, and ways to 
intervene with people who already have disease and the 
caregivers who take so much responsibility in caring for those 
who have Alzheimer's disease.
    In health disparities, epidemiology, et cetera, across this 
broad spectrum, we have seen a huge increase of applications, 
from scientists who have been inspired by the availability of 
resources. And across this whole trajectory, we see a very 
bright future of accelerated progress thanks to the support of 
Congress.
    Mr. Cole. Well, thank you. I have violated my own rule and 
asked you a tough question too near the end of my own time. So 
I apologize to the committee for that.
    And I want to move next, if I may, to the Chairman of the 
Full Committee for whatever questions he cares to ask.

                        PRESCRIPTION DRUG ABUSE

    Mr. Rogers. Thank you, Mr. Chairman.
    Dr. Collins and Dr. Volkow, thank you for both actively 
engaging the issue of prescription drug abuse. We lose 100 
Americans a day from overdoses of prescription medicine and 
heroin. We need a holistic, multipronged approach to the 
epidemic that CDC says we have.
    Before we get to the pills themselves, let me explore a 
sizable part of the problem, oversupply of opioids. As you 
know, over 250 million prescriptions are written each year for 
opioids, many of which need not be written at all. And thanks 
in part to deceptive marketing practices and reckless 
overprescribing, these drugs have become a default solution, it 
seems, for any pain rather than the severe pain for which they 
were intended.
    Doctors should appropriately target pain with appropriate 
and proportionate medicines. Moderate measures for moderate 
pain, more powerful opioids for those who really need them. 
What are we doing to address the lack of effective non-opioid 
treatment for chronic pain?

                            PAIN MANAGEMENT

    Dr. Collins. Mr. Chairman, I want to thank you for your 
leadership in this area over these years, and again, I think 
many of us looking forward to the summit that you are bringing 
us together for in a couple of weeks.
    I am going to ask Dr. Volkow, though, to tell you about 
some of the things that are being explored in other areas of 
pain management.
    Dr. Volkow. I would like to thank you for your leadership 
in this whole area that has been very devastating. Research on 
pain exists across multiple institutes at the NIH, and there is 
a pain consortium that actually aims to integrate these 
efforts.
    So as it relates to the development of new strategies for 
the management of pain, there are several approaches. One of 
them is the one that helping develop abuse-deterrent 
formulations of opioids that cannot be tampered with. That is 
one of the approaches.
    Another approach is the development of analgesics that are 
potent that are not based on opioids and, therefore, are not 
going to be rewarding.
    There is a third approach that aims to the use of 
stimulation technologies in the--that will affect the impulses 
in nerves and in the brain to control and regulate pain. And 
that relates to tools like transcranial magnetic stimulation, 
or electrical direct current, that allows you to either inhibit 
certain areas of the brain or stimulate them.
    There is also research in terms of evaluating behavioral 
and cognitive interventions that can improve the outcomes in 
patients suffering from chronic pain. So there is a wide 
variety of approaches to try to address the lack of effective 
interventions that are safe for management of chronic pain.

                     NEW CDC GUIDELINES FOR OPIOIDS

    Mr. Rogers. Yesterday, CDC announced new prescribing 
guidelines for opioids. There are 12 recommendations, but I 
think here is the bottom line.
    Doctors should avoid using powerful opioids as the first 
line of defense against pain, saying the risks from such drugs 
far outweigh the benefits for most people. With respect to the 
dosage, CDC says start low and go slow.
    Do you think doctors are likely to follow the 
recommendations that the CDC has put forward? And what steps 
can we take to get the medical community more engaged in the 
problem?
    Dr. Volkow. Yes, and indeed, the CDC guidelines are 
actually a step forward in helping improve the prescription 
practices as it relates to the use of opioid medications, 
particularly for the management of chronic pain. And again, the 
CDC guidelines were excluding patients that lead to cancer pain 
or hospice care pain.
    The guidelines put a frame of reference that is based on 
one hand on the current knowledge, but also on experiences. 
There is not sufficient scientific evidence on how to properly 
use opioids, and as a result of that and added with the fact 
that there is an increased awareness that current prescription 
practices of opioids cannot continue the way they are doing 
right now--it is unacceptable--that that education on the 
healthcare system and also in the public, along with guidelines 
like the one of CDC, will facilitate the changing of practices 
of how we prescribe these medications for the management of 
chronic pain.
    While at the same time, I think, because that is the other 
aspect of it, providing adequate care for those patients that 
suffer from chronic pain, which can be very devastating.

                ROLE OF PHYSICIANS IN PRESCRIBING DRUGS

    Mr. Rogers. You know, we fought for years, you and the 
Congress and others have fought for years to get the 
pharmaceutical companies to develop abuse-deterrent 
formulations, to make opioids so they could not be crushed and 
take away the time release of the drug in just a split second. 
And now we have got, I think, five abuse-deterrent opioid pills 
on the market, but doctors are not prescribing them.
    I don't know whether they don't know about them or don't 
care about them or whatever. But the bottom line is they are 
not using what we have developed as an abuse-deterrent 
strategy. What do you think about that?
    Dr. Volkow. Well, it is likely there are different reasons 
why doctors may not be using them, but one that is important 
for us to be aware of is that we have to be certain because 
these abuse-deterrent formulations require development. They 
tend to be more expensive than the old opioid medications.
    So we want to be mindful that there are insurances that 
when a physician prescribe it, the patient will be reimbursed 
for the cost associated with it. So we have to create a system 
that incentivizes the utilization of these abuse-deterrent 
formulations that by default are going to be in general more 
expensive.
    Mr. Rogers. And insurance companies are reluctant to pay 
the increased cost because they say the regular opioids are 
cheaper, and therefore, we are only going to cover the lower 
cost. How can we deal with the insurance companies not paying 
for the abuse-deterrent feature?
    Dr. Volkow. I am going to call on Dr. Collins. I am just a 
pure scientist, and that is above my pay grade. [Laughter.]
    Mr. Rogers. I am way over time here, but can you answer 
that one quickly?
    Dr. Collins. Well, it is a complicated ecosystem you are 
talking about in terms of what we need to do to educate 
physicians about their role, and I think most physicians--I am 
a physician, the people at this table are also--are focused on 
trying to deliver the right care to patients.
    But things take some time to filter down, and we need to 
speed up that process of translating now what we know. And I 
think the CDC guidelines are intended to achieve that.
    In terms of the economics, however, that really comes down 
to whether insurance companies can, in fact, be talked into 
this kind of reimbursement if they are given a strong reason. I 
think we have got a stronger case, yet, that needs to be made 
about moving where we have been from drugs that are so abuse 
prone to things that are safer.
    Mr. Rogers. Well, if there is any insurance companies 
listening, they would be very wise to allow coverage of these 
abuse-deterrent featured drugs because they don't want to know 
what would happen if they don't.
    Thank you.
    Mr. Cole. Thank you, Mr. Chairman.
    And with that, we will go to my good friend, the ranking 
member of the full committee, the gentlelady from New York.

                            CANCER MOONSHOT

    Mrs. Lowey. Thank you very much, Mr. Chairman. And I want 
to say we are all with our big chairman over there on this 
issue.
    But I want to get back to the Cancer Moonshot because when 
you look at the numbers and you think of the number of people, 
I am sure, in this room whose lives have been touched with a 
loved one who is suffering from cancer, I am thrilled that we 
are focusing on this issue. In 2015, there were nearly 1.7 
million cases of cancer diagnosed in the United States. So I am 
very pleased to see this focus of the President and the NIH.
    Dr. Lowy, could you provide specific examples of what the 
Cancer Moonshot hopes to achieve that current research and the 
Precision Medicine Initiative do not address, and how would the 
Cancer Moonshot target cancers that to date have been difficult 
to detect and treat, such as kidney cancer and pancreatic 
cancer?
    Dr. Lowy. Thank you, Congressman Lowey.
    We really appreciate your strong support, the support of 
the Subcommittee, and the support of the Congress not just for 
2016, but also the long-term support that has gotten us to this 
point where incidence and mortality rates from cancer are going 
down. But as you point out, not only is the incidence high, but 
in addition, close to 600,000 people in the United States will 
die this year from cancer.
    The Moonshot is designed to look at many different aspects 
of cancer and to take advantage of the enormous opportunities 
that we have in this area. Two areas of focus are not just 
areas of treatment, but also for prevention and screening.
    In prevention, looking to develop vaccines not just against 
targeted material from infectious diseases, but also 
abnormalities in cancer. And then in addition, for screening, 
taking advantage of new technology, such as Dr. Collins 
mentioned for single cell analysis in peripheral blood, and we 
can--we can make these changes looking at the blood and other 
fluids to try to screen for early detection of pre-cancer and 
cancer.
    These are just two of the highlights in the Moonshot.

                            CAUSE OF AUTISM

    Mrs. Lowey. Well, thank you. And I have a little time left.
    Estimates, and I have been very concerned with the numbers 
in my own district, that 1 in 68 children will have an autism 
spectrum disorder. This is one of the reasons I am such a 
strong supporter of the BRAIN Initiative, which could provide 
deeper understanding of how the brain works and unlock 
treatments for autism, as well as a host of other disorders. 
And I think all of us here appreciate the work that you are 
doing on Alzheimer's disease as well.
    If you could tell us what has the research told us to date 
about the cause of autism, both in genetics and environmental 
factors, and how would the fiscal year 2017 budget request 
bolster these research initiatives both under the BRAIN 
Initiative, as well as other institutes throughout the NIH?
    Dr. Collins. Well, thank you for that question because we 
are enormously excited about what is possible now in terms of 
research on the human brain, probably the most challenging 
frontier in all of biomedical research, the most complicated 
structure in the known universe. There are 86 billion neurons 
in the brain. Each of those have about 1,000 connections, and 
we are just bold enough to think we might be able to understand 
how those circuits work and do the amazing things they do over 
the course of the next 10 years in a very well laid out 
blueprint for that research, which is guiding the BRAIN 
Initiative and which is now in its third year.
    And thank you, the Congress, for supporting it, and we hope 
that will continue to be able to ramp up to its full funding.
    Autism is clearly a complex heterogeneous collection. If 
anybody thought we were going to come up with just one simple 
molecular explanation, that chance has long gone by. It does 
now seem that with careful analysis of DNA, looking at the 
genome information, that something in the neighborhood of 20 to 
25 percent of those with autism--and it tends to be in the more 
severe end of the spectrum--do, in fact, have genetic changes 
that happen for the first time in that child. Not in the 
parents, but it was a mutation that arose during the course of 
spermatogenesis or oogenesis.
    And those have an interesting set of features when you look 
to see what genes are involved. They are mostly genes that code 
for proteins that are active at the synapse, the place where 
neurons talk to each other, and that kind of makes sense that 
autism is a circumstance where the communication systems in the 
brain are not functioning in the normal way.
    But, that gives us hope that we could begin with that 
unifying theory of what is happening in autism, begin to 
develop even better ways of introducing new therapeutics. But, 
this will be one of the many consequences, I think, of the 
investment in the BRAIN Initiative, which is, itself, a basic 
science effort to understand the brain.
    But, it builds a foundation upon which we can apply all 
kinds of other research to understand autism, Alzheimer's 
disease, Parkinson's disease, traumatic brain injury, drug 
addiction, all of which have, of course, roots in the brain's 
circuits that sometimes don't function the way they should.
    So, it is an enormously exciting time for us to push this 
forward. It has resulted in the recruitment of a really 
fascinating array of people coming from different disciplinary 
perspectives. The BRAIN Initiative has lots of technology and 
lots of engineering and lots of neuroscience and 
nanotechnology, all those things folded together.
    Mrs. Lowey. Thank you very much.
    And thank you, Mr. Chairman.
    Mr. Cole. Thank you.
    And we will next go to my good friend, the ranking member 
of the subcommittee, the gentlelady from Connecticut.
    Ms. DeLauro. Thank you very much, Mr. Chairman.

                  SEX BALANCE IN PRECLINICAL RESEARCH

    Dr. Collins, last year we talked about NIH's relatively new 
policy to require applicants to report their plans for the 
balance of male and female cells and animals in preclinical 
studies in all future applications. As you know, this is an 
issue that Congresswoman Lowey and I have been working on since 
we first came to the Congress.
    In our discussion last year, you noted that Institute 
Directors were in the process of finalizing their guidelines 
for all grantees. Let me note a recent analysis in Nature 
magazine. It is a March 3rd article, which showed that as 
recently as 2014, only 53 percent of research papers recorded 
both the sex and age of the animals used in the studies.
    I realize the analysis looks at research papers that 
predate the implementation of NIH's policy about sex balance in 
preclinical research. Can you provide an update on NIH's 
efforts to ensure that research includes both male and female 
animals in preclinical studies, and can you update us on NIH's 
efforts to ensure that preclinical research includes both male 
and female tissues and primary cells?
    Dr. Collins. Well, thank you for the question.
    As you can see in the visual that I put up, this is 
something that NIH has gotten very interested in and committed 
to, and this article that Janine Clayton and I wrote in Nature 
about a year and a half ago, very much points out that from 
NIH's perspective, that you are right. And Mrs. Lowey, you are 
right, and all those who have made this case are right that we 
have not been taking enough attention as we should to balancing 
males and females in preclinical research.
    And in the process, because many animal experiments, 
particularly with mice, have focused solely on males, we have 
been missing out on important differences of biological 
significance that might very well be things we need to know for 
human medicine. We are determined to change all of that.
    I saw the article that you mentioned in Nature, and I am 
happy to say I don't think you would see that article being 
written in another year or so. We did, in fact, put out a 
notice back in June, and it went in effect on January 25th. 
From now on, if you are an NIH-funded grantee and you are doing 
experiments involving animals, you need to include males and 
females.
    If you have some idea that you are not going to do that, 
you have to justify it. If you are studying prostate cancer, 
you can probably get away with sticking just to males. But for 
most other things, it is going to be absolutely required, and 
it will be a condition of the review and the grant award.
    Ms. DeLauro. And that is true with male and female tissue 
and primary cells as well?
    Dr. Collins. And I think that has been a real wake-up call 
as well, that people thought, well, a cell is just a cell. But 
a cell has a sex, too, and we are actually losing out on 
information if we don't take account of that. And that has now 
become part of the norm of the way in which we want to fund 
research.
    Ms. DeLauro. Okay. Thank you very much.
    Dr. Collins. Thank you.

                               DRUG COSTS

    Ms. DeLauro. Taxpayers provide more than about 
$30,000,000,000 annually for NIH's research. Dr. Collins, you 
have said that NIH conducts the basic science that ``fosters 
innovation, ultimately leads to effective ways to treat complex 
medical conditions.''
    And yet, in so many cases, taxpayer-funded research leads 
to drugs that are sold back to the taxpayers at exorbitant 
prices. Example. UCLA led to a patent for Xtandi, a drug to 
treat prostate cancer. The drug now costs patients $129,000. 
The same costs patients in other countries about a third of 
that amount.
    Look, I realize the pharmaceutical companies invest their 
resources. They bring a new drug to market. They should profit 
from that innovation. But what I want to know is why U.S. 
taxpayers are getting gouged for drugs that wouldn't exist 
without the significant investment of U.S. taxpayers.
    Can you better explain why U.S. taxpayers are paying for 
biomedical research on the front end and paying exorbitant 
prices at the back end? And I will just say that 50 of my 
colleagues and myself have sent a letter to you and to 
Secretary Burwell, requesting that the NIH and HHS assert 
March-in rights when taxpayer-funded research leads to a 
patented product that is not available to the public on 
reasonable terms.
    What are reasonable terms? A drug shouldn't cost $129,000 
for people to get access to it.
    Dr. Collins. Well, I know this is a topic of great 
interest, and well it should be. And certainly, my heart goes 
out, as all of us do, to patients who are in need of a 
therapeutic which is outside of their financial means to be 
able to gain access to, and that really ought to be the thing 
that drives us trying to come up with better solutions.
    I would say with regard to March-in rights, we read the 
letter carefully. You saw the response from Secretary Burwell. 
NIH does, in fact, have the ability to march in if reasonable 
terms are not being met and if we have intellectual property 
that is attached to that particular product.
    Ms. DeLauro. What is a reasonable term?
    Dr. Collins. Well, that is very much where it gets down to 
the nitty-gritty, doesn't it? And we have looked at that 
situation several times in the past, and have not felt like we 
reached reasonable terms. But we are totally open to 
considering that on a case-by-case basis, and we will be glad 
to do that with other products that are brought forward for our 
consideration.
    We get it that this is a serious issue.
    Ms. DeLauro. And let us have further conversation. And I 
have gone over my time.
    I thank you, Mr. Chairman.
    Mr. Cole. Absolutely. Next, operating on the order of 
arrival, Mr. Harris, you are recognized for whatever questions 
you care to pose.
    Mr. Harris. Thank you. Thank you very much.
    And good to see all of you again. It was a great visit I 
guess last month up to see what is going on. And you know, 
meeting with Dr. Rosenberg and the patients just reminded me 
of, you know, why I went into medicine. And what am I doing in 
politics? Anyway----
    [Laughter.]

                          VACCINE DEVELOPMENT

    Mr. Harris [continuing]. Let me ask a couple of questions. 
First of all, with regards to the strategic plan, you know, Dr. 
Collins, you had mentioned that one of the 10 things on your 
predictions, you know, is an HIV vaccine. And you know, part of 
what is addressed in the strategic plan is that nonstatutory 
set-aside for research. And when you look at the investment by 
objective, vaccines or a vaccine accounts for less than 
$400,000,000 out of a total of what I assume is now almost 
$3,000,000,000.
    So my question is specific. With the additional 
$2,000,000,000 that was appropriated last year, how much of 
that went into the vaccine development since that--it really 
is--I mean, because you address, you know, the cost, if you can 
bring that down to zero. But the only way to bring it down to 
zero really is we are going to have to develop a vaccine.
    So you are already spending only about 15 percent of the 
budget on the vaccine on HIV. So is it--so the additional 
monies, how much went into vaccines? How much went into non-
vaccine HIV programs?
    Dr. Collins. Well, I appreciate the question, and you and I 
have talked about this issue. And it has been very helpful to 
have your perspective and that of other Members.
    I am glad you mentioned the strategic plan. I hope people 
have read. There is a copy of this at your place. This was 
something you, the Congress, asked us for, and we put it 
forward in a way that we thought could be very helpful in terms 
of defining how we set priorities. So, please, have a look if 
you have not looked at it previously.
    With regard to HIV/AIDS, what we have decided is that it is 
time, just as you have said, to focus on the most important 
priorities to end this epidemic, and the vaccine is right at 
the top of that list. There are other things on that list as 
well.
    And as a result, we have looked at our entire HIV/AIDS 
portfolio this year, and we have identified projects which were 
going to come back for competing renewal which we no longer 
think fit into those highest priorities, four of them. And as a 
result, the dollars that would have gone to renewing those 
programs is becoming open for competition for things that are 
high priority, and vaccine development is very much on that 
list.
    We will, in the course of probably the next couple of 
weeks, announce how we are moving $66,000,000 out of areas 
which were good science, but they don't seem to be high 
priority for HIV/AIDS, into the areas that are. And a 
substantial fraction of that is going to go to vaccine 
preparation.
    Mr. Harris. I would urge that you do that. I mean, there is 
a line here. You know, $100,000,000 a year for basic behavioral 
and social science research. I mean, honestly, I would much 
rather see the $100,000,000 going to accelerating the 
development of that HIV vaccine.
    I just returned from Kenya, around Lake Victoria. Look, the 
solution is we are going to have to vaccinate people in the 
end. I mean, I am becoming convinced that you have treatment 
penetration of only 50 percent. Until we can vaccinate, as with 
other infectious disease, we are really not going to cure it.

                             MARIJUANA USE

    Dr. Volkow, let me just ask you a question because the 
Chairman of the Full Committee, who has left already, you know, 
mentioned marijuana. And there is a--you know, SAMHSA surveys, 
and they survey by State. And they--you can find charts that 
look at the increased use of marijuana.
    And it is interesting to look at what happened in Colorado 
between the 2002-2003 survey for 18- to 25-year-olds and the 
2013-2014 survey for marijuana use in the past month for 18- to 
25-year-olds. And past month is not just I have used it once. I 
mean, I have used it recently.
    It went from 21 percent to 31 percent. 18 to 25, by my 
understanding of the potential adverse effect of marijuana on 
brain function and development, is probably the worst interval. 
Maybe not, maybe even younger use would be bad. But certainly 
up to age 25 is a bad interval.
    The national use, by the way, in that age group went from 
17 percent to 19 percent. So pretty clearly, and I think, you 
know, what happened in Colorado is you legalized the drug. 
Bottom line, you legalized the drug.
    And there is a lot of misinformation out there about what 
happened when you legalized the drug, but honestly, a change 
from 21 percent to 31 percent use in a highly vulnerable 
population is of concern to me. Is it of concern to you?
    Dr. Volkow. How can it not be? I think that actually----
    Mr. Harris. Well, Doctor, I will tell you that the 
advocates for legalization say we shouldn't be concerned about 
the usage figure. So I am interested in what your opinion is.
    Dr. Volkow. Indeed, we are very concerned, and we are 
particularly concerned by the very high rates of abuse of 
marijuana not just on 18 to 25, but actually on teenagers 12 to 
18 years of age. And Colorado has the highest rates in the 
whole country of the use of marijuana in that age bracket.
    We are particularly concerned because cannabinoids, 
actually marijuana is a cannabinoid, interfere with the normal 
formation of synapses, the connections between neurons, how 
they talk to one another. And that process of connections is 
happening from the moment you are born, actually before you are 
born, until you are in your mid twenties.
    So cannabinoids, our own endogenous cannabinoids regulate 
that formation. So when you are smoking marijuana, you are 
interfering with this very carefully orchestrated process by 
which biology, nature ensures that our brain develops into the 
most complex organ so far.
    So, yes, indeed we are very concerned specifically because 
of the potential developmental adverse effects that exposure to 
cannabis may have in young people.
    Mr. Harris. Thank you very much. I yield back.
    Mr. Cole. Thank you very much. The chair is struggling to 
enforce the clock even on himself, which I think shows how much 
interest there is here. So I just would ask Members to try and 
do the best they can in that regard.
    With that, I will go to my good friend, the gentleman from 
Pennsylvania, for whatever questions he cares to pose.

                       UPDATE ON BRAIN INITIATIVE

    Mr. Fattah. Well, I resemble that remark, Mr. Chairman. I 
see you said that right before you came to me.
    But let me thank Dr. Collins and our guests. I authored 
some language that created the Interagency Working Group on 
Neuroscience at NIH, along with the National Science Foundation 
co-chair. Simultaneous to this hearing, the National Science 
Foundation is on another side of the Capitol giving a hearing, 
and these two things are inextricably intertwined. That is the 
science and the work at NIH together is how we are going to 
make disruptive progress, I am convinced.
    Now, we also have now in my other bill put some language in 
creating an interagency working group on imaging, and I know 
that NIH is at the--very engaged in this. What I am interested 
in now is I see the numbers for this year's budget. Dr. 
Collins, if you could talk to the committee for a minute about 
what the 12-year cost is on the BRAIN Initiative so that we can 
see it in totality?
    I spent some time out at Stanford with Dr. Newsome and some 
of his people, but I think it would be helpful. This is I know 
we say the administration's initiative. In truth, it is a 
partnership between the Congress and the Administration, and I 
think that we need to make sure that we have a good 
understanding of how the road--how the runway is out in front 
of us in terms of what we want to achieve.
    Dr. Collins. I appreciate the question because this is 
certainly an area of great excitement. How do we figure out how 
those circuits in the brain do what they do? That is a picture 
of a recent diffusion tensor MRI showing you the ways in which 
all the wiring works in the normal brain. That was taken on a 
perfectly healthy individual who is quite awake at the time 
this was done, new technologies that we didn't really have the 
ability to do until fairly recently.
    Yes, the BRAIN Initiative was, in fact, conceived of as an 
effort that would result in a lot of technology development in 
order to be able to do these measurements on circuits in real 
time in the human brain, but then to move into applications in 
its second 5 years. The overall budget for this was to ramp up, 
beginning in the first year, fiscal year 2014, at $46,000,000, 
and then ramping up to something like $400,000,000 a year, 
which we hope to get to in the next year or two.
    The overall budget over 12 years from--going from fiscal 
year 2014 to fiscal year 2025 is $4,500,000,000 in the proposal 
that was put together. This was an effort that was led by Cori 
Bargmann of Rockefeller and Bill Newsome of Stanford and an 
amazing dream team of neuroscientists who put together this 
plan over more than a year and a half.
    And that blueprint is out there and very much worth 
studying and, of course, will be revisited as technology 
develops. I would say right now we are ahead of our schedule.
    Mr. Fattah. Thank you, Doctor.
    Let me say that the Chairman and our ranking member, along 
with members of the committee, we were very pleased to do the 
$2,000,000,000 increase last year. And I know that the chairman 
made some comments about the administration's proposal and 
where we are on that, and I would join in the Chairman's view 
that that is not acceptable.
    I want to put this in some context. For a good part of the 
years that we have been in Afghanistan, we have been spending 
about $2,000,000,000 a week on average. So, just as a country, 
when we think about all of the lives that are affected by the 
diseases and disorders that you are seeking to cure, you know, 
a $2,000,000,000, even though it is very significant and it was 
some heavy lifting, in perspective, this is a nation that can 
do more in terms of research in science and in medicine that 
will make a difference for tens of millions of Americans. It is 
just a matter of political will.

                          UPDATE ON ZIKA VIRUS

    So I want to make sure that we are clear that the 
$4,000,000,000 is where we have to get to to do the work that 
we want to do. And if you could, I will conclude with my last 
comment, which is Zika virus, is there anything more that we 
need to be helping you do in that regard?
    Thank you, Mr. Chairman. I yield back on time.
    Dr. Collins. Dr. Fauci.
    Dr. Fauci. Thank you very much for that question.
    There is something that the Congress can do. As you know, 
the President asked for a $1,900,000,000 supplement to enable 
NIH, the CDC, FDA, and others, a variety of other agencies to 
respond to Zika. We need that money urgently.
    NIAID has already started a major program in Zika research, 
particularly toward the development of a Zika vaccine, and we 
are doing that with no new funds. And that is not going to last 
very long because in order to prepare for the next phase of 
studies--that would be the efficacy studies of a vaccine--we 
plan to go into a Phase I trial for safety by the end of the 
summer or early fall. We could not take it beyond these studies 
if we do not have the supplemental funding.
    Mr. Fattah. Thank you.
    Thank you, Mr. Chairman.
    Mr. Cole. Absolutely. We now go to the gentlelady from 
Alabama for any questions she cares to pose.

             RESULTS GAINED FROM NATIONAL CHILDREN'S STUDY

    Mrs. Roby. Thank you, Mr. Chairman.
    Dr. Collins, as a mother of two young children, I am very 
interested in the health of the youth of our Nation. And 
specifically, it has come to my attention that NIH has spent an 
estimated $1,500,000,000 on the National Children's Study, NCS, 
since 2000. This effort was halted in 2014 based on your 
recommendation.
    NIH conducted a shutdown of the Children's Study in fiscal 
year 2015 and fiscal year 2016. And last year, the Omnibus 
provided $165,000,000 for the Children's Study follow-on. The 
President's fiscal year 2017 budget requests level funding for 
this program.
    In your fiscal year 2017 budget justifications, you mention 
that NIH will use these funds on a new program, the 
Environmental Influences on Child Health Outcomes--ECHO, I 
believe is what you are calling it--which is designed to study 
a wide range of pediatric conditions.
    The budget justification also states that the ECHO program 
is designed to take advantage of existing resources left over 
from the now-defunct Children's Study. So, what I want to know 
is can you begin by describing first the results that we gained 
from the $1,500,000,000 that we spent on the entirety of the 
Children's Study? If you will start there, and then I have some 
follow-up questions.
    Dr. Collins. So I appreciate your raising the issue because 
this has been an area of intense interest for myself and my 
colleagues. The National Children's Study, originally 
authorized by the Congress 15 years ago, over the course of 
time developed a number of features about its design that began 
to look as if they had not kept up with the technology 
developments and the other opportunities.
    It was painful to look at this a couple of years ago and 
conclude that we needed a different approach, that we didn't 
want to continue to expand a program that clearly had 
deficiencies. It was not going to be as successful as we had 
once hoped. And that was the reason, with much advice from 
experts, that we decided it was time to close down the National 
Children's Study and come up with another strategy.
    There are many samples and data available from the 
individuals who were enrolled in the National Children's Study, 
although it was a modest number. It was all pilot programs, and 
those are available to researchers who are starting to mine 
through them and see what data can be derived.
    But, I think at this point, we very much turned our 
attention to how could we achieve the same goals of 
understanding, what are the environmental influences on 
children's health, and how could we get those answers now in 
2016 in ways we couldn't have imagined possible 15 years ago?

               HOW WILL ECHO BENEFIT FROM NCS INVESTMENT

    Mrs. Roby. But explain to us how that $1,500,000,000 
investment will carry over into ECHO as specifically as you 
can? What can we take from all of that investment and know that 
now, with this additional money, the $165,000,000 that is 
requested for fiscal year 2017, how can we know that that 
$1,500,000,000 is not time and money wasted?
    Dr. Collins. Well, it is not time and money wasted in the 
sense that there are these pilot efforts that were run that 
have research samples available that people can study, which 
will help us guide what kind of decisions we want to make with 
the new program ECHO in terms of what kinds of lab measurements 
and environmental exposures are going to be most important.
    If I can, ECHO is focused, in fact, on four areas, which 
seem to be particularly compelling, based on what we learned 
through the study of the National Children's Study--namely, 
upper and the lower airway, asthma; obesity; pre-, peri-, and 
post natal outcomes; and neurodevelopment, including autism. 
That is where we want to go now.
    But in a way that I think will be more efficient. It will 
result in more meaningful data. It will get there quicker, and 
it will involve many more data access opportunities for 
researchers around the country who have good ideas about how 
they will learn from these, how we can do a better job of 
keeping our children healthy.

                         UPDATE OF ECHO REPORT

    Mrs. Roby. And the report that was required, in the 
language in the omnibus said that you should submit a spending 
plan on the next phase of the study no later than 90 days of 
the enactment of this act. Where are we on that? Can you give 
us some highlights?
    Dr. Collins. I would be glad to. We are planning to submit 
that report a few days late because we are right now at a very 
formative place for ECHO.
    What we are doing with ECHO is to invite those who have 
been running cohorts of children where they have already 
collected a fair amount of data to join this effort--and we 
will make it possible for them to have additional laboratory 
measures added to what they were already doing--and create a 
whole that is greater than the sum of the parts, with perhaps 
70,000 or 80,000 individuals, children, on whose follow-up 
information we can add further data.
    That is going to be, I think, something we will learn about 
fairly soon. The applications are due on April 15th for the 
cohorts to come in and say they want to be part of it. We hear 
a lot of noise out there about that.
    I am in the process of recruiting a director for this 
effort and have a very exciting candidate lined up. So there is 
going to be a lot to report about how we are spending this 
money. We are grateful to the Congress for your confidence that 
this was something you wanted to continue and provide the 
resources for, and I actually think, although we have gone 
through a difficult transition here, we are on the path to do 
is going to be much more successful than I would have thought 
possible 5 years ago.
    Mrs. Roby. Thank you. I yield back.
    Mr. Cole. Thank you.
    We will now go to my good friend, the gentlelady from 
California, Ms. Roybal-Allard.

                     UPDATE ON ECHO ADVISORY PANEL

    Ms. Roybal-Allard. Okay. Thank you, Mr. Chairman.
    And I would like to follow up on the questioning of Mrs. 
Roby with regards to ECHO. I think that you said that you are 
putting together that 10-year plan and that you will include, I 
assume, milestones and funding estimates in that plan. And when 
do you expect that the recommended advisory panel with outside 
experts to be established?
    Dr. Collins. Those are highly appropriate questions. At the 
moment, the plan is for a 7-year effort. We would very much 
want to see how we do in 7 years, but expanding to 10 would be 
the hope if this project is going well because it should 
continue to yield up new information as we follow these 
children over time.
    The advisory committee is being put together. It will be 
formed as a working group of our Council of Councils. That is 
important because this ECHO program involves multiple 
institutes at NIH. You might guess particularly the 
Environmental Health Sciences Institute and the Child Health 
Institute, but others as well. And we, therefore, need to have 
this positioned in a place where we have advice from expertise 
across many different disciplines. That is where our Council of 
Councils comes in, and that is where we are going to position 
the advisory panel for ECHO.

                            ECHO ACTIVITIES

    Ms. Roybal-Allard. The congressional justification mentions 
about six research activities for which NCS funds were directed 
in fiscal year 2015. Are these the existing cohorts that will 
be used going forward, or are you still identifying cohorts to 
include in the ECHO initiative?
    And then also I want to throw in one more question because 
of time. Will the array of cohorts include broad population 
samples and measures that are specifically designed to compare 
the study cohorts to known national samples, such as the 
National Health and Nutrition Examination Survey?
    Dr. Collins. Great questions. In terms of what cohorts will 
be involved, we have decided this was best handled as a 
competition. So we put out a Funding Opportunity Announcement 
and are waiting, as I said, for April 15th to come when we see 
who comes in to apply to take part. And we expect many of these 
cohorts will be very interested in taking part because it gives 
a chance for their work to become even more meaningful. We will 
want to see that happen.
    And certainly, we will want to take full advantage of 
NHANES, the national study that has much data in it about 
environmental exposures and a variety of other measures of 
health and nutrition, to do comparisons with what we see in 
these cohorts. It is wonderful that we have that kind of 
foundation from other studies to do this with.
    I might say there is one other aspect of ECHO that deserves 
mention, and that is an effort to set up in the IDeA States, 
the States that do not currently have a research-intensive 
university setting, a pediatric research network. There are so 
many things that we could be doing in terms of pediatric 
clinical research in those States, but we are not currently set 
up to do so.
    And so this is a proposal to build upon the expertise. It 
is happening in those IDeA States through other programs to 
create a pediatric research network and enhance our ability to 
understand what are the influences in children's health that we 
don't know about yet.

                        STATUS ON NCS ACTIVITIES

    Ms. Roybal-Allard. Okay. And just one final question on 
this, in this area. Your congressional justification also 
states that the NCS-A will be assessed starting in fiscal year 
2017, and that this could drive its future direction 
significantly. When will that assessment begin, and who will be 
involved in doing it?
    Dr. Collins. So, again, we will very much count on our 
advisory group that is being put together. In fiscal year 2017, 
we will have these cohorts now funded and assembled together. 
There will need to be a coordinating center to try to be sure 
that all of this is working in the most effective and 
comprehensive way.
    So fiscal year 2017 will be the point at which we will have 
an assessment to see whether this model is working and 
producing all the data that we believe it should.
    Ms. Roybal-Allard. Okay. Thank you.
    Mr. Cole. We will next go to the gentleman from Tennessee, 
my good friend Mr. Fleischmann.

                             PMI ACTIVITIES

    Mr. Fleischmann. Thank you, Mr. Chairman.
    And may I say to the chairman and the ranking member, it is 
truly a privilege to be on this committee. When we see what the 
NIH and the related agencies are doing, it is tremendous that 
we see the great cooperation and efforts made in this critical 
subcommittee, and I am privileged to be part of it.
    Dr. Collins, let me thank you and your distinguished panel 
again. Your efforts in combating the maladies which face us on 
the health front are difficult, and again, I thank you for your 
successes and your continued efforts.
    I have got a three-part question, which I will read through 
in the interest of time. Dr. Collins, I would like to take a 
moment to address the Precision Medicine Initiative. My first 
question is regarding the direct volunteer portion of the 
research cohort.
    As you know, Vanderbilt University is playing a leading 
role in piloting the direct volunteer portion of the research 
cohort. Can you elaborate further on how that pilot program 
will inform the initiative going forward?
    The second part of my question is regarding the approaches 
NIH is using for recruiting and retaining people in the PMI. 
While I am pleased to see NIH adopting novel practices, 
including the use of social media, to attract these volunteers, 
I would like for you to address some concerns that have been 
presented to me by the scientific community.
    Specifically, can you address NIH plans to interpret and 
understand the inherent biases the approach presents, 
particularly given that many people do not use social media at 
all?
    Finally, is the NIH working with the NCHS or other Federal 
partners that fund or conduct large representative surveys to 
understand the biases in the PMI million-person cohort?
    Thank you, sir.
    Dr. Collins. Well, great trio of questions, and let me 
answer quickly because I know we are under a time constraint.
    The Precision Medicine Initiative is getting launched this 
year. Many of us are working 24-7 to get this up and going and 
are very excited about its potential. Again, the goal is to 
enroll by 2019 a million Americans as full participants in a 
study that will collect information from them, including 
electronic health records, laboratory data, genome sequences, 
environmental exposures, their own reports of medical 
experiences.
    Allow us to really, with a very large-scale longitudinal 
study, understand what are the factors that are involved in 
health and disease. We have never had anything like this 
before, and everybody who has heard about it is pretty excited 
about the kind of inferences we could learn from this 
initiative.
    Yes, you are right. Vanderbilt is right out of the blocks a 
major part of our first launch year because they just received 
an award actually in partnership with Google, which is now 
called Verily, to set up the effort to do a pilot effort to 
recruit direct volunteers. And I say ``pilot'' intentionally 
because we need to learn more about how to do this.
    Your concerns about social media being a biased way of 
involving people have certainly been apparent to us, and we 
don't want to depend solely on that. But at the same time, with 
a partner like Google and Vanderbilt working together, we do 
believe we should be able, just in a few months, to learn more 
about what is it that volunteers are interested in, what makes 
it appealing to them to join this effort, and what things are 
they turned off by. We want to get that really clear before we 
launch.
    Now admittedly, we have two different ways that people can 
come into this. One is by a direct volunteer route, which is 
going to be open to any American starting sometime this summer. 
But, also, we are asking those health provider organizations 
that already are running large cohorts to come in as our 
partners because they already have access to patients and 
information about them.
    And that will be a very substantial part of the effort, and 
that won't depend on any social media concerns. All of these 
individuals will need to be asked their permission, and if they 
decide to consent, then they will become participants in this 
historic undertaking.
    We are also reaching out to the traditionally 
underrepresented groups by working through community health 
centers with our partners at HRSA to be sure that those 
individuals also have a chance to take part. And certainly, we 
are also very interested in working with NCHS and NHANES as we 
get into this to be sure that the kind of data we collect will 
be generalizable to the population.
    We don't want a set of individuals that are so different 
than the population at large that we can't do that 
generalizing, and that will be important then to talk about 
with those experts at NCHS, which we have already been doing.
    So, I guess you can tell I am pretty excited about this. 
This is really something many of us have dreamed about for more 
than a decade. We really appreciate Congress' support in 
getting it started this year, and the appreciation for the 
consideration of expanding it even further next year as we 
really launch this initiative.
    Mr. Fleischmann. Thank you, Dr. Collins.
    It looks like my time has expired, Mr. Chairman. I will 
yield back.
    Mr. Cole. Thanks very much.
    We will next go to my good friend from Pennsylvania, Mr. 
Dent.

                           COLORECTAL CANCER

    Mr. Dent. Thank you, Mr. Chairman.
    Good morning to the whole panel, and again, thanks for 
having us up at the NIH a few weeks ago. I really enjoyed that 
opportunity.
    Dr. Collins, I have been very involved in working on 
obviously the fight against cancer, but including encouraging 
screening for colorectal cancer. In fact, you will see a lot of 
those folks up on the Hill today in their blue shirts.
    The NIH's NCI, cancer institute, is pursuing new cancer 
research to prevent, diagnose, and treat. What are some 
promising areas of cancer research in this area of colorectal? 
I don't know if somebody can talk about that?
    Dr. Collins. I am going to turn to my colleague Dr. Lowy, 
the Acting Director of NCI, to answer your question.
    Dr. Lowy. Thank you very much, Mr. Dent.
    As you probably are aware, March is Colorectal Cancer 
Awareness Month, and part of the Vice President's Moonshot 
initiative involves screening, which you also are vitally 
involved in and to try to use molecular analysis in fluids for 
making this more realistic so that we can have higher uptake of 
colorectal cancer screening.
    One of the big problems with colorectal cancer screening is 
that many people don't follow the screening guidelines, and it 
is really important to try to implement what we already know 
works while we are also doing research to develop better tests 
and more specific tests.
    I can report to you that the incidence of colorectal cancer 
is going down, as is the mortality, as a result of the 
screening that we have to date.

                               SUPER BUGS

    Mr. Dent. Thank you for that answer.
    I will also move to the issue of superbugs. What is the 
latest information on how NIH is working with the CDC on 
treating and curing these antibiotic-resistant bacteria? And 
what advancements have been made in this effort and if you have 
any results you could share?
    Dr. Collins. Dr. Fauci.
    Dr. Fauci. Thank you very much for that question.
    The NIH is part of a multi-agency approach towards 
addressing of problem of antimicrobial resistance. This effort 
is led by the White House, which, had an executive order and a 
related initiative on Combating Antibiotic-Resistant Bacteria, 
or CARB. NIH is a major part of the CARB activities.
    As you know, the CDC is involved in surveillance and 
detection of antibiotic resistance and in providing guidelines 
for the use of antibiotics. The NIH component is research to 
address antibiotic resistance.
    And in that regard, we are responsible for determining at 
the molecular level the basis of the emergence of resistance, 
number one. Number two, we conduct early screening for new 
types of antibiotics. For example, there has been recently 
discovered the teixobactin antibiotic, which is a soil 
antibiotic. This discovery has the potential to open up the 
door to a whole new class of antibiotics for gram-positive 
microorganisms, particularly methicillin-resistant 
Staphylococcus aureus.
    In addition, we have a clinical research network, which we 
have modeled on the clinical networks that we built years ago 
for HIV/AIDS, to test promising antibiotic compounds. And then, 
finally, the most important issue about all of this is 
diagnosis.
    In order to really circumvent the problem of antimicrobial 
resistance, you have to be able to make the diagnosis right on 
the spot. We have been working on very sensitive point-of-care 
diagnostics to determine if you have a viral infection versus a 
bacterial infection--because one of the biggest challenges is 
the prescribing of antibiotics for a disease that isn't even a 
bacterial disease. And so improving diagnostic tests for 
bacterial infections is one of the things that we have been 
working on.
    We are also working on point-of-care diagnostics that can 
determine the resistance profile of an infection. You put all 
of those research activities together, along with the work of 
CDC and others, and you have a rather comprehensive program. In 
addition, we are participating in a diagnostic prize. We have a 
$20,000,000 prize that we, the NIH, are partnering with BARDA, 
the Biomedical Advanced Research Development Authority, in 
order to develop a sensitive diagnostic to be able to quickly 
diagnose infections and determine their resistance profiles.

                             FUNDING CLIFF

    Mr. Dent. Thank you. Thanks, Dr. Fauci, for that.
    And finally, I just want to mention in my remaining time, I 
know the NIH funding cliff through mandatory spending has been 
raised. We are all concerned about it, and I am concerned that 
there is a decrease in discretionary funding at NIH and that an 
increase in mandatory funding, which is obviously going to be 
problematic.
    Last year, you know, we did the $2,000,000,000 increase in 
discretionary funding. This will create a funding cliff for 
NIH, and how will NIH be impacted if the authorizers don't act 
to provide mandatory funding?
    Dr. Collins. Well, it would be pretty devastating if we 
were to lose $1,000,000,000. Chairman Cole asked the same sort 
of question at the outset of the hearing, and I guess I painted 
a pretty gloomy picture, and it was not just because I was 
feeling gloomy. It is because it would be, in fact, 
devastating.
    We would lose 1,000 grants that would otherwise have been 
spent, would have been supported. We would, I think, have 
really done terrible damage to the momentum that has been 
started here in fiscal year 2016, thanks to the Congress. It 
would be a terrible step in the wrong direction, comparable 
only to the sequester in terms of the harm that it might do.
    Mr. Cole. That was a very sneaky way because you knew I 
would like that question. [Laughter.]
    Mr. Cole. Very smart.
    Mr. Dent. Anything to suck up to the chairman.
    Mr. Cole. Yes. Well, we will next go to my good friend from 
Idaho, Mr. Simpson.

                     IMPACT OF GOVERNMENT SHUTDOWN

    Mr. Simpson. Thank you, Mr. Chairman.
    And thank you all for being here today, and thanks for 
hosting us out to the NIH a couple of weeks ago. I always come 
back--I have been out there several times over the years that I 
have been in Congress, and I always come back both amazed and 
inspired.
    It almost makes me feel guilty of having you all come up 
here and testify because you have got actually much more 
important things to do than testify before this committee. But 
obviously, getting out what you do and what NIH does is part of 
what is necessary.
    But as we took a tour, you took us around and visited some 
patients, a young man and his wife. The young man had melanoma. 
And you talked to us about the treatment that he was getting, 
and so forth and so on, and what you were trying to accomplish.
    And somebody, I can't remember which Member it was, asked a 
pretty simple question that I would like you to respond to for 
the record. And that was what did the Government shutdown do to 
you?
    Because we sit here, and you know, most people see it 
visibly as, gee, you didn't get into the national park, or 
something like that, you know? Okay, go next week. I know you 
travel a long ways, et cetera, et cetera, et cetera, but it is 
not life threatening.
    What did the Government shutdown for 16 days do to you, and 
what happens if that occurs again, regardless of whose fault it 
is? And we could argue that from now until the cows come home?
    Dr. Collins. So I have been at NIH for 23 years. Those 16 
days were just about the darkest that I can recall ever going 
through. The laboratories where graduate students and 
postdoctoral fellows and other remarkably talented scientists 
were working were all dark. We had to tell everybody to go 
home.
    They were under threat of criminal prosecution if they came 
onto the campus. Experiments that had been set up that needed 
to go for several weeks were basically ruined and had to be 
started all over again later on, if they got started at all.
    But our clinical center, our largest research hospital in 
the world, also very much affected by this. We were allowed to 
continue the care of patients who were already there, but we 
were not allowed to admit any new patients during those 16 
days.
    Those were people who had planned to come to NIH, their 
last chance, many of them. We are the house of hope for people 
where medical research is needed because there is no real 
answer for what afflicts them. And we had to turn them away, 
hundreds of them. And I personally had to oversee that.
    The only exception was people who were at imminent danger 
of death, and we were allowed to have a few, one or two or 
three per day, with very high-level approval in order to do 
that. And people couldn't understand this. How could this be 
that something like this could have happened?
    So I appreciate your asking the question. I hope and pray 
we will never go back to that situation again. It was very hard 
to preside over that kind of dark 16-day period and feel good 
about the Government.
    Mr. Simpson. I appreciate that answer, and because it is 
the real effects of what happens that people don't see out 
there. As I said, they can see the obvious. Trash didn't get 
picked up on the way to Mount Vernon and stuff or by the Park 
Service or whatever, you know? And they don't really think 
about the life-threatening implications of some of these 
decisions that we make that we make too light-heartedly, 
frankly.
    So I appreciate that answer. I could ask about a lot of the 
other stuff that you have got going on, but I am not smart 
enough to ask it. What I would say is that I appreciate this 
strategic plan that you have given, and what I would encourage 
the Members to do is to look at the last page. A few bold 
predictions for America's future. Interesting.
    If you think of the work that is being done out at NIH, as 
I have said many times, it is the best-kept secret in America 
and best-kept secret in Washington. That is both the good news 
and the bad news.
    And somehow we need to get the American people to 
understand what goes on at NIH and how much of the research 
that is done at universities and extramural programs and stuff 
are done and funded by the taxpayers so that they know what 
they are getting in return for the investment that they are 
making. And quite frankly, we are politicians. We respond to 
the public. And when there are public demands that we invest in 
these types of things, that is when it happens.
    So I appreciate you all being here today. I am sorry that I 
have wasted your time instead of doing the important things 
that you do.
    Thank you.
    Thank you, Mr. Chairman.
    Mr. Cole. Well, I don't think my friend wasted anybody's 
time, and I think that is something that needed to be heard 
broadly, and I appreciate him doing that.
    With the consent of the committee, we are going to move to 
3 minutes so we can try and give as many people as possible an 
opportunity to go. But not before Mr. Rigell gets his full 5 
because you actually finish out the first order, but in the 
second round, we will move to 3 minutes. But you get 5.

                          ALZHEIMER'S DISEASE

    Mr. Rigell. Thank you, Mr. Chairman.
    And I regret that I wasn't able to be here at the start. I 
was, of course, at another hearing.
    Dr. Collins and the full panel, thank you for being here. 
We just really appreciate the good work that you do.
    I have a little window into, I guess, growing old because I 
have been blessed. My two parents are still doing well at 93 
and 88, and you know, I speak to them every week. And there is 
a sad part, though, because they will generally take me through 
some of my childhood friends' parents that I knew growing up, 
and they will just kind of walk through that so many of them 
have Alzheimer's.
    And of course, I knew them growing up, and that is just my 
little window into this profound challenge. You know, we have 
done a real good job I think generally of lengthening life, but 
the quality of life side is lagging a bit.
    And as it relates to Alzheimer's, and I don't have all the 
quantitative data that I want right now. I am kind of working 
in that direction. But I think that as we have increased the 
funding sharply on a bipartisan basis, which I think is a real 
win, but I wonder and I wrestle with this, that even though we 
are in a great fiscal stress and that has my full attention, it 
seems to me that this particular area warrants sharply 
increased funding.
    I mean, like this is a major national priority for a host 
of reasons. And some of them, in all candor, are economic. I 
mean, just the fact if we could get a hold of this. And so 
would you comment on that, please?
    And also how much funding could we--in a perfect world, if 
you could have more--you know, at some point, you get 
diminishing returns. You just can't put it all to good use. I 
mean, you hadn't had that problem yet.
    But how much do you think you could absorb and really, 
really leverage the dollar and get the most out of it? And I 
want to give you time to respond.
    Dr. Collins. I am going to ask Dr. Hodes, who is the 
Director of the National Institute on Aging, as our lead on 
Alzheimer's disease, to answer your question.
    Dr. Hodes. Well, thank you. Thank you for the question.
    It is certainly true that just about everyone has had their 
lives touched by loved ones, family members, who have suffered 
from Alzheimer's disease. And with the great success of the 
biomedical enterprise and the public health enterprise of 
increasing life span, the projections are that unless we are 
able to intervene better, there is just going to be more and 
more of this. So it certainly is an area, among many you have 
heard about today, which is in dire need of further research 
and support.
    In terms of the very direct question about whether a given 
level of funding can be wisely used, it is a critical question. 
It is not enough to have simply an urgent public health 
imperative. We also have to have confidence that there is a 
scientific opportunity behind it.
    And one of the opportunities to test that has actually come 
with the congressional request or requirement of NIH to deliver 
a bypass budget each year--last year was the first one--which 
asks us to estimate the degree of increased funding that would 
be needed to maximally pursue an efficient spending in support 
of research towards the goal, an end.
    And we have taken this very seriously. When we have 
composed that bypass budget, which was first released last July 
for the 2017 budget, we began by convening groups of experts. 
Last year, a summit of several hundred national and 
international experts told us what the opportunities were, what 
the priorities were. We translated that into milestones, all of 
which are available in as much detail as people would like in 
an online database.
    And this was the real scientific estimate of what we could 
accomplish or level of funding as an increment we could use in 
fiscal year 2017. We knew when that budget was submitted that 
there was a possibility, of course, that accelerated funding 
could come in 2016, but we were not sure. And we thank you ever 
so much for the fact that money was forthcoming.
    What that money allowed us to do was to carry out the very 
thoughtful plan accelerating what we proposed could be done 
with increased funding in 2017 and using it in 2016. Now in 
July of this year, we will be forwarding--Francis Collins on 
behalf of NIH--the fiscal year 2018 bypass budget, which 
really, I think, appropriately calls us to do just what you are 
asking, to account for what level of research could be done to 
ensure that we can have research supported efficiently without 
any compromise in its quality with the resources available.
    Mr. Rigell. So within NIH, I mean, there is--and I think I 
have got about 20 seconds left here. But I mean, there is, I am 
sensing here, just a true recognition that this is not to the 
exclusion of other diseases and other things that are 
afflicting us in our human journey, but this particular 
challenge is getting increased recognition as one that really 
needs to be addressed.
    And Dr. Collins, perhaps you can close it out here?
    Dr. Collins. If I may? I think we are not limited by ideas 
about interventions that might be successful. We are not 
limited by talent of scientists, all the way from basic to 
clinical, who are really fired up about tackling this disease.
    So resources are, in fact, much appreciated, and we have 
nowhere near hit the point where we don't know what to do with 
them. And again, the bypass budget is a great way to sort of 
see if resources were available, what could we do? We could go 
faster, and goodness knows, we need to. The cost of this 
economically, over $200,000,000,000 every year.
    Mr. Rigell. I thank you all.
    Thank the chairman for the additional time.

                         NATIVE AMERICAN HEALTH

    Mr. Cole. Thank you.
    And again, we will move to 3 minutes, and I just do want to 
add parenthetically, it was extraordinarily helpful to this 
committee to have access to that kind of data in our decision-
making last year. So I would encourage you to continue that.
    As you know, Dr. Collins, I have got a particular interest 
in Native American issues, and just quickly, I know you look at 
particular populations, and not everybody is the same. 
Obviously, there are gender differences, racial differences, 
all sorts of things. Can you give us an update on what the NIH 
is doing specifically to address Native American health issues?
    Dr. Collins. Well, we are very concerned about all 
populations in the United States, and American Indians are a 
special group, both in terms of their history, their culture, 
and their tribal sovereignty, which has a major effect in terms 
of participation in research that we need to be very respectful 
of, and we aim to do that in every way.
    Actually, thanks to the leadership of my Principal Deputy, 
Dr. Tabak, NIH initiated a Tribal Council Advisory Committee, 
bringing representations of the American Indian community to 
NIH to listen carefully to what they see as priorities that we 
should be focused on and to engage with them in topics like the 
Precision Medicine Initiative.
    And there are sensitivities there, particularly about what 
kind of information is being derived about ancestry, what kind 
of access to the information will be provided to people outside 
of the community. As you know, there have been experiences in 
the past that American Indian communities have gone through 
that causes them to be somewhat less than completely confident 
that researchers are always working in their best interests--
the Havasupai example, for instance.
    So we really need to understand that. In that context, I 
think we do have a number of important programs that have been 
ongoing for a while. I think of the Strong Heart effort that is 
looking at heart disease, for instance, in Indian Country that 
has been conducted by the Heart, Lung, and Blood Institute.
    And on a particular project that I have just recently read 
about that we are supporting, which is aiming to try to deal 
with high-risk pregnancies in the Native American community and 
particularly providing resources to women who are about--early 
in their pregnancy about how to maintain a situation that will 
result in a good outcome, with a very impressive outcome of 
that particular pilot project that has now been implemented 
across many different tribes across the U.S.
    So we are always looking for ways that we can do research 
that is acceptable and embraced by the community, but very 
sensitive to the special nature of those concerns in those 
communities.
    Mr. Cole. Thank you very much for that and appreciate it 
very much.
    And in the interest of time, I will move directly to my 
good friend, the Ranking Member of the Full Committee.
    Mrs. Lowey. I am going to talk very quickly, Mr. Chairman.
    First of all, I want to say, Dr. Collins, your 7 years of 
service have left an indelible mark, and I hope you continue 
your work because we really appreciate you.
    Thank you.
    Secondly, ``even the lab rats are all male'' has been a 
great laugh getter at cocktail parties, but it is really 
serious. And I hope that will continue because it is 
unacceptable.
    Third, Dr. Volkow, I appreciated Dr. Harris' comments. I 
don't think the majority of people in this country understand 
the serious impact of marijuana on the brains, 12 to 18, 18 to 
25, and I do hope you can be aggressive in getting this message 
out.

                                VACCINES

    And I thank you, Dr. Harris.
    And lastly, my friend Dr. Fauci, the Zika vaccine. We know 
the seriousness of dengue. We know the seriousness of 
chikungunya, and I wonder, if there are any seconds left, 
whether the Zika vaccine, they all come from mosquitoes, same 
areas, will certainly have an effect on chikungunya and dengue?
    Dr. Fauci. Thank you for the question, Congresswoman Lowey.
    We have a vaccine for dengue, one that has been approved in 
Mexico and the Philippines and Brazil. It is not as effective 
as we would like. It is about 67 percent effective.
    The NIH started in January a Phase III trial for an NIAID-
developed dengue vaccine in Brazil in association with the 
Butantan Institute. For chikungunya, we have data from a Phase 
I trial of a vaccine we developed that shows the vaccine is 
safe and induces a good immune response. We have had some 
trouble, and I don't think we are going to have much more 
trouble, in getting pharmaceutical partners to work with us for 
the advanced development of this vaccine candidate.
    I think the Zika outbreak has really emphasized the urgency 
of responding to these outbreaks because we now have 
pharmaceutical partners who are interested in working with us 
on a chikungunya vaccine. Importantly, for Zika, although there 
are always challenges in the development of a vaccine, we 
desperately need a Zika vaccine to protect pregnant women 
because they are the most vulnerable to negative outcome from 
Zika. If you get infected during your pregnancy, there is a 
disturbing percentage of fetal abnormalities.
    We will start a phase I trial of a Zika vaccine candidate 
likely in September of 2016 based on the expertise that we have 
developed over a decade or more in working with vaccines for 
similar viruses. And I want to thank you and the committee for 
supporting the work we have been doing and our ability to 
respond rapidly to emerging infectious diseases.
    We have about six Zika vaccine candidates that are in the 
queue. The one that is the furthest ahead, we had a meeting 3 
or 4 days ago with the FDA to discuss plans for the Phase I 
trial that I mentioned would likely start in September, and 
then transition into a Phase II trial likely by the beginning 
of 2017.
    How fast we get an answer on whether the vaccine is safe 
and effective will depend on two things. One, how effective it 
is. And two, how many infections there are.
    If there still is a big outbreak in 2017, we will get an 
answer much more quickly. If the number of infections go down--
it will be good for the public health--but it may take longer 
to get an answer on the vaccine's effectiveness. But we are 
vigorously pursuing Zika vaccine development.
    Mrs. Lowey. And I just want to say, Mr. Chairman, I 
appreciate your leadership and our Ranking Member and the whole 
Committee in getting the extra $2,000,000,000 and I appreciate 
this extraordinary panel and all the work you are doing.
    And I look forward to working with you so we can say the 
chairman of this committee has doubled once again in a 
bipartisan way money for the National Institutes of Health 
because I can't, frankly, think of a more important investment. 
And thank you so much for all the really important work you do 
and your leadership.
    Let us do it, Mr. Chairman. We will go down in history.
    Thank you.
    Mr. Cole. Are you advocating for my budget, or are you just 
pressuring me? [Laughter.]
    Mrs. Lowey. A little bit of both.
    Mr. Cole. A little bit of both. With that, we will go to my 
good friend Mr. Simpson again. Members are advised we are at 
the 3-minute limit.

                        NIH AND DOE RELATIONSHIP

    Mr. Simpson. They have already started timing, and I just 
barely got--no, quick question. The Cancer Moonshot that the 
President announced in his State of the Union and, by the way, 
which I think was great. I support it. Republicans don't always 
criticize everything the President does.
    I think this is a good start. It is Government wide. I 
chair the Energy and Water Development Subcommittee. The 
Department of Energy is going to have a role in this also. They 
are getting more and more involved in the biological sciences 
and stuff. And when I ask them about it, they say, well, you 
know, we were originally involved in the biological sciences 
because of radiation and the cancer caused by radiation from 
weapons development and other things over the years and stuff 
like that.
    What is the relationship between NIH and the Department of 
Energy? What are we looking at in the future? What will be that 
relationship, do you know?
    Dr. Collins. Well, I will start by saying there is a task 
force at the highest level, which was appointed to support this 
effort across Government with the Vice President's leadership, 
and that very much includes the Department of Energy, as well 
as FDA, NIH, strong input from NSF, and a variety of other 
parts of the Government that are involved here, including 
Commerce because of IP issues.
    But I will turn to Dr. Lowy, who could tell you something 
about a direct involvement that is already ongoing between DOE 
and the Cancer Institute.
    Mr. Simpson. And when you answer that, could you also talk 
a little bit about radio--or the medical isotopes, and with the 
Canadian reactor shutting down, are we going to have access to 
the medical isotopes that are necessary?
    Dr. Lowy. Thank you, Dr. Simpson.
    First, with regard to the Department of Energy, we have 
initiated very recently three pilot projects with them in 
cancer research, and they will form a key part of the Moonshot, 
and we are continuing to have ongoing extended discussions with 
people from the Department of Energy, including Secretary 
Moniz, about further extending this because largely they have 
extraordinary computing power and also machine learning, which 
is able to do things that really would be extraordinarily 
helpful in the cancer research area.
    Given the time, let me get back to you for the record in 
terms of the isotope issue.
    Thank you.
    [The information follows:]

                            Medical Isotopes

    Thank you for the question, Congressman. We do expect to have 
access to the medical isotopes we need in the United States, both for 
medical research purposes, and for their use in medical imaging needed 
to diagnose and monitor cancer and other conditions outside of the 
research setting. The critical isotope is known as molybdenum-99 
(Mo99), which is processed into generators that make technetium-99m 
(Tc-99m), which is widely used for cardiac and bone scanning, as well 
as scans of the thyroid. The enactment of the American Medical Isotopes 
Production Act of 2012 positively supported reliable supplies of Mo-99 
produced without highly enriched uranium (HEU), and NCI and others no 
longer need to rely on the Canadian reactor for their supply of Tc-99m. 
NCI also participates in an interagency effort led by the Department of 
Energy's National Nuclear Security Administration and the Office of 
Science and Technology Policy to continue to support sustainable means 
of producing Mo-99 without using HEU.

    Mr. Simpson. Thank you, Mr. Chairman.
    Mr. Cole. Thank you.
    With that, we will go to the Ranking Member of the 
subcommittee, my good friend from Connecticut.

                 PRECISION MEDICINE AND CANCER RESEARCH

    Ms. DeLauro. Thank you, Mr. Chairman. I am going to talk 
fast.
    On antibiotic research, I just came from an Ag Committee 
hearing. I just will say this to you. Seventy percent of 
antibiotics sold in the U.S. are bought for livestock 
production. There is industry guidance today that is voluntary 
through the FDA.
    I don't know what collaboration you have with USDA, with 
FDA, but it is critical. We should not be in silos here. You 
talked about 23,000 deaths. If we know what is going on, let us 
get their research, your research, and look at how we can cut 
that number in half, as you said last year, Dr. Collins, that 
we could do.
    So it truly is unbelievable, and it is voluntary. We need 
to think about guidance--not guidance, voluntary guidance. We 
need to think about how we tell people that and the 
pharmaceutical companies that in a mandatory way, in my view.
    Let me move to the Precision Medicine Initiative, and I 
will just cut to the chase. I was alarmed by a New York Times 
article that raised concerns about the lack of success in 
utilizing genetic testing to identify personal treatment for 
breast cancer patients.
    Just Dr. Lowy, Dr. Collins, what is the clarity on this 
issue and guidance to practicing breast cancer physicians or 
patients?
    Dr. Lowy. Thank you very much, Ms. DeLauro.
    I think that this area really exemplifies both the 
strengths and the limitations that we have of any clinical 
test. You do a clinical test, and for some people, it is 
enormously helpful. And for other people, the results are 
ambiguous.
    The genetic tests that we have can be enormously helpful in 
pointing people with cancer in the right direction in terms of 
treatment, but not for all of them.
    Ms. DeLauro. But is it accurate in terms of the success 
that has been in other areas other than breast cancer? Is 
breast cancer a specific disease that is not responding to PMI, 
or am I--or is this article off base? But help us.
    Dr. Lowy. There have been--there have been specific 
inhibitors. For example, Herceptin, which was the first 
targeted inhibitor, was specifically for breast cancer, and EGF 
receptor inhibitors. So there are specific inhibitors for 
breast cancer. The problem is that when you get an abnormality, 
not all of them are clearly actionable, and not all of them are 
going to be responsive.
    Ms. DeLauro. I would like to continue this conversation to 
look at breast cancer particularly. And I might just ask you to 
take a look at the Wall Street Journal this week. Bristol, and 
this is Bristol-Myers Squibb bets against Precision Medicine. I 
would ask you to take a look at it and tell us, you know, what 
Bristol-Myers Squibb is thinking about or talking about when we 
are trying to move in this direction.

                                  ZIKA

    Ah, I have got 4 seconds left. La-da-da. All I will just 
say is, and this is to Dr. Fauci, if, one, I want to make sure 
that any vaccine that we deal with for Zika is going to be 
available and affordable for people. This is this reasonable 
terms issue.
    But secondly, I will just offer my view. I think it is 
critical for us to deal with supplemental emergency resources 
in order to address this issue and this problem. You are right. 
I will tell you that we are now sending blood products to 
Puerto Rico in response to a Zika outbreak.
    What happens when we are looking at a blood supply that is 
potentially going to be difficult or people are not going to 
understand the safety of a blood supply with regard to Zika, 
and what kind of problems that is going to cause here in the 
U.S.? And let me just tell you, American women are not going 
to--they are going to be outraged if we are not doing something 
about them and about their ability to be pregnant and to bring 
a child to term.
    So thank you for the great work that you are doing in this 
area.
    I have another question, but that is okay.
    [Laughter.]
    Mr. Cole. Well, I am not sure that was a question, but it 
was----
    Ms. DeLauro. Genetically modified mosquitoes. Are they--is 
it--genetically modified mosquitoes?
    Mr. Cole. I am going to ask the gentlelady to take that one 
for the record.
    Ms. DeLauro. Okay. All right. Thank you.
    [The information follows:]

                         Resarch on Mosquitoes

    The National Institute of Allergy and Infectious Diseases (NIAID) 
conducts and supports a wide variety of vector research that aims to 
reduce the spread of infectious diseases, including research focused on 
the mosquitoes that carry flaviviruses such as Zika. NIAID supports 
research on mosquito biology, host-virus interaction, novel vector 
control methods, new insecticide targets, and vector competence studies 
to understand the replication and transmission of flaviviruses and 
other pathogens. Currently, NIAID is supporting research on methods to 
reduce the population of the Zika virus vectors, Aedes aegypti and 
Aedes albopictus, including studies to evaluate the efficacy of 
Wolbachia bacteria as a vector control strategy against these 
mosquitoes. NIAID is in discussions with researchers pursuing a variety 
of novel approaches to vector control, including the development of 
several genetically modified mosquito approaches currently under 
investigation for control of infectious agents, including Zika virus. 
Evidence regarding the impact of transgenic mosquito technology on 
disease still needs to be generated. It is possible that the use of 
transgenic mosquitoes over a large area may not be sufficient and that 
other supplementary vector control methods may need to be used as well. 
One example of a company NIAID is currently discussing transgenic 
mosquito technology with is Oxitec, the company that has tested its 
self-limiting mosquito technology in controlled release studies in 
Brazil

    Mr. Cole. Because I want to make sure our remaining two 
Members get an opportunity.
    So, with that, Mr. Harris, you are recognized for 3 
minutes.

                          MARIJUANA ADDICTION

    Mr. Harris. Thank you very much.
    Dr. Volkow, let me just continue and just follow up a 
little bit because the marijuana use and full legalization is a 
huge issue. It comes before this Congress. It is, you know, we 
have a rider that affects the District of Columbia on our 
appropriations bills usually.
    And let me just--you know, you were a co-author on a 2014 
review article in the New England Journal of Medicine, pretty 
prestigious medical journal. And let me just review some of the 
statistics in it and just confirm that these are still true.
    With regard to marijuana addiction, although the overall 
rate is around 9 percent, if you look at young users or if you 
look at daily users, it is higher with young, perhaps as high 
as 17 percent. Daily users, 25 to 50 percent. Is that still 
true? That is still the state of our knowledge?
    Marijuana dependence, though, can be much higher, and 
depending upon other--because it depends on other factors as 
well, can even be twice that, 20 percent just in general use.
    With regard to the gateway theory, because this is 
continually controversial, my best understanding is there is 
some reason to believe from other studies in rat models that 
potentially there is a gateway. It is a gateway drug, but it is 
still not clear whether that is true in humans. Is that true, 
or are we developing an understanding that it, in fact, is a 
gateway drug to other addictive behavior?
    Dr. Volkow. Animal studies, there is evidence that, yes, 
marijuana could change the sensitivity of the reward centers of 
the brain to other drugs, which would provide a means by which 
you become more vulnerable for addiction. But you cannot 
necessarily directly translate into humans, and the issue in 
humans is still being investigated.
    Mr. Harris. Okay. So, but it is not settled science that it 
is not a gateway drug in humans?
    Dr. Volkow. It is not. And all of the epidemiological 
studies show that it is a drug that frequently precedes the 
addiction to other drugs.
    Mr. Harris. Right, and it is associated with or it is 
causal. I understand. I did animal research. I understand you 
can't always extrapolate to humans.
    Finally, which was interesting to me that when you look at 
the effect on school-age children, and if you are not careful 
in how you control the access to children in school, that it 
impairs critical cognitive function for days after use, which 
was interesting. And that was stated in the article. Is that a 
fact?
    Dr. Volkow. That has been replicated by independent 
investigators.
    Mr. Harris. So that if we don't write the laws carefully 
and you allow children in school access to it, that critical 
cognitive functioning can, in fact, be impaired for days. And 
this is--and again, this is in the setting of where we want to 
actually have children go to school and learn and be 
cognitively functional.
    From a scientist point of view, would you urge 
jurisdictions that are looking into fully legalizing marijuana 
to exert extreme caution in taking that position at this point?
    Dr. Volkow. I basically ask people to look at what the data 
is telling us. We have seen consistently that the most 
devastating effects of drugs in our country are from the legal 
drugs, not from the illegal. Not because they are more 
dangerous, but the legal status makes them much more available 
and more likely to expose many more people and explains why we 
have so many more adverse effects from legalization.
    So I always say do you want to have a third legal drug? Can 
we as a nation afford it?
    Mr. Harris. Thank you very much. I yield back.
    Mr. Cole. Thank you.
    Now for the last question of the day, we go to my good 
friend, the gentlelady from California.

               ZIKA VIRUS'S RELATIONSHIP TO MICROCEPHALY

    Ms. Roybal-Allard. Dr. Fauci, my colleague Congresswoman 
Herrera Beutler and I have recently started a new congressional 
caucus on maternity care to promote optimal birth outcomes for 
women and to highlight issues like the Zika virus that pose a 
risk to childbearing women. And so we have been following with 
great interest the World Health Organization's finding and 
counsel regarding this disease.
    The Committee stressed the urgency for research and 
development of the Zika virus vaccine, which you have talked 
about earlier. But the WHO urgency committee also recommended 
both retrospective and prospective studies of the rates of 
microcephaly and other neurological disorders in areas known to 
have had Zika virus transmission, but where such clusters have 
not been observed.
    So my question is whether or not it is possible that the 
Zika virus has been responsible for cases of microcephaly in 
the United States over the past three to four decades, and has 
there ever been any tracking of this birth defect to see if 
there have been clusters or increased incidences of it in the 
United States?
    Dr. Fauci. That has not been formally examined with regard 
to retrospective studies, but there has been no Zika virus in 
the United States previously. We know that is true because when 
we do serological surveys of what has been in the United 
States, we have not detected locally acquired Zika virus in the 
United States.
    What we have now in the United States are more than 190 
cases that have been imported, mostly people who have been in 
the Caribbean and South America who were infected there and 
came back home to the United States. What we haven't had is 
local outbreaks of Zika virus in the United States similar to 
what we did see a few years ago with dengue in Florida and 
Texas and with chikungunya in Florida.
    There is a very important surveillance capability, which 
will tell us the answer to your question--we haven't had Zika 
in the United States in the past--but will also tell us if and 
when we do have Zika outbreaks in the United States in the 
future. And unfortunately, it is probably likely that we will, 
as the summer comes, see local outbreaks, particularly in the 
Southeast, the Gulf Coast States, Texas, Florida, et cetera, 
because the mosquito--Aedes aegypti, which is the major 
transmitter of Zika virus--is in those areas of the country, as 
it is in Puerto Rico and in South America.
    Finally, what we do have in South America are cohort 
studies to determine definitively what is the fundamental 
baseline level of microcephaly and what is the relationship of 
microcephaly to pregnant women infected with Zika. Two relevant 
studies were recently published. One came out a week ago, 
showing that if you looked at Zika-infected women who were 
pregnant and pregnant women who were not infected with Zika in 
Brazil, 29 percent of the Zika-infected women had ultrasounds 
indicating abnormalities of the fetus, which is very 
disturbing. This is the reason why we feel very compelled to 
develop a vaccine to protect not only the people in South 
America and the Caribbean, but if necessary, if it comes to 
that, in the United States.
    Ms. Roybal-Allard. Let me just give you the personal 
reason, my personal interest in this particular area. My 
grandson was born with microcephaly. This had to be probably 
over about 12 years ago. And as a result of that, both my 
daughter-in-law and my son took every test imaginable to find 
out what the cause was, especially since they planned on having 
other children. And they could find nothing, none of that 
research.
    And so I am just wondering, we are trying to figure out 
what possibly could have been the cause?
    Dr. Fauci. There are a number of causes of microcephaly. 
That is an excellent question, Ms. Roybal-Allard, a very 
important question. People sometimes get the misimpression that 
microcephaly is only associated with Zika because of the 
publicity we are seeing now about Zika.
    Microcephaly has been observed in infants forever, and it 
is typically associated with something that happens usually in 
the first trimester. The cause could be a viral infection such 
as cytomegalovirus, or CMV. The cause could be any of a number 
of viral infections. The cause can be fetal alcohol syndrome. 
The cause could be a variety of things that interfere with the 
developmental process, usually concentrated in the first 15 to 
20 weeks of pregnancy.
    Although we do know now from a recent study that even women 
who get infected with Zika in the second and early third 
trimester can also have abnormalities in the fetus. These 
abnormalities may not necessarily be microcephaly, but the 
abnormalities are nonetheless concerning. Again, this gives us 
further motivation to develop a vaccine.
    Dr. Collins. Another cause, just to mention, is genetics. 
And in the days gone past, it was very hard to actually nail 
that down. The technology wasn't good enough.
    Now that we have the ability to look at the complete genome 
sequence in a situation like that, and many centers are now 
doing that, we are uncovering causes of microcephaly that are 
due to DNA changes that we previously didn't know about.
    Ms. Roybal-Allard. And now they have three healthy, 
beautiful----
    Dr. Collins. And that is wonderful.
    Ms. Roybal-Allard [continuing]. Bright, intelligent----
    Mr. Cole. Well, thank you very much, Dr. Collins. Let me 
begin by thanking you and your colleagues for not only your 
appearance here today, but obviously, your accessibility to all 
of us when we have questions. And appreciate the wonderful work 
that you do.
    This may be--well, we will have plenty of opportunities to 
continue to work together, may be your last appearance before 
this committee. That will be a decision, I would suspect, of a 
new President of the United States at some point. But we hope 
it is not your last appearance here, quite frankly, just 
speaking for myself personally.
    And I again want to thank you for the exceptional 
leadership that you have shown at the NIH for a lifetime, and 
that would go to all of you, quite frankly, of putting the 
health and security of our people, but all people as your 
principal goal in life. It is a quite remarkable achievement, 
and you are all very, very distinguished in your own fields.
    And to see the manner in which you collaborate together and 
work across disciplinary lines and institutional lines is 
really very, very inspiring. And so we, again, just appreciate 
the values that you show and the basic and decent humanity that 
each of you exhibit.
    And it is no surprise to me that it is the NIH that tends 
to bring this committee together, where it puts aside partisan 
differences, ideological differences, and really does try to 
work in common to advance and support the splendid work that 
you are doing. And I am sure that will continue.
    We have plenty of other things, I guess, we can fight 
about, but this isn't going to be one of them. This is going to 
be one of the areas where we work together and, frankly, where 
we protect the discretionary funding that you got last year due 
to the bipartisan efforts on this committee. And well, we try 
to build on that, and frankly, where hopefully, Dr. Collins, we 
can go to the sunny question I asked you in the first round, 
and that is perhaps do a little bit better than even the 
President proposed, who certainly has proposed a generous 
increase.
    But if we can go beyond that and put additional means in 
your hand, then I know, on a bipartisan basis, we will want to 
do that.
    So thank you, and we are adjourned.
    Ms. DeLauro. Thank you very much, Mr. Chairman. You speak 
for all of us.
    Thank you.
    Mr. Cole. Thank you. 
    
    
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                                           Tuesday, March 22, 2016.

                        DEPARTMENT OF EDUCATION

                               WITNESSES

HON. JOHN KING, SECRETARY, DEPARTMENT OF EDUCATION
THOMAS SKELLY, CHIEF FINANCIAL OFFICER, DEPARTMENT OF EDUCATION

                    Opening Remarks by Chairman Cole

    Mr. Cole. Good morning, Mr. Secretary. It is my pleasure to 
welcome you on your first visit to the House Subcommittee on 
Labor, HHS, and Education to present your budget request for 
fiscal year 2017 for the Department of Education. We are 
looking forward to hearing your testimony.
    And I want to congratulate you again on your recent 
confirmation. As we all know, watching the Senate: that is no 
small feat, so well done.
    Since the subcommittee last met to discuss the Department 
of Education budget last year, Congress achieved the 
significant and long overdue accomplishment of reauthorizing 
Federal K-12 education programs through the Every Student 
Succeeds Act. This legislation streamlined and improved many of 
the Department's programs and devolved much of the authority 
over K-12 education issues to the States and school districts 
and was a tremendous bipartisan and bicameral achievement.
    The next step is to support States and school districts in 
their new role by providing sufficient resources to help them 
build capacity. I have concerns about whether your budget 
request for fiscal year 2017 for the key formula and block 
grant programs that support all States and school districts, 
including IDEA, Title I, and the new Student Support and 
Academic Enrichment State Grant, is sufficient to successfully 
implement the new law.
    In addition, you propose almost--or over $7 billion in 
mandatory spending that the Subcommittee has neither the 
authority nor the inclination to implement. We will have to 
remain in discretionary allocation that the full Committee 
ultimately allocates to the Subcommittee.
    With regard to higher education, the Department plays an 
important role not only in assisting students to finance higher 
education, but also in helping them to prepare for, complete, 
and succeed in their studies. I was happy that we were able to 
maintain funding for Pell Grants and provide a significant 
increase for TRIO and GEAR UP in fiscal year 2016. I look 
forward to hearing more about your proposals to make higher 
education more attainable and affordable to students most in 
need in the upcoming year.
    I look forward to having a discussion with you this morning 
to identify your top priorities for the year so that we can 
invest the American taxpayer dollars in the wisest way, given 
our funding constraints.
    As a reminder to the subcommittee and to our witnesses, we 
will abide by the 5-minute rule so that everyone will have a 
chance to get their questions asked and answered.
    I would now like to yield to my good friend, the Ranking 
Member of the full Committee, the gentlelady from New York, 
Mrs. Lowey, for any opening remarks she cares to make.

              Opening Remarks by Ranking Member Mrs. Lowey

    Mrs. Lowey. I want to thank our Committee Chair for your 
leadership of this committee. It is a pleasure to be here 
today.
    Before I begin, Mr. Chairman, I want to note that Tom 
Skelly, the highly respected CFO at the Department, is making 
his last appearance before the Subcommittee today. You have 
been an indispensible resource--42 years in Government 
service--I understand. We congratulate you on your much-
deserved retirement, and we wish you the very best of luck.
    Thank you.
    Mr. Skelly. Thank you, Mrs. Lowey.
    Mrs. Lowey. Okay--so, for today's students to be successful 
in the 21st century economy, we need a renewed focus that will 
enable them to compete in the global market. It is imperative 
that implementation of the Every Student Succeeds Act be swift 
and thorough.
    And I know, Secretary King, you are aware of Common Core. I 
think we have had many discussions about that, and we know that 
in New York, policies can succeed--or elsewhere--or fail based 
on their implementation. It is my hope that with the ESSA, we 
can learn from what has worked and what has failed to ensure 
that this new law provides students, teachers, parents, and 
administrators with the tools to provide children with the best 
education possible.
    I know you care deeply, Mr. Secretary, about this mission. 
I look forward to hearing your testimony on how we can best 
achieve it.
    In December, this committee came together to make sizable 
investments, particularly in K-12 education. Among those were 
increases in Title I grants to school districts for students in 
need as well as increases in IDEA special education funds. 
Still, much work remains, and we must build on last year's 
effort.
    You come before us today with a budget request that would 
provide the Department of Education with an increase of 2 
percent, or about $1.3 billion. Your budget includes advances 
in computer science, STEM, and career technical training to 
help students gains the tools to smoothly transition to the 
workforce.
    I am pleased that the President has proposed measures to 
increase college affordability, such as year-round Pell and 
bonus incentives for students to take additional credits. 
Together, these initiatives will help low-income students, 
increase graduation rates, and reduce debt, all while allowing 
them to enter the workforce faster, increasing their earnings 
and stimulating our local economy.
    The President's Pell initiatives are a win-win, and I hope 
that Congress acts to make these proposals a reality for 
students. However, as you know, Pell is not available to 
everyone. That is why the Federal student loan programs, 
including Direct Loans, Perkins Loans, and Federal Work Study, 
are so vital.
    Student loan debt is not just a check that is written at 
the end of the month. It is a weight on the shoulders of those 
trying to build a career and can make it more difficult for 
hard-working Americans to save for a home, for retirement, and 
one day to pay for college for children of their own. I look 
forward to hearing more from you on how we can increase college 
affordability and reduce the debt burden on our students.
    Lastly, I would be remiss if I didn't mention your proposed 
cuts to after-school programs. For many students, particularly 
in underserved areas, funding through the 21st Century 
Community Learning Centers provides after-school enrichment and 
a safe place for students to learn and develop their skills. I 
would like to hear from you what led to this proposed cut, 
especially when additional after-school programs are badly 
needed in communities throughout the country.
    Thank you.
    Thank you, Mr. Chairman.
    Mr. Cole. I thank the Gentlelady.
    Next, I want to make a point, and then I want to go to my 
friend, Mr. Fattah, who is effectively Acting Ranking Member 
today. I know you are aware of this, Secretary, but we have 
three Members traveling with the President today--so that is 
why attendance is a little bit sparse.
    They are three of our most dedicated Members. They are 
almost always here, but they trust Mr. Fattah so much that they 
have left him, single-handedly, to hold us all off. So, with 
that, I recognize my very good friend from Pennsylvania for 
whatever opening remarks he cares to make.

                     Opening Remarks by Mr. Fattah

    Mr. Fattah. I thank the chairman, and I thank him moreover 
for his leadership on many of the issues affecting education we 
have worked together on over the years.
    One area is GEAR UP, and I would be interested in hearing, 
I know that the proposed $69.4 billion budget would hold GEAR 
UP at a hold harmless number from last year. Last year's number 
was an increase, in part because of many people on the 
committee support it, but mainly because the chairman was 
prepared to hold the line on that increase.
    I was out in Oklahoma at the University of Oklahoma and saw 
some of the GEAR UP kids in a pre-engineering program just 
doing a fabulous job--so I am going to be very interested.
    This is the Nation's largest early college awareness 
program. I authored it some 17 years ago. Millions of young 
people have benefited. The graduation rates are above the 
national average, as are the college completion rates.
    I am interested in where the Department may go inasmuch as 
it is a great program, but it is still at the margins. That is, 
we still have so many of our young people and schools that are 
not benefitting from a program like GEAR UP, and we still have 
a need, as the President has laid out, to return the Nation to 
being the number-one nation in the world producing college-
educated adults.
    We have a program that works. It works in rural communities 
and urban communities. It works particularly among populations 
that we have had challenges with in terms of educational--
access to educational opportunity and, therefore, attainment. I 
am interested in where you sense we can go in terms of creating 
a college-going culture in communities that heretofore haven't 
benefited from even our most successful efforts like GEAR UP.
    Now I have worked with the administration on the American 
Opportunity Tax Credit, and I sponsored the bill that created 
it in 2009. It has helped millions of people and put billions 
in the pockets of families to pay for college costs. And you 
know, I know that we have now made it permanent in the tax 
code, which is a major achievement and a partnership between 
the Congress and the administration to make another $10,000 
available.
    It is not coming out of the education budget. It is coming 
via the IRS, but it is part of the puzzle with the maximum 
Pell, the tax credit, work study.
    But as the Ranking Member from New York, Nita Lowey, said, 
we also have to deal with loan repayment issues. It may come as 
a surprise to some, but we tucked into the Affordable Care Act, 
when we passed it, a loan repayment plan that allowed young 
people to have parts of their loan forgiven to the degree that 
they engage in public service; if they join a local police 
department or they become a teacher or a local public servant 
in some capacity.
    They can have a fifth of their loan retire each year that 
they serve in a public-spirited opportunity in their local 
community. I want to hear more about where we are and have that 
being known to more young people being taken--for them to take 
advantage of.
    And the last question is around--and it is going to be part 
of your prepared testimony, I understand--this whole question 
of equity. You came out of the New York circumstance, so you 
know all too well that young people in our rural and urban 
communities still have the least of everything that we know 
they need in order to get an education compared to those in our 
wealthier suburban communities--so I am interested in the 
department's efforts in this regard.
    We want to welcome you today, and I thank the Chairman.

                        Introduction of Witness

    Mr. Cole. I thank the Gentleman.
    And Mr. Secretary, it is indeed a great pleasure to have 
you here today, and you are recognized for whatever opening 
comments you would care to make.

         Opening Statement by Secretary of Education John King

    Secretary King. Thanks so much.
    Chairman Cole, Ranking Member Lowey, and members of the 
Committee, thank you for inviting me to discuss the 
Department's 2017 budget, the first under the new Every Student 
Succeeds Act. I look forward to building up on our bipartisan 
collaboration as we implement ESSA and work to address our 
biggest challenges in education.
    Increasing equity and excellence in public education has 
been my life's work. Before joining the Department, I led the 
New York State Department of Education and served with Uncommon 
Schools, a network of high-achieving charter schools.
    I began my career as a high school social studies teacher 
and co-founded one of the highest-performing urban middle 
schools in Massachusetts. I am also the proud parent of two 
public school students. These experiences inform and inspire 
every decision I make at the Department.
    This year, the Agency is focused on three principles, which 
reflect themes in our budget. First, ensuring every child has 
the opportunity to access a quality education. Second, 
supporting our Nation's teachers and elevating the teaching 
profession. Third, improving access, affordability, and 
completion in higher education. Allow me to take each of these 
in turn.
    The budget invests in programs to increase educational 
equity so all children--regardless of background, native 
language, zip code, or disability--can achieve their potential. 
For example, the budget ensures our youngest learners get a 
strong start through President Obama's landmark Preschool for 
All initiative.
    In addition, the HHS budget increases funding for the 
jointly administered Preschool Development Grants. To help 
close opportunity gaps, the request provides $15 billion for 
Title I, which is a cornerstone of the Federal effort to ensure 
that all students, especially our most vulnerable, graduate 
from high school prepared for college and careers.
    The Computer Science for All proposals would advance 
comprehensive State and local efforts to offer rigorous 
coursework for all students, with a focus on those who have 
been underrepresented in the STEM fields.
    The budget also would support community efforts to improve 
the educational and life outcomes for children and youth. The 
request increases funding for the Promise Neighborhoods 
program, for example, as well as Native Youth Community 
Projects, which support community-driven, comprehensive 
strategies to improve the college and career readiness of our 
Native children.
    Through our Stronger Together initiative, we would help 
local leaders create more high-achieving, socioeconomically 
diverse classrooms and schools. In today's knowledge-based 
economy, we know we must do more to provide students with 
rigorous and relevant learning experiences. Consequently, the 
budget includes proposals for Next-Generation High Schools and 
Career and Technical Education that will prepare students to 
transition to postsecondary education and real jobs by engaging 
in project-based learning, having the opportunity to earn early 
college credit, and building career-ready competencies.
    Recognizing that educators are our Nation builders and 
vital to our children's success, the budget invests to recruit, 
develop, support, and retain outstanding teachers and school 
leaders. The Teacher and Principal Pathways Program would 
strengthen our pipeline of effective educators, while Teach to 
Lead grants would capitalize on teachers' leadership for 
education improvement.
    To help educators advance through their careers, the budget 
supports innovations in human capital management systems and 
programs like the Teacher and School Leader Incentive Fund. We 
also are proposing RESPECT (Recognizing Education Success, 
Professional Excellence and Collaborative Teaching): The Best 
Job in the World to rethink ways to structure teaching in high-
need schools to attract and retain effective teachers where we 
need them most.
    The programs in our 2017 budget also would make higher 
education more affordable and help additional students earn 
quality degrees. America's College Promise would make 2 years 
of community college free for responsible students. This budget 
also would drive innovations in Pell Grants by supporting 
students who take classes year-round, rewarding those who take 
at least 15 credits per semester, and rewarding institutions 
with high enrollment and completion rates for Pell Grant 
recipients.
    While this budget is focused on helping to meet challenges, 
I also want to acknowledge our country's remarkable gains. High 
school graduation rates are at an all-time high, and dropout 
rates are decreasing. We have seen the largest and most diverse 
class completing higher education in our history.
    This budget leverages local leadership, the source of 
strength for our Nation's education system, to help more 
students thrive from preschool through college. Throughout our 
proposals and programs, we are committed to using and 
developing evidence and data to maximize results for students 
and taxpayers.
    The Department's 2017 budget would support local and State-
led efforts to ensure that in every community and in every 
school, students know that their education can provide them 
with the knowledge and skills to achieve their greatest 
aspirations.
    I look forward to discussing these ideas with you in more 
detail and would be glad to answer your questions.
    Thank you.
    [The information follows:]
    
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    Mr. Cole. Thank you, Mr. Secretary.

                           TRIO DEMONSTRATION

    Let me begin the questioning. I am concerned about the 
Department's request to reduce funding for the more traditional 
grants in the TRIO program to make room for an additional or 
proposed $20 million demonstration project. As I know you are 
aware, there is broad bipartisan, bicameral support for TRIO, 
as these programs are effective in improving access to and the 
completion of higher education for students from disadvantaged 
backgrounds.
    What is the issue or the concern with TRIO programs that 
the Department hopes to address through this proposed 
demonstration project?
    Secretary King. The hope with the demonstration project is 
really to build on the success of the TRIO programs. We see 
TRIO and GEAR UP as critical to our Nation's effort to get back 
to being first in the world in college completion. We think 
evidence is critical to that, and the demonstration project 
gives us the opportunity to build in an evaluation process that 
would generate evidence about what works most effectively in 
TRIO programs. This would then inform the rest of the TRIO 
investment.
    However, as you point out, it is a relatively small 
investment in the context of the overall funding level for 
TRIO.
    Mr. Cole. Can you give me a little bit more in the way of 
specifics in terms of what the evidence is, what are we looking 
for, and how we go about doing that in the proposal?
    Secretary King. Yes. In many ways, this builds on the work 
we have done with what is now called the Education Innovation 
and Research Program within the Every Student Succeeds Act. The 
idea is that we are to do either a randomized controlled trial 
or research using quasi-experimental design to try to produce 
good evidence about best practices that then can inform work 
that is happening across our programs.
    For example, there have been research efforts that have 
shown that exposing students to other first-generation college 
students like them who can talk about their experience from a 
personal perspective is more effective than receiving the same 
information from folks who didn't share that experience. There 
is good research evidence that this makes a meaningful 
difference in students' retention, their grades, and so forth.
    So that is the kind of information that we would like to be 
able to feed into the larger TRIO effort. We think that the 
small investment of $20 million, in the context of the overall 
program, is worth it to try and leverage good information about 
what works.
    Mr. Cole. As you know, TRIO has a very active support group 
and advocacy group of many years standing. Do you know, are 
they supportive of what you are trying to do? Have they taken a 
position on this, one way or the other?
    Secretary King. I will have our team follow up. I don't 
know if there has been a collective response from all the folks 
who are interested in TRIO.
    [The information follows:]

                       TRIO STAKEHOLDER SENTIMENT

    We do not feel that it is appropriate for the Department to 
characterize the positions of the TRIO community, which is comprised of 
national and regional organizations as well as educational leaders and 
individual TRIO alumni, especially when, to our knowledge, none of our 
stakeholders have made such positions publicly available. However, the 
Department believes that such a Demonstration would be most successful 
if it is informed by feedback from the community, and we look forward 
to continuing outreach efforts in that area.

    I will say there has been a lot of enthusiasm for our work 
on the Education Innovation and Research efforts.
    Mr. Cole. Okay. Well, good. We would appreciate any 
information you found, if you do have a chance to do that 
follow-up.

                    NATIVE YOUTH COMMUNITY PROJECTS

    Mr. Secretary, in the fiscal year 2016 omnibus, we provided 
an increase of $20 million for the Native Youth Community 
Projects to support culturally relevant strategies to improve 
college and career readiness amongst Native American children. 
I am pleased to see that you proposed an additional increase 
again this year.
    Can you please give us an update on what you think has been 
accomplished so far in this program and describe how you 
propose to build on that with your 2017 request for an 
additional $31 million?
    Secretary King. Yes. We are certainly early in the process, 
but what we have seen is that by bringing together tribal 
communities to think about what it would take to have 
culturally responsive instruction in the schools, leverage 
students' Native language, to try to ensure that students are 
on a path for college and career readiness, that we can see 
real educational improvement.
    We think this is an important investment. If you look at 
our high school graduation rates as a country, almost every 
group has seen improvement over the last few years except, in 
our most recent data, for Native Americans, who did not make 
improvements. This illustrates that we have more work to do to 
ensure that Native youth understand that college is possible 
for them, that jobs are possible for them.
    You know, when we have met with Native youth and Native 
educators who are working on the Native Youth Community 
Projects, they have talked about the hopelessness you often see 
in many communities. I know you are familiar with this from 
your State.
    That hopelessness then translates into students not being 
motivated in school, not sticking through to graduation, not 
going on to college. So we think this strategy of bringing 
communities together around college and career readiness can be 
high leverage. That is why we proposed a significant increase 
for this activity.
    Mr. Cole. Well, I just want to commend you for doing so and 
appreciate your focus, the department's focus, certainly the 
Administration's focus on this population in this area. You are 
to be commended for it.
    With that, I would like to go my good friend, the Ranking 
Member for the Full Committee, for whatever questions she would 
care to ask.

                    OPTING OUT OF STATE ASSESSMENTS

    Mrs. Lowey. Thank you, Mr. Chairman.
    As you well know, Mr. Secretary, a number of students in 
New York have opted out of taking State assessments. Under both 
No Child Left Behind and the ESSA, the department has the 
ability to penalize school districts by reducing Title I 
funding if less than 95 percent of students take State 
assessment exams.
    Mr. Secretary, I represent a number of school districts 
that did not meet the 95 percent threshold despite the 
participation of the overwhelming majority of students. I am 
very concerned that if the Department does not work with local 
school districts, students--the majority of which sat for State 
assessments--will be punished as a result of a small number of 
students who opted out of the test.
    Will the department provide flexibility to school districts 
who are putting forth a good-faith effort on participation 
rates to ensure that needy students are not punished?
    Secretary King. We think it is hugely important for 
families and educators to have good information about students' 
progress each year. That is the goal of the assessment system 
as required in the Every Student Succeeds Act.
    We have communicated to States their continuing 
responsibility to ensure that all students participate in the 
assessment system, and our experience has been that States are 
working diligently to try to talk with their districts, with 
parents, and with communities about the importance of the 
assessments and the role that they play. We expect States to 
move forward with that.
    There were a small number of States that did not meet the 
participation requirement last year. We have communicated with 
those States what their responsibilities are, and our 
impression is that States are working diligently to address it. 
So, I am optimistic that States will ensure that the districts 
get to a better place where we have seen these issues.
    Mrs. Lowey. I hope I am optimistic, and the issue is of 
critical importance, as you know. I am going to continue to 
monitor the Department's role to ensure it carries out the 
goals of the new ESSA, but it is important that we provide more 
flexibility to those at the local level.

             READY TO LEARN AND OPEN EDUCATIONAL RESOURCES

    A question about Ready to Learn and Open Educational 
Resources. You are aware: I am sure, this past fall, the 
Department published a Notice of Proposed Rulemaking related to 
Open Educational Resources. The proposed rule is far-reaching, 
and would require that any intellectual property produced, even 
in part, with department grant funding be openly licensed and 
available for use, modification, and dissemination free of 
charge by other companies, organizations, and individual 
members of the public.
    After speaking to many people, I have concerns about the 
negative impact this proposed rule would have on public media, 
which already distributes the content created in part through 
the department's Ready to Learn grant to nearly every household 
in the country for free. How does the department plan to 
address the challenges this proposed rule would pose to 
essential partners like public media?
    Secretary King. The context for this proposed rule is that 
Open Educational Resources can be a lever for equity. One 
challenge across communities is access to high-quality 
curricular resources. We see particularly in some of our high-
needs urban and rural communities, a lack of access to those 
materials translating into fewer opportunities for students.
    The premise of the Open Educational Resources effort is 
that where the Federal Government invests funds in the creation 
of materials, we ought to make those materials broadly 
available to advance equity. We are in the stage of reviewing 
public comment on the proposed rule, and we will try to address 
any of the concerns that we have received from grantees.
    As a general matter, I think the reception on the Open 
Educational Resource rule has been very positive because of the 
belief that it will be a lever for equity. But we certainly 
appreciate the important role that public television and public 
media play in American culture and want to make sure that we 
are sensitive to those issues. Certainly, our staff can follow 
up with yours on this issue.
    Mrs. Lowey. Thank you.
    Thank you, Mr. Chair.
    Mr. Cole. Thank you.
    We will go next to Mr. Fattah for whatever questions he 
cares to pose.

    GAINING EARLY AWARENESS AND READINGS FOR UNDERGRADUATE PROGRAMS

    Mr. Fattah. Thank you, Mr. Chairman.
    Let us start with GEAR UP. The department is, and 
rightfully so, focused on evidence and data. Why don't you 
share with the committee what the evidence and data is relative 
to GEAR UP?
    Secretary King. The overall results of the GEAR UP program 
have been very positive. I think you made the point in your 
opening remarks that the TRIO and GEAR UP programs have both 
had positive effects particularly on graduation rates, but also 
on students' readiness to transition to college.
    That is why we think they are important programs. That is 
why the President preserves the funding increases from last 
year in our proposed budget.
    Mr. Fattah. And how many children do we have in GEAR UP 
programs per day?
    Mr. Skelly. Five hundred thousand----
    Mr. Fattah. Five hundred thousand.
    Mr. Skelly [continuing]. Students are served by GEAR UP.
    Mr. Fattah. And they are spread through how many States?
    Secretary King. It is--I think it is 39 States?
    Mr. Skelly. Yes, thirty-nine States.
    Secretary King. Yes.
    Mr. Fattah. And with the increase that the committee 
provided of some $20 million, is there going to be a new 
competition?
    Secretary King. We do expect to have a grant competition to 
add additional programs.
    Mr. Fattah. Okay. Now I have worked with Senator Coons on a 
proposal that the Department, I think, piloted last year or the 
year before to take a few thousand students and seed small 
college savings accounts--it is called the American Dream 
Accounts effort--and to marry it up with online higher ed 
counseling. This is based on some evidence. It is empirical 
analysis that shows that poor children, even when they have as 
small as $100 in a savings account focused on them going to 
college, their grades improve. The expectations improve for 
them by their teachers.
    And I know we are in the early stages of this, but does the 
department have any--this pilot program I think now has some 
10,000 kids in it through GEAR UP. Do we have any information 
about that?
    Secretary King. I don't at the moment, but I will have our 
staff follow up with you on that.
    [The information follows:]

              Student Savings Pilot Program Participation

    We are unable to provide this data because we do not collect 
student-level data on the GEAR UP program.

                        STUDENT LOAN FORGIVENESS

    Mr. Fattah. All right. The loan repayment efforts that were 
embedded in the Affordable Care Act, this opportunity for loans 
to be forgiven for public service. Can we shift gears and you 
talk to us a little bit about where that is and how many young 
people are taking advantage of it?
    Secretary King. Yes. I don't know the precise number of 
students who are taking advantage. We do worry that, in these 
public service forgiveness programs, there is inadequate kind 
of public knowledge and public awareness on the part of 
students.
    One of our goals is to try to increase student awareness of 
the programs, particularly on teaching. There are a number of 
teaching loan forgiveness programs, but the participation rate 
is not as high as we would want. This budget proposes actually 
consolidating those teacher loan forgiveness programs to create 
a streamlined program to provide $10,000 of loan forgiveness, 
up to $25,000 if students have attended what their State rates 
as a ``highly effective'' teacher preparation program.
    This is a place where we are focused on trying to make sure 
that students are as aware as possible of their options.
    Mr. Fattah. All right. This is broader than just the 
teachers, and what we did was we said there were two 
approaches. One was that you could cap your total repayment or 
your amount you had to repay to 10 percent of your income over 
your lifetime, right? Secondly, there was an opportunity to 
have your student loan forgiven, to the degree that you decided 
to go into public service as a police officer or a teacher or 
some other public service profession.
    I was wondering whether the department has some sense of 
whether this is getting out there, or that young people are 
utilizing it and to what benefit?
    Mr. Skelly. We had a tremendous push in the income-driven 
repayment programs to let people know about the availability of 
them and many more students are signing up for them. It is 
still a little early for students to have achieved the 
necessary number of years in public service to get a loan 
forgiven. So we don't have any hard data----
    Mr. Fattah. Right.
    Mr. Skelly [continuing]. Really worth much--on how many 
people are getting loan forgiveness, but it looks like it is a 
very popular option that helps people deal with high student 
debt if they have got it.
    We have a number of proposals in the budget this year to 
reform some of the proposals. That is because it is possible 
the public service forgiveness is giving people an 
inappropriate signal or incentive to borrow more than they 
need, particularly in graduate school. The undergraduates, not 
so much, but a lot of people exceed the $57,500 cap available 
for undergraduate borrowing when they go to graduate school.
    We wanted to make sure that folks know they shouldn't be 
borrowing just because they could and potentially get the loan 
forgiven after 10 years.
    [The information follows:]

             Public Service Loan Forgiveness Participation

    As of February 2016, there were a total of 359,975 borrowers who 
could potentially participate in Public Service Loan Forgiveness 
(PSLF). This figure represents those who have been formally certified 
based on full-time qualifying employment or conditionally certified 
based on part-time qualifying employment. Please keep in mind that this 
number is a total, as we never `release' a borrower from the total 
potential PSLF population, so it may include some borrowers who are no 
longer holding employment, have since paid in full, etc.
    Through the end of 2022, the Department estimates that 331,000 
borrowers will receive Public Service Loan Forgiveness.

    Mr. Fattah. Right. I will stop there, Mr. Chairman. I think 
we need to do a lot more to let young people know about what is 
available. Maybe we will do it after the reform, all right?
    Thank you, Mr. Chairman.
    Mr. Cole. Thank you.
    We will next go to my good friend, the gentleman from 
Tennessee, for whatever questions he cares to ask.
    Mr. Fleischmann. Thank you, Mr. Chairman.
    Good morning, Mr. Skelly, and Mr. Secretary, good morning, 
sir.
    Secretary King. Good morning.

                         STUDENT LOAN SERVICING

    Mr. Fleischmann. Good to see you. Secretary King, I would 
like to ask you a series of questions, sir, regarding student 
loan servicing.
    The contracts that the Department has in place with the 10 
national nonprofit and for-profit servicers specify that 
servicer performance will be measured semi-annually in the 
areas of customer satisfaction and default prevention, and 
these results will determine future loan volume allocations 
twice a year.
    I have a two-part question. The first question, sir, is 
what rationale and under what authority is the Department using 
to unilaterally reduce the allocation window from September to 
July? And then secondly, doesn't this recent announcement 
directly contradict the language included in your servicing 
contracts, which requires the Department to allocate student 
loan volume through services based on performance and capacity 
through fiscal year 2016?
    Secretary King. Thanks for the question.
    Certainly our goal in servicing is to make sure that we 
serve borrowers' interests well and serve taxpayers' interests 
well. The 2016 Appropriations Act required us to reallocate 
loans for this year using existing metrics of performance 
between the not-for-profits and the TIVAS.
    That process took place. We have done a loan reallocation. 
However, one of the challenges is that our existing metrics 
actually do not make an apples-to-apples fair comparison 
between the different servicers. Our next step is to develop 
metrics that more accurately assess performance across the 
different types of servicers based on the mix of loans that 
they have.
    The mix of loans that you have affects many of these 
performance indicators, so we are gathering input from the not-
for-profits and the TIVAS on those metrics now, and we will 
develop new metrics in advance of the next academic year. By 
July, we expect to have new metrics in place for the allocation 
going forward, consistent with what is required in the 2016 
appropriation.
    Mr. Fleischmann. Okay, sir. As a follow-up, last week 
Federal Student Aid announced it was creating new performance 
metrics for loan allocation ``because of the significant 
variation in the composition of loan portfolios between student 
loan servicers.''
    Several questions. What variation is FSA talking about, 
sir?
    Secretary King. The key issue is the nature of the loans 
that are given. For example, if you are a servicer and you have 
loans of currently enrolled students who are not yet in the 
process of paying back their loans, that is very different from 
having loans from students who may be high-risk borrowers. We 
want to make sure that our methodology accounts for variations 
in the loan portfolio.
    Mr. Fleischmann. Okay. Why is the department creating new 
performance metrics when it just completed such a process in 
2014? As a follow-up to that, what new performance metrics is 
the Department considering using going forward?
    Secretary King. As we do the next round of loan 
distribution, beginning this summer, we want to use the best 
metrics to compare performance--again to protect the interests 
of both borrowers and taxpayers. We haven't determined what 
those new metrics will be. That is the process we are in now. 
We are gathering feedback from both the not-for-profits and the 
TIVAS on what those metrics should look like.
    Mr. Fleischmann. Is the Department taking such steps to 
circumvent the language included in the Consolidated 
Appropriations Act, and wouldn't it be more appropriate to 
incorporate such new metrics as part of the upcoming recompete 
instead of changing the rules of the game midstream, sir?
    Secretary King. Well, the challenge is that the 2016 
Appropriations Act changed the methodology for this year from 
prior years. This limited us to existing metrics that don't 
necessarily adequately measure the differences in the loan 
portfolios. We want to make sure before the significant tranche 
of new loans takes place this summer--August/September, some of 
the highest volume months--that we have the best possible 
metrics, focused again on performance for students and 
taxpayers.
    Mr. Fleischmann. Thank you, Mr. Secretary.
    Mr. Chairman, I will yield back.
    Mr. Cole. Thank you very much.
    We will next go to my good friend, the gentlelady from 
Alabama, for whatever questions she cares to offer.
    Mrs. Roby. Thank you, Mr. Chairman.

               STATE AUTONOMY IN STANDARDS AND CURRICULA

    Congratulations, Secretary, on your confirmation, and I 
look forward to getting to know you and, hopefully, being able 
to work together.
    As you know, the ESSA includes provisions that specifically 
prohibit you and your staff at the Department of Education from 
using funding grants or special policy waivers to influence or 
coerce States into adopting certain standards or curricula. And 
as you may or may not know, I proposed that language when I was 
on the Authorizing Committee in a standalone bill, and I worked 
for 3 years to get it in the final bill.
    It was borne out of frustration over department officials 
habitually exercising undue and inappropriate influence over 
State education decisions throughout the former Secretary's 
tenure. So we both know old habits die hard, and it is not hard 
to imagine bureaucrats thinking, ``Hey, we know better than 
Congress. We are going to keep doing what we think is best, 
despite the specific language that is included in the current 
bill.''
    Mr. Secretary, how can you assure this Committee and the 
Congress that your Department will comply with this very, very 
important provision of the law? And how will you change the 
culture at the Department to prevent your team from falling 
into the same bad habits of telling the States what to do?
    Secretary King. Two important elements of the Every Student 
Succeeds Act have important implications for your question. One 
is the requirement that States have standards in place to 
ensure students are ready for success after they leave high 
school.
    In many States across the country, and I know you are 
familiar with this, we see students arriving on college 
campuses only to be told that they need to take remedial 
courses, which really is a euphemism for high school classes, 
because they don't have the academic skills they need for 
success in college.
    We hear all the time from employers, as I am sure you hear 
this from your constituents who say they are struggling to find 
employees with the skills that are necessary. So ESSA 
importantly requires States to have standards that reflect 
college and career readiness. We think that is critical.
    Second, ESSA requires that standards are the province of 
States, for States to determine. We agree with that. The 
Department's position during the last 7 years and today is that 
standards should be determined by States, but those standards 
should be high and should point towards college and career 
readiness.
    I think ESSA strikes the right balance, and we intend to 
adhere to exactly what ESSA requires: the standards are the 
province of the States.
    Mrs. Roby. Well, thank you for your response.
    I really appreciate hearing your commitment to that very 
important provision of the law. I know, though, a lot depends 
on rulemaking, and we need to ensure that those rules comply 
with the intent of Congress. And so as a Member who fought very 
hard for these provisions in the law, let me state very clearly 
again that the intention is to stop Federal coercion in 
education decisions, not just on Common Core.
    I know that that is what the debate seems to center around 
a lot. It is not just about Common Core, but it is the next 
policy that the Department wants to push in the next year or 5 
years or whenever. So I do appreciate your commitment to that. 
We will see how much we can fit in in a minute and 22 seconds.

    COMPETITIVE VERSUS FORMULA CAREER AND TECHNICAL EDUCATION GRANTS

    There is the administration's request for $1.2 billion for 
career and technical education. It is an increase of $77 
million over fiscal year 2016 appropriation. The request would 
provide $1.1 billion for State formula programs and $75 million 
to fund a grant competition for American Technical Training 
Fund.
    So rather than funding a large competition grant, it seems 
to me that the funds would be better used to support State 
formula grants, which would ensure more students are able to 
benefit from the CTE experience. So many of my constituents 
benefit from this. Can you just address the competitive grant 
versus----
    Secretary King. Sure. The goal of the American Technical 
Training Fund is to incentivize partnerships between higher ed 
institutions, school districts, and employers and workforce 
investment boards to provide high-quality career and technical 
education experiences. We think that kind of cross-sector 
partnership is critical to driving quality programs.
    I was just at Alabama A&M last week, meeting with them on 
the STEM programs they have developed in partnership with NASA 
and Lockheed Martin. And you can see the strength of those 
employer-higher ed institution collaborations.
    Our goal in this program is to foster that alongside the 
kinds of career and technical education programs that are 
supported by the traditional Perkins program.
    Mrs. Roby. We will continue this. My time has expired. So I 
will yield back, but we will continue this if there is another 
round.
    Thanks.
    Mr. Cole. I thank the Gentlelady.
    We go next to my good friend, the Gentlelady from 
California, Ms. Roybal-Allard.
    Ms. Roybal-Allard. Thank you, Mr. Chairman.
    And welcome, Secretary King.

   INDIVIDUALS WITH DISABILITIES (IDEA) VERSUS DEMONSTRATION FUNDING

    Each year, children and families are shortchanged when the 
Federal Government does not meet its full commitment to special 
education under the Individuals with Disability Education Act. 
While school districts across the country have a serious need 
for additional resources, IDEA is consistently funded well 
below the 40 percent Federal cost share that was promised under 
the bill's authorization.
    Once again, I am disappointed that the President's budget 
request only funds the Federal share of education for students 
with disabilities at 16 percent. Given the tremendous need that 
exists for students with disabilities, can you please explain 
why the President's budget freezes funding for IDEA State 
grants while requesting $465 million for programs that are 
unauthorized and unproven?
    Secretary King. Let me first say that I share your 
commitment to the important role of IDEA in supporting the 
success of our students with disabilities, as does the 
President. The budget maintains the $415 million increase from 
2016 for IDEA.
    The budget also includes an increase for IDEA preschool and 
IDEA infants and families, so there are IDEA increases.
    One of the constraints in the budget process was to try to 
balance advancing priorities with maintaining the caps that 
were agreed upon in last year's budget agreement. The IDEA 
budget reflects that, that we, again, maintained last year's 
increase and then have an increase for preschool and infants 
and families.
    Ms. Roybal-Allard. The fact is, though, that the 
President's budget does not reflect a dedicated effort to meet 
our Federal obligation to special education and instead has 
requested robust funding for new and unproven programs. And 
that is a big concern.

                STUDENT SUPPORT AND ACADEMIC ENRICHMENT

    As you know, the Student Support and Academic Enrichment 
Block Grant, Title IV-A under the Every Student Succeeds Act, 
consolidates into a single block grant several programs that 
protect the health and safety of students, promote well-rounded 
enrichment opportunities, and invest in education technology.
    Again, I am deeply concerned that the President's budget 
proposes to fund this program at barely $500 million, which is 
less than one-third of its authorized funding level. If the 
President's budget request is implemented, school districts 
will be seriously compromised in their ability to invest in K-
12 services, ranging from advanced placement courses to high-
quality digital learning.
    Competitive grant structures risk leaving many under 
resourced school districts without any Federal support. Can you 
please justify your less-than-adequate funding request for 
Title IV-A and your recommendation to turn the program into a 
competitive grant?
    Secretary King. We think the new version of Title IV under 
the Every Student Succeeds Act has a number of very important 
purposes, including, as you described, supporting well-rounded 
education, school counseling, education technology, and efforts 
by districts to offer Advanced Placement courses. The 
preexisting programs that are folded into Title IV were funded 
in the 2016 Appropriations Act at $278 million. We propose 
Title IV funding at $500 million. That is a $222 million 
increase over last year's spending.
    It is less than the authorized level. Again, we were trying 
to, in our budget, both advance the President's priorities and 
stay within the budget caps that were agreed to in last year's 
budget agreement.
    But we are certainly open to working with you and others on 
the Committee as we move forward in the budget process because 
we do believe that Title IV has very important elements. The 
proposal around competitive awarding of the grant is to give 
States the option to award the grant competitively because we 
worry that without that competitive element, you could have a 
distribution in the State through a formula methodology that 
results in school districts receiving $10,000, which may not be 
enough to offer a meaningful program in school counseling, arts 
education, or Advanced Placement courses.
    So we propose giving States the option to make the grant 
competitive within the State around State priorities with a 
$50,000 floor so that we can ensure that the Title IV grant has 
a meaningful impact for students.
    Ms. Roybal-Allard. I recognize that argument, but on the 
flip side of that, it also leaves a lot of very needy school 
districts and areas--that don't have the resources--with the 
inability to compete and be competitive for those grants. That 
is the flip side of what you are saying.
    Unfortunately, this funding continues the cycle of 
inadequately funding necessary supports for a lot of students 
and leaves out a lot of schools, particularly those that I 
represent.
    I see, Mr. Chairman, that my time is just about up, I will 
wait until the next round.
    Mr. Cole. I have enjoyed the questions. They are great 
questions.
    If I can, I will go to my good friend, the gentleman from 
Arkansas, who is also the Vice Chairman of the Committee, Mr. 
Womack.
    Mr. Womack. Thank you, Mr. Chairman.
    Mr. Secretary, Mr. Skelly, welcome once again. 
Congratulations, Mr. King, on your appointment and your 
confirmation.

            CAREER AND TECHNICAL EDUCATION AND DEMONSTRATION

    My colleague from Alabama opened the door on career and 
technical education, and I would like to go back into that 
subject for just a minute and save her questions later for 
another topic, if she would like to do that.
    First of all, I am a huge believer in career and technical 
education, and it is my opinion, only my opinion, that our 
country has maybe even duped an entire generation of young 
people to believe that the only real road to success is a 4-
year degree, going to your local college or university and 
getting that 4-year liberal arts degree, perhaps. And we left a 
lot of opportunities for these kids begging.
    In fact, when I travel my district, one of the first things 
I hear from my job creators is the skills gap and the fact that 
we had an opportunity to put a lot of kids in that pipeline and 
just did not, and a lot of these skills are just simply not 
able to match the job requirements.
    I want to go back to the fact that there is level funding, 
the $1.2 billion in level funding and the $75 million request 
for a new competitive grant program and get your thoughts as to 
why we would be opening up a new unproven program of $75 
million when we are not able to meet the demands across the 
rest of the spectrum?
    So can you just kind of articulate on that, and then I have 
one other question.
    Secretary King. Yes. Again, I think our goal there is to 
try to create a best practice model through a relatively small, 
targeted competitive grant that would incentivize strong 
partnerships.
    We also would like to see Perkins Career and Technical 
Education Act reauthorization in a way that advances this 
notion of partnership. In my experience in New York, one of the 
things we worked on was creating partnership high schools, 
where high schools were partnered with community colleges and 
employers. Students would graduate with high school diploma and 
associate's degree, first in line for a job at those employers.
    We created those all across the State, and what we found 
was there is huge demand, just as you are describing, from 
employers across industries--from advanced manufacturing to 
pharmaceuticals to the tech industry. We think that notion of 
partnership should drive reauthorization of the Perkins CTE 
program.
    The President also has a Next Generation High Schools 
proposal, which would aim to get high schools to think 
differently about their design so that they can do exactly what 
you are describing--help students see that it is not 
necessarily a question of college versus career. It is the idea 
that postsecondary training is essential, and that it can lead 
you on a career path that might bring you back to school 
multiple times to hone your skills.
    That career could be the hook that gets a high school 
student interested and focused on their future.

                      DEPARTMENTAL COLLEGE RATINGS

    Mr. Womack. On another subject, in our fiscal environment, 
we have been taught that data and evidence-based approaches are 
critical to improving our education system, and we are all 
forced to do more with less. Everybody gets that, and I am a 
big supporter of State and local control when it comes to 
education.
    But I think most of us can agree that there are some areas 
where the Federal Government can play an effective role, and I 
believe one of those areas is research and creating 
transparency through data. I am glad to see the Department of 
Education withdrawing its troubling plan to rate colleges. It 
demonstrates a fine line between providing students and 
institutions with more data and trying to generate a ``one size 
fits all'' system for evaluation.

                           DATA TRANSPARENCY

    I would argue that consumers are probably more suited to 
judge whether an institution is right for them based on their 
unique circumstances rather than a bureaucracy up here.
    I mention this because I noticed in your budget proposal 
that you request funding for an initiative launched this year, 
InformED, that will make the Department's data and research 
across education spectrum more available and actionable for 
internal users and for the public. Can you explain in greater 
detail in the last minute that I have behind this new 
initiative and tell me your plans for making this data 
actionable?
    Secretary King. Yes. As you say, data can inform decision-
making at the local level, State level, and at the Federal 
level. With the college scorecard, our approach was to make 
transparent the Department's data and--while protecting 
transparency--make that data available to nonprofits and others 
who wanted to use it to inform consumers.
    What we have seen, for example, is a program called Pell 
Abacus, which helps students see within a minute how they might 
calculate what their actual costs would be at a given college. 
I was at a high school recently with students, watching as they 
discovered that a college they thought would never be 
accessible to them, based on their financial aid package, 
actually could be within reach. That is a powerful way that 
data can be leveraged.
    The InformED proposal seeks to do that kind of work across 
the department. The bulk of the funding, I think $13 million of 
the $15 million is really for States to improve their data 
quality, data management so that we can pull that data to the 
Federal level in a way that helps it inform States, districts, 
and ultimately students and families.
    Mr. Womack. Thank you, Mr. Chairman.
    Mr. Cole. I thank you, and--oh, the gentleman from Maryland 
is gone. Okay. Well, I will move on and recognize myself then.

           TITLE I FORMULA AND SCHOOL IMPROVEMENT ALLOCATION

    Mr. Secretary, several education advocacy organizations are 
concerned about the Department's funding request for Title I 
grants to local education agencies because they believe it 
would result in a reduction in Title I allocation in many 
schools. In a sense, it is sort of building on the point that 
my good friend from California made.
    Are these groups correct in that, and if so, you know, why 
does the request shortchange district and instead invest in 
some unauthorized competitive grant programs, as opposed to 
something sort of tried and true like Title I?
    Secretary King. Let me give some context to how we 
approached the Title I allocation. Our Title I proposal is 
actually $350 million above the authorized level because we do 
think Title I is very important in getting resources to our 
highest-needs districts.
    What we propose is to divide that $350 million between 
formula dollars and school improvement dollars that would focus 
on the schools that are struggling. For districts that have 
significant numbers of struggling schools, they will likely see 
level funding or an increase because of that school improvement 
focus.
    But because States will determine which schools are most in 
need of improvement, and States are the ones who develop those 
lists, it is not possible for us to project exactly what the 
implications will be for any given district. It will depend on 
how many schools they have that are deeply struggling.
    Mr. Cole. Well, not to push this point too hard, but as I 
am sure you are aware, there is a great deal of unease and 
uncertainty because of that, because there isn't a 
predictability there, and there is concern that some of these 
schools will literally just fall through the cracks or will 
have something done at a State level that really doesn't direct 
the money to where it is needed. So I think that is something 
that a lot of folks have considerable concern about.

               EVERY STUDENT SUCCEEDS ACT IMPLEMENTATION

    The Every Child Succeeds Act represented a significant 
shift of control over K-12 education policies and programs from 
Federal to the State level. How does your budget request 
address this shift and assist in building capacity in States to 
take over these new responsibilities?
    And wouldn't a larger investment in block and formula 
grants, as opposed to the new competitive grant programs 
included in your budget, be a better way to help States to 
succeed under the new law?
    Secretary King. We certainly think that, like the increases 
that we saw in Title I last year, the significant increase we 
proposed in the Title IV programs will be important to Every 
Student Succeeds Act implementation. We also have held public 
hearings and have gathered significant public comment on 
implementation. We have begun negotiated rulemaking in two 
areas based on input from States and districts as well as civil 
rights organizations and community organizations.
    We intend to implement the law in a very collaborative way, 
gathering feedback throughout as we develop guidance and 
regulations. Driving our work on guidance and technical 
assistance will be what we hear from districts and States about 
what they need.
    We do think some of the specific competitive grant requests 
here advance key priorities within the Every Student Succeeds 
Act, but it is worth saying that 94 percent of what we propose 
is directed toward formula dollars. The vast, vast majority of 
what is funded in the President's budget is through formula, 
but we do think there are places where competitive grants can 
highlight or incentivize particular practices that will help 
drive educational improvement.
    Mr. Cole. Well, and this is hardly your fault, but there is 
some concern--certainly, I have concerns--that because Congress 
was late in getting this legislation to you, you know, frankly, 
the President and, with all due respect, you will only be there 
for a certain period of time. A few months, really. I am very 
skeptical about new initiatives when the people that are 
implementing them aren't going to have the timeframe to 
actually be there.
    Do you have any concern of that yourself?
    Secretary King. We think the proposals we have made really 
build on the last 7 years of work, build on the bipartisan 
agreement in the Every Student Succeeds Act, and point toward 
important priorities that are shared bipartisan priorities. We 
propose, for example, an increase in the Preschool Development 
Grant Program because I think there is strong bipartisan 
consensus, not only in Washington, but in State capitals, 
around the importance of investing in early learning.
    We propose a program around computer science because I 
think everyone understands, again in a bipartisan way, that 
computer science is a part of our future competitiveness and 
that we ought to be helping districts and States think about 
how to support their students in achieving around computer 
science so that they are ready to compete for the 21st century 
jobs that will rely on computer science.
    Mr. Cole. Great. If I could, I will recognize my good 
friend from Pennsylvania, Mr. Fattah.
    Mr. Fattah. Thank you, Mr. Chairman.

                        EQUITY AND LOCAL CONTROL

    I want to revisit this issue around equity, and I know my 
colleague from Alabama talked about standards, and you said 
that, you know, standards should be left to the States. I want 
to return us to a different President, President Nixon.
    He said this issue about local control is an injustice 
wrapped up in a virtue, right? That in the Nixon school finance 
commission, in its summary, it said that as long as we have a 
property-based funded school system, poor children in our 
country are going to disproportionately fail.
    The reason for it is that if you are funding schools on a 
property tax, then poor communities aren't going to be able to 
put--they are going to have a higher millage, but they are 
going to put less money behind each child.
    So we have in the classrooms of the poorest children in our 
country today--this has been true since Nixon was President. 
They have in the main teachers who in the major subjects 
haven't a major or minor in the subjects that they are 
teaching--math, science, English--because these school 
districts can't afford to compete with their wealthier suburban 
districts for, you know, the teachers who are certified in 
math, right?
    They have, in many of our States, double the classroom 
size. They have textbooks that haven't been printed in these 
children's lifetime. When we stand here and we talk about, 
well, you know, it is a local matter. It is, and it is an 
unfortunate local matter, right? That is to say that our 
States, you know, the politics of the statehouse is that the 
poor communities and the rural communities in Appalachia and 
big cities, poor communities get the short end of how these 
things get worked out.
    Even when States set up important standards like teacher 
qualifications, they then grant waivers. Everywhere you can 
find a predominant group of poor children, the State waives the 
requirement, right, rather than create an impulse to actually 
get qualified people in the classroom.
    When Education Trust did the study in California, and they 
found 57,000 teachers who had not majored or minored in the 
subjects they are teaching, right? Now I am not blaming the 
teachers--these are good people. But at my alma mater, 
Overbrook High School, a young lady shows up. She has got a 
degree in art history. The principal says, ``Look, I don't have 
anybody teaching geometry. You have to go teach geometry.''
    At the end of the school year, that young lady quit. Those 
kids did not learn a lot of geometry. Down the street at the 
middle school, at Sulzberger, 14 substitute teachers teaching 
math during the course of one year. It is impossible for these 
children under those circumstances.
    I don't want us to pretend like, well, if we leave it to 
State governments, poor children will get a quality education. 
That has never been the history in our country, and if the 
Federal Government doesn't insist, to some degree or another 
as, a referee, that we have to have some form of equity, it is 
not going to happen in any of our States.

                   FEDERAL ROLE IN EDUCATIONAL EQUITY

    I just want the record to be clear on this matter that, 
yes, we have a system of local control of schools. It has never 
served poor children--and particularly children who come from 
generational, intergenerational poverty--well. It won't today, 
it won't tomorrow, we, at some point, if we want to get more of 
our children headed in the right direction, we are going to 
have to do something more about it.
    Secretary King. I certainly share that view. You know, I 
served on the Equity and Excellence Commission that you helped 
to create, and that commission tried to make the point that the 
fate of all of our children is bound up together. As we think 
about local control, we have to remember that all of our 
children are diminished if there are other children who do not 
have access to opportunity.
    We think the implementation of Every Student Succeeds Act 
requires a strong civil rights role for the department in 
ensuring equity. It is important that the law requires 
equitable access to effective teachers and that the law 
requires transparency around per pupil spending and access to 
advanced coursework and access to early learning.
    We expect to fulfill that civil rights responsibility.
    Mr. Fattah. And I think it can be done, and I think we 
can--we have local--we have a basketball team in Philadelphia. 
They are not doing all that well these days. About as well as 
the one in Oklahoma. But the court is the same size. The rim is 
at the same level, right? The ball has got the same----
    I mean, we can create some level of equity so that children 
have an opportunity to succeed. You know, the Sixers have an 
opportunity to play well. They just haven't gotten there yet, 
all right?
    Thank you, Mr. Chairman.
    Mr. Cole. They just don't have Kevin Durant. [Laughter.]
    Mr. Cole. With that, we will go to my good friend from 
Maryland for whatever questions he cares to pose to the 
Secretary.
    Mr. Harris. Thank you very much.
    And thank you, Mr. Secretary. Welcome.

                 OPPORTUNITY SCHOLARSHIP PROGRAM (OSP)

    I am just going to concentrate on one program. It is the 
one I have asked the person who sat in that chair for the past 
3 years about, which is the Opportunity Scholarship Program. 
Just, you know, the opportunity for low-income individuals to 
get a chance.
    The first thing I am going to say, I am glad that, again, 
on page 9 of your--of the budget book, you know, there is this 
effort to promote greater use of evidence and data. Actually, 
on page 6 of your testimony, it says, ``Finally, we extend our 
commitment to improving student outcome by increasing funding 
for programs based on evidence of success.''
    So, I am going to ask you, does the Department of Education 
intend on increasing funding for the OSP? Because I think the 
evidence is pretty good that it is successful. I mean, a 
graduation rate of 90 percent, as opposed to 64 percent in a 
regular D.C. public school, is pretty good evidence of success. 
I mean, a 26 percent increase in graduation rate.
    Is the Department, in accordance with your testimony about 
using evidence and data to increase programs that work, are you 
in favor of expanding the Opportunity Scholarship Program?
    Secretary King. We are committed to implementing the 
program as required by law but don't believe that vouchers are 
a scalable solution to the challenges we face as a country.
    Mr. Harris. So you are unwilling to expand the program?
    Secretary King. Again, we will implement----
    Mr. Harris. Now let me--let me refer to----
    Secretary King [continuing]. The program according to the 
law.
    Mr. Harris [continuing]. What the Washington Post, you know 
the Washington Post has editorialized about this and has called 
the claims made by opponents of expansion ``specious claims.'' 
Just in case you don't know the meaning of ``specious,'' it is 
superficially plausible, but wrong.
    So do you believe the data is just wrong?
    Secretary King. I don't believe that vouchers can be the 
answer to the challenges we face at scale.
    Mr. Harris. Well, let me follow up with that. Thousands of 
families, again in that Washington Post editorial. I am going 
to take them at their word that there are thousands of families 
on the waiting list. Has the Department over the past few years 
actually studied what happens to the children who don't get 
into the program versus the ones who do?
    Because we know the ones who do graduate at a 90 percent 
rate. What happens to the children who don't get into the 
program? What is their graduation rate?
    Secretary King. There was an IES comparative study, I 
believe in 2010, that showed a 12 percentage point difference 
in graduation rates----
    Mr. Harris. That would be----
    Secretary King [continuing]. Between the participating 
students and the nonparticipating students.
    Mr. Harris. That would be an improvement in the graduation 
rates. That is right?
    Secretary King. That is right. That is right.
    Mr. Harris. So, let us say there were 1,000 children on the 
waiting list in a year. That would be 120 children who actually 
graduate that year if they had been given an opportunity 
scholarship. Do you believe that data? And that is old data.
    Secretary King. The IES study was well designed, and there 
is an ongoing evaluation. I would note that the District of 
Columbia district schools have also seen a significant 
improvement in graduation rates over that time period, and 
there are very strong charter schools in the District of 
Columbia.
    Mr. Harris. The District's----
    Secretary King. Not all, but some of the charter schools 
are performing quite well.
    Mr. Harris. The District's improvement rate was from 56 
percent to 64 percent. Of that 100 students, you have helped 8 
of them. Whereas the data shows that you would help 12 with the 
OSP. So I am going to go to your testimony. You said, ``We 
extend our commitment to improving student outcomes by 
increasing funding for programs based on evidence of success.''
    There is evidence of success, and what you are telling me 
is you don't want to increase funding. Is it just some programs 
that have evidence of success? Is it we pick the science and we 
pick the studies, and if it is politically untenable to perhaps 
go against some vested interest, we are not going to support 
it?

               OPPORTUNITY SCHOLARSHIP PROGRAM CARRYOVER

    Anyway, so I want to ask you what about the carryover 
dollars? I mean, we actually--there actually are dollars out 
there that could expand this program. My understanding is that 
the carryover dollars are not being allowed to be spent now by 
the--by Serving Our Children, which is now the administrator of 
the program.
    Is that the position of your department that carryover 
dollars are not allowed to be spent on expanding this program, 
which has proven successful to help needy, low-income children 
actually graduate? Is that the position of the department?
    Secretary King. Just to be clear, the evidence of success 
is an important factor, but another important factor is 
scalability, and we believe public school choice, the district 
and charter options in D.C., are the more scalable option.
    That said, the carryover funds are dedicated to ensuring 
that the students who are currently enrolled in the program 
will have the opportunity to continue. We don't want to see an 
eventuality where students have begun in a school, and there 
isn't funding available, so they are forced to change schools.
    So we have set aside the carryover funds to ensure that the 
currently enrolled students are able to continue.
    Mr. Harris. I yield back. I will yield back. My time has 
run out, and I will just continue in a second round.
    Thank you.
    Mr. Cole. We will go next to the gentlelady from Alabama.
    Mrs. Roby. Thank you, Chairman.

                      STATE CONTROL AND CURRICULA

    Before I move on to a different issue, and I appreciate the 
gentleman from Arkansas talking about the career and technical 
education, I do want to tie a bow around the local control box. 
The language is very explicit in ESSA that the Federal 
Government, the U.S. Department of Education cannot use Federal 
funds to coerce States into adopting certain curricula and 
standards.
    We have agreed on that, and you committed to upholding that 
portion of the law. But I want to also make sure, to get one 
step further, that you have no intention and under your 
leadership the people that work for the U.S. Department of 
Education will not use, per the law, grant programs or waiver 
programs to then coerce States into adopting certain 
curriculum.
    I just want to make sure that our understanding is the 
same, that the law is explicit in its language that you cannot 
do that.
    Secretary King. Yes. As we discussed, standards and 
curriculum are the province of State and local decisions. I 
will again say that we have an important civil rights function.
    Mrs. Roby. Sure.
    Secretary King. For example, if in a given district, 
English language learners were not allowed to access programs 
on an equitable basis, the Department would have a civil rights 
responsibility to intervene.
    Mrs. Roby. But you can't use waiver programs or grant 
programs to require the State of Alabama to adopt certain 
standards or curriculum?
    Secretary King. That is right. The Every Student Succeeds 
Act requires them to adopt standards that----
    Mrs. Roby. I just want to make clear that when it comes to 
curriculum and standards that the U.S. Department of Education 
cannot use waiver programs--because what ends up happening and 
what we have seen happen is that because of what happened in 
the past under the old law is that States ended up spending 
precious dollars to comply with waiver programs to adopt 
because the Federal Government in the past has been able to 
coerce States that could otherwise be implemented--used right 
in the classroom.
    Now with parents and teachers and administrators on a local 
level in the driver's seat, those dollars can be best spent on 
our children, and the States can make the decisions about those 
curriculum and standards. But I wanted to specifically address 
the waiver and grant programs, and I think we are clearly on 
the same page.

                          ON-TRACK PELL BONUS

    I want to move to the administration's proposal for the On-
Track Pell Bonus, which would give $300 to Pell Grant 
recipients who enroll in 15 credit hours per semester in an 
academic year. The objective is to encourage students to 
complete 60 credit hours within a 2-year period and 120 credit 
hours in 4 years.
    So where the goal behind this program is commendable, I am 
concerned that this Pell bonus might encourage students to 
enroll in more credits than they can handle just to receive the 
$300 bonus. Furthermore, I don't see how this program helps 
nontraditional students who are unable to take 15 credit hours 
because they have got a work schedule and/or family that they 
take care of.
    This idea seems to promote quantity over quality and like 
many things that we do around here could lead to some very 
negative unintended consequences. Can you tell this committee 
in a minute and 30 seconds that the On-Track Pell Bonus would 
not lead to abuse or diminished learning outcomes for students 
who feel pressured because of this incentive to take on more 
than they can handle just to get that $300 bonus?
    Secretary King. The goal of the President's proposals 
around college completion addresses the challenge that we see. 
Many of the students who are defaulting on their debt are 
students who start, but don't finish. They have--they don't 
have a degree, but they do have debt. They can't pay it back 
because they can't get a good job because they don't have the 
degree.
    So there is a set of programs that would work together. 
There is good evidence that incentives to take 15 or more 
credits make a difference for college completion. A number of 
efforts around the country, including University of Hawaii, 
have very strong evidence around a focus on 15 credits.
    We also propose summer Pell, allowing students to access 
Pell dollars during the summer, which, for the nontraditional 
student, can be essential because that is an opportunity for 
them to continue their coursework over the summer and stay on 
track to on-time graduation. We also propose an institutional 
bonus that would incentivize colleges and universities to focus 
on completion support.
    I was just at Georgia State last week, same day I went to 
Alabama A&M. They have increased their graduation rate by 22 
points over the last decade while nearly doubling the number of 
students who are Pell-eligible through a focus on supporting 
students through to completion--academic advising, support 
services, good counseling on which courses to take and how to 
fulfill their credit requirements for their major.
    We think this package of efforts will help us address our 
completion challenges.
    Mrs. Roby. My time has expired, but I would just say that I 
have concerns that this would not only lead to people, 
individuals taking on more than they can handle, but also there 
is an opportunity here for abuse to take place, as well as 
diminished learning outcomes.
    As a committee, I hope that we will continue to look into 
this. I yield back.
    Mr. Cole. Thank you.
    Just for informational purposes, some of us have had an 
opportunity to have two rounds. Some of us have not. We are 
going to move to those people that have only had an opportunity 
to have one round. We will start, if we may, with our 
Distinguished ranking member of the Full Committee.
    Mrs. Lowey. Well, thank you very much.

                           STUDENT LOAN DEBT

    Because this issue is so important, although there are 
about three or four hearings going on at the same time, I did 
want to come back. Because this student loan debt, which has 
reached $1.2 trillion nationwide for 40 million borrowers, 
making the average student loan burden $29,000 upon graduation, 
is a major challenge for all of us.
    I want to say at the outset, I think it was 3 years ago or 
three cycles ago that we took away the third cycle of Pell 
Grants. When you visit the community colleges, as I do all the 
time, these kids are now working three, four, five, six jobs. 
If they could get another cycle continuing the three, four, 
five, six jobs, they could get out there and work with a 
degree.
    I want to emphasize this again, ask our distinguished 
chairman maybe we can do something through the appropriations 
process. You are shaking your head. So I know you agree.
    In 1980, Pell Grants covered 77 percent of the cost of a 4-
year college program. Due to the rising cost of college in the 
2015-2016 school year, Pell Grants covered just 29 percent of 
the cost, forcing students to take on additional debt, which we 
have been talking about.
    This is why I was very pleased that the budget request 
includes the maximum value for Pell Grants and I am glad in the 
request you are asking for the third semester, maybe trimester 
of Pell eligibility and provide a bonus to students who take 
additional credits, which, together, would help students 
graduate more quickly with less debt and enter the workforce 
faster.
    To me, it is a win-win. Third cycle, let them get that 
education, let them get out.
    I am concerned that the current level of student loan debt 
is absolutely unsustainable. In addition to your Pell expansion 
proposals, I would like to know what the Department is doing to 
reduce student loan debt and make our higher education more 
affordable. As Congress is preparing to debate a Higher 
Education Act reauthorization, what more can we do to ease the 
financial burden on those trying to pay for college or a 
vocational training?
    Thank you.
    Secretary King. It is a very important question. You know, 
one of the things that we are seeing that is promising, as we 
discussed earlier, was students enrolling in the income-based 
repayment program. We propose streamlining that income-based 
repayment process so that students can enroll in programs that 
cap their student debt payments at 10 percent of their income.
    We would like to see rapid expansion of that effort, and we 
are reaching out to students so that they are aware of that 
possibility. That would be helpful. There are a number of 
proposals, including in the RED proposals around students' 
ability to refinance, we think would be potentially helpful to 
students if done in the right way.
    The President has also proposed America's College Promise, 
as you know, which would guarantee for hard-working students 
that they would be able to go to 2 years of community college 
for free or the first 2 years at a historically Black college 
or university or a minority-serving institution. We think that 
can be a powerful lever.
    In the structure of that program, we also require States to 
meet the national average commitment, and the amount that the 
State gets is tied up with how close they are to that national 
average commitment. The intention there is to incentivize 
States to maintain or increase their investment in public 
higher education.
    As you know, one of the reasons why we have seen the 
shifting of cost to students is in many States around the 
country, we have seen a retreat from investment in public 
higher education.
    Mrs. Lowey. Thank you, and I hope to continue the 
discussion. With my one minute, I just wanted to get another 
issue on the record because I think it is so important, Title 
VI and anti-Semitism.

                       TITLE VI AND ANTI-SEMITISM

    The International Education and Foreign Language Studies 
Program within Title VI advances national security, foreign 
policy, and economic interests. I really have very great 
concern about reports that some recipients of these funds are 
disproportionally focused on or are biased against Israel. In 
2014, the department revised many Title VI program performance 
measures by focusing on quantitative metrics.
    How did these reviews affect the International and Foreign 
Language Studies Program? What step is the department taking to 
ensure that Federal investments are not perpetuating an anti-
Israel bias? And, I just want to say, the reports I have been 
getting, there is a bipartisan caucus, as you probably know and 
are a part of, on anti-Semitism. And what is going on on the 
college campuses, I have personally witnessed it, it is truly 
outrageous.
    So, Mr. Chairman, if you would give the distinguished 
Secretary a minute just to tell us what you can do, what we can 
do, and I know many of us are working together to address this.
    Secretary King. Yes. In terms of the international 
programs, international language and education programs, we can 
follow up with more detail on those programs.
    [The information follows:]
    
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    I would say important to us is that in all of those 
programs, we are supporting the celebration of diversity and 
pluralism and how we approach those.
    One of the first things I did on becoming Secretary is also 
the last thing Secretary Duncan did, was we signed a joint 
letter that went to all of our universities and school 
districts around issues of tolerance and religious tolerance 
and celebrating diversity and protecting students from bullying 
and harassment based on religion or other issues of prejudice.
    We are very committed to setting the right tone around 
that, and certainly our Office for Civil Rights responds to 
complaints we get, whether it is from higher education 
institutions or districts, around intolerance, prejudice, and 
harassment that may occur on campuses.
    We had a convening last year with higher education 
institutions focused on campus climate and issues of racial and 
ethnic harassment. We are eager to continue to work with you 
and others on the committee on this issue.
    Mrs. Lowey. Thank you.
    Thank you, Mr. Chairman. The reports I have gotten are 
really outrageous. New York City public colleges, UCLA, we saw 
those reports. I think this is an issue that we should pursue 
together, as we are, Democrats and Republicans. Seeing what we 
can do through the programs, which we fund, to address this.
    Thank you.
    Mr. Cole. I thank the Gentlelady.
    We will next go to the Gentlelady from California for any 
questions she cares to ask.

                        ADULT EDUCATION FUNDING

    Ms. Roybal-Allard. Mr. Secretary, in California alone, 5.6 
million individuals need adult education services. However, 
under Title II of the Workforce Innovation and Opportunity Act, 
the State is only able to serve about 500,000 with adult 
education, skill training, and workforce preparation.
    While Congress intended Title II of the Adult Education and 
Family Literacy Act of WIOA to receive additional funding each 
year, and this is reflected in the legislation's graduated 
authorization levels, the budget request for WIOA adult 
education State grant program is only level funded from fiscal 
year 2016. Why has the Administration chosen not to request 
funding that would allow adult education State grants to meet 
their full authorized amount under the Workforce Innovation and 
Opportunity Act?
    Secretary King. Again, this is a place where one of our 
challenges is how we pursue our priorities within the caps that 
were agreed to in last year's budget agreement. We do propose 
an increase in adult education funding because we think that is 
hugely important.
    We are working very closely with the Department of Labor on 
WIOA implementation. The President also proposed on the 
mandatory side $5.5 billion that would be directed towards 
programs that are focused on adult education, training, 
disconnected youth, and trying to make sure our disconnected 
youth are connected to education and job readiness.
    All of the mandatory proposals in the President's budget 
are paid for in the budget and would result in a net reduction 
in the deficit. We do believe that that set of proposals that 
we made jointly with the Department of Labor would get at 
exactly the issues that you were describing.
    Ms. Roybal-Allard. Well, let me just explain my frustration 
with the way this program is not being funded at the level that 
it should be. In my district alone, only 51.7 percent of my 
constituents 25 and older are high school graduates. Programs 
under the Adult Education State Grant Programs, such as 
Workplace Literary Programs, English Literacy Programs, and 
Civics Education are absolutely essential.
    So I would again urge that the administration prioritize 
proven programs that are badly needed, as opposed to 
unauthorized, unattested proposals as it has a tendency to do 
when it presents its budget.
    In closing, I just want to associate myself with the 
Ranking Member's statement about the value and the importance 
of year-round Pell Grants, and I was pleased to see that the 
Pell for accelerated completion proposal was in the President's 
budget request because it really is critical. In fact, the 
year-round Pell has a very strong return on Federal investment.
    Secretary King. Absolutely. Thank you.
    Ms. Roybal-Allard. I yield back.
    Mr. Cole. I thank the Gentlelady.
    We will next go to the Gentleman from Maryland for whatever 
questions he would care to ask.
    Mr. Harris. Thank you very much.

                 OPPORTUNITY SCHOLARSHIP PROGRAM (OSP)

    First, I want to associate myself with the Full Committee 
Ranking Member's comments on the anti-Semitism that prevails on 
some college campuses, and I would hope that as the Ranking 
Member suggests, that since we fund a lot on those college 
campuses, we ought to have a say when they deny diversity 
because of your religious background, in this case, again, 
anti-Semitism.
    Let me go back to the Opportunity Scholarship funds because 
I just don't understand what the evidence is that these aren't 
scalable. I just don't--I mean, I am not talking about doubling 
the problem. But you know, you can expand it 5, 10 percent.
    I mean, is it that there aren't schools to accept these 
students? Because I find that hard to believe. What is the 
evidence that it is not scalable?
    Secretary King. Well, the reality nationally is that there 
is not the private school capacity----
    Mr. Harris. Mr. Secretary, we are not talking about 
nationally. We are talking about the District of Columbia. We 
are talking about the Opportunity Scholarship Program. What is 
the evidence in the District of Columbia that this program is 
not scalable? Because you do understand, there have been more 
students in this program in the past.
    I mean, in fiscal year 2016 is the lowest number of 
students in the past 5 years in the program. What is the 
evidence that it is not scalable?
    Secretary King. Well, both nationally and in the District 
of Columbia, it is clear that private school capacity is not 
sufficient to replace the important role of public education. 
So our belief is that----
    Mr. Harris. Mr. Secretary----
    Secretary King [continuing]. The District's----
    Mr. Harris [continuing]. I am going to have to interrupt 
you here. I am not talking about replacing public education. I 
am talking about an expansion of the program. I am not talking 
about replacing public education. We are going to--if we are 
going to have a serious discussion, you can't set up a straw 
man that I am suggesting replacing public education.
    What is the evidence that if we merely go back to the 
levels of 4 fiscal years ago that we are not helping dozens of 
students who would otherwise not graduate based on the 
evidence? We have evidence. Yes, the public school system is 
getting better. But we have a 90 percent graduation rate in the 
OSP program.

                            OSP SCALABILITY

    What is the evidence that it is not scalable to increase it 
by 10 percent? Is there evidence? Do we have evidence?
    Secretary King. Well, as we discussed, the original 
question was about student access to current funding. We will 
ensure that students are added in a way that spends current 
funding.
    A separate issue is the carryover, and our view on the 
carryover is that that should be preserved so that the students 
who are enrolled have the opportunity to complete their 
educational program within the schools that they are enrolled 
in.
    We will add students this year--I don't know the precise 
number, that will depend on attrition and so forth--to make 
sure that we are spending current dollars. We will preserve the 
carryover for the long term.
    If the question is as a public policy matter, do we think 
it is a good idea to expand voucher programs? No, because we 
don't believe, as I said, that they are a scalable solution to 
the challenges we face, and we would prefer to see those 
resources invested in public school choice, quality district 
and charter options.
    Mr. Harris. Mr. Secretary, I fully get that. I am just 
going to point page 6 of your testimony where you say, ``We 
extend our commitment to improving student outcomes by 
increasing funding for programs based on evidence of success.''
    Let me summarize what you have said today. There is 
evidence that the graduation rate is higher, right? The IES 
study, the graduation rate is higher.
    There is no evidence that it is not scalable to previous 
levels, none at all. Zero. You have no evidence of that.
    So, when I read your testimony, you want me to believe that 
if you see the scientific study, which the IES study we could 
argue is scientific study, based on evidence, you say you want 
to increase funding in your testimony, written testimony, but 
your verbal testimony is different.
    Let me just point out one issue with the program is that if 
a poor family has tried to do right for their student, and they 
have scraped by and they are working two, three jobs to pay 
that private school tuition, $7,000, $8,000, $9,000 in a lot of 
cases, they are not eligible for this.
    To be eligible for this program, is it true that they would 
have to--their child would have to drop out of the school they 
are in to then enter the lottery to be eligible for funding to 
go back into that same school? Because income is the prime 
determinant, but if you happen to be in a--not in the public 
school system, you are not eligible for the lottery at this 
point in time?
    Is that a correct summary of the way things are run?
    Secretary King. Well, the original intent of the program 
was to create opportunity for students who otherwise wouldn't 
have that opportunity, and so the funding is awarded in a way 
that respects that intent. Otherwise, you would have the risk 
of merely funding students who were already enrolled.
    Mr. Harris. These are all--I mean, let us get it straight. 
The income level is $22,000. To make a $7,000 or $8,000 payment 
to a school for tuition, you are scraping by. You are a parent 
who is trying to do what is right. As usual, the Government 
kind of punishes you for that.
    I get it, Mr. Secretary. I yield back.

          STUDENT SUPPORT AND ACADEMIC ENRICHMENT BLOCK GRANTS

    Mr. Cole. Mr. Secretary, I was surprised, and this touches 
on a point that Ms. Roybal-Allard made earlier, but I was 
surprised that your budget request included only $500 million 
for the newly authorized Student Support and Academic 
Enrichment State Grant. That is less than a third of the 
authorized level.
    The program is intended to be a flexible funding stream 
that allows States and school districts to invest in those 
areas that are most needed to improve the quality of education. 
I was disappointed that the request seeks--I was also 
disappointed that the request seeks to change the local 
allocations from a formula basis to a competitive basis, which 
would further shortchange many school districts and, frankly, 
in my view, circumvents congressional intent.
    Again, I understand the resources are limited here, and it 
would be a challenge under any circumstances to fully meet the 
authorized level. But the funding at the requested level seems 
to me to significantly curtail its potential usefulness to 
support school districts.
    Why does your--is it simply a math problem, you know, a cap 
problem that we are this low on this? Again, it seems to me 
there are other areas where you have requested funding that, 
frankly, I would rather see the money here in these kind of 
things than perhaps in some of the other areas.
    I want to give you an opportunity to elaborate on that.
    Secretary King. Sure. You know, again, we were--we see this 
as a significant increase over the preexisting program. The 
four programs that were funded previously were only at $278 
million. Taking it up to $500 million is a significant 
increase.
    We do think there is an opportunity for more discussion in 
a bipartisan way about how to move forward with the Title IV 
program. The competitive grant component would be an option for 
States. We are not requiring--we are not proposing requiring 
States to make it competitive.
    The concern, as I mentioned earlier, was if the formula 
delivers a grant that is just too small to do anything 
meaningful, then that is a missed opportunity. We see this as 
an opportunity for States to identify priorities within the 
many available uses of Title IV dollars and then to have a 
competitive process.
    States could weigh in that process, you know, attention to 
rural issues. They could weigh in that process attention to 
perhaps pooling of resources across smaller districts. We want 
to make sure that folks have an opportunity to advance the 
purposes of Title IV around a well-rounded education, school 
counseling, advanced placement courses, so forth.
    Mr. Cole. Okay. Well, thank you for the explanation.
    I will go to my good friend from Pennsylvania next.

                         STUDENT LOAN REPAYMENT

    Mr. Fattah. Yes, I just want to circle back on this loan 
repayment thing. I got my facts straight now.
    In the portion of the Affordable Care Act that was entitled 
the Student Aid and Fiscal Responsibility, which was a separate 
bill altogether. We just included it on the train that was 
going along, and Senator Kennedy and former chairman George 
Miller and others worked on this. It says basically that for 
new borrowers, starting in 2014, will be able to have their 
payments capped at 10 percent of their discretionary income and 
that, furthermore, that if for 10 years of public service work, 
they could have their loans forgiven, right?
    This doesn't affect people who already have loans, who are 
already in the process. But it may be helpful for families and 
students who are matriculating through higher education now or 
contemplating it to understand that there will be a 
circumstance in which managing their debt would be a lot more 
plausible and even more affordable to the degree that they 
followed the others into public service.
    I just want to make sure that the record is clear, and I 
think it would be very helpful if the Department could make 
sure that families know about this. Because at least as for 
myself, I have a 17-year-old who is looking around at colleges, 
and you know, some of them are a little pricier than others, 
but it is an important consideration, I think, for families as 
to this.
    I think even as we think about the Pell Grant, we also have 
to think about the other things that the Congress and the 
administration has done together, including the American 
Opportunities Tax Credit, which I was proud to author, but is 
another way where we are helping families and many of them at 
incomes, you know, in which they might not think they could get 
help, but they are receiving, you know, dollar for dollar, a 
reduction on their higher ed cost, up to $2,500.
    I want to thank you. I would be glad if you want to respond 
to that, you can.
    Secretary King. Yes, just I would say on the income-based 
repayment portion, there I think we have seen very significant 
growth. I think we are well over now 4 million folks who are 
participating in income-based repayment and see a path to 
adding many more.
    On the loan forgiveness, public service loan forgiveness, 
we will get back to you with the details that we have on 
students participating now and what we project over the next 
few years.
    Mr. Fattah. Thank you.
    Thank you, Mr. Chairman.
    Mr. Cole. Thank you.
    Mr. Harris, you are recognized for whatever additional 
questions you would care to pose.

                 OPPORTUNITY SCHOLARSHIP PROGRAM (OSP)

    Mr. Harris. No, I just want to thank the Secretary, and 
welcome to the job. You know, as you probably figured out, I 
have some passion for the Opportunity Scholarship Program. I 
think we really have to provide educational choice.
    I think the evidence is that when we do, everyone benefits. 
That I believe that the increased graduation rate in the public 
school system in D.C. is partly because there actually was an 
educational choice alternative. And I think that that is part 
of the solution.
    Again, I hope to work with you on some way to be able to 
bring the numbers up to their historic numbers in that program 
and you know, again, just give these children of low-income 
families a chance at the American dream.
    Thank you very much for coming before the Subcommittee.
    Secretary King. Thank you.
    Mr. Cole. I will recognize my good friend from Pennsylvania 
to make an additional point.

                ROLE OF FEDERAL INVESTMENT IN EDUCATION

    Mr. Fattah. I met with the Secretary Hite--I mean 
Superintendent Hite--from Philadelphia yesterday, and he was 
focused, and I know this has been mentioned earlier, on this 
apprenticeship program. We had your counterpart, the Secretary 
of Labor in last week, and we talked about apprenticeship 
efforts. We have some wonderful programs in Philadelphia that 
have been federally funded.
    I know the chairman took some issue with that, but they are 
doing great work. They are helping young people who are not 
going to college, but to find their way into careers that allow 
them to make a living capable of raising families.
    So, thank you, and just wanted to put that in the record.
    Thank you, Mr. Chairman.
    Mr. Cole. Well, thank you, my friend.
    First of all, Mr. Secretary, you got through the first one 
without too much problem. So very fine job.
    Secretary King. Thank you.

                                Closing

    Mr. Cole. Mr. Skelly, I want to join our Ranking Member of 
the Full Committee and just thank you for 42 years of wonderful 
service to help educate young people and put this country in 
the right direction. You had a wonderful career to be very, 
very proud of, and you have earned your retirement.
    We have probably kept you working for a few extra years 
since you put a child through Grinnell. Believe me, having gone 
there, that is an expensive proposition. We just thank you for 
your wonderful service to our country.
    Mr. Fattah. I agree. Thank you.
    Mr. Skelly. Thank you very much, Mr. Chairman.
    Mr. Cole. Okay. With that, we will conclude the hearing. 
Mr. Secretary, again, it was great to have you.
    Secretary King. Thank you.
    
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                                         Wednesday, March 23, 2016.

               CENTERS FOR DISEASE CONTROL AND PREVENTION

                                WITNESS

THOMAS FRIEDEN, M.D., DIRECTOR, CENTERS FOR DISEASE CONTROL AND 
    PREVENTION
    Mr. Cole. Good morning. It is good to have you here, Dr. 
Frieden. And it is my pleasure to welcome you to the 
Subcommittee on Labor, Health and Human Services, and Education 
to discuss the fiscal year 2017 Centers for Disease Control and 
Prevention budget request.
    I am looking forward to hearing the testimony of Dr. 
Frieden. I look forward to discussing in greater detail 
priorities that I know we all share, such as reducing opioid 
abuse, antibiotic resistance, and chronic diseases in our 
country.
    I also want to better understand the steps the CDC is 
undertaking to address Zika.
    Last year, Congress provided CDC with a 4 percent increase, 
double the request. This year, the administration has proposed 
a 3 percent decrease for fiscal year 2017. I would like to talk 
more today about the reason for this proposal and the impact it 
may have on public health.
    I understand two more countries now have met the World 
Health Organization criteria to be considered free of the Ebola 
transmission. We know the CDC has been actively engaged in the 
Ebola fight and are glad to hear about such progress.
    Many other public health threats face our Nation, and we 
want to give you the resources you need to combat them. I want 
to caution you, however, that we also want to ensure that 
precious taxpayer dollars are not wasted on politically 
motivated activities outside the mission of the CDC, such as 
promoting gun-control or lobbying local communities to ban the 
consumption of certain products.
    Today, we welcome Dr. Thomas Frieden, the CDC director, to 
the subcommittee. Although we will continue to work with you 
throughout the year, this may be the last time you appear 
before our subcommittee during this administration. In fact, I 
want to publicly thank you for the splendid, splendid work that 
you have done and how well you have worked with every member of 
this committee and with Congress in carrying out your important 
functions.
    You genuinely represent the finest traditions in public 
service. So we are so happy to have the opportunity to work 
with you.
    As a reminder to our subcommittee and our witness, we will 
abide by the 5-minute rule. But before we begin, I also want to 
announce some housekeeping. We will be voting sometime during 
this hearing, so I want to go as far as we can in terms of 
opening statements by everybody. When the vote occurs, we will 
recess and then we will come back immediately after the vote. 
So you do not have to worry about juggling back and forth. We 
will recess the hearing, so people have an opportunity to put 
their questions to Dr. Frieden.
    I am pleased, obviously, we have the big chairman here 
today. So if I may, I am going to yield to him for his opening 
statement, and then I am going to go to the ranking member for 
her opening statement.
    Mr. Rogers. Mr. Chairman, thank you very much for your 
recognition.
    Dr. Frieden, welcome to the subcommittee, and your 2017 
budget request for CDC.
    CDC performs a critical mission to protect Americans from a 
host of health threats, both domestic and foreign. Your request 
of $7,039,000,000 constitutes a 3 percent reduction from last 
year's enacted level, largely taken from immunization funds and 
flexible Preventive Health and Human Services Block Grant 
funding.
    At the same time, like a number of agencies within the 
Department of Health and Human Services, you have requested to 
add $30,000,000 in new mandatory funding outside the purview of 
this committee. Behavioral health is a topic meriting 
discussion and our support, but it must take place within the 
confines of our discretionary authority.
    I look forward to working with you so this committee can 
adequately fund your mission for fiscal year 2017.
    I want to start off this morning thanking you and your 
colleagues at CDC for your tremendous work to help build a 
healthy work force through the prevention and treatment of 
serious health concerns in my region and across the country.
    As you know from having traveled in my district, we have 
lost around 10,000 coal mining jobs in the past few years. To 
help build a stronger economy for Appalachia, I have been 
working with both the current Kentucky Governor Matt Bevin and 
his predecessor, Governor Steve Beshear, on a regional 
development initiative known as Shaping Our Appalachia Region, 
SOAR.
    As we build a network across the region to strengthen and 
expand the economy, it is important to understand the vital 
role of having a readily available and healthy work force. 
Currently, Kentucky is plagued with some of the Nation's 
highest rates of heart disease, cancer, diabetes, kidney 
disease, and others.
    I appreciate your visit to my district for 3 straight days 
a couple years ago and for the wonderful work your CDC team 
members are doing on the ground in Eastern Kentucky working 
with SOAR. By helping coordinating what is called a health 
hackathon with MIT scheduled for later this year, and assisting 
with substance abuse, heart disease, and diabetes health 
disparities, the CDC is truly making a difference in helping my 
region address serious health concerns.
    Another longstanding challenge in my region, as you know, 
has been the abuse of prescription medications. As the abuse of 
opioids, including heroin, has spread to new heights across the 
Nation, you have rightly characterized this emerging threat as 
an epidemic, and I thank you for dedicating your personal 
attention and resources to addressing this terrible problem 
that has taken too many lives and touched too many families.
    In particular, I salute you for working to produce new 
guidelines for prescribing opioids for chronic pain, just in 
the last few days. These science-based and data-driven 
recommendations constitute a landmark achievement.
    A poll conducted since you released the guidelines last 
week indicates that they earned tremendous support from both 
the patient and prescribing community.
    For too long, a narrow focus on opioids as a cure-all for 
pain and runaway prescribing have directly led to many of the 
40 deaths each day, I am told, from opioid overdoses. For the 
first time, thanks to you and your colleagues, doctors will 
have clear recommendations for what factors to consider before 
prescribing opioids, how much they should prescribe when 
warranted, how often they should check back in with their 
patients after sending them home, and how to respond if their 
patients succumb to addiction.
    So your guidelines are a major step forward, and I 
congratulate you and thank you for a signal achievement.
    I am anxious to see that the medical community follows 
through now with these recommendations and prescribes 
responsibly.
    In particular, I am glad to see you acknowledge the breadth 
of options for treating pain outside of opioids. As your 
recommendations reflect, addictive painkillers like oxycodone 
are certainly appropriate when a patient faces serious pain and 
has exhausted other options, but it should not be the default 
option.
    I am so glad that you emphasize the importance of the 
continual interaction between doctor and patient. This 
relationship can and should be the start of an honest 
conversation at each step of the process. Fully embracing this 
may well save tens of thousands of lives each year.
    I know that this message will be well-received when you 
address the National Rx Abuse & Heroin Abuse Summit next week 
in your current home of Atlanta. And I thank you again for 
taking the time to focus on these important issues. And I am 
pleased to say that you will be joined at the summit this time 
by the President of the United States, who will be addressing 
this national summit, I think the best summit there is on 
prescription drug abuse and heroin abuse, in Atlanta, the fifth 
annual.
    Finally, you and I have spoken extensively about your 
request for Zika virus prevention and preparedness. I just came 
back along with Chairman Cole and others from a visit to South 
America, including Brazil, where we met with various leaders 
and health officials about the spread of this virus.
    Our committee has made countless inquiries to the 
administration about the use of currently available dollars to 
address this crisis, and I hope you came prepared with some 
answers in that regard today.
    Just to reiterate the position of our committee, when we 
received the request from the administration for a 
supplemental, we consulted and checked into the records. And 
when we wrote you a letter, it was to explain that we stand 
ready to help. We think there are available funds that are 
unobligated from the Ebola campaign that could be quickly 
utilized in an emergency basis to get the fight against Zika 
going, giving us time then to see what else might be needed 
down the road, in which case we can consider a supplemental, if 
necessary, or take care the problem in the 2017 regular order 
bills.
    So that is sort of where we are, and we stand ready to 
help. I want to make that clear, that we are here to help you.
    We are trying to find out now from the administration what 
monies are available for this purpose; whether or not they are 
being used; and if so, how much and where; and what is the 
bottom-line request or need that we can try to fulfill.
    Thank you, Mr. Chairman.
    Mr. Cole. Thank you, Mr. Chairman.
    We have been joined by the ranking member of the full 
committee, my good friend, the gentlelady from New York. She is 
recognized for whatever opening comments she cares to make.
    Ms. Lowey. I want to thank my good friend, Chairman Cole, 
and Ranking Member DeLauro for holding this hearing.
    I also want to thank you, Chairman Rogers, for your 
leadership for quite a few years on opioids. It is your 
leadership that is really making a difference, so I thank you 
very much.
    And I thank Director Frieden. For nearly 7 years, you have 
guided the CDC with a steady hand from one public health crisis 
to another. We appreciate your dedication, your skill, your 
service, and your testimony today.
    It was just a year ago that we were discussing how the 
CDC's efforts mitigated the tragic losses due to Ebola. A year 
later, we are faced with yet another public health emergency, 
as the Zika virus is growing through South and Central America 
and the Caribbean.
    Our mission to eradicate Ebola is not yet complete, and the 
CDC's efforts to combat Zika, in addition to other infectious 
diseases, are pushing public health infrastructure resources to 
the breaking point.
    Last month, the administration requested an emergency 
supplemental to combat Zika. Sadly, Congress has sat on its 
hands while the number of Zika cases continues to rise. The 
World Health Organization estimates Zika could eventually 
affect as many as 4,000,000 people. As you know, this is 
particularly dangerous for women who are pregnant or who could 
soon be pregnant, causing birth and development defects that 
could result in miscarriage or death.
    The world is looking to the United States to lead on 
combating Zika, and I hope Congress will face the seriousness 
of this threat and act without delay.
    At a time when CDC's resources are already stretched thin, 
you come before us with a budget that would reduce CDC's 
overall program level by 3 percent. I am really very concerned 
about your proposed cut to chronic health and cancer 
screenings, particularly at a time when diabetes, heart 
disease, and more risks not only the health of the patient, but 
the health of our Nation's economic well-being.
    I was pleased to see a proposed increase for combating the 
opioid epidemic, as well as a $15,000,000 increase for Global 
Health and an additional $40,000,000 to combat antibiotic 
resistance, which causes more than 23,000 deaths annually and 
poses a serious risk to the future of our health system.
    Finally, the budget once again includes $10,000,000 for gun 
violence prevention research at the CDC. As you know, I have 
been working to advance this research for 20 years, having 
authored the first amendment to strike the prohibition from 
this bill in fiscal year 1997. Since then, hundreds of 
thousands of Americans have died as a result of firearms. Since 
2001, nearly 10,000 children were wounded or killed as a result 
of an accidental shooting.
    Even Congressman Dickey has changed his mind and called for 
the removal of his rider and for funding this important public 
health matter. I am baffled, frankly, that Congress cannot come 
together and find a bipartisan path forward on gun violence 
research.
    This is not about confiscating firearms or restricting the 
sale of weapons. This is pure and simple about looking to 
public health experts for research on how to make our 
communities safe.
    I do hope, Mr. Chairman, that, this year, we may be able to 
solve this issue once and for all. We are talking about 
research. Thank you very much.
    Mr. Cole. I thank the gentlelady.
    Now I move to my good friend, the ranking member of the 
subcommittee, the gentlelady from Connecticut, for whatever 
remarks she cares to make.
    Ms. DeLauro. Thank you very much, Mr. Chairman.
    I would like to welcome Dr. Frieden this morning and add my 
thoughts and appreciation for the great work that you have done 
over the years. It has been an honor to work with you and with 
the Centers for Disease Control. Thank you so much for your 
commitment, your personal commitment.
    This morning, we discuss the 2017 budget request for the 
Centers for Disease Control and Prevention. The CDC is the 
first line of defense in protecting Americans from public 
health emergencies. It is vital to the well-being and safety of 
American families, and it is an essential part of our country's 
defense and its security apparatus.
    Most of CDC's funding supports core public health 
infrastructure across the country, including State and local 
health departments, public health laboratories, and nonprofit 
and community-based organizations. The CDC also plays a primary 
role in responding to emerging public health threats.
    One year ago, we were in the midst of a worldwide response 
to the Ebola outbreak in West Africa. CDC ultimately deployed 
more than 2,000 staff to West Africa to respond to the Ebola 
threat, protecting American lives, as well as those in West 
Africa.
    Right now, we are facing three public health crises on 
three fronts, and the CDC is critical to confronting each of 
them to protect American families and children--the Zika virus, 
the opioid epidemic, and the lead poisoning crisis in Flint, 
Michigan.
    Unfortunately, Congress is dragging its feet, leaving 
Americans at risk.
    The Zika virus is affecting thousands of pregnant women and 
causing their babies to be born with severe birth defects. It 
is infecting travelers returning to the United States. And it 
is even being transmitted sexually.
    We are about to send hundreds of American athletes, men and 
women, to Rio for the Olympics, and thousands more will attend 
as spectators. We are sending blood supply to Puerto Rico.
    We need to act quickly on the administration's request for 
emergency supplemental appropriations to defend against this 
serious threat.
    Some of my colleagues have expressed a desire to shift 
unobligated funds Congress has provided for Ebola to respond to 
Zika. I strongly oppose that idea because of the activities we 
would have to forgo if we shift funds away from Ebola to Zika. 
And I hope that Dr. Frieden will discuss these today.
    We need to be able to respond to multiple public health 
threats at the same time. That is why this Congress and the 
last Congress, I proposed funding the Public Health Emergency 
Fund to enable the Federal Government to immediately respond to 
public health threats. It is modeled on the Disaster Relief 
Fund, which is at $7,300,000,000.
    This fund enables a rapid Federal response following a 
natural disaster. If we can act quickly to respond to floods, 
hurricanes, and other natural disasters, we should be able to 
act quickly to respond to public health emergencies.
    I might add that, since 2010, when it has come to the CDC 
cooperative agreement efforts with State and local governments, 
we have cut that fund from 2010 to 2016 by 8 percent. Our 
hospital preparedness program from 2010 to 2016 has been cut 39 
percent. Then we wonder why we are not prepared.
    Before I move to fiscal year 2017, I want to take a moment 
to review the fiscal year 2016 omnibus. Last year, we provided 
an increase of $308,000,000 for CDC. That is about 4.5 percent 
over the 2015 level, including a critical investment of 
$160,000,000 to address the threat of antibiotic resistance, 
which has the potential to threaten the entire health care 
system. And we provided an increase of $50,000,000 to respond 
to the opioid and prescription drug crisis.
    Of the over 47,000 drug overdose deaths in 2014, heroin was 
a factor in 10,574 deaths, and opioids were involved in 20,808. 
Sadly, opioid deaths are likely undercounted. Thousands more 
people are addicted or are in recovery.
    Responding to this crisis, I was pleased to see that the 
CDC released new prescribing guidelines, helping providers and 
clinicians to strike a balance between pain management and 
patient safety. We must work to find alternatives to opioid 
prescriptions and only use them when appropriate.
    It is our responsibility to address this need, and Congress 
should support the President's request for $1,100,000,000.
    I am concerned we were unable to fund other high-priority 
areas of health in 2016. The majority of last year's increase, 
about 83 percent, was allocated to three programs--antibiotic 
resistance, opioid abuse prevention, and the Strategic National 
Stockpile. That means that only one-sixth of last year's 
increase was allocated to support the rest of CDC's critical 
work.
    Chronic disease prevention was cut by 22 percent, including 
a 3 percent cut to tobacco prevention. Prevention of HIV/AIDS, 
hepatitis, STD, and tuberculosis was increased by less than 
one-half of 1 percent. And environmental health was increased 
by less than $3,000,000, including an increase of only 
$1,500,000 for the Childhood Lead Poisoning Prevention Program.
    Given what we are seeing play out in Flint, Michigan, we 
need to support this program. I am disappointed that the 
administration's proposal for this year would not fund lead 
poisoning programs in all 50 States. We can and we must do 
better than this.
    Do we not understand that children and adults are at risk 
of lead poisoning all over the country? And according to the 
CDC, in the United States, more than 500,000 children under the 
age of 5 have elevated blood levels. That is unconscionable 
that we would cut back on this program.
    That brings us to the 2017 budget request. There are good 
proposals in this budget. There are modest increases for 
antibiotic resistance and prescription drug abuse prevention, 
as well as a request for $10,000,000 for gun violence 
prevention research.
    These are important initiatives, and I will support them. 
But I am overall concerned that this proposal cuts CDC's 
program level by $194,000,000 below current levels. I see that 
once again, the budget includes cuts to cancer screenings, 
immunizations, minority outreach, occupational health, as well 
as complete elimination of the Preventive Health and Health 
Services Block Grant.
    These programs are critical to American families and they 
are too critical for American families to sacrifice. That is 
why this subcommittee's allocations that will be released next 
month will be so important.
    I hope my colleagues on the other side of the aisle will 
join us in urging an increase for Labor-HHS in fiscal year 
2017.
    When I look at this budget, and I read the mission of the 
Centers for Disease Control and Prevention, I cannot help but 
feel that we are nickel-and-diming the Centers for Disease 
Control, an agency whose mission is the defense of the American 
people. The initiatives that you lead have the power to defend 
American children and families from life-threatening health 
crises. We need to treat the CDC funding level with the gravity 
that it deserves.
    I thank the chairman.
    And I look forward to your testimony, Dr. Frieden, and 
today's discussion. Thank you.
    Mr. Cole. Thank you.
    Dr. Frieden, you are recognized for whatever opening 
statement you care to make.
    Dr. Frieden. Thank you very much, Chairman Rogers, Chairman 
Cole, Ranking Members Lowey and DeLauro, for your very kind 
words about CDC. I greatly appreciate that. It is an honor to 
lead the Nation's leading public health agency, the agency that 
is responsible for protecting the country, our first line of 
defense in public health.
    We work 24/7, and we have the world's top experts in most 
of the diseases that affect Americans. We support States, 
tribal nations, communities, health care providers, 
universities, and other groups to protect the Nation's health 
security.
    And we greatly appreciate the committee's support in fiscal 
year 2016. I think you appropriately recognized that CDC and 
public health is a best buy, that when we invest in prevention 
and in supporting communities, we can not only improve health 
and save lives, but also save money.
    Thank you, in particular, for the emergency funding for the 
Ebola and Global Health Security supplemental last year.

                                 EBOLA

    Ebola is not over. Just last week, a new cluster of cases 
occurred in a remote area of Guinea, Nzerekore. I have been 
there. It is difficult to reach. It is difficult to get to. We 
have had, so far, six confirmed cases. We have more than 100 
high-risk contacts who are being tracked. We have more than 
1,000 potential contacts who are being tracked. We have 84 of 
our own top doctors, scientists, nurses, other staff there 
responding.
    So Ebola continues. It has an unfortunately long tail of 
this very challenging epidemic that we have been fighting now 
for 2 years.
    There has been, though, enormous progress. We have helped 
these countries establish systems. The last seven clusters have 
been promptly identified and promptly stopped. To do that, we 
need a large infrastructure, and we need to continue to 
strengthen the country's own capacity to detect and respond.
    Much more is needed for us to understand how Ebola is 
spreading. We still do not know all the details of what is 
causing these recurrent clusters. To better deploy 
countermeasures such as the vaccine, which is going to be used 
in this and other responses, to finish our own vaccine and 
therapeutic and other trials that are being done in West Africa 
and elsewhere, these investments pay off.

                         GLOBAL HEALTH SECURITY

    I recently returned from Tanzania where the Global Health 
Security investments are helping to improve response to a 
massive cholera outbreak.
    I also visited Ethiopia, where a devastating drought is 
causing severe health problems, and the Global Health Security 
approach is being used to mitigate the health impacts there.
    In Benin, Togo, and Nigeria, we are fighting Lassa fever, 
another hemorrhagic fever analogous to Ebola that can also 
spread through rodents and other measures.
    In an indication of how much the world has changed, we had, 
tragically, a death of a medical missionary from Lassa fever. 
His organization called me at night a week ago. We were then 
able to medically evacuate a second medical missionary to Emory 
University Hospital, where he is under treatment.
    That did not get anything like the coverage that the 
evacuations got 1.5 years ago. That is a reflection of the 
progress I think that we are making regularizing and realizing 
that the new normal is that we are tightly interconnected as 
the world, and an outbreak anywhere is potentially a threat 
everywhere.
    It would be dangerous to let down our guard now. It would 
be dangerous to let down our partners now. There are many risks 
out there, whether it is Ebola or Lassa or MERS or SARS or the 
next HIV.
    We are dealing now with a very large yellow fever outbreak 
in Angola. This could spread throughout Africa and potentially 
to Asia and outstrip available vaccine supply.
    There are also new epidemic threats, many of which we 
cannot predict with certainty. There are tickborne diseases 
that can cause severe and fatal illness that we are now 
identifying as more widely disseminated because of the Global 
Health Security support.
    Drug-resistant pathogens have the potential to undermine 
our work. We are focused on keeping America safe and healthy.
    Investments in CDC are a best buy. Congress and this 
committee supported our request for advanced molecular 
detection some years ago. Those resources are saving lives.
    They are improving our detection of diseases such as 
listeria, where we have been able to get contaminated products 
off shelves faster and save lives. They allowed us to 
accelerate our production of a Zika diagnostic test.
    They are also enhancing our response to diseases such as 
the outbreak of HIV in Indiana related to opioids. We were able 
to rapidly sequence that and understand what was occurring.
    And we can better respond to and prevent diseases, such as 
improving our flu vaccination production.
    I also want to thank you for your support for initiatives 
in 2016 that are continuing in 2017, with the continued 
increase in antibiotic resistance funding requests. This is 
crucially important to protect modern medical care and reduce 
the number of deaths, so we can rapidly detect outbreaks, 
respond effectively, and prevent them wherever possible.

                       OPIOID OVERDOSE PREVENTION

    Also, thank you, Chairman Rogers, for your long-term 
leadership on the battle against opioid overdose. We continue 
to struggle to make progress in this field, and it will require 
all of us in society doing more to get to a better place with 
our relationship with these dangerous medications and illicit 
substances.
    We know of no other medication used routinely for a 
nonfatal condition that results in death so often. Our recent 
guideline emphasizes that for patients and physicians to begin 
an opiate is a momentous decision, and it needs to be taken 
with a full understanding of the risks and the benefits that 
this involves.
    We also have a proposal to increase funding for Indian 
country programs. We would be delighted to discuss this further 
going forward.

                                  ZIKA

    Zika is an emergency, and there is much that we still do 
not know about it. We are learning more literally every day. We 
have already been able to get two new diagnostic tests approved 
through the Emergency Use Authorization at FDA.
    Our staff are working literally around the clock. We have 
produced more than 500,000 test kits. We have more than 800 
staff working on the Zika response now. We are scraping 
together money from wherever we can find it to respond 
effectively.
    But a robust response, I do believe, will take emergency 
funding. If you look at the definition of emergency--
unanticipated, potentially catastrophic, permanent damage--I 
cannot imagine a situation that meets this more than Zika.
    Unanticipated. There has never before been a mosquito-borne 
illness that can cause a birth defect. We have never seen that 
before.
    Potentially catastrophic. Each child affected can cost more 
than $10,000,000. And it is a horrific tragedy for the families 
that are involved. And we do not know the full range of 
illness. Microcephaly is a horrific birth defect, but that may 
be just part of the spectrum of severe problems these infants 
may face.
    And permanent. These are lifelong disabilities that they 
will be facing.
    So I want to thank you very much for your support of CDC 
and our work to protect Americans, and I will be happy to 
answer any questions that you have.
    [The information follows:]
    
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    Mr. Cole. I thank you very much. As I know you are aware, 
again, we have votes soon, and the chairman and ranking member 
have multiple committees, so I am going to go first to them for 
whatever questions they would care to pose.
    So, Mr. Chairman, you are recognized.
    Mr. Rogers. I thank you, Mr. Chairman, for that courtesy.

                                OPIOIDS

    Dr. Frieden, your medical expertise and forward-leaning 
approach is what helped put the wheels in motion for the new 
guidelines for prescribing opioids. I am truly grateful for 
your commitment and your actions in this fight that we are in.
    A Harvard University poll conducted since you released the 
guidelines for prescribing opioids shows that Americans are 
overwhelmingly in favor of your recommendations. I, for one, am 
pleased that these guidelines clearly address the problem 
holistically, an approach that I have long advocated, as have 
you.
    There are a couple things I want to try to clarify with 
you.
    I am pleased that consultation of the prescription drug 
monitoring programs in all States except Missouri is a key 
recommendation for prescribers. PDMPs are an essential tool for 
good medical practice, because it allows a physician or 
pharmacy to find out whether or not a prescription they have 
been presented has already been filled in some other place, to 
prevent double-filling of the prescription.
    Yet, doctors are not using the PDMPs. It is there for them, 
and all they have to do they do is contact that State computer 
number and find out if this person that is in to see them has 
already been to a doctor and prescribed medicine. That is a 
huge source of the pills that we find available for young 
people to overdose on.
    First, not all States are interconnected with one another 
with the PDMPs. We still have a problem. And they are not real-
time. They are getting better. And interoperability is 
available in some States, but not all.
    But nevertheless, what steps can we take at the Federal 
level to be sure that doctors consult PDMPs?
    Now in Kentucky, the State Legislature passed a law 
requiring doctors to consult PDMPs before they prescribe.
    Is that the answer? Or is there a better answer?
    Dr. Frieden. Thank you for your question, Mr. Chairman. And 
again, thank you for your leadership on this issue.
    I have a lot of sympathy for the physician who is often 
harried, overworked, facing a patient who is in pain. There is 
no objective measurement of whether that patient is in pain. 
And I fully agree that PDMPs have tremendous potential, and 
that potential is not being fully met.
    There is a pilot that was done some time back that I think 
is encouraging in this regard. This was the integration of the 
prescription drug monitoring programs and electronic health 
records, so that doctors do not need to sign onto two different 
systems, and it pops up right immediately in their EHR system.
    I think that would be a very important area to pursue. As 
with so much with this terrible problem, I do not think there 
is one simple answer. I do think that States that try things, 
as Kentucky has done, trying those things, evaluating, seeing 
what works, and scaling that up is going to be critically 
important.
    So I think the goals are clear, as you exactly outlined. 
You used interoperable, real-time. I would add actively managed 
by the State.
    We need to work together both at the State and Federal 
levels, and with private industry, including the electronic 
health record vendors, to make sure that that happens.
    Mr. Rogers. Let me ask you about naloxone. Guideline eight 
says, ``Clinicians should incorporate into the management plan 
strategies to mitigate risk, including considering offering 
naloxone when factors that increase risk for opioid overdose 
are present.''
    Is that suggesting that doctors co-prescribe naloxone along 
with opioids in these higher risk cases?
    Dr. Frieden. Yes.
    Mr. Rogers. Are you at all concerned that this might 
actually have the unintended consequence of giving a patient 
false sense of security that could lead to more cavalier 
behavior?
    Dr. Frieden. We are aware of that concern. But what we have 
seen so far is that many of the overdoses are unintentional. In 
fact, the overwhelming majority are unintentional.
    One of the things that was so striking to me in the 
evidence review running up to the release of these guidelines 
was the astonishingly high rate of overdose in people at higher 
doses. Once you got to over 90 or 100 MME per day, you 
increased about ninefold the risk of overdose. When you were at 
more than 200 MME per day, the risk of overdose in just a few 
years was about 1 in 32. This is just an astonishing level.
    These are very dangerous medicines. The fact that we do 
have essentially a method of reversal suggest that they need to 
be used.
    So I would see these things in parallel. We need to reduce 
the use of medications. But for those on them, we need to 
increase the safety with which we use them.
    Mr. Rogers. Thank you.
    Mr. Chairman, my time is expired. Thank you.
    Mr. Cole. Thank you, Mr. Chairman.
    We will now go to the ranking member of the full committee, 
the gentlelady from New York.

                                  ZIKA

    Ms. Lowey. Thank you, Mr. Chairman.
    And welcome, again, and thank you for all your good work, 
Dr. Frieden.
    In addition to the budget request, the administration 
requested more than $1,800,000,000 for an emergency 
supplemental to combat the Zika virus. Nearly half of this 
funding would support the CDC's efforts to respond to the 
virus, including enhanced mosquito control, rapid response 
teams, surveillance in domestic cases, and improved diagnostics 
and laboratory capacity.
    This is a huge task, and much of South America and the 
Caribbean, including American citizens in Puerto Rico and the 
U.S. Virgin Islands, are looking to Congress for leadership to 
tackle this public health emergency.
    How will the CDC work with physicians and public health 
experts to get the best information into the hands of Americans 
and, in particular, women who are pregnant or could be pregnant 
in the near future, so they are protected from the dangers 
associated with the virus? And if supplemental funds are not 
provided, how would the CDC's response capabilities to both 
Ebola and Zika be curtailed?
    Dr. Frieden. We are doing everything we can to respond to 
Zika. We are currently at our highest level of activation, 
Level 1, for the Zika response. We have, as I mentioned 
earlier, more than 800 staff working on Zika. We have already 
dedicated essentially all of our dengue branch, which is 
located in Puerto Rico, to Zika.
    We have been working really on three different fronts. In 
the continental U.S., where dozens of States have mosquitoes 
that can sometimes spread viruses like Zika, and about a dozen 
or little over a dozen States in the south of the U.S. have the 
particular mosquito that is most efficient at spreading this 
type of virus.
    It is possible that, come summer, we will have a situation 
where a woman gets pregnant and through bad luck is bitten by a 
mosquito that is infected by Zika and may have an affected 
child. We want to do everything in our power to prevent that 
from occurring.
    The second front is in the U.S. territories. Puerto Rico, 
as you indicate, these are American citizens. Unfortunately, 
through a bad roll of the dice, if you will, they have an 
environment that is both a natural environment and a human 
environment that is extremely conducive to the spread of Zika.
    We know that when chikungunya infected Puerto Rico, within 
2 months of the introduction, it was all over the island. 
Within 8 months, nearly 1 in 5 adults were infected.
    If this occurs with Zika, which it may well, we could see 
thousands of affected pregnancies there. So we are really doing 
everything we can to protect pregnant women, to support vector 
control so we can optimize the control for mosquitoes--this is 
a very challenging mosquito to control--and to increase access 
to voluntary effective contraception for women who choose to 
delay pregnancy.
    The third front is international. Since they are at the 
front lines of this, we can both help them and learn more about 
what is occurring. We have teams on the ground in Brazil, and I 
thank the committee for meeting with our team there, and in 
Colombia. And they are really very robust and productive 
partnerships there that will help us learn more and help them 
control better.
    I am concerned that, if we have to, we will take every 
dollar we can find to work on the Zika response. But there will 
be implications. All of the dollars allocated were allocated by 
you, by Congress, for specific activities. We are aware that 
there are tradeoffs.
    With the Ebola and Global Health Security supplemental, 
when I look at the international components of that 
supplemental, all of those dollars are planned to be used.
    In fact, I received last night a request from an Ambassador 
in an African country where we had hoped to be able to put a 
staff person, but we do not have the resources to do it. 
Nothing related to Zika, but just because the Ebola and Global 
Health Security dollars do not meet the entire need to protect 
Americans and keep us safe by strengthening systems in 
countries that most need it around the world. This was the 
Ambassador to Benin, which is currently experiencing an 
outbreak of Lassa fever, another hemorrhagic fever.
    So I am challenged with recognizing that we do not have all 
the resources in place to protect Americans as well as we 
could, should, and would like to. Now we have this new 
unanticipated challenge of Zika that we are really scrambling 
to respond to as effectively as we can.
    Ms. Lowey. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Cole. I thank the gentlelady. We are going to now put 
the committee in recess, so members can go have the opportunity 
to vote. We will resume immediately after votes. Again, we 
apologize for the inconvenience.
    [Recess.]
    Mr. Cole. We are going to go ahead and reconvene the 
hearing, if we can. Obviously, we will have members coming back 
from votes. We have some that may be disappearing home.
    So regardless, again, Dr. Frieden, we apologize for having 
to interrupt the session. We appreciate your patience.

                             INDIAN COUNTRY

    I am going to pick up a subject that we are just visiting 
about before we reconvened the hearing. I want to thank you 
again for some of the work that CDC is doing in Indian country, 
particularly, as you mentioned in your testimony, the Good 
Health and Wellness in Indian Country program. We appreciate 
that. However, it is one program. As you know, we have multiple 
issues with this population.
    I would like, if you could, discuss that but also discuss 
what your thoughts are on where the CDC could be helpful in 
funding other programs in Indian country on issues like 
suicide, motor vehicle accidents, cancer, HIV, the whole range. 
This population obviously has a higher incidence of all these 
things than the rest of the population.
    So I would appreciate your focus and any thoughts you have 
on things we ought to be doing or considering.
    Dr. Frieden. Thank you. As you well know, Mr. Chairman, as 
you have highlighted, these are really some of the most stark 
health disparities that we know of in this territory.
    Indian nations have a great degree of diversity with some 
having health statuses that are relatively good and others 
shockingly bad. What we have tried to do with the modest 
proposal in the 2017 budget is indicate what could be done to 
strengthen capacity within Indian country through tribal 
epidemiology centers, through more information on what the 
burdens are and what the potential ways to address them are, 
and then to implement prevention programs, working in 
conjunction with communities.
    That means sometimes building on traditional practices that 
are healthy, whether it is food, physical activity.
    We have also seen some very positive results reducing motor 
vehicle risks by working with communities, getting communities 
engaged in reducing alcohol-impaired driving and improving 
adherence to safety belt and car seat use.
    So I think this involves the importance of getting data 
there and involving the communities in the solution, and 
recognizing that with hundreds of tribes, we have the challenge 
between going deep or going broad, whether we work with a few 
tribes and document what works well, or try to get a widespread 
effort.
    I think our approach is to try to get data, so we 
understand both where the burdens are and what are the programs 
that are likely to work best, and then engage communities in 
solutions. There are some communities that have ample 
resources, and it is a question of dedicating them to things 
that make the most difference, like cardiovascular prevention. 
There are other communities where there are dire needs for 
everything from safe water to very fundamental issues of health 
care access.
    And in far too many communities, as we were just 
discussing, there is a problem of substance abuse and suicide. 
These are areas where solutions are not quick and they are not 
simple. But there are things that we can do to support 
communities, support parents, support families in reducing 
risks.
    Mr. Cole. We appreciate that and would ask you to continue 
those efforts. As you know, in many cases you work directly 
with State and local health departments, and quite often tribes 
are just simply left out of that equation by States. So having 
Federal involvement here to make sure there is some equity and 
those communities are given ample attention I think is very 
important.

                              HEART HEALTH

    Dr. Frieden, in the minute or so I have left, the American 
Heart and Stroke Association--remain our number one most 
expensive killer. They cost us roughly $1 billion a day. This 
committee significantly expanded resources in those areas last 
year, increasing the amount by about $70,000,000. That includes 
a $10,000,000 increase that doubled the National Diabetes 
Prevention Program.
    Could you explain to us how those funds are being awarded 
and again look ahead a little bit and tell us what we ought to 
be thinking about this year in that very important area?
    Dr. Frieden. Thank you very much, and thank you for the 
support there. Heart disease and stroke, as you know, are 
leading killers. They are largely preventable, probably more 
than half of all the heart attacks and strokes that occur in 
this country could be prevented with today's technologies. Our 
flagship project in this area is the Million Hearts program. We 
think we can prevent 1,000,000 heart attacks and strokes over a 
5-year period by implementing programs that are community-wide 
and also individual.
    One of those key areas is control of hypertension. High 
blood pressure is the single leading killer, the single thing 
that could save the most lives if we do a better job in our 
health care system, and yet we are only at about 52 percent 
control in the country as a whole.
    We have a system to recognize leaders in hypertension 
control. Treatment does not have to be expensive. It does not 
have to be complex. It can be done by a health care team that 
involves nurses and pharmacists, and community outreach 
workers. I think this is one of the areas that has the most 
potential for progress.
    We also appreciate your support for the National Diabetes 
Prevention Program, and I think we will be hearing more about 
that today from Secretary Burwell.
    Mr. Cole. Thank you very much.
    I now want to go to my good friend, the ranking member of 
the subcommittee, the gentlelady from Connecticut.

                                  ZIKA

    Ms. DeLauro. Thank you, Mr. Chairman.
    Dr. Frieden, you have been showing a series of slides that 
depict the rapid expansion of chikungunya, that infection in 
Puerto Rico. It starts in a few pockets, spreads rapidly, 
covers the entire island.
    My understanding is that public health experts are 
expecting the Zika virus to spread in the same way. I have 
heard also from your CDC colleagues, as well as Dr. Fauci at 
NIH, and they predict that clusters of Zika infections will 
reach Florida, Texas, and parts of the Gulf Coast. It really is 
only a matter of time, which is why, as you know, I support the 
administration's request and the $828,000,000 that it proposes 
for CDC.
    And I wholeheartedly agree with Leader Pelosi that Congress 
should stay in session until we have dealt with emergency 
funding for Zika.
    Let me pose a series of questions, so that you can get them 
down.
    How many States are you expecting to be at high risk for 
transmission? Is the plan limited to the Gulf Coast States? 
What about States that are too far north for the Aedes aegypti 
mosquito?
    Second, Puerto Rico is now importing its blood supply, 
because the danger of Zika-infected blood is high. What does 
that say about the risk of Zika to the health of the 
population? What will happen to the blood supply in Gulf Coast 
States when Zika is more prevalent in the coming months? Can 
you talk about your work with State and local health 
departments?
    My understanding as well--this is the fourth question--FDA 
recently issued an Emergency Use Authorization for a PCR assay, 
a diagnostic tool that enables doctors to tell if an individual 
is infected with chikungunya, dengue, or Zika. How many labs 
will get access to the test? Is the CDC distributing this assay 
across the country or to the Gulf States or Puerto Rico?
    The Kaiser Foundation, in 2014, said there was a total of 
783,000 births in Gulf Coast States--Texas, Louisiana, 
Mississippi, Alabama, and Florida. Given the risk factors along 
the Gulf Coast, is there an estimate for how many pregnant 
women in those States are expected to be infected by Zika virus 
in 2016?
    Sorry.
    Dr. Frieden. Okay, I will see how quickly I can do that.
    First, the number of States at high risk. There are the 
Aedes aegypti States, and the surveillance for mosquitoes is 
not perfect. It is not up-to-date. That is one of the problems 
with vector control, that we do not know definitively where it 
is. But there are at least 13 States that have Aedes aegypti.
    Aedes albopictus also can spread Zika. It is probably a 
less efficient vector, and there are more than 30 States.
    We tier our support to States based on their risk from 
mosquitoes and the number of travelers that they are likely to 
receive. There are more than 40,000,000 travelers to and from 
the Zika-affected areas in the U.S. each year.
    In terms of blood supply, we are hopeful that within a 
month or so, there may be a way of testing blood for Zika that 
would allow blood supply to resume in Puerto Rico. In terms of 
the Gulf Coast States, if there are clusters, we are in active 
discussion with the Food and Drug Administration, which is the 
regulatory authority, about what would happen in that 
circumstance.
    Ms. DeLauro. But that is potentially at risk, the blood 
supply in those States, as it is in Puerto Rico?
    Dr. Frieden. There could be a risk, although we think the 
risk would be dramatically lower than in Puerto Rico.
    In terms of local and State governments, we have a Zika 
action plan summit in Atlanta on April 1. We have more than 30 
States that will be coming, and we will be working hard with 
them on what their preparation plans are, what the needs are, 
what can be done now.
    We have a tremendous degree of interest and expertise from 
the States, and we work closely based on the risk.
    The supplemental, as you know, has as its largest component 
the $453,000,000 of the $828,000,000 that would be support to 
State and local and support within the continental U.S.
    There are two different Emergency Use Authorizations from 
the Food and Drug Administration.
    We have superb laboratorians. They have done just 
phenomenal work around the clock. On March 17, we had the 
second EUA. This is a Trioplex Real-time PCR that can tell 
Zika, dengue, and chikungunya. Also, earlier than that, on 
February 26, we had an IgM, the CDC MAC-ELISA test, which is an 
antibody test.
    The MAC-ELISA test is currently up and running in six 
States. We would like to get it up in as many States as wanted 
through the Laboratory Response Network the CDC coordinates. 
There are 28 labs that are already using Real-time PCR with 
materials provided by CDC.
    So we are getting these out as rapidly as possible. Our lab 
in Fort Collins is working nightshifts around the clock 7 days. 
So the quicker the States can do it, the better for us.
    Ms. DeLauro. Across the country, just the Gulf, or Puerto 
Rico? It is going to be across the country?
    Dr. Frieden. Across the country.
    Ms. DeLauro. Okay. The last question.
    Dr. Frieden. In terms of the number of pregnant women----
    Mr. Cole. Can we make this pretty quick?
    Dr. Frieden. I do not have an estimate.
    Ms. DeLauro. Can we get an answer to that and can we get a 
list of the States, your first tier, your second tier, that are 
going to be in jeopardy?
    Dr. Frieden. We can get you a list of States.
    Ms. DeLauro. Can we get the number of births in these 
States that we can anticipate here, based on prior data and 
prior statistics?
    Dr. Frieden. The number of births, we can get you. The 
number that might be infected would be hypothetical.
    Ms. DeLauro. No, the number of----
    Dr. Frieden. Yes, we can do that.
    [The information follows:]
    
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    Mr. Cole. Thank you very much.
    I am advised that our good friend from Virginia has an 
appointment and is going to have to leave early, so Mr. Harris 
is graciously allowing me to skip down to recognize Mr. Rigell 
for his questions.

                      HOSPITAL ACQUIRED INFECTIONS

    Mr. Rigell. Mr. Chairman, thank you.
    And, Dr. Harris, thank you very much. I appreciate it. I 
will try to reciprocate, if I can.
    Dr. Frieden, thank you for being here and for your 
testimony to us today. I count it as one of the privileges of 
public service, certainly in the House of Representatives, to 
be able to interact with you and engage you on these matters.
    I want to just call your attention to a remarkable company 
that I visited in my district. It may seem a bit self-serving 
to bring this up, but I left there just really wowed by what 
they are doing, optimistic about what they are doing, and 
inspired, because I think this is what we do as Americans. We 
innovate. We discover. We push the boundaries.
    The company is called EOScu, and they have a preventative 
biocidal surface. It is the only synthetic hard surface that 
has been recognized by the EPA for health claims. It 
continually kills harmful bacteria within 2 hours of exposure.
    So we are looking at these uses in a hospital environment, 
for the bed rails, for the sinks, anywhere.
    My first question is just a general one. Are you familiar 
with the technology and maybe even perhaps the company, EOScu? 
And if not, just generally, the potential for this course of 
action, the potential that it represents?
    Dr. Frieden. I am not personally familiar. My staff may be. 
We are looking always for new technologies, particularly 
because hospital-borne infections, as you indicate, are severe 
problems.
    [The information follows:]

           Rep. Rigell: EOS Synthetic Antibacterial Surfaces

    CDC is committed to protecting patients and healthcare personnel 
from infections, promoting safe, quality care across the continuum of 
care, and addressing the role of the environment to reduce the spread 
of antibiotic resistant bacteria. CDC is always looking for new 
evidence based-technologies that reduce the risk of transmission of 
pathogens from the environment to patients in healthcare settings. CDC 
was not specifically aware of EOS, but we are aware of several other 
surface technologies being developed to prevent healthcare-associated 
infections. CDC values engagement with industry including hearing about 
innovations that can improve patient safety. Each year, CDC hosts 
several Vendor Days which allow industry to visit CDC and discuss their 
healthcare products and technologies with CDC scientists. CDC will 
contact EOS with information about this opportunity.

    If we look, for example, at C. difficile, there are 500,000 
infections and 15,000 deaths per year in the U.S. And new 
technologies, including better ways to sanitize hospital 
environments, are important.
    Mr. Rigell. Well, I am glad that I have this opportunity 
just to bring this company to you and your staff's attention. 
Again, it might seem a bit self-serving, but as the chairman 
often points out, I am not seeking reelection. It is just an 
exceptional company doing really wonderful things. So I hope it 
is looked at by the CDC.

                            PROSTATE CANCER

    I want to pivot to another organization that I just 
consider such a privilege to represent, and that is Hampton 
University and specifically Dr. Bill Harvey. He is going to be 
coming appear today, and the chairman was kind enough to agree 
to an appointment to meet with him.
    I have come to know him and respect him over the years. He 
leads a historically Black university, Hampton University, 
which is a real treasure to us in the Hampton Roads southeast 
portion of Virginia. Several years ago, his leadership resulted 
in the formation of the Hampton proton therapy center.
    One of the things that they are really focused on there, 
and not exclusively, but prostate cancer. It disproportionately 
affects African-American men. The numbers that I have seen, 
they are between 1.6 and 2.4 times more likely to be diagnosed 
with prostate cancer.
    In the couple minutes I have here, I wanted to just ask 
your general assessment of that particular cancer, how it 
disproportionately strikes our fellow Americans in the African-
American community, and the potential I believe--and I would 
like to understand your view--on what proton therapy represents 
for that.
    Dr. Frieden. Thank you very much. You are absolutely 
correct that prostate cancer is a serious problem and 
disproportionately affects African-Americans.
    Unfortunately, the current state of our science on the 
prevention and treatment of prostate cancer is inadequate.
    When objective groups have looked at this, there is no 
clear benefit for early screening or early detection. There is 
a fair amount of debate about that, and some groups believe 
that there is a benefit for early screening and early 
detection, but I think the weight of scientific evidence 
suggests that, unfortunately, that may not be the case.
    That being said, it is critically important that more 
research is done on understanding the different types of 
prostate cancer and what therapies may make the most sense.
    In our minds, I think we have a model of cancer. That model 
of cancer is: It is small. It grows. If it grows too big, it is 
too late.
    That model works for certain skin cancers, for cervical 
cancer, for colon cancer. That model does not work for breast 
cancer and prostate cancer, which are very heterogeneous 
entities that work differently in different people, and for 
which research will be needed, but currently public health 
interventions are limited.
    Mr. Rigell. Well, I am encouraged just as a fellow American 
that there are good, hardworking Americans really cross the 
land, certainly in Virginia's Second Congressional District, 
who are pushing the envelope in these matters from a biocidal 
hard surface to the good work being done in proton therapy 
specifically at the proton center there related to Hampton 
University.
    I thank Dr. Harris. I thank the chairman for the time. 
Thank you.
    Mr. Cole. Thank you very much. We will next go to my good 
friend, the gentlelady from California.

                       LEAD POISIONING PREVENTION

    Ms. Roybal-Allard. Thank you, Mr. Chairman.
    Dr. Frieden, I would like to go back to the issue that was 
raised by Congresswoman DeLauro, and that is lead poisoning 
prevention.
    This is an issue that impacts millions and millions of 
families in this country. I would like to use an example in my 
own district, because while the entire country is rightfully 
focused on that tragic lead poisoning of an entire community in 
Flint, Michigan, not many people know about the battery 
recycling plant in my 40th Congressional District that had been 
emitting lead, arsenic, and other dangerous pollutants for over 
20 years.
    When the Vernon, California, plant was officially closed in 
2015, State officials revealed that the lead contamination 
extended as far as 1.7 miles from the plant and may have 
contaminated schools, parks, and as many as 10,000 homes.
    Last week, the California Department of Toxic Substances 
Control reported that more than 99 percent of the roughly 1,000 
properties tested so far have lead levels high enough to 
require cleanup.
    Many experts in the public health community believe that 
Flint and Exide may represent the tip of an iceberg, and that 
children in many communities across the country are at risk of 
exposure to lead hazards from various sources.
    Now I know that you know that lead is a poison that affects 
virtually every system in the body, and it can cause 
irreversible damage to the developing brain, the nervous 
system, fetuses and young children. Lead poisoning lowers IQs, 
limiting the opportunity for children to reach their full 
potential. It increases learning disabilities, attention 
disorder, and behavioral disorders. And lead-poisoned children 
are six times more likely to drop out of high school and are 
more likely to enter into the juvenile justice system.
    The medical and special education expenses alone can equal 
$5,600 for each child with serious lead poisoning, and lead 
poisoning results in an average loss of lifetime earnings of 
$723,000 per child.
    The reason I have outlined this is because this is the 
impact that we are seeing in the community that I represent 
that is impacted by this lead poisoning.
    For that reason, I am particularly concerned about the lack 
of adequate funding for the CDC Healthy Homes and Lead 
Poisoning Prevention Program, which provides critical 
surveillance and monitoring of elevated blood lead levels and 
community education to prevent and mitigate childhood lead 
poisoning.
    With the increased number of children who are now above the 
updated lead reference level of 5 micrograms per deciliter, 
what has the CDC done since 2013 to increase support to the 
States it funds? And do you believe that your budget request 
for $17,000,000 will be sufficient for CDC to provide critical 
surveillance in every State in the country?
    Dr. Frieden. Thank you very much.
    Confronting and reversing and preventing lead poisoning has 
been a priority for CDC for a long time. In fact, as you may 
know, it was the NHANES survey of NCHS at CDC that identified 
lead as a huge problem and led to the elimination of lead from 
gasoline as well as the elimination of lead from paint in this 
country, and that has resulted in a steady decrease in lead 
poisoning.
    But this is a far from finished effort. There are still far 
too many children and far too many adults affected by lead 
poisoning.
    As you know, there was a large reduction in the CDC lead 
poisoning prevention program several years ago. It was 
partially restored several years back. And both in terms of 
lead poisoning and larger environmental health tracking 
programs, we have a very strong program, the world's best 
environmental lab, terrific health professionals. We are not 
able currently to support all States in monitoring lead levels 
and intervening at the level of resources that we have.
    Ms. Roybal-Allard. You are not able to?
    Dr. Frieden. No.
    Ms. Roybal-Allard. And yet the fact remains that there are 
millions of homes and families who are exposed to this, 
probably in every State in this country.
    Dr. Frieden. That is correct.
    Ms. Roybal-Allard. The Advisory Committee on Childhood Lead 
Poisoning Prevention provided scientific and technical advice 
to the CDC and HHS, but its charter expired in October 2013. In 
light of Flint, Exide, and other incidents, do you believe that 
a new charter should be established?
    Dr. Frieden. What we did at CDC was to involve our Board of 
Scientific Counselors of our National Center for Environmental 
Health, which is superbly led by Dr. Pat Breysse, to have a 
subcommittee on lead. We feel that is the appropriate way to 
manage it. That incorporates input from scientific experts and 
the community. It is a FACA operating under the FACA 
responsibilities and can address any issue related to lead and 
lead poisoning.
    Mr. Cole. The gentlelady's time is up.
    Ms. Roybal-Allard. Okay. I apologize.
    Mr. Cole. We will come back.
    Ms. Roybal-Allard. Okay.
    Mr. Cole. With that, my good friend from Maryland, Dr. 
Harris, is recognized.

                                 SODIUM

    Mr. Harris. Thank you very much.
    I have a couple different areas I am going to touch on.
    First, in regard to the sodium dietary guidelines, my 
understanding is that the CDC may be engaging in a systematic 
review of the scientific literature regarding sodium intake in 
advance of developing a new DRI.
    My question is, as you look at the systematic review, is 
this going to be a review of all-cause mortality or is the 
predominance going to be using blood pressure as some kind of 
proxy for things that happen, with particular reference to the 
study that shows that in some people actually restricting 
sodium leads to an increase in all-cause mortality?
    Dr. Frieden. The systematic review will look systematically 
at all dated related to health.
    Mr. Harris. So all-cause mortality will be considered in 
it, I take it?
    Dr. Frieden. I believe so.

                COMMUNITY PREVENTIVE SERVICES TASK FORCE

    Mr. Harris. Okay. Let me ask you a question about something 
that has come up with some wording that was in the omnibus 
bill, and that has to do with the Community Preventive Services 
Task Force, which I think, if I am correct--I think it is 
correct--that the language in the report stated quite clearly 
the committee does not provide support for the community guide 
or the operations the Community Prevention Services Task Force.
    Can you affirm that since no funds were provided through 
the Prevention and Public Health Fund, because that is where we 
restricted it, use from that fund, that the task force is not 
being funded in this fiscal year?
    Dr. Frieden. We would have to get back to you on the 
details of that. The task force is an authorized activity by 
Congress and has support not only through the prevention fund.
    Mr. Harris. So you may be using funds from other areas to 
fund that, despite Congress' intent not to provide support for 
it.
    Dr. Frieden. We would have to get back to you on that.
    [The information follows:]
    
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    Mr. Harris. Okay. Because that raises a concern. If there 
is this money sloshing around CDC that can be used for 
something that Congress actually took a specific position 
against, I hope that it can slosh around to help you with Zika.

                      STRATEGIC NATIONAL STOCKPILE

    With regards to the biodefense community, I have to ask a 
question about coordination between BARDA and then, of course, 
once things reach approval stage, things kind of get shifted 
for stockpiling to CDC. Is the coordination adequate to make 
sure that things do not get dropped in the pipeline, things 
that BARDA has expended a fair amount of effort in developing, 
actually get acquired at some point?
    Dr. Frieden. I think we have very good coordination with 
BARDA. We have had a very positive relationship along a whole 
host of activities.
    Just to give you an example, when we were working on the 
vaccine trials for Ebola in West Africa, BARDA staff actually 
traveled to West Africa and helped us with the implementation 
of those trials. So there is very good coordination between 
ourselves and BARDA.
    I think the bigger challenge is that there are a great 
number of needs and limited funds.
    Mr. Harris. Sure. With regards to the SNS, because the SNS, 
the role kind of expanded from this idea where it is going to 
help us stockpile for bioweapons and now it is kind of 
everything, natural disaster response, things like that, 
providing medical things.
    Is that going to be a problem in terms of having adequate 
resources to do what it was initially established to do, which 
is to stockpile against bioweapons?
    Dr. Frieden. I think really, if I step back, our commitment 
is to use every dollar that is entrusted to us to protect 
Americans as effectively as possible.
    With the SNS, we look at an all-hazards approach: What are 
the things most likely to harm Americans? And what can we do 
that has the most impact at mitigating those harms? And how can 
we ensure that we are not just putting stuff in a warehouse 
somewhere, but that in the event of an emergency, they would 
actually be able to be deployed and used to protect Americans?
    That is, in broad strokes, our approach to the SNS.
    Mr. Harris. But it appears to me that perhaps a shift has 
occurred from where it is stockpiling specific therapeutic 
measures to stockpiling general medical supplies to----
    Dr. Frieden. I do not think that is the case.
    Mr. Harris. Then what was deployed, for instance, after 
Superstorm Sandy, because things were deployed from SNS? And 
that was not an infectious disease. That was not by a bio-
response.
    Dr. Frieden. There are some Federal medical units that can 
be provided in a disaster that would be basically the framework 
for responding to an emergency. We have also looked at things 
like respirators, because when we do models of what could be a 
worst-case scenario, there is likely to be a shortage of 
ventilators that could be critically important.
    [The information follows:]
    Rep. Harris: Is SNS expanding beyond its mission of preparedness 
for bioterrorism to an all hazards approach? Is this consistent with 
the initial intent of SNS or current authorities?
    In 1998, Congress appropriated funds for the CDC to acquire a 
pharmaceutical and vaccine stockpile to counter potential biological 
and chemical threats that could affect large numbers of persons in the 
civilian population. The program was originally called the National 
Pharmaceutical Stockpile program, but on March 1, 2003, became the 
Strategic National Stockpile (SNS) program and now includes not just 
drugs but medical supplies and medical equipment required to protect 
America's public health and safety from multiple hazards (terrorist 
attack, earthquake, emerging infectious disease threats such as flu, 
Ebola, Zika). As defined in 42 U.S. Code 247d-6b, the Secretary is 
``directed to maintain a stockpile or stockpiles of drugs, vaccines and 
other biological products, medical devices, and other supplies in such 
numbers, types, and amounts as are determined consistent with section 
300hh-10 of this title by the Secretary to be appropriate and 
practicable, taking into account other available sources, to provide 
for the emergency health security of the United States, including the 
emergency health security of children and other vulnerable populations, 
in the event of a bioterrorist attack or other public health 
emergency.''

    Mr. Harris. I understand the ventilators. Again, I am 
concerned that the initial intent just has been expanded to 
this disaster mitigation.
    I yield back. Thank you.
    Mr. Cole. Thank you very much.
    I will now go to my good friend from Pennsylvania for 
whatever questions he cares to pose.

                                  ZIKA

    Mr. Fattah. Thank you very much, Mr. Chairman. And thank 
you, Doctor, for all the work that you are doing.
    Obviously, there is a lot that we can talk about that is 
very beneficial, but usually when we are talking to the CDC, we 
are talking about more challenging circumstances, so I want to 
return to the Zika virus.
    This is a mosquito, the one that is transporting this 
virus, that we have seen before in the Philadelphia area, many, 
many years ago, bringing an epidemic to our city. So we know 
that it can do so very effectively.
    I know there is first a concern about young women and 
pregnancy. I have seen reports that there could even be other 
challenges for people who do not fall into that category. So I 
wonder if you could just spend a minute and talk to the 
committee about what we think the health consequences are. And 
then I want to ask a question about what more we could be 
doing.
    Dr. Frieden. Thank you.
    With regard to Zika, we are literally learning more every 
day. It is a mosquito-borne virus spread by primarily two 
different mosquitoes that are present in the U.S.
    From the best of what we understand, for the vast majority 
of people, it has few symptoms or none at all. When it does 
cause illness, it tends to be for about a week with rash, 
fever, red eyes, joint pain, and then it resolves.
    But we have seen two consequences that are concerning.
    One is Guillain-Barre syndrome. That is a form of paralysis 
that is usually temporary. It follows many different types of 
infections, so that is not particularly unprecedented. We have 
seen this after influenza, after Campylobacter, and intestinal 
infection, and after others. We anticipate that this will be 
confirmed as a post-infectious complication of Zika.
    What is really unprecedented is the birth defects that we 
are seeing in Brazil now being reported in Colombia and Panama, 
that we saw in one woman who lives in Hawaii, who traveled to 
Brazil during the first trimester of her pregnancy.
    We do not yet know many things. We do not know what 
proportion of women who are infected with Zika will deliver a 
Zika-affected child. We do not know what proportion of infants 
who do not have microcephaly will have a severe neurological 
complication.
    But CDC's laboratories have actually identified the Zika 
virus in the brain tissue of infants who died in the first 24 
hours of life with severe microcephaly. This indicates to us 
that it is what is called a neurotrophic virus. It targets the 
brain.
    We are very concerned that, in addition to microcephaly, 
there may be many other consequences of Zika for infants who 
are infected.
    In addition, there was a recent article in the New England 
Journal that suggested that it was not just the first 
trimester, which we would think might be the most susceptible. 
But in fact, even in the second and third trimester, there were 
some severe complications of the Zika infection.
    Mr. Fattah. So now the game plan is to detect this in a 
variety of ways, all the way up to and including developing 
male mosquitoes. Talk to us about us line of attack here.
    Dr. Frieden. In public health, we use basically an approach 
of find it, stop it, prevent it. So those are the three ways 
that we work.
    We find it by doing better diagnostics, and CDC labs have 
worked around the clock to get test materials out around the 
country, around the world, so that we know what is happening.
    Stop it. Stopping Zika is not easy. It spreads in the same 
way that dengue spreads. If you look at how dengue has spread 
in many communities, it is explosive and very difficult to 
stop. Efforts to mitigate dengue have been hard.
    So it is a matter of mosquito control, and the four aspects 
of that are outdoor mosquitoes, indoor mosquitoes, larval or 
baby mosquitoes, and adult mosquitoes. For each of those four 
areas, there are things that we can do. One of CDC's roles is 
to figure out what works best.
    It would be States and localities that are implementing 
mosquito control activity, but what we can do is identify best 
practices and help to spread those. In addition, in places like 
Puerto Rico where Zika is likely to spread widely, we want to 
ensure that if a woman decides to delay pregnancy, that access 
to voluntary effective contraception is available to her.
    Mr. Fattah. Thank you, Mr. Chairman.
    Mr. Cole. Thank you very much.
    We now go to the gentlelady from Alabama for whatever 
questions she cares to pose.
    Ms. Roby. Thank you, Mr. Chairman.

                              OPIOID ABUSE

    And thank you, Dr. Frieden. It is good to see you again. I 
know oftentimes in our visits over the years, we have talked 
about my children, and I am very blessed today to have Margaret 
Roby--you cannot see her behind the chair--with me. But that 
has certainly been the inspiration for a lot of our 
discussions, my two children. So again, I appreciate your 
willingness to be here.
    I am sure the chairman of the full committee touched on 
this, but all of us on this committee share a very deep concern 
about the opioid epidemic raging across our country.
    I have just recently become even more aware. I very 
recently watched the video that was put out by DEA and the FBI, 
Chasing the Dragon, which really just brought it home for me to 
see not only the mother of a child who lost her life but also a 
mother who lost everything in her life because of her own 
addiction.
    So it has really hit home, having not walked through that 
with a family member or anybody close with me, which I think 
you have to do really deeply appreciate it. But that is a very 
powerful video, and I encourage everybody on the committee to 
watch that. It is easy to find.
    I am encouraged as well by the recent CDC guidelines for 
prescribing opioids for chronic pain. I hope these new 
guidelines will help limit access of individuals who try to 
game the system to get ahold of these prescription drugs.
    While this development will attempt to decrease the overuse 
and abuse of opioids over time, we have to focus in on the 
impact of overdoses occurring every day. I was stunned to learn 
that, in 2014, there were 47,000 overdose deaths in the U.S.
    For years, organizations have offered opioid overdose 
prevention services with training and kits containing naloxone, 
a drug used to treat a narcotic overdose in emergency settings.
    So my question is, could you began by addressing the 
possible safety concerns of providing naloxone to untrained 
individuals? And how are fellow drug users expected to help 
someone suffering from cardiac arrest, which I understand is a 
very real potential byproduct of this drug as it is being 
administered as a result of reaction to the drug? And what 
steps are CDC, in collaboration with other agencies such as DEA 
and FDA, taking to address any concerns about nonmedical 
personnel administering naloxone?
    I know from the testimony from the administrator of DEA 
that all of their personnel are trained not just how to 
administer the drug, but also how to address any issues as a 
reaction to the drug.
    So if you could just start talking about that, that would 
be great.
    Dr. Frieden. Thank you.
    Naloxone is a very specific reversal drug, so it reverses 
an opiate effect on the human body. I have used it in patients 
I have cared for. It has a dramatic impact on reversing 
overdose.
    Overdose is life-threatening. Someone stops breathing. So 
every moment matters.
    Communities around the U.S. have tried different things, 
and we encourage communities to try things and rigorously 
evaluate them.
    One thing that has been expanding is naloxone access in 
even ambulances, because not all ambulances have it. So that 
should be universal, in my personal view.
    The FDA has been very helpful in approving a new 
formulation of naloxone that is intranasal, so it does not 
require injection. That makes it easier for a layperson to 
provide.
    Training, as you say, is very important. We have seen 
communities around the U.S. provide naloxone. There are now 
problems with the cost of naloxone, and there are efforts being 
used to reduce the cost.
    But they report a large number of reversals, and the 
recommendation is you just do not give naloxone. You give 
naloxone and call 911 at the same time, because the person 
needs emergency care. But that may buy you the 5 or 10 minutes 
that may make a difference between life and death or between 
permanent brain damage and not permanent brain damage.
    So I think the optimal use of naloxone is something that 
communities need to work out. There are a complex set of 
issues, including Good Samaritan laws and issues of reporting 
of drug paraphernalia and law enforcement. But as communities 
work through those consistent with their values and their 
service availability, it has a role, I believe, in reducing the 
risk of fatal overdose.
    Ms. Roby. Are there more specific things that CDC is doing 
to work with these community organizations?
    My time is running short, so maybe you can get back to me.
    I think all of us have a shared concern about how we, as 
Members of Congress, could help people at the local and State 
level have access to not just prevention and how to deal with 
this opioid epidemic, but also tools and solutions such as this 
that can be utilized in the moment that someone is suffering 
from that.
    Dr. Frieden. Yes. We will get back to you. We work through 
States. With the support from Congress, we are able to support 
all States in opioid response. One component of that is 
naloxone access.
    [The information follows:]
    
    
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    Ms. Roby. Okay, great. Thank you so much.
    Thank you, Mr. Chairman. I yield back.
    Mr. Cole. Thank you very much.
    I have been advised that your schedule is a little 
flexible. If that is the case, what we would like to do, since 
we missed so much time because of votes, is give every member 
about 3 more minutes to ask any additional questions they might 
have, so if you can indulge us, Doctor?
    Dr. Frieden. Sure.
    Mr. Cole. Very good. Then I will go first.
    I am going to ask you a series of three interrelated 
questions, if I may.

                               CDC BUDGET

    First, obviously, we increased your budget last year by 4 
percent, which was about double, if I recall, of the 
administration request, because we thought that was important, 
and all of us on a bipartisan basis appreciate the good work. 
This year, the budget is being reduced by 3 percent.
    So I am going to ask you, one, can you give us the 
rationale for the reduction?
    Two, I know you are working, as NIH has been working, on a 
strategic plan to sort of prioritize your work, so could you 
give us your top three priorities looking forward in the 
context of this budget?
    And three, I am going to ask you a happier question, which 
is, if we found extra money, what would you do with it, beyond 
what is in your budget?
    Dr. Frieden. Thank you very much, Mr. Chairman. And thank 
you so much for your support in the 2016 budget.
    As with any budget proposal, the administration had 
difficult choices to make. In fiscal year 2016, the House was 
very supportive of CDC, and I hope to see that again in the end 
with the budget.
    CDC is a best buy and investing in public health saves both 
lives and money.
    In terms of a strategic plan or top three:
    Antibiotic resistance, we have to continue to make 
progress. The bugs are dividing every minute, and we need to be 
able to try to get ahead of this very concerning trend.
    The second is prescription drug overdose. We really 
appreciate the support. As just mentioned, this allows us to 
support every State in the country or offer support to every 
State in the country. And we want to continue to extend that 
and improve prescribing patterns. And our support for Indian 
country we would really like to expand.
    If we had additional resources, well, there is a lot that 
we would like to do. The way I look at public health is I break 
it into four quadrants, basically. There are the infectious 
diseases in the U.S. There are the infectious diseases 
globally. There are the chronic diseases in the U.S., and the 
chronic diseases and injuries globally. So those are the four 
areas.
    In each of those areas, there are best buys. There are 
things where we can save many, many lives through the efforts 
that we implement.
    I think we indicated in antibiotic resistance, for example, 
that $264,000,000 a year over 5 years would allow us to save 
$7.7 billion, prevent more than 30,000 deaths and 600,000 
hospitalizations. So we would like to fully implement that 
program, if resources were available.
    Furthermore, on issues of preventing cardiovascular 
disease, we have shown that some of the programs that we have 
are remarkably cost-effective. We can save a life for less than 
$3,000. There are not a lot of programs that can do that. And 
yet, they are not fully funded for whole-year activities. If we 
are able to do that, we could save many more lives and much 
more money.
    I think also our work on health-care-associated infections 
is an unsung success story, but a very partial one. We continue 
to lose tens of thousands of Americans to infections that they 
pick up in hospitals each year. We would like to work very 
closely with States and health care facilities to drastically 
reduce health-care-associated infections.
    Mr. Cole. Thank you. I noticed your very capable staff was 
shoving answers up there when the idea of additional money came 
up. So I look forward, offline, to talking to you about those.
    Dr. Frieden. And I forgot to mention our buildings, which 
are in desperate need of repair.
    Mr. Cole. With that, we will go to the gentlelady from 
Connecticut.

                            CHRONIC DISEASES

    Ms. DeLauro. Thank you, Mr. Chairman.
    Let me pick up on this chronic disease prevention and 
antibiotic-resistant drugs.
    Eighty-six percent of annual medical costs in the U.S., 70 
percent of deaths, can be attributed to chronic disease. A 
hundred million Americans live with one or more chronic 
conditions.
    We had a $66 billion increase for defense and nondefense, 
and we actually cut funding for chronic disease prevention at 
CDC by $22,000,000, or about 2 percent. Shortsighted, in my 
view.
    Talk about the threat of chronic disease, what will happen 
to health care spending, if we fail to address chronic disease, 
which is largely preventable.
    And I would like to get to antibiotic-resistant question as 
well.
    Dr. Frieden. Chronic diseases are largely preventable with 
current technologies. I mentioned the Million Hearts campaign, 
hypertension control. Our Tips from Former Smokers campaign is 
truly a best buy. It is saving tens of thousands of lives a 
year. Our tobacco control program is helping to drive down 
tobacco use rates in kids and others. And our injury prevention 
control program also has been a real success story.
    We should be able to invest in programs like prevention of 
senior falls, document what works and then scale that up. Those 
are extraordinarily not only expensive, but they undermine 
independence of seniors all too often.
    So this is a crucial area where we can protect Americans 
from threats.
    Ms. DeLauro. What I will do is follow up with you on where 
are one or two places which, if we could increase funding in 
terms of chronic diseases, what would make sense.

                         ANTIBIOTIC RESISTANCE

    Antibiotic-resistant bacteria, we know all the dangers on 
this. I just want to ask you about your work with the USDA.
    Antibiotic sales for food animal production are significant 
and increasing. They account for 70 percent of total medically 
important antibiotic sales by volume, a 23 percent rise since 
2009. Animal feed and the development of bacteria that cannot 
be killed now by antibiotics, what are we doing in this area? 
What kind of collaboration do you have with USDA, so that we 
can look at scaling back in this effort?
    Dr. Frieden. We work closely with both USDA and FDA. We 
have a weekly conference where we review clusters that may 
reflect outbreaks of infectious disease.
    One of the things that does concern us is that we are 
seeing a continuing increase in the volume of antibiotics used 
in animal husbandry.
    We had a summit at the White House last year and had more 
than 150 commitments from organizations to do a wide range of 
things, including reduce use in animals. I think one of the 
things that is crucially important is to track the actual 
numbers--what gets measured can get managed--and see if that 
reduction is occurring.
    Ms. DeLauro. Do we have oversight capability, knowing what 
they have done?
    Dr. Frieden. I cannot answer that question. We would have 
to get back to you.
    [The information follows:]

    Rep. DeLauro: What Oversight Do We Have Over Antibiotic Use in 
                              Agriculture?

    CDC recognizes the importance of collection of antibiotic use data 
in agriculture. Just as in human medicine, good data about antibiotic 
use and resistance can help us identify areas of concern or 
improvement. CDC strongly supports the important work of FDA, USDA, and 
others to improve antibiotic stewardship in veterinary medicine and 
agriculture. FDA's Guidance for Industry #209 and #213 are important 
steps, and CDC applauds the actions that veterinary pharmaceutical 
manufacturers and food producers are taking to effectively implement 
these changes that end labeling of antibiotics for growth promotion and 
bring the remaining uses of antibiotic under veterinary oversight. 
Recognizing that minimal data on antibiotic use in animal agriculture 
currently exist, CDC supports FDA's recently released funding 
opportunity to support antibiotic use data collection in animal 
agriculture (http://grants.nih.gov/Grants/Guide/rfa-files/RFA-FD-16-
046.html).
    In addition, CDC is participating in an interagency working group 
with FDA and USDA to evaluate approaches for measuring antibiotic use 
in food animals and how use relates to antibiotic resistance. Tracking 
the use of antibiotics is critical to know how we are doing with 
stewardship. Good information about where, why, and how antibiotics are 
used is the basic information needed to know when stewardship is going 
well and when it can be strengthened.
    CDC has led antibiotic stewardship efforts in human health that 
could serve as a model for antibiotic stewardship in animal health. CDC 
has also shared information with FDA and USDA about CDC's core elements 
for antibiotic stewardship, antibiotic use and resistance data 
collection in human health, and partnerships to promote antibiotic 
stewardship. CDC partners with veterinary and agricultural 
associations, veterinary schools, and food safety experts, for example, 
working through the National Institute for Animal Agriculture to 
discuss shared interest in reducing antibiotic use and shared CDC's 
efforts to reduce use in clinical settings and measure antibiotic use.

    Ms. DeLauro. Okay. Thank you.
    Mr. Chairman, if I could put this into the record, it is a 
Los Angeles Times article that talks about the Zika virus. It 
raises more questions and answers for pregnant women.
    Mr. Cole. Without objection.
    [The information follows:]
    
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    Ms. DeLauro. Thank you.
    Mr. Cole. Thank you.
    The gentlelady from California, is recognized for 3 
minutes.

                          NEURAL-TUBE DEFECTS

    Ms. Roybal-Allard. Dr. Frieden, for many years, the 
Congressional Hispanic Caucus has been working with the March 
of Dimes and the American Academy of Pediatrics to get corn 
masa fortified with folic acid to reduce the elevated incidence 
of neural-tube defects, especially among Hispanics.
    It looks like the FDA will soon approve a petition to allow 
this fortification, and hopefully it will result in a 
significant decrease in spina bifida and anencephaly in our 
communities.
    Concerns have been raised, however, that recent 
recommendations by the USDA to prioritize the consumption of 
whole grains in the American diet and mandate 100 percent whole 
grains in the school meal programs could result in lowering the 
intake of fortified grains and reverse the progress that we 
have made reducing neural-tube defects.
    The CDC has been a leader in research, tracking, and 
prevention of neural-tube defects for over 2 decades, and your 
folic acid education program can take much credit for the 
progress that we have made in raising awareness of the 
importance of dietary folic acid for all childbearing women, 
and lowering the incidence of these birth defects.
    How does the natural folic acid in whole grains compare 
with the levels found in enriched products? And for women of 
childbearing age, what are your recommendations about the 
consumption of whole grains versus enriched grain products?
    Dr. Frieden. Well, Congresswoman, on the issue of corn masa 
flour, this is something that we have been deeply engaged with 
the company, with the March of Dimes, and with the FDA for more 
than 7 years.
    Ms. Roybal-Allard. I was going to say, we have been working 
on it for years.
    Dr. Frieden. Yes. And we have been trying hard to move 
forward, so we look forward to FDA action on that.
    On the issue of whole grains, I will have to get back to 
you with a detailed answer of what our recommendations are and 
what the analysis is of both fortified and unfortified.
    [The information follows:]

  Rep. Roybal Allard: Comparison of Natural Folate in Whole Grain to 
                            Fortified Grains

    The CDC recommendation remains that women capable of becoming 
pregnant should take 400 micrograms of synthetic folic acid daily, from 
fortified foods or supplements or a combination of the two, in addition 
to consuming food with natural folate from a varied diet.
    Studies have shown that there are many health benefits associated 
with consuming whole grains. Because of those health benefits, CDC 
supports the Dietary Guidelines for Americans' recommendation that at 
least half of grain consumption be whole grains and we support USDA's 
rule that 100% of grains in school lunches should be whole grain-rich 
(at least 51% whole grain). Because of those health benefits, CDC 
supports the recommendation by the USDA to prioritize the consumption 
of whole grains in the American diet. Commercially prepared whole wheat 
bread has about one-fourth the dietary folate equivalents (unit used to 
combine and compare natural food folate and folic acid in foods) of 
enriched white bread. If dietary patterns shift from enriched products 
to whole grain products, we would anticipate a reduction in folic acid 
intake.
    Women can consume folic acid through both fortified foods and 
supplements. CDC recommends that women who choose to consume no or 
limited amounts of folic acid-fortified foods should be sure to consume 
a supplement containing folic acid before and during early pregnancy. 
This is consistent with the CDC and the Food and Nutrition Board of the 
National Academy of Sciences Institute of Medicine recommendation that 
to reduce their risk for an NTD-affected pregnancy, women capable of 
becoming pregnant should take 400 micrograms of synthetic folic acid 
daily, from fortified foods or supplements or a combination of the two, 
in addition to consuming food with natural folate from a varied diet.
    The recommendation specifies the dosage of folic acid intake from 
supplements, because there are no studies of the amount of natural food 
folate intake needed to decrease NTD risk. Therefore, the 
recommendations rely on studies that show that folic acid supplements 
or fortification of 400 micrograms per day before and during early 
pregnancy reduces NTD risk.

    Ms. Roybal-Allard. Okay, I appreciate that. Thank you.
    Mr. Cole. And for the last round of questions, my good 
friend from Pennsylvania is recognized for 3 minutes.

                                  ZIKA

    Mr. Fattah. I will try not to consume all 3 minutes.
    You said there were going to be 30 States participating in 
the conference on the Zika virus. The other States are not 
participating because?
    Dr. Frieden. They do not have the mosquito that spreads it.
    Mr. Fattah. Okay. And there is no fear? You said there were 
two types of mosquitoes?
    Dr. Frieden. Yes. They do not have either.
    Mr. Fattah. All right, we are good.
    Thank you, Mr. Chairman.
    Mr. Cole. Thank you very much. That was quick.
    Dr. Frieden, again, I want to thank you very much for your 
testimony. Thank you again for your terrific public service. We 
look forward to working with you and your staff as we go 
forward this year.
    Again, I appreciate all the good work on behalf of the 
American people.
    Mr. Fattah. We are going to remember the buildings.
    Ms. DeLauro. We will not forget you. Thank you.
    Mr. Cole. With that in the record, we are adjourned.
    
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                           W I T N E S S E S

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                                                                   Page
Collins, F. S....................................................     1
Fauci, A. S......................................................     1
Frieden, Thomas..................................................   215
Hodes, R. J......................................................     1
King, Hon. John..................................................   167
Lowy, Douglas....................................................     1
Skelly, Thomas...................................................   167
Volkow, N. D.....................................................     1