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


       EXAMINING LEGISLATION TO IMPROVE HEALTH CARE AND TREATMENT

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            DECEMBER 9, 2015

                               __________

                           Serial No. 114-108
                           
                           
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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman
JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
GREG WALDEN, Oregon                  GENE GREEN, Texas
TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
  Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                     Massachusetts
RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota
                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois               LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III, 
RENEE L. ELLMERS, North Carolina         Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York                  officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)
  
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     3
Hon. Renee L. Ellmers, a Representative in Congress from the 
  State of North Carolina, opening statement.....................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
Hon. Doris O. Matsui, a Representative in Congress from the State 
  of California, prepared statement..............................    96

                               Witnesses

Chad Asplund, MD, MPH, FACSM, Director, Athletic Medicine and 
  Head Team Physician, Georgia Southern University...............     8
    Prepared statement...........................................    11
Jonathan Reiner, MD, Director, Cardiac Catheterization 
  Laboratory, George Washington University Hospital..............    18
    Prepared statement...........................................    20
Anthony R. Gregg, MD, Professor and Chief Division of Maternal-
  Fetal Medicine, University of Florida Department of Obstetrics 
  and Gynecology.................................................    31
    Prepared statement...........................................    33
Ginger Breedlove, PhD, CNM, APRN, FACNM, President, American 
  College of Nurse Midwives......................................    41
    Prepared statement...........................................    43
Deborah E. Trautman, PhD, RN, FAAN, President, American 
  Association of Colleges Of Nursing.............................    51
    Prepared statement...........................................    53
Ovidio Bermudez, MD, FAAP, FSAHM, FAEd, F.iaedp, CEDS, Chief 
  Clinical Officer and Medical Director of Child and Adolescent 
  Services, Eating Recovery Center Senior Board Advisor, National 
  Eating Disorders Association...................................    60
    Prepared statement...........................................    62
    Answers to submitted questions...............................   140

                           Submitted material

Mr. Pitts' submitted material
    Statement of Congresswoman Jaime Herrera Beutler.............    97
    Statement of the American Congress of Obstetricians and 
      Gynecologists..............................................    99
    Statement of the National Nursing Centers Consortium.........   106
    Statement of the National Association of Clinical Nurse 
      Specialties................................................   111
    Statement of the Nursing Community coalition.................   114
    Statement of the Society for Maternal-Fetal Medicine.........   119
    Statement of the National Leaque for Nursing.................   122
    Statement of the National Athletic Trainers' Association.....   127
    Statement of the Perinatal Quality Foundation................   129
Mr. Guthrie's submitted material
    Statement of sports medicine coalition.......................   131
    Statement of the American Association of Orthopaedic Surgeons   132
    Statement of the American Medical Association................   137
    Statement of the American Osteopathic Association............   138
    Statement of sports leagues and organizations................   139

 
       EXAMINING LEGISLATION TO IMPROVE HEALTH CARE AND TREATMENT

                              ----------                              


                      WEDNESDAY, DECEMBER 9, 2015

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 9:59 a.m., in 
room 2322, Rayburn House Office Building, Hon. Joseph R. Pitts 
(chairman of the subcommittee) presiding.
    Present: Representatives Pitts, Guthrie, Shimkus, Murphy, 
Burgess, Blackburn, Lance, Griffith, Bilirakis, Ellmers, 
Bucshon, Brooks, Collins, Green, Engel, Capps, Schakowsky, 
Castor, Matsui, Schrader, Kennedy, Cardenas, and Pallone (ex 
officio).
    Staff Present: Leighton Brown, Press Assistant; Rebecca 
Card, Assistant Press Secretary; Karen Christian, General 
Counsel; Peter Kielty, Deputy General Counsel; Carly 
McWilliams, Professional Staff Member, Health; Katie Novaria, 
Professional Staff Member, Health; Graham Pittman, Legislative 
Clerk; Adrianna Simonelli, Legislative Associate, Health; Heidi 
Stirrup, Health Policy Coordinator; John Stone, Counsel, 
Health; Jen Brennan, Minority Press Secretary; Jeff Carroll, 
Minority Staff Director; Waverly Gordon, Minority Professional 
Staff Member; Samantha Satchell, Minority Policy Analyst; and 
Arielle Woronoff, Minority Health Counsel.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. The subcommittee will come to order. The chair 
will recognize himself for an opening statement.
    Today's hearing will examine several different legislative 
proposals that will address shortcomings in current law, and 
reauthorize an important nursing training program.
    H.R. 921, the Sports Medicine Licensure Clarity Act 
sponsored by the Health Subcommittee vice chair, Brett Guthrie, 
clarifies medical liability rules for athletic trainers and 
medical professionals to ensure they are properly covered by 
their malpractice insurance while traveling with their athletic 
teams to other states.
    H.R. 1209, the Improving Access to Maternity Care Act, 
sponsored by another member of our Health Subcommittee, Dr. 
Michael Burgess, requires the Health Resources and Services 
Administration to designate maternity care health professional 
shortage areas inside existing primary care health professional 
shortage areas, and review these designations at least 
annually. The Department of Health and Human Services would 
also be required to collect and publish data on the shortage 
areas to better ensure access to maternity care.
    H.R. 2713, the Title VIII Nursing Workforce Reauthorization 
Act, sponsored by Representative Lois Capps, reauthorizes the 
current nursing workforce development programs to continue 
nursing education at all levels and provide additional support 
for nurses practicing in medically underserved communities.
    H.R. 3441, the Accurate Education For Prenatal Screening 
Act, sponsored by Representative Jaime Herrera Beutler, directs 
the Centers for Disease Control and Prevention to develop, 
implement, and maintain programs to educate patients as well as 
healthcare providers on the purpose of cell-free DNA prenatal 
screenings. The reasons for such screenings, what conditions 
may be detected as well as the risk, benefits, and alternatives 
to such screenings.
    H.R. 4152, the Cardiac Arrest Survival Act, sponsored by 
Representative Pete Olson, expands immunity from civil 
liability related to the use of automated external 
defibrillator devices.
    H.R. 4153, the Educating to Prevent Eating Disorders Act of 
2015, sponsored by Representative Renee Ellmers, yet another 
Health Subcommittee member, establishes a pilot program to test 
the impact of early intervention on the prevention, management, 
and course of eating disorders.
    We will hear from a panel of experts and stakeholders as to 
their ideas and recommendations on these bills.
    I now yield to Dr. Burgess.
    [The statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    The subcommittee will come to order.
    The Chairman will recognize himself for an opening 
statement.
    Today's hearing will examine several different legislative 
proposals that will address shortcomings in current law and 
reauthorize an important nursing training program.
    H.R. 921, the Sports Medicine Licensure Clarity Act, 
sponsored by the Health Subcommittee Vice Chairman Brett 
Guthrie (KY) clarifies medical liability rules for athletic 
trainers and medical professionals to ensure they are properly 
covered by their malpractice insurance while traveling with 
their athletic teams to other states.
    H.R. 1209, the Improving Access to Maternity Care Act, 
sponsored by another Member of our Health Subcommittee Dr. 
Michael Burgess (TX) requires the Health Resources and Services 
Administration (HRSA) to designate maternity care health 
professional shortage areas inside existing primarily care 
health professional shortage areas, and review these 
designations at least annually. The Department of Health and 
Human Services would also be required to collect and publish 
data on these shortage areas to better ensure access to 
maternity care..
    H.R. 2713, the Title VIII Nursing Workforce Reauthorization 
Act, sponsored by Rep. Lois Capps (CA) reauthorizes the current 
Nursing Workforce Development programs to continue nursing 
education at all levels, and provide additional support for 
nurses practicing in medically underserved communities.
    H.R. 3441, the Accurate Education for Prenatal Screenings 
Act, sponsored by Rep. Jaime Herrera Beutler (WA) directs the 
Centers for Disease Control and Prevention to develop, 
implement, and maintain programs to educate patients as well as 
health care providers on the purpose of cell-free DNA prenatal 
screenings, the reasons for such screenings, what conditions 
may be detected, as well as the risks, benefits, and 
alternatives to such screenings.
    H.R. 4152, the Cardiac Arrest Survival Act, sponsored by 
Rep. Pete Olson (TX) expands immunity from civil liability 
related to the use of automated external defibrillator devices.
    H.R. 4153, the Educating to Prevent Eating Disorders Act of 
2015, sponsored by Rep. Renee Ellmers (NC), yet another health 
subcommittee member, establishes a pilot program to test the 
impact of early intervention on the prevention, management, and 
course of eating disorders.
    Today we have two panels, including. Additionally, we will 
hear from a panel of experts and stakeholders as to their ideas 
and recommendations on these bills.
    I will now yield to Dr. Burgess.

    Mr. Burgess. Thank you, Mr. Chairman.
    I just want to comment on the bill we have before the panel 
today. Across the country, women with the greatest need for 
maternity care services lack access to providers of such care. 
This bill introduced with Representative Capps will help place 
more maternity providers where they are needed and to improve 
access to maternity care and advance the health of mothers and 
babies. The National Health Service Corps provides for student 
loan repayment to physicians and other health professionals in 
exchange for our commitment to provide care in a designated 
health professional shortage area.
    The program has been effective in reducing provider 
shortages by inspiring new providers to start where they are 
needed the most. Maternity care providers currently participate 
in the program based on a determination in an area that is a 
primary care shortage area. This bill would more effectively 
allocate maternity care providers based on an area or 
population's specific needs.
    In other words, a maternity care provider will continue to 
be able to participate, but their participation will be based 
on a designation of a maternity care shortage area, not just 
simply a primary care shortage area. We are continuing to work 
with HRSA to ensure that this narrow targeted provision will 
improve access to mothers and the care that they and their 
babies need.
    And thank you, Mr. Chairman. I will yield back.
    Mr. Pitts. The chair thanks the gentleman. The chair now 
recognizes the distinguished ranking member of the Health 
Subcommittee, Mr. Green, from Texas, 5 minutes for opening 
statement.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman. Today we are here to 
review six bills aimed at improving our healthcare system. But, 
first, and since this is, hopefully, our last hearing of the 
year, I want to start by thanking all of my colleagues on the 
Health Subcommittee, Ranking Member Pallone, Chairman Upton, 
and, of course, Chairman Pitts, for all of their work that went 
into the bills that comprise our shared success. It has been an 
incredibly productive year, and this subcommittee serves as an 
example of what we can accomplish when we work together on 
behalf of the American people.
    From the 21st Century Cures Act, which passed with 
overwhelming support in the House last summer, to the Medicare 
Access and CHIP Reauthorization Act, which repealed and 
replaced the SGR and extended funding for the CHIP program in 
community health centers to dozens of public health bills 
signed into law, to ongoing efforts along the salient issues 
such as regulation of laboratory developed tests, the success 
of undertakings of this subcommittee are numbered in 
significance. None of this would have happened without the 
strong leadership on both sides of the aisle and the commitment 
to bipartisanship and a tireless dedication of staff, House 
legislative counsel and advocates, including the 
administration. I want to thank all of you and look forward to 
seeing what we can accomplish in the coming year.
    Now to our bills today. H.R. 921, the Sports Medicine 
Licensure Clarity Act, will promote the safety of our athletes 
by ensuring that sports teams' physicians and athletic trainers 
who treat their athletes while outside their home state can 
treat their patients regardless of whether they are home or 
away. Many medical liability insurance carriers do not offer 
coverage for care provided outside of the State in which the 
provider is licensed, making it difficult for team physicians 
to maintain adequate coverage while traveling throughout a 
sport season. This legislation would clarify certain aspects of 
the medical liability and malpractice insurance for those 
providers to address this issue in a targeted manner.
    H.R. 4152, the Cardiac Arrest Survival Act, aims to 
increase the deployment of automated external defibrillators, 
or AEDs, by providing a baseline protection from civil 
liability for persons who own or use AEDs and doing a good-
faith medical emergency. Numerous studies have demonstrated the 
value of prompt use of AED during an out-of-hospital cardiac 
arrest as the likelihood of survival decreases by 7 or 10 
percent for every minute delayed until defibrillation.
    H.R. 3441, the Accurate Education for Prenatal Screening 
Act, aims to advance the use of cell-free DNA prenatal 
screening. The development and delivery of genetic and genomic 
health care will continue to transform the practice of medicine 
and improve the diagnosis, prevention, and treatment of 
disease. While I thank the bill sponsors for their commitment 
to the promise of genetics and the improving care for women 
with high-risk pregnancies, I have some concern that this 
legislation is overly prescriptive and premature and that 
information surrounding these tests is not evaluated by the FDA 
for their clinical or analytical validity.
    H.R. 1209, Improving Access to Maternity Care Act, was 
introduced to increase access to maternity care services by 
creating a new designation within primary care health 
professional shortage areas, HPS designation--HPSA. As someone 
who represents an underserved area, I appreciate the bill 
sponsors, Representative Mike Burgess and Lois Capps, for their 
commitment to targeting gaps in access and ensuring women can 
obtain vital maternity care services.
    H.R. 2713, the Title VIII Nursing Workforce Reauthorization 
Act, will extend successful advanced nurse--education nursing 
grants to support clinical nurse specialist programs. The Title 
VIII nursing workforce development programs have a long history 
of success and bipartisan support in Congress. Continued 
investment in these programs will ensure we have an adequate 
nursing workforce in the future. I want to thank Congresswoman 
Capps, the bill's sponsor, an unwavering champion for her work 
to reauthorize these critical programs, for her long history of 
working to improve nursing workforce demand, education, 
practice, recruitment, and retention.
    H.R. 4153, the Educating to Prevent Eating Disorders Act, 
will create a pilot program through the Agency on Healthcare 
Research and Quality to test the efficiency of early 
interventions on eating disorders. According to the NIH, eating 
disorders frequently present during teens and early adulthood, 
affect as many as 25 million Americans.
    I look forward to hearing from our witnesses and learning 
more about the merits of each legislative proposal before the 
subcommittee.
    And I thank you, and I yield back my time.
    Mr. Pitts. The chair thanks the gentleman.
    And now, in lieu of the chairman, Mr. Upton, the chair 
recognizes the gentlelady from North Carolina, Mrs. Renee 
Ellmers, 5 minutes for opening statement.

OPENING STATEMENT OF HON. RENEE L. ELLMERS, A REPRESENTATIVE IN 
           CONGRESS FROM THE STATE OF NORTH CAROLINA

    Mrs. Ellmers. Thank you, Mr. Chairman.
    And thank you to our panelists for being here today for 
this subcommittee hearing today. Through my experience as a 
nurse, I recognize and have witnessed the serious implications 
that stem from eating disorders.
    These disorders impact a person's emotional and physical 
health. So it is all the more important that we put in 
evidence-based programs in place to better understand the early 
warning signs of the disease. Our legislation, H.R. 4153, 
creates a pilot program within middle schools to begin 
educating school counselors, teachers, nurses, and parents 
about the signs and symptoms typically associated with these 
disorders.
    Education is a critical first step, if we hope to prevent, 
identify, manage, and intervene on behalf of the struggling 
adolescent. It is my hope that this legislation provides school 
officials and healthcare professionals with the education and 
resources they need to help thwart this mental illness from 
taking root. Thirty million Americans will struggle with an 
eating disorder at some point in their lives.
    H.R. 4153 aims to amend the Public Health Service Act to 
establish a pilot program to test the impact of providing 
students with interventions to prevent, identify, intervene, 
and manage eating disorders. The bill would establish a 3-year 
pilot program to provide grants to eligible schools for eating 
disorder screening, which would be implemented based on best 
practices recommendations from experts in the field of eating 
disorders. The pilot program would also include educational 
information and seminars on eating disorders developed by 
experts in the field for teachers, and parents, and eligible 
schools.
    The intent of H.R. 4153 is to detect risk factors and 
symptoms so that young people can be directed to help when it 
is most effective. H.R. 4153 could be the most important 
proactive piece of legislation for the early intervention and 
prevention of deadly eating disorders.
    I look forward to beginning this important discussion 
today, and thank you, again.
    I yield back the remainder of my time.
    Mr. Pitts. The chair thanks the gentlelady.
    Is anyone else on this side of the aisle seeking 
recognition?
    The chair thanks the gentlelady, and I now recognize the 
distinguished ranking member of the full committee, Mr. 
Pallone, 5 minutes.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman. This morning we will 
be discussing a wide variety of bills. The first, H.R. 921, the 
Sports Medicine Licensure Clarity Act, stipulates that if a 
team doctor or athletic trainer crosses State lines for a game, 
any care provided at the out-of-State event will be treated as 
if it were a home game for the purpose of medical licensure and 
liability.
    The second bill, H.R. 4152, the Cardiac Survival Act, 
expands civil liability protections related to the usage of 
automated external defibrillator devices, or AEDs. This bill 
would offer broad protections for both the owners of AEDs and 
any lay person that may use it. While I strongly support the 
intended goal of this bill, I do have some concerns surrounding 
State law preemption, especially as itmay relate to various 
State AED training laws.
    Third is H.R. 3441, the Accurate Education for Prenatal 
Screenings Act, would direct CDC to develop patient and 
provider education programs and materials to inform them about 
the use of cell-free DNA prenatal screening tests for genetic 
conditions such as Down syndrome. These screenings are intended 
to provide patients with genetic information regarding their 
pregnancy. However, these screenings are not regulated by FDA 
and have a history of false positives and false negatives. 
Further, these tests are often misunderstood by both patients 
and providers. More must be done to ensure that the information 
provided about these tests is accurate and truthful to ensure 
that patients and providers can better understand these 
screenings and their limitations.
    The fourth bill, H.R. 1209, the Improving Access to 
Maternity Care Act, as introduced by Representatives Burgess, 
Capps, and Duckworth, would make changes to the National Health 
Service Corps definition of a primary care health professional 
shortage area by creating a subcategory specifically for 
maternity care providers. This would allow the National Health 
Service Corps to better target maternity care providers towards 
the areas with the most need.
    And then we have H.R. 2713, the Title VII Nursing Workforce 
Reauthorization Act as introduced by Representative Capps and 
Joyce, would reauthorize the Title VIII nursing workforce 
programs which provide valuable training to our Nation's 
nursing workforce through 2020. It also provides technical 
updates that more accurately reflect the current state of the 
nursing profession.
    And, finally, H.R. 2153, the Educating to Prevent Eating 
Disorders Act, as introduced by Representatives Ellmers, Clark, 
and Castor, creates a pilot program to test new approaches to 
early interventions for eating disorders.
    I would like to yield the remainder of my time to Mrs. 
Capps.
    Mrs. Capps. I thank my colleague for yielding.
    And I thank you, Mr. Chairman and Ranking Member Green, for 
holding this hearing. I am particularly pleased that two pieces 
of legislation I have worked on for a long time are also 
included in this discussion. Each would help strengthen our 
healthcare workforce and improve access to care for patients 
across the Nation.
    H.R. 1209, the Improving Access to Maternity Care Act, 
would help identify and fill gaps in maternity care through the 
National Health Service Corps. My colleague from Texas has 
already described this, but I want to underscore the fact that 
the National Health Service Corps is one of our most effective 
programs to improve access to care in underserved areas.
    Maternity care professionals are already included in the 
program, but their placement is based on data looking at 
primary care access shortages, not maternity care data. And 
this bill would make this more efficient by allowing these 
professionals to serve in areas with shortages in maternity 
care access, not just those with primary care deficiencies. It 
may seem like a small thing, but it is actually pretty 
significant.
    I am pleased to have also co-authored this legislation with 
Dr. Burgess, and I want to highlight the work of our colleague, 
Representative Roybal-Allard on this issue over the years. 
Quality maternal care is vitally important for both the health 
of women and their future children, and it is our interests to 
do all we can to break down barriers to access for this care.
    I am also very pleased that we are considering H.R. 2713, 
the Title VIII Nursing Workforce Reinvestment Act--Workforce 
Reauthorization Act. Sorry. Title VIII is the primary program 
our Nation has to strengthen and grow the nursing workforce. 
Title VIII has supported the recruitment, retention, and 
distribution of the highly educated professionals who comprise 
our Nation's nursing workforce and have been doing so for over 
50 years through Title VIII. These programs bolster nursing 
education at all levels, from entry-level preparation through 
graduate study, and they provide support for institutions that 
educate nurses for practice in rural and medically underserved 
communities. Moreover, these programs are designed to address 
specific needs within the nursing workforce and America's 
patient population. The Nursing Workforce Reauthorization Act 
would ensure that these critical programs are available for 
years to come.
    I want to thank my nursing caucus co-chair, Representative 
David Joyce, for coauthoring this legislation and the over 50 
nursing groups that we have worked with to move this 
reauthorization forward. It is a great day.
    So, again, thank you for including these bills in today's 
hearing.
    And with that, I yield back to my colleague, but I don't 
think there is any time. Thank you.
    Mr. Pitts. The chair thanks the gentlelady.
    As usual, all written opening statements of the members 
will be made a part of the record.
    I have a UC request. I would like to submit the following 
documents for the record: Statements from Representative 
Herrera Beutler, from the American Congress of Obstetricians 
and Gynecologists, from National Nursing Centers Consortium, 
from the National Association of Clinical Nurse Specialists, 
from the Nursing Community Coalition, from the Society for 
Maternal Fetal Medicine, from the National League for Nursing, 
and the National Athletic Trainers' Association. Without 
objection, these will be made a part of the record.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. I will now introduce the panel. We have six 
witnesses today. I will introduce them in the order of their 
testimony.
    First of all, Dr. Chad Asplund, Director, Athletic 
Medicine, Head Team Physician for Georgia Southern University, 
and Dr. Jonathan Reiner, Director, Cardiac Catheterization 
Laboratory, George Washington University Hospital, and Dr. 
Anthony Gregg, Professor and Chief, Division of Maternal Fetal 
Medicine, University of Florida, Department of Obstetrics and 
Gynecology.
    Dr. Ginger Breedlove, President, American College of Nurse 
Midwives; Dr. Deborah Trautman, President and CEO of American 
Association of Colleges of Nursing, and Dr. Ovidio Bermudez, 
Chief Clinical Officer and Medical Director of Child and 
Adolescent Services Eating Recovery Center, Senior Board 
Adviser, National Eating Disorders Association.
    Thank you, each, for coming today. Your written testimony 
will be made a part of the record. You will each be given 5 
minutes to summarize your testimony. You have a little series 
of three lights; green for the first 4 minutes, yellow for the 
last minute, red when your time has expired. So thank you for 
coming.
    And at this point, Dr. Asplund, you are recognized 5 
minutes for your summary.

STATEMENTS OF CHAD ASPLUND, MD, MPH, FACSM, DIRECTOR, ATHLETIC 
MEDICINE AND HEAD TEAM PHYSICIAN, GEORGIA SOUTHERN UNIVERSITY; 
    JONATHAN REINER, MD, DIRECTOR, CARDIAC CATHETERIZATION 
 LABORATORY, GEORGE WASHINGTON UNIVERSITY HOSPITAL; ANTHONY R. 
   GREGG, MD, PROFESSOR AND CHIEF DIVISION OF MATERNAL-FETAL 
 MEDICINE, UNIVERSITY OF FLORIDA DEPARTMENT OF OBSTETRICS AND 
GYNECOLOGY; GINGER BREEDLOVE, PHD, CNM, APRN, FACNM, PRESIDENT, 
 AMERICAN COLLEGE OF NURSE MIDWIVES; DEBORAH E. TRAUTMAN, PHD, 
   RN, FAAN, PRESIDENT, AMERICAN ASSOCIATION OF COLLEGES OF 
 NURSING; AND OVIDIO BERMUDEZ, MD, FAAP, FSAHM, FAED, F.IAEDP, 
CEDS, CHIEF CLINICAL OFFICER AND MEDICAL DIRECTOR OF CHILD AND 
   ADOLESCENT SERVICES, EATING RECOVERY CENTER SENIOR BOARD 
         ADVISOR, NATIONAL EATING DISORDERS ASSOCIATION

                   STATEMENT OF CHAD ASPLUND

    Dr. Asplund. Thank you, Mr. Chairman, Ranking Member Green, 
members of the committee. Thank you for inviting me here to 
discuss H.R. 921, the Sports Medicine Licensure Clarity Act. My 
name is Chad Asplund. I am a family medicine, sports medicine 
physician, and I am the head team physician at Georgia Southern 
University.
    I graduated from the United States Coast Guard Academy, 
completed medical training at the University of Pittsburgh, 
family medicine residency at DeWitt Army Community Hospital at 
Fort Belvoir, and my sports medicine fellowship at Ohio State 
University. Additionally, I completed a master's of public 
health degree at the University of Florida.
    In my experience as a sports medicine physician, I have had 
the opportunity to take care of athletes at all levels; 
Olympic, professional, NCAA division 1, 2, and 3, as well as 
recreational and high school athletes. I am here today 
representing the American Medical Society for Sports Medicine, 
the largest organization of team physicians in the world, which 
I serve as its chair of the practice and policy committee. I 
would not be here also without the support of the National 
Athletic Trainers' Association, the American Academy of 
Orthopedic Surgeons, and many others.
    Nearly every day in this country, athletic teams travel 
across state lines to compete in their contests. Every day 
those athletes are out on the field they are subject to danger 
and to harm. And because of this, physicians and athletic 
trainers are there to ensure their safety. In the United States 
there are approximately 14,000 athletic trainers and physicians 
that are dedicated to team care, and each week in America 300 
to 500 of these professionals travel across state lines to 
provide care to the teams that they support.
    What you may not realize is that in many cases by doing 
this, by crossing state lines to perform their jobs, they are 
risking their professional licenses and personal assets to make 
sure that those athletes have the best care by the medical 
professionals who know them best.
    H.R. 921 would protect medical professionals that keep 
these athletes safe. H.R. 921 has three main components. First, 
to ensure medical professionals' licenses are valid when 
crossing state lines when they travel with their teams for 
sanctioned events as long as the care they provide is within 
the confines of the bill.
    Second, to ensure that the Medical Practice Act in the 
medical professional's home state dictates their scope of 
practice, licensure requirements, laws, rules, and regulations 
governing their actions. And third, to ensure that a medical 
professional's medical malpractice and liability coverage can 
and will cover them while they were traveling to support their 
teams.
    As you are aware, it is college football bowl season. Many 
teams will travel across state lines to play football, which at 
times can be a violent and dangerous sport. Athletic trainers 
and physicians travel with these teams in order to ensure their 
safety. I would like to share a personal story of an incident 
that happened to us.
    During this football season, during a game at Troy 
University, one of our Georgia Southern football players 
received a hit to the head and was laying unconscious, face 
down on the football field. Our medical team ran onto the 
field, and upon finding him, he was found to be unconscious and 
unresponsive. It was determined that he would need to be spine 
boarded and transported to the nearest emergency medicine 
facility.
    The complex choreography of stabilizing the cervical spine, 
managing the remainder of the spine while rolling the patient 
and placing him on a backboard is something that takes lots of 
training and lots of practice between physicians and athletic 
trainers that work together all the time. Our athlete was 
placed on a spine board and was transported to EMS. Thankfully, 
his further evaluation was all negative. He was diagnosed with 
a concussion, and has since made a full recovery.
    At the beginning of this incident, the Georgia Southern 
University medical team provided the medical care to this 
patient, which was then transferred to the emergency medical 
services when he was placed in the ambulance. Had there been an 
adverse event and a lawsuit had been filed, the protection of 
those members that provided that care would be uncertain. Their 
medical licenses and their personal assets would be at risk.
    But there is no need to put medical professionals at risk. 
Today you can take a significant step to solve this problem. 
You can choose to protect athletes and medical professionals by 
supporting and passing H.R. 921. I urge you, again, to support 
and pass this bill. And thank you very much for your time 
today.
    [The statement of Dr. Asplund follows:]
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    Mr. Pitts. The chair thanks the gentleman.
    And, Dr. Reiner, you are recognized 5 minutes for your 
summary.

                  STATEMENT OF JONATHAN REINER

    Dr. Reiner. Mr. Chairman, Ranking Member Green, members of 
the committee, thank you for the opportunity to testify on 
behalf of the Cardiac Arrest Survival Act and the many 
thousands of lives this bill has the potential to save. I am a 
professor of medicine and cardiologist at the George Washington 
University, and I have spent most of my adult life treating 
people with heart disease. This is a topic I care about deeply.
    Every year approximately 350,000 Americans experience an 
out-of-hospital cardiac arrest. Sudden cardiac arrest, or SCA, 
is a condition that results most often from the abrupt onset of 
a heart rhythm abnormality called ventricular fibrillation. 
This extremely rapid and chaotic arrhythmia causes the heart to 
quiver, effectively blocking its ability to pump. With no heart 
function, blood pressure drops to zero, breathing stops, and 
organs, most quickly the brain, begin to die. Without immediate 
measures, the victim has just a few minutes to live. SCA is a 
supremely lethal event that results in the death of about 90 
percent of those it afflicts.
    Sudden cardiac arrest is an equal opportunity killer. It 
kills the young and the old, the rich and the poor, those 
suffering from chronic heart disease, and those who have never 
before been sick. It kills our husbands and our wives, our 
parents, and our partners, our friends, and neighbors, and our 
children. The annual death toll from sudden cardiac arrest is 
about twice the number of those who die from breast cancer, 
lung cancer, and HIV-AIDS combined.
    Defibrillation with an automated external defibrillator, an 
AED, is the only effective treatment for sudden cardiac arrest. 
An AED is a small device, about the size of a lunch box, that 
can deliver a therapeutic shock to essentially reset the 
electrical circuitry of the heart. Contemporary AEDs, the type 
you see throughout airports and here in the hallways of the 
Capitol, have algorithms that automatically determine whether a 
shock is indicated and step-by-step audio prompts that guide 
the rescuer through the surprisingly simple process of saving a 
life.
    This is time-tested technology designed for use by people 
who have had no prior medical training. In the late 1990s, when 
clinical studies proved unequivocally that public access to 
defibrillation saved lives, states began to enact AED laws. 
Over the next several years, all 50 states and the District of 
Columbia passed such legislation. Unfortunately, the unintended 
consequence of this effort was that the enacted AED measures 
were all different, creating a confusing patchwork of 
regulatory requirements and liability provisions.
    The American Heart Association has stated that the 
variations and complexities of state laws have complicated 
efforts to disseminate AEDs around the country. For example, 
more than 30 states require the registration of AEDs with local 
authorities, a process that is different in each state and can 
be quite cumbersome. Despite the fact that AEDs are designed to 
be used by lay rescuers, several states still prohibit AEDs by 
untrained operators.
    Forty states require oversight of an AED program by a 
licensed physician. Although all 50 states have enacted some 
form of Good Samaritan protection for AED responders, the laws 
differ as to who in particular is eligible for immunity. 
Collectively, the varied state laws create a confusing series 
of bureaucratic hurdles that must be crossed before an AED 
program can commence. While individual state laws make the 
process of instituting a single AED program cumbersome, state-
to-state regulatory heterogeneity and differences in Good 
Samaritan protections create an air of liability uncertainty 
for national corporations considering enterprise-wide AED 
programs.
    The Wall Street Journal, noting that hotels around the 
United States have been reluctant to deploy defibrillators, 
describe their liability concerns as the, quote, ``no good deed 
goes unpunished exposure.'' American retail stores have been 
similarly reluctant to deploy defibrillators. For example, you 
can purchase an AED from Walmart for about $1,000, however, 
should you experience a cardiac arrest while shopping in most 
stores, resuscitation will have to wait until the paramedics 
arrive.
    To facilitate the placement of AEDs in businesses and 
public places across the United States, there must be a single 
unambiguous nationwide platform of liability protections. This 
is what the Cardiac Survival Act of 2015 does. The bill 
essentially decouples liability protection from the very state 
requirements for AED implementation, and in so doing, creates a 
national uniform baseline of civil liability protection for 
Good Samaritan rescuers and the entities that own the device. 
Reducing the current uncertainty surrounding AED acquisition 
and use will encourage the deployment of additional AEDs across 
the Nation and ultimately, this will save lives that otherwise 
that would have been lost.
    In conclusion, Mr. Chairman, the current jumble of state 
AED provisions creates great uncertainty regarding liability 
exposure and has become a virtual speed brake on the 
dissemination of the simple, irreplaceable, decades-proven 
therapy. Congress has the ability to remedy this problem with 
the passage of the Cardiac Arrest Survival Act. Thank you.
    [The statement of Dr. Reiner follows:]
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    Mr. Pitts. The chair thanks the gentleman, now recognizes 
Dr. Gregg, 5 minutes for your summary.

                   STATEMENT OF ANTHONY GREGG

    Dr. Gregg. Good morning, Mr. Chairman, members of the 
subcommittee. I am Anthony Gregg, professor and chief of the 
Division of Maternal-Fetal Medicine at the University of 
Florida. I am board certified in obstetrics and gynecology, 
maternal-fetal medicine, and clinical genetics. I have been in 
practice for over 20 years specializing in high-risk 
pregnancies. I am here today as a representative of the 
American College of Medical Genetics and Genomics.
    ACMG is a specialty society representing U.S. clinical and 
laboratory medical geneticists, who are certified by the 
American Board of Medical Genetics and Genomics. There are 
nearly 2,000 ACMG members, including genetic counselors, 
nurses, and public health geneticists. Delivery of genetic and 
genomic health care is an exciting area that has transformed 
and continues to alter the practice of medicine.
    Medical genomics refers to the knowledge of human DNA 
organization and structure along with an appreciation of the 
environmental impacts that lead to health and disease. Medical 
genomics is now applicable in the delivery of prenatal and 
postnatal patient care, including fetal and neonatal screening 
for genetic conditions.
    I am also here today in the capacity as lead author of the 
May 2013 ACMG policy statement on noninvasive prenatal 
screening for fetal aneuploidy. The genetics and genomics world 
is fast moving. Noninvasive prenatal screening, NIPS, using 
cell-free DNA was introduced clinically in the United States 
about 4 years ago. The ACMG statement on this technology 
outlines test limitations and major issues to consider with 
regards to test limitations. It emphasizes the screening nature 
of this test and states clearly that false positive and false 
negative results occur. In fact, ACMG introduced the name, 
noninvasive prenatal screening, NIPS. The S in the acronym is 
meant to emphasize the screening nature of this test.
    The ACMG document addresses the importance of clear 
language when conveying laboratory test results and recommends 
that laboratories offering this testing adhere to accepted 
standards and guidelines for practice. Uniquely, the statement 
includes a number of information resources available to 
patients and providers.
    ACMG supports H.R. 3441, the Accurate Education for 
Prenatal Screenings Act. H.R. 3441 recognizes that NIPS is 
unique. It has better screening test metrics than any 
technology which has preceded it and any other currently in 
use. It is a technology that is easy to implement. It is 
noninvasive, which means it requires only a blood draw from a 
patient's perspective. These features within a rapidly changing 
genetics and genomic medical practice environment creates 
challenges for many patients and providers of obstetric care.
    NIPS has seen rapid uptake by providers and their patients, 
and it is increasingly offered to a large proportion of 
pregnant women. This has caused a paradigm shift in the way 
prenatal genetic screening takes place. Every aspect of 
screening is impacted, including pretest counseling, sample 
collection and shipping, laboratory testing, and post-test 
counseling, and follow-up.
    Counseling patients is at the heart of the clinical utility 
of NIPS. Nondirective, but informed counseling requires 
training and skill. Patient aids, literacy level, spoken 
language, and baseline anxiety varies among patients. Medical 
geneticists are uniquely trained to address patient 
heterogeneity. ACMG agrees with the goal of H.R. 3441. 
Clinicians are going to provide patients with both pretest and 
post-test counseling when offering NIPS in order to avoid any 
potential harm or confusion.
    There are nearly 4 million U.S. births annually, and it is 
imperative that obstetric care providers, including 
obstetricians, family medicine doctors, nurse midwives, and 
practitioners have access to accurate educational materials 
that ensure patients receive accurate pretest counseling. 
Pretest education and counseling leading to informed 
decisionmaking are critical components of any genetic screening 
process. The great majority of normal results are communicated 
to patients by the provider or their designee that counseled 
and offered the test. However, abnormal results may not be easy 
for nongenetics trained professionals to interpret. Sometimes 
these must be put into the context of personal and medical 
family history in order for patients to receive accurate 
information. A deep understanding of genomic medicine is 
required.
    We applaud Congressmen Herrera Beutler and Roybal-Allard 
for including provisions in H.R. 3441 that emphasize the 
importance of both pretest education and counseling as well as 
the need for accurate and patient-specific follow-up when 
results point to a possible fetal genetic condition.
    Mr. Chairman and members of the committee, thank you for 
focusing on this important issue for women and families. ACMG 
looks forward to working with you to ensure access to accurate, 
reliable, and up-to-date information. Thank you.
    [The statement of Dr. Gregg follows:]
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    Mr. Pitts. The chair thanks the gentleman and now 
recognizes Dr. Breedlove, 5 minutes for your summary.

                 STATEMENT OF GINGER BREEDLOVE

    Dr. Breedlove. Chairman Pitts, Ranking Member Green, and 
members of the subcommittee on Health, it is truly my honor to 
be with you today to discuss the status of maternity care in 
the United States and the need for Congress to work with 
maternity care providers, including midwives, to improve a 
woman's access to these essential services.
    I am a certified nurse-midwife with 37 years of clinical 
experience and a professor of graduate nursing and nurse-
midwifery at Shenandoah University in Winchester, Virginia. 
Today I join you as president of the American College of Nurse-
Midwives.
    ACNM is the professional organization for certified nurse-
midwives and certified midwives, and our vision is a midwife 
for every woman. Our mission is to support midwives and advance 
the practice of midwifery in order to achieve optimal health 
for women through their lifespan with expertise in well-women 
and gynecologic care promoting optimal pregnancy, physiologic 
birth, postpartum care, and care of the newborn through the 
first 28 days of life. CNMs are licensed, independent 
healthcare providers with prescriptive authority in all 50 
states, the District of Columbia, American Samoa, Guam, and 
Puerto Rico.
    Medicare, Medicaid, and all other Federal programs provide 
access to midwifery services. Approximately 82 percent of CNMs 
have a master's degree, and as of 2010, a graduate degree is 
required to entry into our practice. As president of ACNM, I am 
proud to fully support the Improving Access to Maternity Act, 
H.R. 1209, as authored by Representative Michael Burgess and 
Representative Lois Capps. I thank them for championing this 
important public health initiative on behalf of women in rural 
and urban areas experiencing shortages of qualified maternity 
care providers.
    I also wish to thank the American College of Obstetricians 
and Gynecologists, which has been a strong partner supporting 
this legislation along with numerous nursing and maternal 
health groups.
    H.R. 1209 would establish a maternity care shortage 
designation within existing designated health professional 
shortage areas. The goal of this legislation is to identify 
areas in the U.S. experiencing significant shortages of full 
scope professionals, including midwives. Such information will 
enable Congress and the administration to better understand and 
address needs of women of child-bearing age and allow 
appropriate resources to be focused on those unique needs.
    ACNM believes enabling access to maternity care 
professionals in underserved areas can reduce overall maternity 
care costs by ensuring women have access to necessary prenatal 
and delivery options. For example, we know nearly half of the 4 
million annual births in the U.S. each year are covered by the 
Medicaid program. Thus, both Federal and state governments have 
a clear financial stake in ensuring high-quality care is being 
provided at a reasonable cost. Too many of these births require 
expensive interventions that could double the cost of a birth 
and, in fact, increase a woman's risk for maternal mortality. 
The CDC reports that the rate of maternal mortality has more 
than doubled in the past few decades.
    Today, women giving birth in our country are at a higher 
risk of dying than those giving birth in China or Saudi Arabia. 
This tragedy must be addressed. While there are several causes, 
one solution is better access to maternity care providers, 
including midwives, who can monitor a woman's pregnancy, 
provide prenatal care, adequate postnatal care, and promote a 
healthy transition to parenthood without complications.
    Research shows that in 2011, some 40 percent of counties 
had neither a certified nurse midwife nor an OB-GYN to provide 
direct patient care services. For millions of women, shortages 
in maternity care providers can result in long waiting times 
for appointments, and long travel times to their prenatal care 
or site of their birth. We know inadequate prenatal care is 
associated with increased risk of prematurity, stillbirth, and 
neonatal death.
    H.R. 1209 will ensure policymakers have necessary 
information on maternity care shortage areas. Midwives and OB-
GYNs are already full participants in the National Health 
Service Corps, which places practitioners in underserved areas, 
yet, no maternity care shortage designation exists. Allowing 
the National Health Service Corps to place them where their 
unique skills are most needed will benefit the women of our 
country.
    Thank you for your consideration of this legislation today.
    [The statement of Ms. Breedlove follows:]
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    Mr. Pitts. The chair thanks the gentlelady, now recognizes 
Dr. Trautman, 5 minutes for your summary.

                STATEMENT OF DEBORAH E. TRAUTMAN

    Ms. Trautman. Good morning. My name is Deborah Trautman, 
and I am the chief executive officer for the American 
Association of Colleges of Nursing. I want to thank the 
chairman for hosting this important meeting today, also 
recognizing Ranking Member Green and the opportunity to speak 
to you all about a very important issue for our Nation's 
health.
    On behalf of H.R. 2713, Title VIII Nursing Workforce, I 
would also like to extend my gratitude to Representatives Capps 
and Joyce for introducing this legislation and for their work 
as the nursing caucus. Both of them are fierce champions for 
the nursing profession and for improving health in our Nation.
    Additionally, I wish to thank House Energy and Commerce 
Committee members who have cosponsored this legislation, 
including Representatives Castor, Kennedy, Loebsack, Matsui, 
Schrader, and Yarmuth. AACN, as you may know, represents 781 
schools of nursing across the country in all 50 States and the 
District of Columbia. Our membership extends to 475,000 
individuals, 18,000 full-time faculty, 457,000 nursing 
students, and deans who lead these institutions.
    Healthcare delivery models are not static, as you know, 
neither is nursing education. This legislation would modernize 
the Title VIII nursing workforce development programs, thus 
creating alignment with transformational efforts underway in 
nursing and health care. With over 3 million licensed 
providers, registered nurses are the largest healthcare 
workforce in America and essential members of the healthcare 
team.
    As we continue to ensure that all communities have access 
to care, it is essential that Title VIII nursing workforce 
development programs be reauthorized. This will ensure a 
continued pipeline of support for providers who spend the most 
time with patients, our Nation's nurses.
    AACN, along with 51 other nursing organizations, 
collaborated with Representatives Capps and Joyce to identify 
four technical changes. The mutually agreed-upon changes 
promote the clinical nurse specialist role, which employs 
expertise to specific patient populations, nurse managed health 
clinics, which provide essential primary care, and the clinical 
nurse leader role, which is vital to care coordination.
    Title VIII programs have supported the nursing profession 
for over five decades. In 2015, the Title VIII programs awarded 
1,166 new and continuing grants. These grants bolster the 
nursing workforce, address nursing workforce diversity, improve 
and increase nursing faculty, improve quality, promote inter-
professional education and training, and help meet the needs of 
our aging population.
    Today, regional demands for nurses reflect some of the 
barriers to recruitment and retention, particularly in areas of 
nursing shortage. One Title VIII program, the advanced 
education nursing traineeship, helps us address this. In a 
study HRSA did recently, this program supported 5,650 students, 
of which 56 percent of these students received training in 
medically underserved areas, and 48 percent received training 
in primary care settings.
    One future nurse, who is a recipient of this traineeship, 
Britney Keplera, a doctor of nursing practice student at the 
University of Pittsburgh, students like Britney are prime 
examples of how this program reaches those who provide care to 
the underserved. Britney, as others, look forward to serving 
their local community, and Title VIII funding allows students 
to prioritize their future practice settings over choosing an 
area where salary will help offset their loans.
    Another nurse, Lisa Van Cleave, a Ph.D. student at Hardin-
Simmons University in Abilene, Texas, is supported through the 
nurse faculty loan programs. Lisa states that this financial 
aid will assist her in becoming a doctorally prepared faculty 
member. There is a critical demand for doctorally prepared 
faculty across the country.
    Each year, hundreds of students like Britney and Lisa share 
with AACN how the nursing workforce development programs have 
provided them financial opportunity to work towards their 
ultimate career goal, providing high-quality, cost-effective 
care, and for many of them that includes becoming the faculty 
of the future who will teach tomorrow's nurses.
    I thank the subcommittee for the opportunity to share the 
tremendous impact that Title VIII programs have had and how its 
recipients and their careers have and will continue to improve 
the health of our Nation.
    I applaud the subcommittee for bringing H.R. 2713 to a 
hearing, as it is the necessary legislative step to support 
America's patients, their families, and the communities in 
which they live.
    AACN is dedicated to working with this subcommittee and 
Congress to advance this legislation.
    Thank you for the opportunity to comment.
    [The statement of Ms. Trautman follows:]
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    Mr. Pitts. The chair thanks the gentlelady, now recognizes 
Dr. Bermudez, 5 minutes for your summary.

                  STATEMENT OF OVIDIO BERMUDEZ

    Dr. Bermudez. Thank you, Mr. Chairman, and members of the 
Subcommittee on Health for the opportunity to testify before 
you today to support H.R. 4153, the Educating to Prevent Eating 
Disorders Act of 2015.
    My name is Dr. Ovidio Bermudez, and I serve as chief 
clinical officer and medical director of child and adolescent 
services for the Eating Recovery Center, a treatment facility 
in Denver, Colorado.
    I also serve as senior advisor for the board of the 
National Eating Disorders Association, which is a not-for-
profit organization that supports both families and individuals 
who have been impacted by eating disorders.
    I applaud this subcommittee for their consideration of this 
legislation, and in particular Congresswoman Ellmers for her 
leadership in championing this very important cause. As a 
medical doctor working in the field of eating disorders now for 
over 25 years, I would like to emphasize the importance of 
screening and early recognition and intervention in the 
prevention of eating disorders.
    Over the last two and a half decades, I have treated 
thousands of children and adolescents suffering from eating 
disorders and have learned a few things about them that I would 
like to share with you. First, those who suffer from an eating 
disorder and their families bear a heavy burden of disease. 
However, many of the personality characteristics that have 
rendered them at risk for the development of these illnesses 
also render them productive members of society once they have 
recovered from their illness.
    Second, those in touch with the daily lives of young 
people, meaning parents and school personnel, specifically 
teachers, are in the best position for early detection. There 
are attitude changes in a young person that often precede the 
development of eating related pathology and behaviors, and thus 
can clue us into the needs for assessment and further 
intervention.
    Third, eating disorders are curable mental illnesses, but 
the later the diagnosis and the institution of appropriate 
intervention, the harder the course of illness and worse the 
outcome. So early recognition and early intervention are 
essential to improve treatment outcomes and avoid the 
chronicity and early death often associated with eating 
disorders.
    In the U.S., 20 million women and 10 million men suffer 
from a clinically significant eating disorder at some point in 
their lives, including anorexia nervosa, bulimia nervosa, or 
binge eating disorder. Eating disorders are real; they are 
complicated, complex, and devastating conditions and can have 
serious consequences for health, productivity, and 
relationships. They are not a fad. They are not a phase. They 
are not a lifestyle choice. In fact, they are not a choice at 
all.
    Eating disorders are serious, potentially life-threatening 
conditions that affect a person's emotional and physical health 
and can impact every organ of their body, including the brain. 
If left untreated they can damage the brain, the liver, 
kidneys, gastrointestinal tract, teeth, skin, hair, bones, and 
heart. They can result in serious medical conditions such as 
retarded growth, osteoporosis, kidney problems, 
gastrointestinal dysfunction, and heart failure.
    In fact, eating disorders have the highest mortality rate 
of any mental illness, yet, due to the lack of awareness and 
education about them, many people do not receive the treatment 
they need and deserve. Due to this lack of information, eating 
disorders are often not recognized or diagnosed until the 
physical health of an individual is compromised, at which point 
irreversible damage may have already occurred. But the good 
news is that eating disorders are treatable conditions. Early 
recognition may prevent the development of eating disorders and 
subsequent chronic physical and mental conditions, including a 
high risk of suicide.
    Studies have demonstrated a link between early intervention 
and better treatment outcomes. The American Academy of 
Pediatrics has recommended the screening questions about eating 
patterns and body image be asked of all preteens and 
adolescents to detect the onset of eating disorders early and 
halt their progression. The cost of treating a full-blown 
eating disorder is quite expensive, and so prevention really 
pays.
    H.R. 4153 aims to amend the Public Health Act to establish 
a pilot program to test the impact of early intervention 
through screenings, under-prevention management, and course of 
eating disorders that would establish a 3-year pilot program to 
provide grants to eligible schools for eating disorders 
screenings. The screenings would be implemented based on best 
practices from recommended experts in the field of eating 
disorders.
    To me, the reality is, is that this is an important 
opportunity to protect one of the most valuable sectors of our 
population, which is young people.
    So I want to thank you for hearing this testimony and for 
the consideration of supporting H.R. 4153 to improve the health 
and well-being of youth across our Nation by helping to prevent 
eating disorders. Thank you.
    [The statement of Dr. Bermudez follows:]
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    Mr. Pitts. The chair thanks the gentleman. That concludes 
the oral presentations of the witnesses. We will now begin 
questioning.
    I will recognize myself 5 minutes for that purpose.
    Dr. Asplund, has your organization discussed H.R. 921 with 
any medical malpractice insurers, and if so, what are their 
thoughts on the need to clarify lines of jurisdiction when a 
team physician or trainer is providing care for an athlete 
outside the state which they are licensed or insured?
    Dr. Asplund. Thank you for the question. A group of 
colleagues from the American Medical Society for Sports 
Medicine contacted 20 of the Nation's largest medical 
malpractice providers and asked them the question, would you 
cover a team physician practicing across state lines?
    Approximately 25 to 30 percent said that they would 
regardless of the place where care was covered, 45 to 50 
percent said it would depend, and 30 percent outright said that 
they would not cover that medical professional who provided 
that care outside of the state. So there is a potential for 
anywhere from 30 to 80 percent of medical providers who may not 
be covered by their malpractice, simply for traveling with 
their team and doing their job.
    Mr. Pitts. Thank you.
    Dr. Reiner, you mentioned in your testimony that all 50 
states have passed legislation, including the liability 
protection for citizens that use a defibrillator on someone 
during the course of an apparent medical emergency, and for 
businesses that have defibrillators installed for such 
purposes. Can you speak to how these laws vary and the impact 
such variation is having on increased deployment of lifesaving 
devices? And how would H.R. 4152 lead to more widespread 
deployment, and how many lives could they save?
    Dr. Reiner. Mr. Chairman, in Pennsylvania, for instance, if 
a business wants to institute an AED program, they can do so, 
but they are required to train their employees in the use of 
the device.
    Mr. Green, in Texas, there is no such training requirement. 
In Virginia, there are no requirements at all. So if you want 
to purchase a defibrillator for your coffee shop or your 
hardware store, you can buy one on Amazon and put it on the 
wall.
    So the essential problem is that although all states have 
enacted some form of legislation, the legislation differs from 
state to state. So if you are a national corporate entity that 
wants to do business around the United States, you have the 
problem of getting 50 different state laws correct. And they 
differ just enough to create an uncertainty in your mind that, 
if I don't get this right, then this is my problem.
    Imagine if you have a hotel and your state requires a 
trained employee on duty 24/7, and that night someone dies in 
your hotel and somehow the resuscitation doesn't go well. Well, 
now, that is potentially your problem. And the owner of the 
hotel might say, gee, it might have been better for me just not 
to have a defibrillator at all.
    So simply what this bill does is decouple all of the state 
provisions, training, supervision. If the states find an 
interest in those, that is great. But it just decouples those 
different training and supervision requirements from liability 
protection. If you have a working defibrillator that is kept in 
good order, you are protected from liability.
    Mr. Pitts. Thank you.
    Dr. Gregg, does the training OB-GYNs receive in genetics 
prepare them to interpret cell-free DNA prenatal screening 
results and communicate them effectively to patients?
    Dr. Gregg. I think this is the fundamental problem and 
probably what brings this bill to this body today. The 
obstetrician, gynecologist can certainly read a report where 
the report says normal and can read a report that says the 
patient has an abnormal test result. What follows is a detailed 
discussion on post-screening test results in the context of 
what does an abnormal test result really mean.
    Patients have taken that test result to mean that they 
definitely have a child that has Down Syndrome, and in some 
cases due to time constraints, fear has led them in directions 
that, as we have heard through the lay press, were directions 
that weren't what they would have expected.
    The problem, then, becomes in understanding that this is a 
screening test and what types of tests need to follow. In 
addition, understanding the positive and negative predictive 
value of the results at hand.
    Mr. Pitts. The chair thanks the gentleman. My time is 
expired. The chair recognizes the ranking member, Mr. Green, 5 
minutes for questions.
    Mr. Green. Thank you, Mr. Chairman.
    Dr. Trautman, we appreciate you joining to discuss the 
Title VIII nursing workforce programs. Title VIII programs have 
long enjoyed bipartisan support, and I am glad that it has 
continued with the introduction of H.R. 2173. The Title VIII 
Nursing Workforce Reauthorization Act by Representative Capps 
and Joyce, like many, I am concerned about the nursing shortage 
facing the U.S. and baby-boomer generations further 
exaggerating the great need for more healthcare providers.
    According to a report, the United States registered nurse 
workforce report card and shortage forecast published in the 
American Journal of Medical Quality in January of 2012, the 
shortage of registered nurses is projected to spread across the 
country to 2030 with the most intense shortages in the South 
and the West. I understand that one of the contributing factors 
in the shortage of nursing facilities. In fact, in 2012, 
nursing undergraduate and graduate programs turned away 80,000 
qualified applicants due to the lack of capacity.
    Doctor, could you elaborate on the difficulty in attracting 
students and professionals entering in the nursing faculty 
workforce?
    Ms. Trautman. Yes, thank you, Chairman. That is a very good 
question. And I want to thank you, again, for the support that 
has occurred over the decades that has allowed us to attract 
individuals to nursing programs.
    We have a strong desire to continue to advance those who 
are interested in not only the sciences but in caring for 
individuals to join the nursing profession. And we have done 
more with respect to these programs and recognizing that it is 
important to get to our youth earlier and speak to them about 
the profession, educate them.
    Title VIII funding, as you know, has been targeted 
recently, some of the advance practice work in serving the 
underserved areas. As you mentioned, it is correct that the 
nursing workforce, like the American public is aging, so while 
our past efforts have been successful, we must do more. A part 
of doing more, which Title VIII supports, is advancing doctoral 
education for nursing because we need doctorally prepared 
nurses to be faculty to teach the future nurses. It is an 
extraordinary profession, and we will continue to work with our 
colleagues in Congress and outside to educate others about the 
benefits of being a member of the nursing profession.
    Mr. Green. OK. Since we had so many applicants, qualified 
applicants who couldn't get in, does this legislation help in 
that lack of capacity?
    Ms. Trautman. Yes, it does. It helps in two regards. The 
problem is primarily related to either clinical placements and/
or faculty. Although, again, there is regional variation, some 
areas of the country have no problem. But in those areas that 
do, Title VIII helps support, as well as some other programs, 
but it helps support, again, preparing doctorally prepared 
faculty. And the clinical placements are not a part of Title 
VIII, but the nursing community and other stakeholders 
recognize the importance.
    The nurse managed clinics, though, which are in Title VIII, 
do provide an opportunity for additional clinical settings, and 
that will help us accept more students.
    Mr. Green. OK. Great, thank you.
    We also have all heard about the difficulty in accessing 
maternity care services in certain areas and where there is 
certain populations. It is surprising that we do not have good 
data to understand the problem.
    Dr. Breedlove, what do we know about the existing shortage 
in maternity care providers?
    Dr. Breedlove. We know there is an increasing shortage of 
OB/GYNs graduating from residency programs. And ACOG has 
supported data on the critical workforce shortage of OB/GYNs, I 
believe, in their testimony. We also know that 40 percent of 
counties in our country have no maternity care provider, 
whether that be an OB/GYN or a midwife. So it is astounding 
that so much of the geographic region of our country can 
provide services through the National Health Service Corps 
through primary care providership, which both these professions 
are a part of. However, the specialty they provide often is not 
identified in the primary care shortage definition. So a 
physician, OB, or midwife may go to one of these primary care 
shortage areas but not be able to deliver the services they are 
uniquely trained for.
    Mr. Green. OK.
    Will H.R. 1209, Improving Access to Maternity Care, help us 
collect that information?
    Dr. Breedlove. Absolutely. This directs HRSA to create 
definitions and collect data that can help us place 
particularly new graduates in these professions and setting 
where they are most needed.
    Mr. Green. OK.
    Thank you, Mr. Chairman. I yield back.
    Mr. Pitts. The chair thanks the gentleman and now 
recognizes the gentleman from Illinois, Mr. Shimkus, for 5 
minutes for questions.
    Mr. Shimkus. Thank you, Mr. Chairman.
    Welcome. This is a great panel, great issues. The challenge 
of health care is apportionment of costs because everyone is 
really there to serve the public. And it is just a great aspect 
of being on this committee. I just have two--I think, Dr. 
Reiner, so in the 108th Congress, we passed the Adam's Memory 
Act, which allowed emergency auxiliary defibrillators to be 
placed throughout in public areas. And it was based upon an act 
of young boy who got hit in the chest with a baseball at a 
diamond and went down. And just, fortunately, there was a 
policeman there and had one in the truck of the car. And that 
caused us to move a year or two later to help place these 
throughout open-access areas. And they have changed quite a bit 
since technologically. So I think a good way to really kind of 
reinforce the language of this bill is to just have one here 
because they tell you what to do. It is like: Open the case; 
grab these little wires; put them here; press start. Right? So 
that is what you basically need, to be able to follow 
instructions and listen to them to use one of these auxiliary 
emergency defibrillators today. Isn't that correct?
    Dr. Reiner. That is right, sir. The devices were really 
made to be used by people with no training. And the favored 
study that I point to is a study that compared sixth grade 
kids, basically 12-year-olds, to trained paramedics. So they 
set up a mock cardiac arrest. And they told the kids outside 
the room--who had never seen a defibrillator--that all you have 
to do is open it because, as you said, there are audio prompts 
that talk you through. And, importantly, the device cannot 
deliver a shock to a person who would not benefit from it. So 
they compared 20 kids to 20 paramedics. And, obviously, the 
paramedics knew how to do it. And the paramedics beat the kids 
by only about 20 seconds, 20 seconds. Every kid could do it. 
Every kid did it properly. Every kid did it right the first 
time.
    But the laws are confusing, and they are intimidating. I 
travel through O'Hare from time to time. And signage on the 
defibrillators is terrifying. The signage says ``to be used 
only by trained responders.'' Well, why should it say that? The 
devices are designed to be used by anyone, trained or 
untrained. It says that because there is a piece of Illinois 
law that makes that necessary.
    So all that this bill says is if you have a working 
defibrillator and it is used with good intent to try and save 
the life of somebody, that the owner of the defibrillator is 
protected, as is the Good Samaritan. It doesn't change the 
requirements that some States may have for training or 
supervision. It simply says that whatever the State rules are, 
if you are using it with good intent and you have a working 
device, everyone is protected.
    Mr. Shimkus. Excellent. Thank you.
    And I will just finish up with Dr. Gregg. And I appreciate 
this bill too. There is going to be a continued debate, I mean, 
between those who consider ourselves pro-life and believe life 
begins at conception and should be protected and then the 
challenges that we face under medical ethics, under genomic 
testing, and then decisions that are made because of that which 
may not sometimes--as you pointed out, we need to make sure 
that they are an accurate as possible description to inform the 
family of what may or may not be. If you want to comment on 
that, you can. That is a challenge that I think the healthcare 
community has to work on.
    Dr. Gregg. Sure. Let me just say that noninvasive prenatal 
screening, or NIPS, has the best test metrics for screening 
available today, better than anything we have used over the 
last 30 years, the best positive predictive value, negative 
predictive value, sensitivity, and specificity. In a New 
England Journal of Medicine paper published last spring, this 
best testing metrics was confirmed across all reproductive age 
groups, so not just what is classically defined as advanced 
maternal age patients, but all reproductive age groups.
    Having said this, it is imperative that patients and the 
providers understand that it is still a screening test and that 
there is a need for follow up.
    As far as women and their reproductive choices, I will say 
that the American College of Medical Genetics and Genomics has 
as a fundamental ethics tenet that counseling is performed in a 
nondirective fashion. And screening takes place today. This is 
not adding screening to a healthcare system that doesn't 
already have it, but it is trying to refine the educational 
piece. And, to me, that is what this bill does. It brings the 
educational piece to the forefront, not screening or not what 
women do with the screening.
    Let me say that the false positive rate with this 
particular test is less than 1 percent--in fact, in some 
studies, less than a half a percent. Other screening tests that 
have been in play now for now more than 25, 30 years have a 
false positive rate of 5 percent. That brings more people to 
the high-risk obstetrician with anxiety. And it brings more 
people potentially to diagnostic procedures that have some 
small but real measurable risk associated with them.
    So it is these educational aspects--I will just say one 
more thing, that this is becoming an increasingly complex 
testing environment as we move from common aneuploidies, Down 
syndrome being one of the most commonly talked about, to now 
other aspects of genomics. Other aspects where small pieces of 
DNA are deleted or duplicated, we are now able to identify 
these. These have a different positive and negative predictive 
value. And different things are done in response to these test 
results. And that is the educational piece, not sort of the 
simpler aneuploidy piece. I think that can be done in a 
paragraph. But it is how to keep in front of the evolution of 
this technology as it comes forward.
    Mr. Shimkus. Thank you.
    Thank you, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the ranking member of the full committee, 
Mr. Pallone, for 5 minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    I want to ask Dr. Trautman some questions and then, if I 
have time, Ms. Breedlove.
    Dr. Trautman, as you know, there are four advanced practice 
registered nurse roles: Nurse practitioner, certified 
registered nurse anesthetist, certified nurse midwife, and 
clinical nurse specialist. And I am interested in learning more 
about the role of the clinical nurse specialist. Could you 
explain the role of the clinical nurse specialist within the 
healthcare system, and what are the education and training 
requirements of clinical nurse specialists?
    Ms. Trautman. Thank you. As you have described, there are 
four advanced practice roles in nursing. The clinical nurse 
specialist is a role that is focused on a specialty, so a 
specialty area. The education for a clinical nurse specialist 
is a graduate degree. There are master's prepared clinical 
nurse specialists. And there are increasingly more doctorally 
prepared clinical nurse specialists.
    Mr. Pallone. OK. Now, the advanced nurse education grant 
program supports projects that develop and test innovative 
academic practice partnership models for clinical training and 
prepare primary care and advanced practice registered nurses to 
provide safe, quality care. Can you explain why this program is 
important to supporting the nursing workforce?
    Ms. Trautman. Certainly. Thank you. That is an excellent 
question. Academic practice partnerships are critically 
important. Gone are the days where the academic community can 
be separate from the practice community. As we as a Nation move 
forward in all of our efforts to improve health and health 
care, those partners and leaders and practitioners in practice, 
as well as our educators, must come together. And when we do, 
we benefit from the expertise of both of those very important 
disciplines to not only advance the profession, but we have had 
significant examples in the VA and in other settings of how we 
improve the experience of care for individuals and their 
families.
    Mr. Pallone. OK. Now, currently only three of the four 
advanced practice register nurse roles are eligible for this 
program. Could you elaborate on why it is important to include 
the clinical nurse specialists in the advanced nursing 
education program?
    Ms. Trautman. Certainly. The request for the change, the 
technical change in the reauthorization, is to allow us to 
standardize, as you have just mentioned, across all advanced 
practice nursing roles. And because the education, as I have 
shared, is similar, at graduate level and above, the 
competencies of the clinical nurse specialist, it will, by 
making this technical change, it allows us to create parity 
within all of the advanced practice roles.
    Mr. Pallone. OK. Thank you.
    So let me go to Ms. Breedlove, I wanted to ask some 
questions about the increase in maternal mortality. According 
to the CDC, the rate of maternal mortality has more than 
doubled in the past few decades, increasing from 7.2 deaths per 
100,000 births in 1987 to 17.8 deaths per 100,000 births in 
2011. Could you explain some of the reasons leading to this 
increase?
    Dr. Breedlove. Absolutely. Thank you for the opportunity to 
comment.
    Just this morning, the World Health Organization released a 
statement related to maternal mortality with a specific focus 
on issues related to pre and postnatal care. Most specifically, 
contributors include preeclampsia, lack of early diagnosis, 
post partum hemorrhage, and post partum infection. And when you 
think about the provider shortage challenging the ability for 
pregnant and postdelivery women to access immediate care for 
evaluation and referral to appropriate services, particularly 
in rural areas of our country, we know there are ways to 
address this. But we have to have providers who are accessible 
to the women who need that care.
    Mr. Pallone. And specifically how would the creation of the 
maternity care health professional shortage areas help reduce 
maternal mortality?
    Dr. Breedlove. By placing the most qualified providers of 
the unique services to women during the childbearing years in 
the areas where the need is more clearly defined. Right now, we 
have no ability to designate maternity shortage areas under the 
Health Service Corps definition, nor do we have any idea what 
that shortage area percentage might be. But we are aware from 
many stories and the poor outcomes that we are facing that 
health care is needed in those areas. So it would be a very 
simple way to introduce a new definition without changing those 
who already exist in the Health Service Corps.
    Mr. Pallone. Thank you very much.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentleman from Pennsylvania, Dr. 
Murphy, 5 minutes for questions.
    Mr. Murphy. Thank you, Mr. Chairman.
    And thank you to the panel for being here.
    Dr. Breedlove, let me continue on with some of those areas 
that Mr. Pallone was asking. With regard to the number of OB/
GYNs available, do we have any idea of the cost we would 
encounter from having them involved in this?
    Dr. Breedlove. There would not be additional costs. We are 
talking about providers who already qualify in the National 
Health Service Corps. So what we are talking about in this bill 
is enabling the right provider to be at the right place at the 
right time.
    Mr. Murphy. But it comes out of the funding for the medical 
corps, medical service that is existing. So does that mean it 
takes away from the current areas designated for shortage are 
primary care, dental care, and mental health care. So it would 
pull from the same amount of money, not additional?
    Dr. Breedlove. I am not exactly sure how to answer your 
question, other than these provider types which we currently 
have already fulfill the primary care opportunities.
    Mr. Murphy. I am just trying to think in terms of funding. 
There is a certain block of money. So we add them to that list, 
and then they all pull from that same list. Am I correct in 
terms of----
    Dr. Breedlove. I am not able to answer your question.
    Mr. Murphy. That is OK. All right. I just want to make sure 
because given that--I don't know what the cost savings would be 
and maybe you could get us some estimates. I know we went to 
Dr. Tom Insel here, the immediate past head of the National 
Institute of Mental Health. He said the current cost in our 
mental health system is $444 billion. That does not include the 
justice system, which is probably another $50 billion to $100 
billion, so half a trillion dollars per year. I just want to 
make sure we are not cutting other services for a group that we 
already have a massive shortage on. But I agree with you; we 
need to do this part too.
    Dr. Bermudez, welcome. I want to ask you about some of the 
aspects you brought out about eating disorders. And thank you 
for talking about that. You said that there are perhaps tens of 
millions of mostly women and some men who are affected by this. 
But in your testimony, you really emphasized the role of the 
family and the role of teachers to early identification and 
facilitate treatment. And toward the end of your testimony, you 
also said basically once an eating disorder takes hold, it is 
very difficult to reverse. The physical, emotional, and 
financial toll it takes on families is devastating.
    I am a psychologist by training so that you know. And in 
this, would you say--and I have seen this in other studies too, 
first of all--that a person who has an eating disorder can 
sometimes be so deeply involved in their psychiatric problems 
that they may resist treatment, true?
    Dr. Bermudez. True.
    Mr. Murphy. And under those circumstances, I read another 
study that says whether a person is involuntarily or 
voluntarily committed, that the outcome is good if you get them 
in treatment. It is much better if they are in treatment versus 
not in treatment. Is that correct?
    Dr. Bermudez. The data is clear on that.
    Mr. Murphy. OK. That is very important because sometimes 
people say, ``Well, we shouldn't involuntarily commit 
someone,'' but a person's mind may be so disturbed from the 
psychiatric illness, they are not cognitively aware of what 
they need. Further, some people with eating disorders may also 
be in the category of severe mental illness--schizophrenics, 
bipolar--so they have dual diagnoses on top of that, which 
makes it even more complicated. Am I correct?
    Dr. Bermudez. Absolutely.
    Mr. Murphy. So in this getting a family member involved, 
one of the big dilemmas that oftentimes occurs are HIPAA laws, 
where if you are treating someone with bulimia or anorexia and 
the issue is if they are not even going to their appointments 
and the family member doesn't even know their diagnosis or the 
treatment plan or where they are supposed to go or a change in 
appointment or the medication, very often providers say, by 
HIPAA laws, I am not even allowed to tell you information to 
facilitate treatment. Am I correct?
    Dr. Bermudez. So what I wanted to tell you is that I agree 
with that for adults. Now, that is part of the beauty of the 
opportunity here is that we are talking about a group of 
illnesses that generally presents in early adolescence and 
toward the latter part of adolescence. So the opportunity of 
the involvement of the family at a very meaningful level is 
clearly there, in spite of HIPAA laws and wanting to work and 
respect----
    Mr. Murphy. And during that time, a provider could 
certainly build a relationship with family members and 
understand who to trust, who is part of the team. So even when 
that person turns 18, for example, severe mental illness, 50 
percent of severe mental illness emerges by age 14; 75 percent 
by age 24. It is a critical time. They are no longer in school. 
They are past 18. HIPAA dynamics change. But from what I hear 
you saying, from your testimony, it is very important that, for 
the prognosis of that person, to keep the family member 
involved and find ways to make sure the HIPAA law doesn't get 
in way so that person can be involved. Would that be fair to 
state?
    Dr. Bermudez. That is a fair statement. And we have clearly 
shifted as a field in our understanding of eating disorders and 
moving away from really blaming families to really partnering 
with families. Families are critical as agents of change, not 
only to be aware early on and recognize in a timely fashion and 
bring their loved ones to care, which secures better outcomes, 
but I think, at the same time, to remain involved and continue 
the appropriate followup of these illnesses. As you know, from 
a psychological perspective, these are not things that change 
overnight. And, therefore, involvement of a support system--
i.e., the family--is critical in the success of treating these 
illnesses.
    Mr. Murphy. Thank you. I appreciate it.
    I yield back.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentlelady from California, Mrs. Capps, 
5 minutes for questions.
    Mrs. Capps. Thank you, Mr. Chairman.
    Thank you all for your testimony.
    And before I begin, Dr. Trautman, I would like to ask my 
first question of you. But I want to clarify, my colleague, Mr. 
Murphy, just raised an issue about funding for maternal-child 
health. And I just want to clarify this money is already being 
spent, to my colleague. Mr. Murphy?
    Mr. Murphy. I am sorry?
    Mrs. Capps. I just want to clarify something to you as I 
started because of the statement that you made regarding 
funding and allocations coming. This is money that is already 
now being spent. So there are no new providers being added or 
taken into the program for maternal-child health or for any of 
these nursing programs. It would just help to drill down within 
the existing programs for primary care designations to place 
these maternity care professionals where they are needed most.
    Mr. Murphy. I understand.
    Mrs. Capps. I just want to make sure----
    Mr. Murphy. Make sure we are robbing from Peter to pay 
Paul. We need to do more. Not less.
    Mrs. Capps. Exactly. So, Dr. Trautman, as you well know 
more than most of us, the Institute of Medicine's 2010 Future 
of Nursing Report is a landmark study for our profession. In 
it, the IOM laid out the current state of our nursing workforce 
and a roadmap of what needs to happen to prepare for the 
healthcare system of the future. Just last week, IOM's 
evaluation committee released a followup report reviewing the 
progress made on the Future of Nursing's recommendations. One 
of their recommendations was an increased focus on nursing 
workforce diversity. Title VIII Nursing Workforce Diversity 
program has supported increasing diversity. No one is arguing 
with this.
    So, Dr. Trautman, can you discuss what progress you see 
being made in nursing school enrollments regarding diversity? 
And how does the title VIII program, for all of us to 
understand it better, how does this program support this goal?
    Ms. Trautman. Thank you very much, Representative Capps. 
And thank you again for your fierce, strong commitment to the 
profession and what ultimately again is going to improve the 
health of our Nation. Thank you.
    The importance of diversity in all health professions, most 
certainly in nursing, is clearly understood. And title VIII has 
been very effective in helping us make improvements. In the 
years, looking at the data, from 2010 to 2014, we have improved 
the diversity of the nursing student population at all levels. 
At the baccalaureate, at the master's, and at the doctoral 
level, we are now at 30 percent of those students represent 
diversity. And while that is significant progress, it is not 
yet enough. Much more needs to be done. Some of that, most 
certainly, has within the past been directly related to title 
VIII and so will the future in these programs that are 
specifically targeted to help us not only to bring diverse 
individuals into the profession but, as you know, equally 
important that we are serving areas of the country most in 
need.
    Mrs. Capps. Yes.
    Ms. Trautman. So that is very important. We will also do 
other things beyond the law, the legislation, the changes that 
are proposed in the health professions. One example that you 
are aware of, I know, is this holistic review, which is an 
approach to looking at individuals who enter the profession, 
and it includes the individual as a whole. So we look at 
personal attributes, in addition to the academic metrics that, 
in the past, most health professions had solely relied upon.
    Mrs. Capps. I appreciate that. Thank you very much.
    Switching gears here, the goal of the Improving Access to 
Maternity Care Act is to better target the maternity care 
professionals to the communities that need it most. We know 
that prenatal care is so critical to pregnant women. But far 
too many women are not getting the recommended care, as you 
know.
    So, Dr. Breedlove, from your perspective as a certified 
nurse midwife--I am big supporter of that program, of course--
and an educator of midwives, what impact does proximity to 
prenatal care--that, I think, is something we really want to 
zero in on--and post partum care, maternity care have on the 
quality of a pregnancy for a woman and for the child?
    Dr. Breedlove. Thank you so much for your fierce support of 
our profession but also of access to prenatal care for women in 
our country. The issue really is around whether or not there 
can be adequate screening, which we have heard a little bit 
about today, whether there is an opportunity to assess women 
for potential risk, could be preconception, early pregnancy, as 
well as routine prenatal visits, which we know have a huge 
impact on the ability to diagnose early signs of preeclampsia, 
again, one of the problems of maternal mortality in our 
country. So it really is critical that if women are driving, 
you know, an hour and an hour and a half to find prenatal care, 
the likelihood of her having routine care and not missing 
visits, in addition to driving even longer than that for the 
birth facility is a very challenging thing for our families and 
really is clearly evident of some of the challenges that we 
have in all women in our country having in the prenatal care 
they need in a timely fashion.
    Mrs. Capps. Thank you very much both of you.
    And I yield back my time.
    Mr. Pitts. The chair thanks the gentlelady.
    I now recognize the gentleman from Texas, Dr. Burgess, 5 
minutes for questions.
    Mr. Burgess. Thank you, Mr. Chairman.
    And, Ms. Breedlove, forgive me, Dr. Bucshon had eclipsed 
you temporarily.
    Thank you, Doctor. You are so kind to me.
    Let me ask you a question because, I mean, because in your 
statement, your testimony, the suggestion that the maternal 
mortality rate has increased over the last 10 to 12 years' 
time, can you give us--I know you have been asked this 
previously--but can you give us the breakdown of where those 
deaths have occurred?
    Dr. Breedlove. We are collecting data under the guidance of 
CDC and the Maternal Mortality Commission. I attended an all-
day workshop at the ACOG annual meeting in San Francisco last 
year. It is very clear that not only is it based on prenatal 
and postnatal adequacy of care but also in systems of care 
within the hospital setting itself so that there are clearly 
defined clinical pathways and the management of women who are 
at risk of stroke, who are at risk for hemorrhage, and who are 
at risk for hypertension that is poorly managed. So there are a 
variety of projects that are interdisciplinary in nature going 
on around the country, developing we call them bundles for care 
that are collaborative in nature and codeveloped by all the 
disciplines within healthcare maternity services.
    So we know more about some of the challenges. But we also 
are keenly aware that if you have no one available to help 
diagnose and early screen and provide services prior to 
hospital admission, you have increased risk of those families.
    Mr. Burgess. I think that is the lesson we are in danger of 
overlooking when we have this discussion. The drop in maternal 
mortality, not just in this country but worldwide, was 
dramatic. And it occurred about 1937. It is important to me 
because my grandfather was an academic obstetrician at the 
Royal Victoria Hospital in Montreal. So he was part of that 
generation of doctors. These are doctors who practiced before 
antibiotics were widely available, before anesthesia was as 
reliable or survivable as it is today. Certainly the same could 
be said about blood banks. If you were fortunate enough to get 
a blood transfusion, the likelihood that you would survive it 
was certainly problematic before modern blood banking 
techniques emerged. And all of that coalesced around 1937, and 
the numbers dramatically dropped. So it is the presence of a 
trained attendant at birth that really probably has made more 
difference in maternal mortality than anything else, which is 
why your testimony intrigued me because we shouldn't forget the 
lessons of the past. So one of the things that this will do, 
with all deference to my friend from Pennsylvania, we are not 
taking his money, but we are trying to make certain that the 
money that is available in the primary care space goes where it 
is most needed. And the other thing that, interestingly enough, 
has been found over the years is that doctors tend to go or 
stay, rather, where they train. We are not terribly 
imaginative, as it turns out. And so we don't wander far from 
where it is that we took our--generally our residency training, 
perhaps subspecialty training. We tend to marry people who are 
in that area. And, as a consequence, we don't move from there 
unless our spouses give us permission. We tend to establish 
referral patterns: who you can trust, who you can't. So the 
degree of professional comfort is greatest in the area in which 
you train. It certainly was true for me and a great number of 
my cohort. The significance there is if we can bring to the 
medically underserved from a maternal standpoint, if we can 
bring practitioners to the medically underserved area, the 
likelihood that they will then populate those areas is higher 
than if we try to entice them with other inducements. So that 
is why this change in designation, although it is really not 
more money and we are not taking money from someone else, this 
is really an important thing to accomplish and why I am 
grateful that Representative Capps has partnered and that we 
are now having the legislative hearing, and we are working on 
getting it done.
    And, Dr. Gregg, I just want to say to you--and thank you 
for your testimony--we are struggling--I shouldn't say ``we'' 
are struggling. I am struggling--the committee seems, everyone 
else seems comfortable with letting the FDA have further 
regulatory ability over what are called laboratory-developed 
tests. And I am nervous about that. And people on this 
committee know that. But I was encouraged by some of your 
comments. A screening test is a screening test. No one takes 
someone to the operating room because of a screening test. You 
do the confirmatory test.
    Now, it is one of the idioms or one of the axioms of 
medicine that the confirmatory test will always be equivocal. 
But, nevertheless, you don't start a clinical action based on a 
screening test. So I appreciate your testimony on that very 
much.
    Mr. Chairman, thank you. I will yield back.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentleman from Oregon, Dr. Schrader, 5 
minutes for questions.
    Mr. Schrader. Thank you, Mr. Chairman.
    A question on the Cardiac Survival Act for Dr. Reiner. I am 
familiar with the use of the devices. And you indicated in the 
testimony some of the queries that anyone can pretty much use 
those. So the device discerns between like atrial fibrillation 
and ventricular fibrillation. So it is not up to the individual 
using the device?
    Dr. Reiner. That is right. And, in fact, there is really no 
way to deliver a shock to someone who doesn't have what is 
programmed into the system as a, quote, shockable rhythm, which 
is basically ventricular fibrillation or a very fast 
ventricular tachycardia. So if someone has just passed out, for 
instance, but they don't have one of those rhythms, you cannot 
actually deliver a shock.
    Mr. Schrader. OK. Good to know.
    For Dr. Gregg, I guess, on the cell-free DNA testings, 
screenings, those can be ordered by anybody, anywhere, any 
time? It is not through a physician?
    Dr. Gregg. It can be, these can be ordered by advanced 
practice nurses, yes, sir.
    Mr. Schrader. I mean, just laypeople.
    Dr. Gregg. No.
    Mr. Schrader. OK. OK.
    Dr. Gregg. You would have to have an MPI number.
    Mr. Schrader. And there is a concern that advanced practice 
nurses and physicians are unclear about how to interpret the 
results on these and, therefore, would advise people perhaps 
incorrectly?
    Dr. Gregg. On the pre-test side, there is a concern that 
patients may not and are not getting the adequate information 
to understand well the tests that they are having done and what 
that test is actually doing.
    Mr. Schrader. But if that is done in concert with the 
physician or advanced nurse practitioner, wouldn't that take 
care of that potential problem?
    Dr. Gregg. Again, the concern here is that the advanced 
practice nurse and/or physician does not have the depth of 
knowledge to completely understand what it is they are 
ordering. And then when results come back, this becomes an even 
more complex problem when the result is abnormal. When the 
result is abnormal, it is not simply reading an abnormality is 
here, and then there is an algorithmic next step. In 
interpreting abnormal results, there are many subsequent steps 
that should take place following.
    Obstetric care, as you know, is provided by people that 
range in their knowledge base. Midlevel providers provide 
obstetric care under the direction of physicians and so forth. 
Midwives provide obstetric care independently.
    Mr. Schrader. Would they be interpreting these results too? 
Is that what you are----
    Dr. Gregg. That is exactly right, that there is a wide 
variety of people interpreting these results.
    Mr. Schrader. OK. I understand.
    Then, I guess, for Dr. Breedlove, if I may, on the 
Maternity Care Act, my understanding from some of the 
information we have gotten is that primary care shortage areas, 
of which this is one, is already recognized. And the reason for 
this is to draw even more attention to it? Or I am not exactly 
clear why it is called that.
    Dr. Breedlove. Actually, no. The maternity care designation 
is not listed under the primary care scope. So what we are 
asking is that there be a definition within primary care.
    Mr. Schrader. OK. Great. I misinterpreted that then. And 
then, I guess, last but not least our nursing person here, talk 
a little bit about title VIII and how we can develop the next 
generation of nursing educators so critical to improving the 
number of nurses out there and why there is such a shortage.
    Ms. Trautman. Well, thank you very much. Title VIII has 
made a contribution already. We have improved significantly the 
number of doctorally prepared nurses. We now have had in both 
the research doctorate as well as the practice doctorate an 
increased number of enrollees that is unprecedented. What we 
now also need to do beyond quantity is also start earlier in 
the nurse's career. And so we have begun to create programs 
that facilitate earlier attainment of the knowledge and skills 
that are necessary for one to be competent and practice at the 
doctoral level. So it is a very exciting time and unprecedented 
in our Nation's history how the schools across the country are 
responding to assure that we have quality, high standards in 
education programs but that we facilitate ease of access and 
progression.
    Mr. Schrader. Thank you, Doctor.
    With that, I yield back, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentleman from Virginia, Mr. Griffith, 
5 minutes for questions.
    Mr. Griffith. Thank you very much, Mr. Chairman.
    I appreciate all of you being here today. I want to start 
with Dr. Asplund and just say I am a cosponsor of the bill. I 
think it is a good concept. My reading of the bill, and I think 
it goes in a good direction, but my reading of the bill 
indicates this would also apply not only to college and 
professional athletes, but it would also apply to those folks 
who have trainers with high school teams if they are competing 
in a nationally sanctioned or sponsored event, something that 
some national organization puts on. Is that your understanding 
of the reading as well?
    Dr. Asplund. Thank you for your question. So with the 
National Federation of High Schools being a sanctioning body of 
all high school athletes, it was the intent in our language for 
high school athletes to be covered by this bill as well. As 
many people are aware, there are far more high school athletes 
in America than at any other time. There are far more contests 
across state lines in the high school level. I live in Augusta, 
Georgia. We frequently cross the river to South Carolina pretty 
much weekly to do that and, as such, are crossing into a state 
where many of my colleagues do not have licensure. So, yes, 
high schools were intended to be included through the line with 
the national sanctioning body being the National Federation of 
High Schools.
    Mr. Griffith. I represent a district that borders four 
other states. And we have lots of high school competition going 
on. So I appreciate that. And I think that is a very good 
aspect of the bill. And I do appreciate that.
    Dr. Reiner, I have got concerns about the AEDs or the bill 
at least. I think that the Federal policy does need to be 
looked at just simply because the good news is the bill that 
was passed in 2000, one of the criteria was you notify the 
local EMS. I think that at the time that made a lot of sense. 
Today, those AEDs are in a lot more places than they were in 
2000. I think now it is impractical, in fairness, to notify 
local EMS for a lot of the small businesses that have these. 
Which EMS do they notify? Our area is all generally referred to 
where I live as the Roanoke Valley--but you have the city of 
Salem, the city of Roanoke, and Roanoke County, all of which 
are completely separate and have separate fire, police, and 
rescue squad folks. Some are paid. Some are volunteer. And so 
it might be difficult. I think we do need to look at that 
policy.
    But that being said, one of your examples kind of struck 
something that--my friends who are trial lawyers have raised an 
issue, and that is, it appears that when you look at the actual 
lawsuits, there are more lawsuits for not having the AED on 
premises than there are for having it but using it improperly. 
In fact, they can't find a whole lot of cases where that has 
been the case based on the existing law. And I was concerned 
because one of your examples was Walmart sells them, but they 
may not have them. And I actually think that is a bigger 
liability issue for whatever retail establishment, whether it 
be Walmart, Kmart, whomever, if they are selling the device but 
they don't have one charged up ready to go, that is probably a 
bigger liability issue than having one prepared and then having 
somebody who is doing the best they cannot use it properly. 
What do you have to say to that? Because I am trying to decide 
what to do on this bill, and I think both sides have some merit 
to their arguments.
    Dr. Reiner. So it is important to know that the bill leaves 
State laws alone. So any provision in a State law that the 
folks in that State feel is important as it pertains to 
training or registration or supervision, any of those 
provisions remains in force. All that this bill says is that if 
you have a working defibrillator, you are protected. So that 
entities like Walmart or Target can know that, look, they are 
going to do the best they can to get all these local ordinances 
right. But it is important for them to protect their community 
and their employees. And they are going to do the best they 
can. But they need to know that if their defibrillator is in 
working order, they are protected.
    So it doesn't create new law. It doesn't cost industry a 
cent. It doesn't cost the government a penny. But there are a 
lot of people who die from this. I see folks who come to my 
hospital in two conditions: One person has had an out-of-
hospital cardiac arrest, and they have been in close proximity 
to a defibrillator, and if they have been shocked pretty 
quickly, that person goes home to their family. The second 
patient has been someplace; it has taken a while for paramedics 
to get there. And they come to my place in a different 
circumstance, and they go to the morgue.
    Mr. Griffith. And I appreciate that. I think we want to get 
that policy right. I apologize for cutting you off. But my time 
is up, and I have to yield back.
    Thank you, sir. I appreciate your testimony today.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentlelady from Florida, Ms. Castor, 5 
minutes for questions.
    Ms. Castor. Good morning. Thank you, Mr. Chairman, for 
calling this hearing. And thanks to all the witnesses for being 
here today, especially for including H.R. 4153, the Educating 
to Prevent Eating Disorders bill, and H.R. 2713, the Title VIII 
Nursing Workforce Reauthorization Act. And I want to thank my 
colleague, Representative Lois Capps, for introducing the Title 
VIII Nursing Workforce Reauthorization Act. I am a proud 
cosponsor of this bill, which would reauthorization critical 
nursing workforce initiatives that are so desperately needed.
    And I hear from Dianne Morrison-Beedy, the dean of the 
College of Nursing at the University of South Florida in Tampa, 
and her excellent team there, some of the most passionate 
advocates for a strong nursing workforce. That is one reason 
why USF's College of Nursing was ranked as one of the top, the 
best graduate schools this year on the national ranking. I am 
very proud of them. Ensuring that we have qualified registered 
nurses and advanced practice nurses is critical to meeting our 
Nation's healthcare needs.
    I would also like to thank my colleagues and friends, 
Representative Renee Ellmers and Yvette Clarke, for introducing 
H.R. 4153, Educating to Prevent Eating Disorders. We filed this 
bill last week. It is an important bill that is aimed at 
reducing eating disorders with early intervention. 
Specifically, our bill would create a 3-year pilot initiative 
which would provide grants to schools, serving middle-school-
aged children to test the impact of providing students with 
interventions to prevent, identify, intervene, and manage 
eating disorders. We will help the pilot schools hire a 
healthcare provider who will administer the initiative. The 
schools participating in the pilot will submit a report 
detailing the process they used and the outcomes that they 
achieved. And it will be posted on the Agency for Healthcare 
Research and Quality Web site. There is a huge desire for 
accurate, up-to-date information on these challenges. And we 
have got to do more to prevent young people from suffering from 
an eating disorder. I am a mother of two teenage girls. And we 
know some of their friends who have struggled with these 
issues. And, oftentimes, families just don't know where to 
turn. There are not resources out there to help them deal with 
this. And as Representative Ellmers knows and has championed, 
you have got to intervene early. So I am grateful to all of 
you.
    I want to thank Dr. Bermudez for being here. And I would 
like to ask you, could you briefly discuss the different types 
of eating disorders and the serious health consequences they 
cause and whether or not we have seen a rise in the number of 
individuals impacted by an eating disorder?
    Dr. Bermudez. Sure. Glad to. Thank you.
    The main eating disorders that we are really talking 
about--anorexia nervosa, bulimia nervosa, and binge eating 
disorder--now, an important characteristic here to distinguish 
is that these are not fads. These are serious mental illnesses. 
You can't tell somebody who has an eating disorder by looking 
at them. And this is no longer an illness of Caucasian, 
privileged young women. This is an illness that affects all 
genders, all races, all ethnicities, all social economic 
statuses. And that is important to come at it from.
    Anorexia nervosa really constitutes a caloric restriction 
with loss of weight. These are people that when the disease is 
advanced, you can see them and you can recognize them as people 
who are alarmingly underweight.
    In the case of bulimia, these people often binge eat, which 
means that they consume a very large amount of calories in a 
short period of time and then feel very guilty and tend to 
induce some form of purging, most of the time by vomiting, 
inducing vomiting, or abusing laxatives. But there are other 
forms as well.
    And binge eating disorders are people who will binge 
recurrently and not engage in the compensatory mechanisms that 
include the purging behavior.
    So that is really what we are talking about, the 
opportunity for early identification and appropriate early 
intervention I think would save many, many, many, lives.
    Ms. Castor. Does the data show that the number of cases is 
increasing? Has it stayed level?
    Dr. Bermudez. So the data shows that the number of cases, 
number one, is increasing. But also that the presentation, the 
clinical presentations of the cases are also increasing. So we 
are seeing some what is called demographic drifts. We are 
seeing younger and younger children involved in eating 
disorders, as young as 7 and 8 years of age. That was unheard 
of a few years ago. More mature people in midlife, more women 
than men but men also in midlife, people from different races, 
and different ethnicities. So the protective factors that 
certain groups, like African Americans on Asian Americans or 
Hispanic Americans, had, those protective factors have eroded. 
And we are seeing more men represented across the spectrum of 
eating disorders, from anorexia to bulimia to binge eating 
disorder.
    Ms. Castor. Thank you very much.
    I yield back my time.
    Mr. Pitts. The chair thanks the gentlelady.
    I now recognize the gentleman from Indiana, Dr. Bucshon, 
for 5 minutes for questions.
    Mr. Bucshon. Thank you, Mr. Chairman.
    I was a cardiovascular and thoracic surgeon for 15 years 
prior to coming to Congress. So I want to comment primarily on 
the defibrillator issue.
    I recently helped distribute defibrillators to a couple of 
the counties for law enforcement and other businesses based on 
grants through the Lugar Center, former Senator Lugar, and our 
state has a grant program that helps with these type of things. 
And H.R. 4152 is a necessary step in furthering the 
dissemination of AEDs.
    Let me give you some personal experience. You commented, 
Dr. Reiner, about the two situations, that you see patients. 
And I have seen some also that have survived but have not 
survived in a state which is consistent with their pre-arrest 
state. I have specifically two patients that I ended up doing 
surgery on that have long-term brain injury that changed their 
lives dramatically and the lives of their family. And I have 
also been consulted on many patients who are in the ICU who 
were found to have coronary disease. But I ultimately ended up 
not treating that patient with surgery because of a very severe 
brain injury for which they never woke up essentially and did 
not recover.
    My two patients that had brain injuries had cardiac arrest 
at work. They had colleagues who were trained in BLS, basic 
life support, almost immediate CPR, no defibrillator available, 
5 to 10 minutes' time before a defibrillator became available. 
They survived but had injury. So this is really important.
    The other thing is--and I am going to ask you to comment on 
this--education of the public in the use and importance of 
these is critical. Employees and businesses, school children, 
as is pointed out by your study, it is very important. And I 
think for the future we probably need to start training school 
children, I would think, in their health class or something 
just about this because one of the biggest barriers to use, 
even if they are available, is fear. And I had a colleague of 
mine in an airport traveling to Washington who saw a person 
that had an arrest. There were people standing around. And he 
was a physician. And he said: Is there a defibrillator 
available?
    Of course, there was. And they used it. And that patient 
survived and, subsequently, had heart surgery and is normal. 
But had he not been there as someone who was available to 
overcome his fear because of his training, that may not have 
happened. So there are some barriers.
    So, in combination with availability, can you comment on 
what your thoughts are also on the importance of education and 
helping people overcome their fear?
    Dr. Reiner. I think that is a wonderful point, Congressman. 
The biggest issue is that people don't know that they can do 
this. We took a defibrillator out to the Verizon Center a 
couple years ago and filmed people as they walked down the 
street. We said: Hey, do you want to try and use a 
defibrillator? These were folks who had never used it. And they 
all could do it. They could do it very quickly. And the 
universal response: Oh, now I won't hesitate to use it if I 
ever have to.
    But this kind of uncertainty is not just for the general 
public, but it exists for corporations. They are afraid of 
being sued if they get it wrong. All this bill says is if you 
have a defibrillator that works, you are protected from 
liability. It is a simple bill. But once national organizations 
start educating people about the bill, then I agree; we need to 
educate everyone how to use these devices. Imagine having a 
fire extinguisher in the corner that had labels on it that said 
``for use by trained rescuers only.''
    Mr. Bucshon. Right. Right.
    Dr. Reiner. This is a fire extinguisher that talks to you.
    Mr. Bucshon. I agree with that. And that is why I have a 
real issue when trial lawyers, for example, have questions 
about people using things in good faith that save people's 
lives. And as a physician, my personal view is it is really sad 
that they would consider the financial benefits of suing people 
doing things in good faith. I really take offense to that, 
honestly.
    Dr. Gregg, you commented on your screening test. Are they 
better than an amniocentesis?
    Dr. Gregg. That is the point. An amniocentesis is the 
diagnostic test.
    Mr. Bucshon. I guess the reason I am asking is because at 
some point, when did the screening test supplant a more 
invasive study and become the standard?
    Dr. Gregg. Screening tests have been in place for more than 
30 years. The initial screening test was age alone. You will 
remember that age 35 was what rattled people's cage a little 
bit. Today, we recognize that the detection rate of age alone 
is not better than about 30 percent, just using age as a marker 
to go to the amniocentesis, as you are implying.
    Over the last decades, multiple other screening paradigms 
have been put into place. Today, with noninvasive prenatal 
screening, we are at a 98-percent detection rate from that 30 
percent for advanced maternal age. The followup test is the 
amniocentesis or the chorionic villus sampling.
    Mr. Bucshon. I guess my point is, at some point, a 
screening test becomes a standard of care for the test, and it 
supplants a more invasive test. My time is up.
    Dr. Gregg. An EKG doesn't replace what you do.
    Mr. Bucshon. Understood. Fair point.
    I yield back.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentleman from California, Mr. 
Cardenas, 5 minutes for questions.
    Mr. Cardenas. Thank you very much, Mr. Chairman.
    Thank you Doctor, Doctor, Doctor, Doctor, Doctor, Doctor, 
and all of the people here who are on the panel giving us their 
expertise and also my colleagues who have practiced as well. 
Thank you so much for shedding light on many of these issues.
    I am not a doctor, nor do I play one on TV. But I do care 
about the state of health care for our country and certainly 
now that a new chapter in my family's life has begun, as our 
daughter and her husband announced to us very nonchalantly that 
they are pregnant and our first grandchild is on the way. And 
that being the case, it leads to my first question having to do 
with prenatal screenings.
    An article late last year in Disability Scoop discussed 
some limitations of cell-free DNA prenatal screenings and 
suggested that the need for quality control needs to be 
improved. So my first question is to Dr. Gregg. Are you aware 
of any noninvasive prenatal tests that are regulated by the 
FDA?
    Dr. Gregg. No.
    Mr. Cardenas. No? OK. Some companies that make these tests 
have made claims about the high accuracy of their results or 
have made claims of very few false positives. Do any Federal 
agencies, such as the FDA, evaluate the claims that these 
companies are making to ensure that they are valid and 
supported by clinical data?
    Dr. Gregg. Currently, the FDA does not regulate this 
particular LDT.
    Mr. Cardenas. So those claims, where and how are they 
validated by third parties today?
    Dr. Gregg. By third parties?
    Mr. Cardenas. Yes.
    Dr. Gregg. I am not aware that they have been validated by 
third parties.
    There have been a significant number of peer-reviewed 
publications, large international trials, that validate the 
test metrics of these particular tests.
    Mr. Cardenas. Is that, do you feel that that suffices to 
ensure the public that that accuracy is in line with what the 
claims are? Or could we possibly enlist some kind of agency to 
go ahead and help us understand that accuracy and have more, at 
least more appreciation for that accuracy?
    Dr. Gregg. I am satisfied with the claims. I would say that 
an involvement of a Federal agency has value. We think there 
should be some oversight of these laboratories. CLIA and CAP 
currently provide this oversight. To me and to ACMG, one of the 
principal values of FDA oversight would involve labeling and 
marketing aspects. Clinical validity has been established for 
other types of prenatal screening for aneuploidy. These out-of-
the-box kits are probably regulated already but not molecular-
based testing in this way.
    Mr. Cardenas. Yes. What can Congress possibly do to assure 
the quality of these tests and that the tests are providing 
accurate and reliable information to providers and specifically 
pregnant women?
    Dr. Gregg. Well, the tests already provide accurate 
information. The laboratories themselves do currently have CLIA 
and CAP oversight. So that is already in place.
    Mr. Cardenas. So, right now, as you see it, Dr. Gregg, the 
environment is at least satisfactory for those assurances and 
understanding by not only the practitioners but also the 
patients?
    Dr. Gregg. No, I don't think it is satisfactory as far as 
it relates to practitioners or patients. And that is what H.R. 
3441 proposes to do, is put in place the educational 
initiatives so that they are detailed, indepth, and provide for 
a balanced and accurate information as the technology evolves.
    Currently, the technology has expanded beyond simple 
aneuploidies or common aneuploidies. As I said earlier, there 
are genomic changes that the technology is now being used to 
report screening results to. There is a need for more studies. 
And what we haven't talked about here is the underlying 
bioinformatics that follows what happens in the laboratory. The 
bioinformatics is a big piece. It is proprietary. And at some 
level, there probably needs to be some digging into that black 
box to make sure that we can validate the bioinformatic pieces. 
The companies sure can play a better role in disclosing the 
data that they have access to. I think they probably with a 
nudge would be willing to do that. But that is the type of 
oversight I think that needs to be in place on the laboratory 
side.
    Mr. Cardenas. One last point, if you will allow me, Mr. 
Chairman, I think that, unfortunately, proprietary information 
should not preclude us from making sure that what is going on 
out there is safe. And I think the government can play a 
protective role in protecting that proprietary information and 
bringing a better semblance of the environment for what is 
going on. Thank you so much.
    Thank you, Mr. Chair.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentleman from Florida, Mr. Bilirakis, 
5 minutes for questions.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it so 
very much.
    And I want to thank all of the sponsors of these really 
good bills.
    And thanks for agenda-ing the bill today, Mr. Chairman, 
having the hearing.
    Dr. Bermudez, the subject of eating disorders has been of 
great importance to several of my constituents. They have come 
to my office, both in D.C. but also locally. In October, I met 
with a group of advocates and heard their personal stories 
about how they or their loved ones were affected by these 
debilitating mental illnesses. What are some of the biggest 
challenges to identifying the early signs of an eating 
disorder?
    Dr. Bermudez. So eating-related pathology has an 
interesting characteristic, which is that people tend to not 
want to be discovered, right. So people in other areas of 
medicine want to seek the help and want others to know because 
that is the path to accessing help. In eating disorders, that 
is not the case. There is a lot of secretiveness in the 
clinical presentations of an eating disorder. So imagine a 14-
year-old, who learns about some of this on the Internet or may 
have some friends that have been affected. They talk about it, 
and she sort of begins to change her behavior through 
restriction and dieting and exercise. Well, she doesn't want 
anybody to know. That is one of the biggest challenges. This is 
not a child who is going to come to the parents and say: Mom, 
Dad, I am struggling; I have a problem. This is a child that is 
going to work hard not to be discovered. Hence, the importance 
of educating those in the front lines, those individuals that 
really, day to day, are interacting with children.
    Mr. Bilirakis. So which are they--I know you brought it up. 
I hate to interrupt. What should we look for, our loved ones 
look for, a parent look for? How can we detect this?
    Dr. Bermudez. We should look for change. We should look for 
signs that are telling us that something is really changing in 
the way this individual views themselves and is trying to 
project themselves and fit into the world around them. So when 
a young person starts to make self-deprecating statements about 
their size, their weight, their appearance, their desirability; 
when a young person starts to make excuses to not eat; when a 
young person is losing weight and stops participating in the 
normal activities that they had interest in and love, 
especially social aspects of them, then I think families need 
to sort of pick that up and become concerned and seek 
appropriate assessment.
    Mr. Bilirakis. Thank you. What are the most effective early 
intervention treatments?
    Dr. Bermudez. So formalizing the diagnosis becomes very 
important. So after a screening test that raises a level of 
suspicion or parental familial concern, a thorough assessment 
becomes really important. And that assessment includes looking 
for medical complications of the eating disorder behaviors and 
psychiatric complications of the eating disorder behaviors. 
Once that diagnosis is made, then you can sort of assess the 
level of severity: Where is the illness in the spectrum of 
severity of the illness? Because that may determine where we 
start the treatment process. And so the different levels of 
care, including medical stabilization, psychiatric 
stabilization, outpatient services that are age-appropriate, 
disease appropriate, intensive outpatient programs, partial 
hospitalization, residential treatment, and inpatient eating 
disorder specialized efforts are all in the armamentarium, and 
so that assessment helps guide the family in making the 
decision as to where is the appropriate place to start.
    Mr. Bilirakis. How many millions of people are affected by 
this disorder?
    Dr. Bermudez. About 30 million people, so about 20 million 
women and 10 million men at some point in their lives will be 
affected by an eating disorder in the United States.
    Mr. Bilirakis. Not just teenagers? All ages?
    Dr. Bermudez. All ages.
    Mr. Bilirakis. OK. Thank you.
    Thank you, very much, doctor.
    Dr. Asplund, thank you for your testimony, again, today. As 
an avid sports fan and an attorney, the issue of athletes being 
able to receive medical attention from their team physician 
while across State lines has been of interest to me for a very 
long time, even when I was in the legislature in Florida.
    You mentioned that merely exempting team physicians from 
the State's licensure requirements would not be sufficient 
because there is still a risk of a lawsuit. Can you explain how 
this complicates or hinders your ability to provide the best 
possible care for athletes?
    Dr. Asplund. Thank you for your question. I am not sure 
that the language of the bill or the law hinders an ability to 
provide health care. What it does, though, is it takes away 
protection for the athletic trainer or the physician after they 
have provided that health care in case something were to go 
wrong.
    As I testified earlier, many medical malpractice carriers 
tie that malpractice coverage to that licensure link. And so of 
the major malpractice carriers that we surveyed, almost 30 
percent said they wouldn't cover someone out of state 
regardless of licensure if they were out of state; 50 percent 
said they would cover them out of state only if they had a 
license in that second state; and there is 25 percent that 
wouldn't cover them regardless of what state they were in. So 
having the licensure piece overlooked or not married up will 
put physicians and athletic trainers and other providers that 
provide that care at potential great malpractice risk.
    Mr. Bilirakis. Teams are having trouble hiring physicians 
for these positions because of the risk of lawsuits?
    Dr. Asplund. I am not aware of any difficulty in hiring 
providers. It is nearly the provision of care and then the risk 
that that may involve.
    Mr. Bilirakis. Very good. Thank you so much.
    Dr. Asplund. Thank you.
    Mr. Bilirakis. I appreciate it.
    And I yield back, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentleman from New York, Mr. Engel, 5 
minutes for questions.
    Mr. Engel. Thank you very much, Mr. Chairman.
    Dr. Breedlove, before I came, Mr. Pallone asked you a 
question about the rate of maternal mortality. I am wondering 
if we could come back to that because I wasn't quite sure--we 
were listening on the TV. I wasn't quite sure what the answers 
are.
    The statistics I have is that it increased from 7.2 deaths 
per 100,000 births just in 1987, and it is more than double 
today, 17.8 deaths per 100,000 births in 2011. What is the 
reason for that? That is really alarming, or it seems alarming. 
What is the reason for that, and are other developed countries 
experiencing the same thing in mortality rates?
    Dr. Breedlove. I think from the data that is being 
collected by the CDC and the collaborative work groups related 
to maternal mortality in our country, we are finding that some 
of it does have to do with access to prenatal care and early 
assessment, the risk criteria during pregnancy, but some of it 
also has to do with care provision in the hospital systems 
themselves, whether that is the level of care provided, that 
the appropriate providers are in the right place for crisis 
management, or that those who are in hospital facilities have 
adequate training and resources to provide the provisions they 
need for critical high-risk patients.
    So, unfortunately, there are many variables, including the 
rising rate of cesarean section and the complications that come 
with that. So the effort that is occurring by many 
collaboratives, including ACOG, Society for Maternal-Fetal 
Medicine, AWHONN, the nursing organization, is to begin to 
implement care bundles that are hospital-based but also to 
define levels of maternal care which will have the right 
providers at the right facility for the need of the patient.
    Mr. Engel. Is part of it that older women are having more 
babies than they were 30 years ago, or does that have nothing 
to do with it?
    Dr. Breedlove. I am not sure I could answer that question.
    Perhaps my colleague, Dr. Gregg could, in terms of advanced 
maternal age and increased risk. Certainly, the increase in 
multiples can play a part in that, but I would defer to Dr. 
Gregg.
    Mr. Engel. OK.
    Dr. Gregg.
    Dr. Gregg. I actually co-chair the Florida maternal 
mortality committee, which is recognized as one of the most 
thorough maternal mortality committees in the country. We 
review every maternal death in the state that has specific 
criteria.
    Let me just say that a couple of things have happened. The 
way data on maternal mortality is ascertained has changed. So I 
heard somebody say there was a drop and somebody else say it is 
increasing. So all of that relates to who is obtaining the 
data. There were two entities within CDC both obtaining data, 
and now it is obtained across more states than ever before. So 
we are seeing what appears to be an increase in numbers are due 
to better ascertainment. And when that is compared worldwide, 
it looks like the U.S. does poorly. We have to remember that, 
worldwide, many countries don't collect any data or have very 
spotty data-collection capabilities. So I just want to put that 
out there.
    There are increasingly--women of advanced maternal age are 
getting--not 35; to me, it is much higher than that--are 
getting pregnant. They have other associated medical conditions 
that go along with advanced age.
    We have more women getting pregnant that in times past 
couldn't get pregnant because they had underlying medical 
conditions that did not support pregnancy well. We have 
interventions to help them get pregnant. So now we are seeing 
sicker patients enter pregnancy, and we are having to manage 
sick patients in a pregnancy that challenges their physiology, 
so----
    Mr. Engel. Thank you. It makes sense. Since I have you, let 
me ask you another question not related to this, but I 
understand that, as drafted, the patient and provider education 
campaigns, including in H.R. 3441, would need to be funded 
using existing resources. So has any analysis been done to 
determine what the cost of these campaigns might be or where 
the funding might be pulled from to finance them?
    Dr. Gregg. I am not aware of a financial analysis or 
financial analysis report and don't have the data on that. I 
apologize.
    Mr. Engel. OK. Thank you.
    Let me ask Dr. Reiner. In your testimony, you discuss the 
patchwork of laws that exist across 50 States with respect to 
liability for those who own or deploy automatic external 
defibrillators. And I would be interested to know what kinds of 
laws exist with regard to training and storage for these 
defibrillators. And the reason I am asking this is, while I 
take your points concerning liability, it occurs to me that we 
really should also be considering how we can enhance awareness 
and skill around these defibrillators. Obviously, they save 
lives. The usage rates might improve if defibrillators had to 
be stored, say, in permanent locations, and I know state laws 
vary. So if you could perhaps shed some light on how they vary 
in this respect. If you can----
    Dr. Reiner. Thank you for the question, Mr. Engle. I 
completely agree. Defibrillators work best when they are 
located in places where people congregate. And in a building 
like this, they are easy to find. But in other parts of busy 
cities, they are not. So part of the solution is education to 
the business community, community at large, educating people 
that these are easy to use, teaching kids--I love the idea to 
teach kids how to use these while they are in middle school and 
high school. But the other piece of this is removing the 
concern for liability, what I think is the unnecessary concern 
for liability that business owners do have for acquiring this 
technology. An AED cost about the same as a MacBook. It is 
cheap. This is decades-proven technology, but businesses are 
afraid of it.
    Mr. Engel. Thank you. I want to just say in concluding that 
I always like when there are a bunch of doctors in the room, so 
I feel if anything happens to me, we can get good care.
    Thank you all for testifying today. We really appreciate 
it.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the vice chairman of the subcommittee, Mr. 
Guthrie, 5 minutes for questions.
    Mr. Guthrie. Thank you very much. I appreciate all of you 
being here, but I want to focus on the Sports Medicine 
Licensure Clarity Act. That is the one that I am the sponsor 
of. I have a friend who is an emergency room physician, but he 
also is--I don't know if he is a team doctor or designated 
doctor. He is one of the doctors who travel with Auburn 
University. So I remember when I first came across this issue 
and got interested in it because of his experience, I said: Do 
you realize when you were at the BCS game in California and the 
Rose Bowl, as much fun as you were having, enjoying it, you 
were probably there with--you are unclear what your liability 
coverage would be if you are there?
    And I know one of my colleagues was--I don't know where 
they were going with it--but talked about being a lawyer. This 
isn't preventing opportunities for people to bring malpractice 
suits. It just makes sure you are covered, your insurance is 
covered, so it is not taking away anybody's ability to move 
forward. It is just making sure that doctors have the surety 
that they are being covered.
    And, also, I would just like to compliment Georgia 
Southern. I got to see you guys play a couple of years ago at 
Georgia Tech. I was there for a game. My son is there. And it 
was a closer game than some thought, and I think there was a 
controversial overturn that changed the game for Georgia Tech's 
behalf, and so a lot of fans get upset. But I remember walking 
out and going: Wow, Georgia Southern handled everything with 
class and a lot of--great program, a lot to be proud in that 
program. And I know you are going to Mobile, so you are going 
to have to go to Alabama without a license, right, practicing 
license.
    So that is the thing that we are trying to fix is that, you 
have got Western Kentucky University. You are playing Bowling 
Green. We are from Bowling Green. A lot of people think we are 
playing you guys, but we are Western Kentucky University, and 
we are going to Miami. And so I remember, last year, we 
actually went to the Bahamas Bowl, and it is amazing how many 
18- to 22-year-old young men do not have passports. So my 
office actually spent about a month trying to get everybody 
cleared to go. So when these games happen and it is a single 
game somewhere, you just can't do paperwork for every scenario 
that you are moving forward.
    So we just want to fix it. I think it just makes it 
smarter. I think everybody agrees that the team physician 
should be able to travel with the team--who knows the young men 
and women, and knows there may be a previous injury, what they 
are favoring. So instead of bringing a local physician there 
who doesn't know the history of each kid, it is important to do 
so.
    So I just want to ask you about the licensing process for 
sportsmen and professionals at the state level, and I know it 
would be very expensive and cumbersome and maybe even 
impossible, from the time you get a full bid until you are 
ready to play a ball game, to get licensed as a sports 
professional in a state. So what is kind of the process 
currently to be licensed as a sports professional in Georgia or 
any other state you are familiar with?
    Dr. Asplund. Mr. Guthrie, thank you for the question, and 
thank you for the support of our bill.
    You are correct. All 50 states and territories have 
differing requirements or processes to get a medical license. 
They generally look at your educational background, your 
malpractice claims, your continuing medical education, and then 
they issue a license. And while each state has sort of an 
underlying--they are all similar, but yet they are different. 
And so we have been to Alabama twice, and we are going to go 
back a third time. And had I known with enough time to get a 
temporary 14-day license--which, according to the State of 
Alabama, would cost $500 and would only last for 14 days. So on 
our initial trip to south Alabama, I could have paid $500, 
gotten 14 days of coverage. Two months later, when we went to 
Troy, I would have to pay another $500 to get 14 days of 
coverage and, now that we are returning to Mobile, another $500 
for this 14 days of coverage. So the temporary medical 
licensing may work on occasion when you know that you have--
when you know where you are going.
    Mr. Guthrie. But even if you are licensed there, there is 
no guarantee that your malpractice insurance recognizes that, 
right? That is what we are trying to clarify as well.
    Dr. Asplund. That is correct. And in a study that we talked 
about, malpractice carriers sometimes tie their coverage to 
your state of license. So each state is different. The process 
is costly, anywhere from $150 to $900 per state, and the 
timeframe on that is anywhere from 2 to 6 months until that 
paperwork can process.
    Mr. Guthrie. I want to get to a couple of other questions. 
So the bill doesn't restrict what you can do. You couldn't have 
gone to Troy hospital--or if you went to Montgomery or wherever 
you went or Birmingham--and performed an orthopedic surgery on 
a player that was hurt?
    Dr. Asplund. Correct.
    Mr. Guthrie. And it does restrict what you can do. So 
pretty much what we understand is on-the-field coverage?
    Dr. Asplund. Yes. It restricts it to on-the-field or in-
the-training-room type coverage. Any coverage that would occur 
in a medical facility, like a hospital or a clinic, would not 
be covered by this bill. It is typical stuff that you would do 
on the sidelines, in the training room, underneath the stadium.
    Mr. Guthrie. And why is that important? I have got just a 
couple of seconds, so I want to make sure. Why is it important? 
Because I know my friend was telling me that, you know, this 
person has a sore ankle; this person has done it before; if he 
hurts it again in the game, I know where to go. Why is it 
better to have--I guess I am answering it--but why is it better 
to have you with your team than just hire a local doctor to 
come cover the game?
    Dr. Asplund. Well, you highlight some of the concerns with 
the orthopedic issues, but we are seeing more and more young 
people with complex medical issues that are playing sports at 
the highest level. We have several asthmatics, several 
diabetics. We have two athletes who have no colon at all. And 
so there are complex medical issues that also come into play. 
The example I highlighted in my testimony of a spinal cord 
care, that process is practiced and rehearsed weekly with our 
team, and so if a new doctor were just to fall in on our team, 
there may be some miscommunication and a potential catastrophic 
injury if the neck was turned too soon or the back was turned 
too soon, rendering an athlete paralyzed.
    Mr. Guthrie. Are you employed by the school, or are you a 
private physician who travels with the team?
    Dr. Asplund. In this particular job, I am employed by the 
school and, hence, the state, and so would likely be covered by 
the Georgia Tort Act for performing my job, but when I was at 
Ohio State, I was a private practice contract.
    Mr. Guthrie. That is what my friend is. So you would be in 
the same situation, so not everybody is covered?
    I am running over time.
    Dr. Asplund. Correct.
    Mr. Guthrie. So it is important that we do this. And I 
appreciate being involved in it.
    Dr. Asplund. Thank you very much.
    Mr. Guthrie. Thank you.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the gentlelady from North Carolina, Mrs. 
Ellmers, 5 minutes for questions.
    Mrs. Ellmers. Thank you, Mr. Chairman.
    Again, thank you to our panel. This has been a very good 
subcommittee hearing, and the testimony has been wonderful.
    Dr. Bermudez, my questioning is primarily for you on our 
bill, on our eating disorders bill. And I would just like to 
ask you, you mentioned some of the myths that are associated 
with eating disorders. Can you just expand a little bit on what 
some of those myths are?
    Dr. Bermudez. Absolutely, and thank you. The reality is 
that eating disorders affect everybody. Everybody is at risk.
    Mrs. Ellmers. It is not just young females.
    Dr. Bermudez. Yes. If you have sons and daughters and if 
you have nieces and nephews and if you have grandchildren, they 
are all at risk in a societal context like ours. So the key is 
to take it away from the concept of choice, such as people 
choose to do this and this is about lookism, and take it into 
the context of this is a brain-based mental illness that 
profoundly affects the lives of not only the person who is 
identified with the illness but all of those affected and 
surrounding them as well. So that is one important shift.
    The other important shift is it is everybody's disease, 
every gender, every race, every ethnicity, every socioeconomic 
status, and so that no one is exempt because of who they are or 
what they look like. Those are, I think, the two important 
distinctions in dispelling the myths.
    Mrs. Ellmers. Now, as far as the most common eating 
disorders, I know we talked a little about anorexia. We talked 
about binge eating, which certainly, we know that that is part 
of the bulimia nervosa. Do you also consider, kind of along the 
line of the binge eating, those who are overweight and eating 
disorders associated with, maybe not the binge side of it but 
the eating--we know that we have kind of an epidemic in this 
country of obesity. Would you consider that part of this too or 
no?
    Dr. Bermudez. So I think we need to make some distinctions 
and highlight some similarities. I think the main distinction 
that is really important, I think, for the public to understand 
is that obesity is a real problem in our country, but obesity, 
in and of itself, is not a mental health illness.
    Mrs. Ellmers. Correct. And that would be one of the 
clarifications that would be made in the process of treatment?
    Dr. Bermudez. Absolutely.
    And so the other distinction that, to me, is really 
important, though, is that there are similarities. There are 
potential advantages here. There is potential value to better 
understand and address some of the issues with obesity because 
at the end of the day, in a stressful living situation, in a 
complex society likes ours, which really means that kids grow 
up with significant perceived stress, we tend to either eat too 
little or eat too much. The reality is that the relationship 
between our developmental stance, our constant concept of self 
or self-view, and our relationship with food are integrally 
tied. So as we learn about prevention, as we better understand 
how to do early intervention and teach the front line, parents, 
teachers, about what to recognize and the steps to take to 
secure more adequate next-step assessments, not only would we 
be protecting the most vulnerable, but we will learn a whole 
lot about the resiliency factors that keep those that stay 
well. So we may very well learn how to keep them well. And 
along those lines, we may very well learn what happens when the 
eating goes not just toward bingeing or purging or anorexia but 
simply eating too much and ending on the side of obesity.
    Mrs. Ellmers. Which leads to its own set of----
    Dr. Bermudez. Right.
    Mrs. Ellmers. You did mention that we have seen this in 
children as young as 7 or 8. So I have a very basic question. 
We are looking at middle school as starting the pilot program. 
Do you think maybe we should rethink that and maybe start it 
earlier?
    Dr. Bermudez. I think, based on the information we know, 
the demographics of eating-related pathology that we know 
today, middle school is a critical place to start.
    Mrs. Ellmers. OK.
    Dr. Bermudez. It is a vulnerable time of life. It is a time 
when, in the normal process of separation, individuation, kids 
are beginning to sort of find their own path. Peer influence 
and cultural influences sort of are highlighted. So it is 
really a vulnerable time of life. Statistically speaking, I 
think this is really where the payoff is.
    Mrs. Ellmers. The best----
    Dr. Bermudez. But we should not ignore the fact that 
younger children may also be affected.
    Mrs. Ellmers. Very good.
    And I have one last question with 30 seconds left. I want 
to target where we were going with the eating disorder and 
early intervention and possibly not being able to make the 
goals that we want and leading to some of the physical 
illnesses that end up happening. And I know, in your testimony, 
you basically said eating disorders are serious, potentially 
life-threatening conditions that affect a person's emotional 
and physical health. And it goes on to say that it could affect 
your organs, going on to heart, brain, other vital organs, 
retarded growth, osteoporosis, kidney problems, 
gastrointestinal dysfunction, and even heart failure.
    With that in mind--and one of our biggest challenges here 
in Washington is being able to put forward legislation with 
funding, moving forward so that we can actually show that there 
is going to be progress made into the future, which will 
eventually lead to fiscal savings when we are talking about 
things like Medicaid, Medicare coverage. Now, I know you are in 
eating disorders, and that is your specialty. But in your 
medical background, would you not say that if we could prevent 
this and keep this person healthier as a result of 
intervention, that this will help to save that person from 
having lifelong or end-of-life issues that would affect them 
and the cost of health care?
    Dr. Bermudez. Representative Ellmers, I think that is a key 
point of H.R. 4153. We are talking about not just saving lives 
and saving people from suffering, but this is an area in which 
an ounce of prevention is worth many, many, many pounds of 
cure. So these are expensive illnesses to treat. These take a 
significant toll on a very important sector of our society, 
which is our bright, otherwise healthy young people. And my 
sense is that what we will learn from this pilot program is 
that this is really where the future is to say: Let's get ahead 
of the curve here and not just continue to sort of do the 
remedial care that we have been focused on.
    Mrs. Ellmers. Yes. Focus on prevention.
    Well, thank you, again, so much.
    And, again, thank you to our panel. This has been a very, 
very good subcommittee hearing, but I have learned a lot as 
well. So thank you.
    Mr. Pitts. The chair thanks the gentlelady.
    We have a UC request?
    Mr. Guthrie. Thank you, Mr. Chairman.
    I do have a unanimous consent to add into the record or put 
into the record several letters, one from a coalition of 
healthcare providers supporting the bill, a letter of support 
from the American Association of Orthopaedic Surgeons, a letter 
of support from the American Medical Association, also from the 
American Osteopathic Association, from the National Athletic 
Trainers' Association.
    And I know we were discussing how this affects college 
football more than anything because of your role, but this is 
also one from Major League Baseball, the NBA, the NCAA, NHL, 
NFL, and the Olympic and Paralympic Committees. And I will ask 
unanimous consent they be put into the record.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. That concludes our time of questioning.
    I will have some followups, so I will send those to you in 
writing. We ask that you, please, respond promptly.
    I remind members that they have 10 business days to submit 
questions for the record. Members should submit their questions 
by the close of business on Wednesday, December 23.
    Really a very, very excellent hearing, very informative, 
very high-quality testimony. Thank you very much for coming and 
speaking to the subcommittee today.
    Without objection, the subcommittee stands adjourned.
    [Whereupon, at 12:26 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

               Prepared statement of Hon. Doris O. Matsui

    Thank you, Mr. Chairman for holding this hearing today. I 
look forward to hearing from each of the witnesses about the 
targeted public health problems we are aiming to address, and 
your thoughts on the best solutions to these challenges.
    In particular, I would like to highlight my support for the 
Nursing Workforce Reauthorization Act, and I thank my colleague 
Representative Capps for her leadership on that issue.
    Additionally, I would like to thank my colleague, 
Representative Ellmers for her work on the eating disorders 
legislation we are discussing today.
    As many as 30 million Americans suffer from an eating 
disorder, but only 1 in 10 ever receives treatment. Eating 
disorders can have severe consequences and medical 
complications such as heart failure, organ failure, 
malnutrition, and suicide.
    That is why I support the Anna Westin Act, which I have 
worked on with my colleague Representative Lance as well as the 
coauthors Representatives Deutch and Ros-Lehtinen.
    The Anna Westin Act would train doctors and teachers to 
recognize at-risk behaviors in order to ensure earlier 
diagnosis and treatment, and it would clarify mental health 
parity for eating disorders so that insurers can't pick and 
choose mental disorders to exclude from coverage.
    The pilot project in the legislation we are discussing 
today would test the impact of early intervention on the 
prevention, management, and course of eating disorders in 
grades 6 through 8. This is certainly a project that we should 
undertake.
    I encourage support of this legislation, and I also 
encourage the Committee to take our work on eating disorder 
prevention a step farther by reviewing the Anna Westin Act as 
well. Thank you.
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