    [Senate Hearing 114-768]
    [From the U.S. Government Publishing Office]

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

                                  ----------

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

                             DEPARTMENTAL WITNESSES

    Prepared Statement of the Association of Public Television Stations and
                        the Public Broadcasting Service
        On behalf of America's 170 public television licensees, we
    appreciate the opportunity to submit testimony for the record on the
    importance of Federal funding for local public television stations and
    PBS. We urge the Subcommittee to support level funding of $445 million
    in 2-year advance funding for the Corporation for Public Broadcasting
    (CPB) in fiscal year 2017, and pre-sequester level funding of $27.3
    million for the Ready To Learn program at the Department of Education
    in fiscal year 2015.
    Corporation for Public Broadcasting--fiscal year 2017 Request: $445
            million, 2-year advance funded
        Local stations and PBS are committed to serving the public good in
    education, public safety, creating a well-informed citizenry,
    preserving and promoting American history and culture, and other
    essential fields. Federal funding for CPB makes these services possible
    and is deserving of continued support. The overwhelming majority of
    Americans agree. In a bi-partisan Hart Research Associates/American
    Viewpoint poll, nearly 70 percent of American voters, including
    majorities of self-identifying Republicans, Independents, and Democrats
    support continued Federal funding for public broadcasting. In addition,
    polls show that Americans consider PBS to be the second most
    appropriate expenditure of public funds, behind only military defense.
        Over 70 percent of the Federal funding for CPB goes directly to
    local stations, resulting in a nationwide system of locally owned and
    controlled, trusted, community-driven and community-responsive media
    entities that form an incredibly successful public-private partnership
    providing unique and essential local public services.
    Education
        Local public television stations are America's largest classroom,
    meeting their communities' lifelong education needs by providing the
    highest quality educational content and resources on multiple media
    platforms and in person. Public television's exceptional content,
    available to nearly every household in America, has helped more than 90
    million pre-school age children get ready to learn and succeed in
    school.
        PBS, in partnership with local public television stations, has
    created PBS LearningMedia, an online portal where educators can access
    more than 35,000 standards-based, curriculum-aligned interactive
    digital learning objects created from public television content, as
    well as material from the Library of Congress, National Archives and
    other high-quality sources. More than 1.3 million teachers are
    registered to use PBS LearningMedia in K-12 classrooms serving millions
    of students throughout the country. In addition, twenty-eight thousand
    homeschoolers use PBS LearningMedia to enrich their curriculum in
    history, science, the arts and other subjects. Public television
    stations also operate virtual high schools that bring high-quality
    instruction in the most specialized fields to the most remote locations
    in our country.
        Through the American Graduate Initiative, CPB and public media
    stations are working to confront the dropout crisis in America's high
    schools by providing resources and services to raise awareness,
    coordinate action with local community partners, and work directly with
    students, parents, teachers, mentors, volunteers and leaders to lower
    the drop-out rate in their respective communities. In addition, by
    operating one of the most comprehensive non-profit GED programs in the
    country, public television stations have helped hundreds of thousands
    of second-chance students and adult learners get their high-school
    equivalency certificates and prepare themselves for meaningful work in
    a competitive marketplace.
        Public television stations have made it a top priority to help
    retrain the American workforce, including veterans, by providing
    digital learning opportunities for those looking for training,
    licensing, continuing education credits and more.
    Partners in Public Safety
        Public broadcasting stations throughout the country are also
    leading innovators and irreplaceable partners to local public safety
    officials--working in communities with schools, businesses and
    stakeholders to provide real-time emergency support for local law
    officials in times of crisis. In many communities, public broadcasting
    stations are the last locally-owned and operated media outlets--serving
    as a critical public safety life line.
        The Nation's digital presidential alert and warning system depends
    on the backbone infrastructure of local public television stations to
    deliver critical national messages. This same digital infrastructure
    provides the backbone for emergency alert, public safety, first
    responder and homeland security services in many states and local
    communities. Stations are partnering with their local emergency
    responders to customize and utilize public television's infrastructure
    for public safety in a variety of critical ways: equipping police cars
    with school blueprints when a crisis arises, providing access to 24/7
    camera feeds for a variety of security challenges, connecting public
    safety agencies in real time, and more. Local public television
    stations are also using their broadcast equipment to help send
    emergency alert text messages to cell phone subscribers through their
    providers--reaching citizens wherever they are, even when the power is
    out. Many local stations are serving as their states' primary Emergency
    Alert Service (EAS) hub for weather and AMBER alerts.
    Supporting an Informed Citizenry
        Public television strengthens the American democracy by providing
    citizens with access to the history, culture and civic affairs of their
    communities, their states and their country. Local public television
    stations serve as the ``C-SPAN'' of many state governments, providing
    the most remote corners of the country with access to the state
    legislative process, Governors' messages, court proceedings and more.
    As one of the only locally-owned and operated media remaining in
    America, public television provides more public affairs programming,
    local history, arts and culture, candidate debates, specialized
    agricultural news, and citizenship information of all kinds than anyone
    else in the media universe.
    Public Broadcasting is a Smart Investment
        All of this is made possible by the Federal funding to CPB which
    amounts to an annual cost of about $1.35 per year for each American. On
    average, Federal funding for CPB makes up approximately 15 percent of
    local television station's budgets. However, for many smaller and rural
    stations, Federal funding represents more than 30-50 percent of their
    total budget. This funding is particularly important to rural stations
    that struggle to raise local funds from individual donors due to the
    smaller and often economically strained population base. At the same
    time it is often more costly to serve rural areas due to the topography
    and distances between communities. As a result, public broadcasters,
    with their commitment to universal service, are often the only local
    broadcaster serving rural communities. For all stations, Federal
    funding is the ``lifeblood'' of public broadcasting, providing critical
    seed money to local stations that enables them to build additional
    support from state legislatures, private foundations and corporations,
    and ``viewers like you.''
        Public broadcasting creates important economic activity while
    providing an essential educational and cultural service. For every
    Federal dollar, local public media stations raise an additional six
    dollars in non-Federal funding, providing a strong public-private
    partnership and an impressive 6 to 1 return on investment. In addition,
    public broadcasting supports approximately 20,000 jobs, with the vast
    majority in local public television and radio stations in hundreds of
    communities across America.
    Two-Year Advance Funding
        Two-year advance funding is essential to the mission of public
    broadcasting. This longstanding practice, proposed by President Ford
    and embraced by Congress in 1976, establishes a firewall insulating
    programming decisions from political interference, enables the
    leveraging of funds to ensure a successful public-private partnership,
    and provides stations with the necessary lead time to plan in-depth
    programming and curriculum coordination with educational institutions
        Public television's history of editorial independence has been
    rewarded in unprecedented levels of public trust--for the eleventh
    consecutive year, the American people have ranked PBS as one of the
    most trusted national institutions. Advance funding and the firewall it
    provides between the development of content and extraneous interference
    and control is vital to maintaining this credibility among the American
    public.
        In addition, local public broadcasting stations leverage the 2-year
    advance funding to raise state, local and private funds, ensuring the
    continuation of this strong public-private partnership. These Federal
    funds act as essential seed money for fundraising efforts at every
    station, no matter its size, and since many state legislatures are
    part-time institutions that budget State funds on a 2-year cycle and
    relate state funding to Federal funding, advance Federal funding is
    essential to the success of this unique partnership
        Finally, the 2-year advance funding mechanism also gives stations
    and producers the critical lead time needed to partner with local
    community organizations and plan and produce high-quality programs. The
    signature series that demonstrate the depth and breadth of public
    television, like Ken Burns's The Civil War, take several years to
    produce. In addition, 2-year advance funding is essential to the
    creation of local programming over multiple fiscal years as stations
    convene the community to identify needs, recruit partners, conduct
    research, develop content and deliver services.
    Ready To Learn--fiscal year 2015 Request: $27.3 million (Department of
            Education)
        The Ready To Learn (RTL) competitive grant program uses the power
    of public television's on-air, online, mobile, and on-the-ground
    educational content to build the literacy and STEM skills of children
    between the ages of two and eight, especially those from low-income
    families. Through their RTL grant, CPB and PBS are delivering evidence-
    based, innovative, high-quality transmedia content to improve the math
    and literacy skills of high-need children via broadcast television, the
    Internet, mobile and other dynamic new technologies. CPB and PBS, in
    partnership with local stations, have been able to ensure that the kids
    and families that are most in need have access to these groundbreaking
    and proven effective educational resources. In addition to the content,
    CPB and PBS are creating new tools like a sophisticated progress
    tracking system that gives parents the means to measure student
    progress, in real time.
    Results
        RTL is rigorously evaluated for its appeal and efficacy so the
    program can continue to offer America's youngest citizens the tools
    they need to succeed in school and in life. Studies show that RTL
    content has a significant and positive effect on the educational lives
    of children who use it. Highlights of recent studies show that: use of
    PBS KIDS content and games by low-income parents and their preschool
    children improves math learning and helps prepare children for entry
    into kindergarten; \1\ use of RTL content has been associated with a 29
    percent improvement in reading ability in children grades K-2; \2\ and
    parents who used RTL math resources in the home became considerably
    more involved in supporting their children's learning outcomes.\3\ In
    combination, RTL games, activities and videos provide early learners
    with the critical math and literacy skills needed to succeed in school,
    and in the process, help level the academic playing field.
    ---------------------------------------------------------------------------
        \1\ McCarthy, B., Li, L., Schneider, S., Sexton, U., & Tiu, M.
    (2013). PBS KIDS Mathematics Transmedia Suites in Preschool Homes and
    Communities. A Report to the CPB-PBS Ready to Learn Initiative. Redwood
    City, CA: WestEd. McCarthy, B., Li, L., Tiu, M. (2012). PBS KIDS
    Mathematics Transmedia Suites in Preschool Homes. Redwood City, CA:
    WestEd
        \2\ Public Broadcasting Service (2012). KBTC Ready To Learn
    Initiative 2012 Summary Report, pp. 15,16.
        \3\ McCarthy, B., Li, L., Schneider, S., Sexton, U., & Tiu, M.
    (2013). PBS KIDS Mathematics Transmedia Suites in Preschool Homes and
    Communities. A Report to the CPB-PBS Ready to Learn Initiative. Redwood
    City, CA: WestEd. McCarthy, B., Li, L., Tiu, M. (2012). PBS KIDS
    Mathematics Transmedia Suites in Preschool Homes. Redwood City, CA:
    WestEd
    ---------------------------------------------------------------------------
    An Excellent Investment
        In addition to being research-based and teacher tested, the RTL
    Television program also provides excellent value for our Federal
    dollars. In the last 5-year grant round, public broadcasting leveraged
    an additional $50 million in funding to augment the $73 million
    investment by the Department of Education for content production.
    Without the investment of the Federal government, this supplemental
    funding would likely end.
    The Dangers of Consolidation
        The President's fiscal year 2015 budget proposes consolidating RTL
    into a larger grant program. APTS and PBS oppose this proposal as it
    would abandon the unique national-local partnership that has resulted
    in RTL's ground-breaking educational impact on kids nationwide,
    particularly those with limited access to other educational resources.
    The current model effectively uses an economy of scale to create high-
    quality television and online content at the national level and then
    distribute it through local stations who can tailor outreach to the
    specific needs of their communities. This model allows PBS and local
    stations to annually reach 80 percent of America's children ages 2 to 8
    through television and another 13 million per month online and on
    mobile apps. The national-local partnership has made RTL tremendously
    efficient and effective and consolidation or elimination of the program
    would severely affect the ability of local stations to respond to their
    communities' educational needs, eliminating the critical resources
    provided by this program for children, parents and teachers. RTL
    symbolizes the mission of public media and is a successful public-
    private partnership that leverages Federal funds to create the most
    appealing and impactful children's educational content that is
    supplemented by online and on-the-ground resources. Without the RTL
    program, millions of families would lose access to this incredible
    high-quality education content, especially the low-income and
    underserved households that are a particular focus of this program.
    Conclusion
        Americans across the political spectrum rely on public
    broadcasting--on television, on the radio, online, and in the
    classroom--because we provide essential education, public safety, and
    informed citizenry services that are not available anywhere else. And
    none of this would be possible without the Federal investment in public
    broadcasting. A 2007 GAO report concluded that these Federal Community
    Service Grants are an irreplaceable source of revenue for public
    broadcasting, and a 2012 study requested by this Subcommittee and
    conducted by an independent third party for CPB came to the same
    conclusion as the GAO: Federal funding for public broadcasting is
    irreplaceable.
        For all of these reasons we request that Congress continue its
    commitment to the highly successful, hugely popular public-private
    partnership that is public broadcasting by providing level funding of
    $445 million in fiscal year 2017 for the 2-year advance of the
    Corporation for Public Broadcasting and pre-sequester level funding of
    $27.3 million in fiscal year 2015 for the stand alone Ready To Learn
    Program.
                                     ______

                Prepared Statement of the National Public Radio
        Dear Chairman Harkin, Ranking Member Moran and Members of the
    Subcommittee: Thank you for this opportunity to urge the Subcommittee's
    support for an annual Federal investment of $445 million in America's
    public media system through annual appropriations to the Corporation
    for Public Broadcasting (CPB). With your support, the public radio
    system, consisting of some 950 locally managed, locally controlled and
    locally programmed stations, serves communities all across America. And
    these stations are as diverse as the communities they represent. Public
    radio is committed to being America's public radio, bringing the
    diverse and changing voices of Americans to the airwaves and the new
    platforms that so many Americans are using. We strive to create a more
    informed public, one challenged and invigorated by a deeper
    understanding and appreciation of events, ideas, and culture within the
    United States and across the globe.
        The public radio system, a uniquely American public service, non-
    commercial, media enterprise, includes stations in every State capitol
    and hundreds of American communities, large and small, urban and rural.
    Producers and distributors of public radio programming, including
    American Public Media (APM), Public Radio International (PRI), the
    Public Radio Exchange (PRX) and NPR are united by a commitment to the
    highest standards of journalist ethics. Every minute of every program
    broadcast to some 38 million Americans weekly is routed through the
    Public Radio Satellite System (PRSS), a content distribution utility
    owned by the public radio system.
        Partnerships and collaborations are integral components of the
    programming and service found in the public radio system. Available on
    air, online, and on new and emerging mobile platforms, public radio is
    expanding its ability to reach audiences. And as traditional media
    undergoes dramatic changes, public radio is positioning itself to serve
    the needs of a growing audience in a shifting media landscape and
    rapidly changing world.
        A clear example of these new adaptations to improve journalism and
    meet audience needs comes from the recently formed merger between St.
    Louis Public Radio and the St. Louis Beacon newspaper, the area's two
    largest nonprofit news organizations. This move combines newsrooms and
    significantly changes the face of independent local news in the region
    by providing more depth and perspective on issues and stories that
    impact the community. The consolidation creates an innovative model for
    a multiplatform news operation that results in more in-depth coverage
    of urban events and issues. St. Louis Public Radio's move to join
    forces and expand serves as an example of how public radio news
    organizations are adjusting to an ever-changing media environment that
    involves greater competition for consumers and financial support.
        This new merger is just one among a growing list of public
    broadcasters teaming up with other nonprofit news outlets to beef up
    their local and investigative journalism. In Denver, Rocky Mountain
    PBS, public radio station KUVO, and I-News, the Rocky Mountain
    Investigative News Network, merged to create a cross-platform news
    operation that could better cover Colorado. WWNO in New Orleans hired
    its first-ever news director last spring to expand its coverage of
    stories. Oregon Public Broadcasting is building a statewide news
    network with 40 to 50 small news outlets across Oregon. Lastly, Harvest
    Public Media, a reporting collaboration of public radio stations KCUR,
    KBIA, Iowa Public Radio, Nebraska Public Broadcasting, KUNC and WUIS,
    focuses on issues of food, fuel and field. Based at KCUR in Kansas
    City, Harvest covers these agriculture-related topics through an
    expanding network of reporters and partner stations throughout the
    Midwest.
        But the partnerships don't stop there for public radio. A recent
    collaboration includes Boston's WBUR and NPR joining forces to expand
    and re-launch the daily public radio show Here & Now as a two-hour
    national news program for audiences in the middle of the day. The
    program airs weekday afternoons and is aggressively updated to provide
    local audiences with live, updated news coverage during mid-day.
        Public radio's partnerships with public safety officials play a
    critically important role when natural or man-made disasters strike.
    Public radio stations provide essential and timely public emergency
    information, such as evacuation routes, shelter locations and severe
    weather updates. Effective emergency warnings allow people to take
    actions that save lives, and reduce damage and human suffering. Federal
    funding helps to bring crucial news and alerts to millions of
    Americans.
        Public radio's innovative partnerships also expand our public
    service mission by enabling radio reception to all Americans during
    local emergency situations. This year, 26 public radio stations based
    in Alabama, Florida, Louisiana, Mississippi and Texas are working with
    NPR Labs, the Public Radio Satellite System (PRSS) and the U.S.
    Department of Homeland Security/FEMA to demonstrate the delivery of
    emergency alerts to people who are deaf or hard-of-hearing. This is the
    first effort to deliver real-time accessibility-targeted emergency
    messages, such as weather alerts, via radio broadcast texts. Our hope
    is to expand the pilot over time to other regions of our country thru
    the use of radio equipment to reach people who are both deaf and blind
    and non-English speaking.
        In addition, many public radio stations provide critical services
    through partnerships with radio reading services. These long
    established centers are in every major market in the United States to
    provide millions of visually impaired persons the ability to function
    more independently in their communities.
        Music in America would sound very different without public radio.
    Local stations take creative risks, nurture new talent, and give
    emerging artists a chance to be heard. They celebrate traditional music
    genres like classical and jazz, and partner with local music
    organizations to take these art forms to new heights of performance
    excellence and new audiences. And they play a key role in their local
    music economies, sustaining and growing the careers of musicians by
    connecting them to local listeners. Across the country, more than 180
    local public radio stations have full-time music formats and more than
    650 stations air play music as part of their programming lineups.
        Mr. Chairman and Senator Moran, public radio is essential in
    providing news, information and cultural programming to America and
    connecting with audiences wherever they are. We're embracing America's
    changing demographics and using digital media to connect better, more
    quickly and in more diverse ways. Today's public radio isn't going
    away, it's going everywhere and we are working every day to earn the
    trust of the 38 million Americans who rely on us for news and insights
    that guide and inform. We ask for your continuing support in funding
    for stations that serve your communities, your constituents and
    America's Democracy.

        [This statement was submitted by Michael Riksen, Vice President--
    Policy & Representation, National Public Radio.]
                                     ______

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

        [This statement was submitted by Michael S. Schwartz, Chairman,
    Walter A. Barrows, Labor Member, and Jerome F. Kever, Management
    Member, Railroad Retirement Board.]
                                     ______

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

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

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

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

                           NONDEPARTMENTAL WITNESSES

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

        [This statement was submitted by Mary Pat Raimondi MS, RD, Vice
    President, Strategic Policy and Partnerships Academy of Nutrition and
    Dietetics.]
                                     ______

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

                     FIGURE 1: THE HEALTH RESEARCH CONTINUUM
    ------------------------------------------------------------------------

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

        [This statement was submitted by Dr. Lisa Simpson, President & CEO,
    AcademyHealth.]
                                     ______

          Prepared Statement of the Ad Hoc Group for Medical Research
        The Ad Hoc Group for Medical Research is a coalition of patient and
    voluntary health groups, medical and scientific societies, academic and
    research organizations, and industry. We appreciate the opportunity to
    submit this statement in support of enhancing the Federal investment in
    biomedical, behavioral, social, and population-based research conducted
    and supported by the National Institutes of Health (NIH).
        The Consolidated Appropriations Act of 2014 included a welcome and
    much needed increase for the NIH. However, this increase did not
    restore all of the funds cut by sequestration in fiscal year 2013 or
    the purchasing power NIH has lost over the past decade due to
    inflation. We hope fiscal year 2014 represents a first step toward
    restoring our Nation's preeminence in medical research.
        The Ad Hoc Group for Medical Research recommends that NIH receive
    at least $32 billion in fiscal year 2015 as the next step toward a
    multi-year increase in our Nation's investment in medical research. The
    Ad Hoc Group also urges Congress and the Administration to work in a
    bipartisan manner to end sequestration and the continued cuts to
    medical research that squander invaluable scientific opportunities,
    discourage young scientists, threaten medical progress and continued
    improvements in our Nation's health, and jeopardize our economic
    future.
        The Ad Hoc Group is deeply grateful to the Subcommittee for its
    long-standing and bipartisan leadership in support of NIH. We continue
    to believe that science and innovation are essential if we are to
    continue to improve our Nation's health, sustain our leadership in
    medical research, and remain competitive in today's global information
    and innovation-based economy.
    NIH: A Public-Private Partnership to Save Lives and Provide Hope
        The partnership between NIH and America's scientists, medical
    schools, teaching hospitals, universities, and research institutions is
    a unique and highly-productive relationship, leveraging the full
    strength of our Nation's research enterprise to foster discovery,
    improve our understanding of the underlying cause of disease, and
    develop the next generation of medical advancements. Approximately 84
    percent of the NIH's budget goes to more than 300,000 research
    positions at over 2,500 universities and research institutions located
    in every state.
        The Federal Government has an irreplaceable role in supporting
    medical research. No other public, corporate or charitable entity is
    willing or able to provide the broad and sustained funding for the
    cutting edge research necessary to yield new innovations and
    technologies of the future.
        Research funded by NIH has contributed to nearly every medical
    treatment, diagnostic tool, and medical device developed in modern
    history, from a new treatment for cystic fibrosis to an awareness
    campaign that resulted in a dramatic decrease in the number of infants
    lost to Sudden Infant Death Syndrome to a new vaccine to prevent
    cervical cancer. We are all enjoying longer, healthier lives thanks to
    the Federal government's wise investment in this lifesaving agency.
    Examples of recent clinical breakthroughs made by NIH-supported
    scientists include:
      --NIH-funded researchers have discovered a way to harness the body's
            own immune system to fight cancer. The promising results in
            both adults and children with leukemia lead Science Magazine to
            name Cancer Immunotherapy as the 2013 Breakthrough of the Year
            for all of science;
      --NIH scientists have developed new treatments for hepatitis C--the
            leading reason for liver transplants in the U.S.--that have
            shortened treatment times and produced cures in 85 to 95
            percent of patients, even those with advanced disease;
      --NIH-funded researchers found that certain molecules in urine can
            provide an early sign of kidney transplant rejection, a test
            that allows doctors to act earlier to protect transplanted
            kidneys;
      --An NIH-supported clinical trial demonstrated that an intensive
            early behavioral intervention delivered before the age of 2
            years can improve symptoms as well as normalize brain activity
            in some children with autism; and
      --NIH-funded scientists developed an innovative method to quickly
            identify antibiotics that can treat multidrug-resistant
            bacteria--and reveal how these bacteria-killing medications
            work.
        For patients and their families, NIH is the ``National Institutes
    of Hope.''
        NIH is the world's premier supporter of merit-reviewed,
    investigator-initiated basic research. This fundamental understanding
    of how disease works and insight into the cellular, molecular, and
    genetic processes underlying life itself, including the impact of
    social environment on these processes, underpin our ability to conquer
    devastating illnesses. The application of the results of basic research
    to the detection, diagnosis, treatment, and prevention of disease is
    the ultimate goal of medical research. Ensuring a steady pipeline of
    basic research discoveries while also supporting the translational
    efforts absolutely necessary to bring the promise of this knowledge to
    fruition requires a sustained investment in NIH.
        The research supported by NIH drives not only medical progress but
    also local and national economic activity, creating skilled, high-
    paying jobs and fostering new products and industries. According to a
    report released by United for Medical Research, a coalition of
    scientific advocates, institutions and industries, in fiscal year 2011,
    NIH-funded research supported an estimated 432,000 jobs all across the
    United States, enabled 13 states to experience job growth of more than
    10,000 jobs, and generated more than $62 billion in new economic
    activity.
    Stagnant Funding Threatens Scientific Momentum
        Despite the increase provided in the current year, over the past
    decade NIH has lost more than 22 percent of its budget after inflation,
    significantly impacting the Nation's ability to sustain the scientific
    momentum that has contributed so greatly to our Nation's health and our
    economic vitality. The leadership and staff at NIH and its Institutes
    and Centers has engaged patient groups, scientific societies, and
    research institutions to identify emerging research opportunities and
    urgent health needs, and has worked resolutely to prioritize precious
    Federal dollars to those areas demonstrating the greatest promise. But
    a continued erosion of our national commitment to medical research
    threatens our ability to support a medical research enterprise that is
    capable of taking full advantage of existing and emerging scientific
    opportunities.
        Perhaps one of the greatest concerns is the obstacle these
    continued cuts will present to the next generation of scientists, who
    will see training funds slashed and the possibility of sustaining a
    career in research diminished. NIH plays a significant role in
    supporting the next generation of innovators, the young and talented
    scientists and physicians who will be responsible for the breakthroughs
    of tomorrow.
        The challenges of maintaining a cadre of physician-scientists to
    facilitate translation of basic research to human medicine, ensuring a
    biomedical workforce that reflects the racial and gender diversity of
    our citizenry, and maximizing our Nation's human capital to solve our
    most pressing health problems will only be addressed through continued
    support of NIH.
    NIH is Critical to U.S. Competitiveness
        Our country still has the most robust medical research capacity in
    the world, but that capacity simply cannot weather repeated blows such
    as persistent below-inflation funding levels and cuts of sequestration,
    which jeopardize our competitive edge in an increasingly innovation-
    based global marketplace.
        Other countries have recognized the critical role that biomedical
    science plays in innovation and economic growth and have significantly
    increased their investment in biomedical science. Between 1999 and
    2009, Asia's share (including China, India, Japan, Malaysia, Singapore,
    South Korea, Taiwan, and Thailand) of worldwide research and
    development (R&D) expenditures grew from 24 percent to 32 percent,
    while U.S. R&D expenditures declined from 38 percent to 31 percent.
    While the U.S. currently leads the world in R&D spending, China's
    increasing investment in R&D is projected to close the gap and surpass
    the U.S. in total R&D spending by about 2022. The European Commission
    also has recently urged its member Nations to increase their investment
    in research substantially, recommending budgets of 80 billion Euro
    (equivalent to $108 billion) from 2014 to 2020, a 40 percent increase
    over the previous 7-year period.
        This shift in funding raises the concern that talented medical
    researchers from all over the world, who once flocked to the U.S. for
    training and stayed to contribute to our innovation-driven economy, are
    now returning to better opportunities in their home countries. We
    cannot afford to lose that intellectual capacity, much less the jobs
    and industries fueled by medical research. The U.S. has been the global
    leader in medical research because of Congress's bipartisan recognition
    of NIH's critical role. To maintain our dominance, we must reaffirm
    this commitment to provide NIH the funds needed to maintain our
    competitive edge.
    NIH: An Answer to Challenging Times
        The Ad Hoc Group's members recognize the tremendous challenges
    facing our Nation's economy and acknowledge the difficult decisions
    that must be made to restore our country's fiscal health. Nevertheless,
    we believe strongly that NIH is an essential part of the solution to
    the Nation's economic restoration. Strengthening our commitment to
    medical research, through robust funding of the NIH, is a critical
    element in ensuring the health and well-being of the American people
    and our economy.
        Therefore, the Ad Hoc Group for Medical Research recommends that
    NIH receive at least $32 billion in fiscal year 2015 as the next step
    toward a multi-year increase in our Nation's investment in medical
    research.
                                     ______

     Prepared Statement of the AIDS Alliance for Women, Infants, Children,
                                Youth & Families
        Dear Chairman Harkin Ranking Moran, and Members of the
    Subcommittee: AIDS Alliance for Women, Infants, Children, Youth &
    Families was founded in 1994 to help respond to the unique concerns of
    HIV-positive and at-risk women, infants, children, youth, and families.
    AIDS Alliance conducts policy research, education, and advocacy on a
    broad range of HIV/AIDS prevention, care, and research issues. We are
    pleased to offer written testimony for the record in opposition of the
    fiscal year 2015 budget proposal consolidating Ryan White Part D
    funding into Part C and in support of maintaining Part D of the Ryan
    White Program as part of the fiscal year 2015 Labor, Health and Human
    Services, Education, and Related Agencies appropriations measure. This
    testimony also has the support of the Elizabeth Glaser Pediatric AIDS
    Foundation.
    Ryan White Part D Funding Request
        Sufficient funding of the Ryan White Program is necessary to
    provide quality care for individuals living with HIV/AIDS. We thank the
    Subcommittee for its continuous support of Ryan White Part D Programs,
    providing $75 million to the program in fiscal year 2014. While the
    AIDS Alliance for Women, Infants, Children, Youth & Families
    understands that these are difficult economic times, we are requesting
    the Subcommittee to maintain its commitment to the Ryan White Part D
    program and restore its funding eliminated in the President's fiscal
    year 2015 budget proposal and increase Ryan White Part D funding by
    $9.9 million in fiscal year 2015.
    Ryan White Part D Background and History
        Over concerns with the increase in the number of pediatric AIDS
    cases, Congress first acted to address pediatric cases in 1987 by
    providing $5 million for the Pediatric AIDS Demonstration Projects in
    the fiscal year 1988 budget. Those demonstration projects became part
    of the Ryan White CARE Act of 1990 which today is known as Ryan White
    Part D and have served thousands of women, infants, children, youth and
    families. Since the program's inception in 1988, Part D programs have
    been and continue to be the entry point into medical care for women and
    youth and, in many communities or regions, Part D programs are the only
    perinatal clinical service available to serve HIV-positive pregnant
    women and youth when payments for such services are unavailable from
    other sources. Ryan White Part D programs have been extremely effective
    in bringing the most vulnerable populations into and retained in care
    and is the lifeline for women, infants, children and youth living with
    HIV/AIDS. The Part D programs are instrumental in preventing mother-to-
    child transmission of HIV and for ensuring that women, including HIV-
    positive pregnant women, HIV exposed infants, children and youth have
    access to quality HIV care. The program is built on a foundation of
    combining medical care and essential support services that are
    coordinated, comprehensive, and culturally and linguistically
    competent. This model of care addresses the healthcare needs of the
    most vulnerable populations living with HIV/AIDS in order to achieve
    optimal health outcomes.
        In 2012, Part D provided funding to 114 community-based
    organizations, academic medical centers and hospitals, federally
    qualified health centers, and health departments in 39 States and
    Puerto Rico. These federally, directly-funded grantees provide HIV
    primary care, specialty and subspecialty care, oral health services,
    treatment adherence monitoring and education services pertaining to
    opportunities to participate in HIV/AIDS-related clinical research.
    These grantees also provide support services which include case
    management (medical, non-medical, and family-centered); referrals for
    inpatient hospital services; treatment for substance use, and mental
    health services. Part D grantees also receive assistance from other
    parts of the Ryan White Program that help support HIV testing and
    linkage to care services; provide access to medication; additional
    medical care, such as dental services; and key support services, such
    as case management and transportation, which all are essential
    components of the highly effective Ryan White HIV care model. This
    model has continuously provided comprehensive quality healthcare
    delivery systems that have been responsive to women, infants, children,
    youth and families for two decades.
    A Response to Women, Infants, Children, and Youth
        The Ryan White Program has been enormously successful in meeting
    its mission to provide life-extending care and services. Yet, even
    though we have made significant progress in decreasing HIV-related
    morbidity and mortality, much work remains to be done. While accounting
    for less that 6 percent of Ryan White direct care dollars (minus ADAP
    and Part F), Ryan White Part D programs have been extremely effective
    in bringing our most vulnerable populations into care and developing
    medical care and support services especially designed to reach women,
    children, youth, and families. Part D funded programs played a leading
    role in reducing mother-to-child transmission of HIV-from as many as
    2,000 babies born HIV positive in 1990 to roughly 200 cases in 2010
    through aggressive efforts to reach out to pregnant women. Appropriate
    funding is critical to maintain and improve upon this success, as there
    are still approximately 8,000 HIV-positive women giving birth every
    year in the United States that need counseling, services and support to
    prevent pediatric HIV Infections. According to the CDC, youth account
    for 39 percent of all new HIV infections in the U.S. As of 2010, one in
    four new HIV infections occur among young people ages 13-24. Most new
    HIV infections in youth (about 70 percent) occur in gay and bisexual
    males, most of whom are African Americans. Of the new HIV infections
    among youth, 2,100 are among young women; two-thirds of these are among
    young African American women. Ryan White Part D programs are the entry
    point into medical care for many HIV positive youth and leads the
    Nation's effort in recruiting and retaining HIV positive youth to
    comprehensive medical care and support services. According to the
    Health Resources and Services Administration, more than 37 percent of
    women receiving medical care in Ryan White Programs do so through Part
    D. Additionally, Part D provides medical and supportive services to a
    large number of women over 50 who are heading into their senior years
    as HIV survivors which is a testament to the high standard of care
    provided to Ryan White Part D programs. Support and care through the
    Ryan White Part D program was and continues to be funding of last
    resort for the most vulnerable women and children, who often have
    fallen through the cracks of other public health safety nets. Full
    implementation of the Affordable Care Act with continuation of the Ryan
    White Program will dramatically improve health access and outcomes for
    many more women, infants, children, and youth living with HIV disease.
    Proposed Consolidation
        The medical and supportive services provided by Ryan White Part D
    are unique and are not currently being provided by other parts of the
    Ryan White Program, including Ryan White Part C. These services are
    uniquely tailored to address the needs of women, including HIV positive
    pregnant women, HIV exposed infants, children and youth living with
    HIV/AIDS. The proposed consolidation of Part D funding into Part C in
    the Federal budget would eliminate a strong safety net for our most
    vulnerable populations and weaken the systems of care Part D programs
    have created and invested in for more than 25 years. Furthermore, the
    loss of Part D funds in some community areas would profoundly impact
    access to comprehensive HIV care and treatment for women, infants,
    children and youth. Many of the population served by Part D will be
    lost or never enter into care. We will not make progress in ending HIV/
    AIDS in this country without supporting all of the Parts of Ryan White.
    Conclusion
        These are difficult economic times, and we recognize the
    considerable fiscal constraints Congress faces in allocating limited
    Federal dollars as well as the need to reduce administrative burdens
    associated with the overall operational aspects of Ryan White programs.
    However, it is unclear how the proposed consolidation of Part D funding
    into Part C of the program will be implemented to ensure the
    continuation of the delivery of life-saving HIV/AIDS care and treatment
    to the most vulnerable populations without destabilizing existing
    models of care created to address the unique needs of these
    populations. Without the Ryan White Part D program, many of these
    medically-underserved women, infants, children and youth would not
    receive the vital primary care and support services traditionally
    provided to them.
        The AIDS Alliance for Women, Infants, Children, Youth & Families
    respectfully requests that the Subcommittee consider this written
    testimony for the record as you develop your fiscal year 2015
    appropriations bill. Thank you.

        [This statement was submitted by Dr. Ivy Turnbull, Deputy Executive
    Director, AIDS Alliance for Women, Infants, Children, Youth &
    Families.]
                                     ______

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

        [This statement was submitted by Carl E Schmid II, Deputy Executive
    Director, The AIDS Institute.]
                                     ______

                     Prepared Statement of The AIDS United
        I am Ronald Johnson, Vice President of Policy and Advocacy at AIDS
    United writing in reference to HIV funding at the Department of Health
    and Human Services, on behalf of the 32 organizational members of our
    Public Policy Committee and our over 90 programmatic directly funded
    organizational grantees all of whom are many of the leading AIDS
    Service Organizations across the Nation. AIDS United is a national
    organization that seeks to end the AIDS epidemic in the United States
    by combining private-sector fundraising, philanthropy, coalition
    building, public policy expertise, and advocacy--as well as a network
    of passionate local and State partners--to respond effectively and
    efficiently to the HIV/AIDS epidemic in the communities most impacted
    by the epidemic. Through its unique Public/Private Partnerships, Public
    Policy Committee and targeted special grant-making initiatives, AIDS
    United and its partners reach over 300 grassroots organizations. These
    organizations provide HIV prevention, care, treatment, and support
    services to underserved individuals and populations most impacted by
    the HIV/AIDS epidemic including communities of color, women and gay and
    bisexual men and men who have sex with men (MSM) as well as education
    and training to providers of treatment services. It is our request that
    you increase funding for the Department of Health and Human Services by
    $7.361 billion in fiscal year 2015. This request includes an increase
    of $931 million over fiscal year 2014 throughout the detailed request
    listed below.
        AIDS United understands the fiscal environment that the country is
    wrestling with right now is austere. However, we know that investment
    in prevention and retention in HIV care are critical in lowering the
    number of new infections in the domestic HIV epidemic. As competing
    budget priorities are weighed please keep in mind that HIV is 100
    percent preventable, if we as a Nation muster the political will and
    funding to address domestic HIV on level that meets the needs of the
    epidemic. The increased funding for the domestic HIV/AIDS portfolio in
    fiscal year 2015 will help reach the National HIV/AIDS Strategy (NHAS).
    We look forward to working with you and your Administration in the
    coming year on the fiscal year 2015 budget.
    The Ryan White Program
        Early and reliable access to HIV care and treatment is cost
    effective and helps patients with HIV live healthy and productive
    lives. The needs of the Ryan White Program (RWP) continue to grow, even
    with the beginning of the implementation of the Affordable Care Act
    (ACA) and the integration of the RWP there may still be many needs
    unmet. In order to improve the continuum of care and progress toward an
    AIDS-free generation, continued, robust funding for all parts of the
    Ryan White Program in fiscal year 2015 will be necessary. The Ryan
    White Program works in conjunction with Medicaid, Medicare and now the
    Affordable Care Act, and as a result we believe more people living with
    HIV will be able to receive and remain in care and on treatment.
        It will take some time for enrollment to occur and assess the
    impact of the ACA on the Ryan White Program. In the meantime, we urge
    you to fund the Ryan White Program at a total of $2.44 billion in
    fiscal year 2015, an increase of $123 million over fiscal year 2014,
    distributed in the following manner: Part A: $687 million, Part B
    (Care): $428 million, Part B (ADAP): $943 million, Part C: $225
    million, Part D: $85 million, Part F/AETC: $35 million, Part F/Dental
    $15 million.
        AIDS United disagrees with the President's budget request and does
    not support the consolidation of Part D with Part C. We believe it
    should only be considered as part of a larger authorization process
    after key data questions about the value of consolidation are answered.
    HIV Prevention
                CDC HIV Prevention and Surveillance
        There still are 50,000 new infections annually and about 1 in 6
    people living with HIV do not know they have the virus. Gay, bisexual,
    and other men who have sex with men (MSM) account for 66 percent of all
    new HIV infections. Between 2008 and 2010, infections among MSM
    increased by 12 percent, and among MSM aged 13-24 years by 22 percent.
    Black and Latino MSM, and especially those who are young continue to be
    disproportionately affected. While we are making progress in decreasing
    new infections among women, black women accounted for 64 percent of
    women infected in 2010. Black and Hispanic women ages 13-24 accounted
    for 82 percent of young women living with HIV in 2010 even though
    together they represent only about 30 percent of women these ages.
        Investing in HIV prevention today translates into less spending in
    the future on care and treatment. Most CDC funding is distributed to
    the primary implementers of prevention activities--State and local
    public health departments and community based organizations. Increased
    investments are critical to expand comprehensive prevention programs
    and to successfully reach individuals at highest risk for infection.
    Early detection of HIV, linkage and retention in care, and adherence to
    treatment will suppress individual and community viral loads. Adequate
    resources are necessary to carry out increased HIV testing programs,
    targeted interventions, public education campaigns, and surveillance
    activities needed to track new infections andCD4 and viral load
    reporting.
        For fiscal year 2015, we request an increase of $55 million over
    fiscal year 2014 for a total of $812.7 million for the CDC Division of
    HIV prevention and surveillance activities.
                Division of Adolescent and School Health (DASH)
        One-third of all new HIV infections are among young people under
    the age of 29, the largest share of any age group. DASH is the only
    federally funded adolescent health program in our Nation's schools,
    helping education agencies provide school districts and individual
    schools with the tools to implement high-quality, effective, and
    sustainable programs to reduce HIV and other STD infections in
    adolescents. Increased funding would help expand this vital
    infrastructure beyond the currently funded 36 State or local education
    agencies.
        We request that the CDC Division of Adolescent and School Health
    receive a total of $50 million, an increase of $21 million over fiscal
    year 2014 final funding. This request includes $3 million in evaluation
    transfer funds.
                CDC STD Prevention
        Given the strong link between HIV and other STDs, including high
    rates of co-infection among certain populations, an increased
    investment in STD programs is an essential component of HIV prevention.
    Investments in STD prevention and treatment further the National HIV/
    AIDS Strategy's goal of reducing new infections.
        We request an increase of $54 million for a total of $211 million
    for the CDC's Division of STD Prevention in fiscal year 2015.
                CDC Viral Hepatitis Prevention
        CDC estimates that up to 5.3 million people are living with
    hepatitis B (HBV) and/or hepatitis C (HCV) in the U.S., and as many as
    75 percent are not aware of their infection. In 2010 alone, 35,000
    Americans were newly infected with HBV and 17,000 with HCV. It is
    estimated that 10 percent of people living with HIV are co-infected
    with hepatitis B and 25 percent are co-infected with hepatitis C.
        We request an increase of $31 million above the fiscal year 2014
    level, for a total of $60 million for the CDC's Division of Viral
    Hepatitis.
                Access to Sterile Syringes
        About 1 of 12 new infections (8.6 percent) of HIV in 2011 was
    related to injection drug use, a 28 percent decrease from 2008. One
    factor leading to this reduction has been syringe exchange programs.
    Numerous studies have shown syringe exchange programs can be an
    evidence-based and cost-effective means to lower HIV and hepatitis
    infections, reduce the use of illegal drugs and help connect people to
    medical treatment, including substance abuse treatment. In a May 2012
    letter, the President's Advisory Council on HIV/AIDS also supported
    ending the Federal ban on syringe exchange and noted that doing so is
    supported by public health, HIV/AIDS, viral hepatitis and harm
    reduction communities as well.
        We urge you to add language to end the ban on the use of Federal
    funds for syringe exchange programs and to maintain language that
    allows the use of local funds for syringe exchange programs in the
    District of Columbia.
                Abstinence-only
        We also request that you eliminate the funding for failed
    abstinence-only-until-marriage programs.
    HIV/AIDS Research at the National Institutes of Health (NIH)
        Research continues until better, more effective and affordable
    prevention and treatment regimens--and eventually a cure--are developed
    and universally available. For the U.S. to maintain its position as the
    global leader in HIV/AIDS research for the 33 million people globally
    of whom 1.1 million are Americans living with HIV, we must invest
    adequate resources in the NIH. NIH AIDS research has produced startling
    advances, including the HPTN 052 study of the prevention effects of
    treatment that was named Breakthrough of the Year by Science magazine,
    improved treatment programming and the first partially effective HIV
    vaccine, continued AIDS research funding is essential.
        In line with the Trans-NIH AIDS Research By-Pass Budget Estimate
    for fiscal year 2013, please include $3.6 billion for HIV research at
    the NIH, an increase of $610 million over fiscal year 2014.
    Minority HIV/AIDS Initiative
        HIV/AIDS continues to impact communities of color at an alarming
    rate. According to the CDC, African Americans, more than any other
    racial/ethnic group, continue to bear the greatest burden of HIV in the
    U.S. While blacks represent approximately 12 percent of the total
    population, they accounted for 44 percent of all new HIV infections in
    2010. Hispanics represent approximately 16 percent of the total
    population, but accounted for 21 percent of all new HIV infections. In
    the Asian Pacific Islander, and Native American communities the numbers
    of HIV infection are just as startling.
        We request that the MAI be funded at $610 million in fiscal year
    2015. We note that most of these funds are contained within the budgets
    of the programs described above.
                                     ______

               Prepared Statement of the Alzheimer's Association
        The Alzheimer's Association appreciates the opportunity to comment
    on the fiscal year 2015 appropriations for Alzheimer's disease
    research, education, outreach and support at the U.S. Department of
    Health and Human Services.
        Founded in 1980, the Alzheimer's Association is the world's leading
    voluntary health organization in Alzheimer's care, support and
    research. Our mission is to eliminate Alzheimer's disease and other
    dementias through the advancement of research; to provide and enhance
    care and support for all affected; and to reduce the risk of dementia
    through the promotion of brain health. As the world's largest nonprofit
    funder of Alzheimer's research, the Association is committed to
    accelerating progress of new treatments, preventions and, ultimately, a
    cure. Through our funded projects and partnerships, we have been part
    of every major research advancement over the past 30 years. Likewise,
    the Association works to enhance care and provide support for all those
    affected by Alzheimer's and reaches millions of people affected by
    Alzheimer's and their caregivers.
    Alzheimer's Impact on the American People and the Economy
        In addition to the human suffering caused by the disease,
    Alzheimer's is creating an enormous strain on the healthcare system,
    families and the Federal budget. Alzheimer's is a progressive brain
    disorder that damages and eventually destroys brain cells, leading to a
    loss of memory, thinking and other brain functions. Ultimately,
    Alzheimer's is fatal. Currently, Alzheimer's is the sixth leading cause
    of death in the United States and the only one of the top ten without a
    means to prevent, cure or slow its progression. Over five million
    Americans are living with Alzheimer's, with 200,000 under the age of
    65.
        A Federal commitment can lower costs and improve health outcomes
    for people living with Alzheimer's today and in the future. By making
    Alzheimer's a national priority, we can create the same successes that
    we have been able to achieve in other diseases that have been
    prioritized by the Federal Government. Leadership from the Federal
    Government has helped to lower the number of deaths from other major
    diseases like heart disease, HIV/AIDS, many cancers, heart disease and
    stroke. While those deaths have declined, deaths from Alzheimer's have
    increased 68 percent between 2000 and 2010.
        Alzheimer's is the most expensive disease in America. In fact, an
    NIH-funded study in the New England Journal of Medicine confirmed that
    Alzheimer's is the most costly disease in America, with costs set to
    skyrocket at unprecedented rates. If nothing is done, as many as 16
    million Americans will have Alzheimer's disease by 2050 and costs will
    exceed $1.2 trillion (not adjusted for inflation), creating an enormous
    strain on the healthcare system, families and the Federal budget. The
    expense involved in caring for those with Alzheimer's is not just a
    long-term problem. As the current generation of baby boomers age, near-
    term costs for caring for those with Alzheimer's will balloon, as
    Medicare and Medicaid will cover more than two-thirds of the costs for
    their care.
        Due to these projected increases, the graying of America threatens
    the bankrupting of America. Caring for people with Alzheimer's will
    cost all payers--Medicare, Medicaid, individuals, private insurance and
    HMOs--$20 trillion over the next 40 years, enough to pay off the
    national debt and still send a $10,000 check to every man, woman and
    child in America. In 2014, America will spend an estimated $214 billion
    in direct costs for those with Alzheimer's, including $150 billion in
    costs to Medicare and Medicaid. Average per person Medicare costs for
    those with Alzheimer's and other dementias are three times higher than
    those without these conditions. Average per senior Medicaid spending is
    19 times higher.
        A primary reason for these costs is that Alzheimer's makes treating
    other diseases more expensive, as most individuals with Alzheimer's
    have one or more co-morbidity that complicate the management of the
    condition(s) and increase costs. For example, a senior with diabetes
    and Alzheimer's costs Medicare 81 percent more than a senior who only
    has diabetes. Nearly 30 percent of people with Alzheimer's or another
    dementia who have Medicare also have Medicaid coverage, compared with
    11 percent of individuals without Alzheimer's or dementia. Alzheimer's
    disease is also extremely prevalent in nursing homes, where 64 percent
    of Medicare residents live with the disease.
        With Alzheimer's, it is not just those with the disease who
    suffer--it is also their caregivers and families. In 2013, 15.5 million
    family members and friends provided unpaid care valued at over $220
    billion. Caring for a person with Alzheimer's takes longer, lasts
    longer, is more personal and intrusive, and takes a heavy toll on the
    health of the caregivers themselves. More than 60 percent of
    Alzheimer's and dementia caregivers rate the emotional stress of
    caregiving as high or very high, with one-third reporting symptoms of
    depression. Caregiving may also have a negative impact on health,
    employment, income and family finances. Due to the physical and
    emotional toll of caregiving on their own health, Alzheimer's and
    dementia caregivers had $9.3 billion in additional health costs in
    2013.
    Changing the Trajectory of Alzheimer's
        Until recently, there was no Federal Government strategy to address
    this looming crisis. In 2010, thanks to bipartisan support in Congress,
    the National Alzheimer's Project Act (NAPA) (Public Law 111-375) passed
    unanimously, requiring the creation of an annually-updated strategic
    National Alzheimer's Plan (Plan) to help those with the disease and
    their families today and to change the trajectory of the disease for
    the future. The Plan is required to include an evaluation of all
    federally-funded efforts in Alzheimer's research, care and services--
    along with their outcomes. In addition, the Plan must outline priority
    actions to reduce the financial impact of Alzheimer's on Federal
    programs and on families; improve health outcomes for all Americans
    living with Alzheimer's; and improve the prevention, diagnosis,
    treatment, care, institutional-, home-, and community-based Alzheimer's
    programs for individuals with Alzheimer's and their caregivers. NAPA
    will allow Congress to assess whether the Nation is meeting the
    challenges of this disease for families, communities and the economy.
    Through its annual review process, NAPA has enabled, for the first
    time, Congress and the American people to answer this simple question:
    Did we make satisfactory progress this past year in the fight against
    Alzheimer's?
        As mandated by NAPA, the Secretary of Health and Human Services, in
    collaboration with the Advisory Council on Alzheimer's Research, Care
    and Services, has developed the first-ever National Plan to Address
    Alzheimer's Disease in May of 2012 and subsequently released the 2014
    Update to the National Plan to Address Alzheimer's Disease this past
    April. The Advisory Council, composed of both Federal members and
    expert non-Federal members, is an integral part of the planning process
    as it advises the Secretary in developing and evaluating the annual
    Plan, makes recommendations to the Secretary and Congress, and assists
    in coordinating the work of Federal agencies involved in Alzheimer's
    research, care, and services.
        Having a plan with measurable outcomes is important. But unless
    there are resources to implement the plan and the will to abide by it,
    we cannot hope to make adequate progress. If we are going to succeed in
    the fight against Alzheimer's, Congress must provide the resources the
    scientists need. Understanding this and following the recommendation of
    scientists at NIH, Congress passed the Consolidated Appropriations Act
    of 2014 (Public Law 113-76) which included a $100 million increase for
    Alzheimer's research. These funds are a critically needed down payment
    for needed research and services for Alzheimer's patients and their
    families.
        A disease-modifying or preventive therapy would not only save
    millions of lives but would save billions of dollars in healthcare
    costs. Specifically, if a treatment became available in 2015 that
    delayed onset of Alzheimer's for 5 years (a treatment similar to anti-
    cholesterol drugs), savings would be seen almost immediately, with
    Medicare and Medicaid spending reduced by $42 billion in 2020.
        Today, despite the Federal investment in Alzheimer's research, we
    are only just beginning to understand what causes the disease.
    Americans are growing increasingly concerned that we still lack
    effective treatments that will slow, stop, or cure the disease, and
    that the pace of progress in developing breakthrough discoveries is
    much too slow to significantly impact on this growing crisis. For every
    $26,500 Medicare and Medicaid spends caring for individuals with
    Alzheimer's, the National Institutes of Health (NIH) spends only $100
    on Alzheimer's research. Scientists fundamentally believe that we have
    the ideas, the technology and the will to develop new Alzheimer's
    interventions, but that progress depends on a prioritized scientific
    agenda and on the resources necessary to carry out the scientific
    strategy for both discovery and translation for therapeutic
    development.
        For too many individuals with Alzheimer's and their families, the
    system has failed them, and today we are unnecessarily losing the
    battle against this devastating disease. Despite the fact that an early
    and documented formal diagnosis allows individuals to participate in
    their own care planning, manage other chronic conditions, participate
    in clinical trials, and ultimately alleviate the burden on themselves
    and their loved ones, as many as half of the more than five million
    Americans with Alzheimer's have never received a formal diagnosis.
    Unless we create an effective, dementia-capable system that finds new
    solutions to providing high quality care, provides community support
    services and programs, and addresses Alzheimer's health disparities,
    Alzheimer's will overwhelm the healthcare system in the coming years.
    For example, people with Alzheimer's and other dementias have more than
    three times as many hospital stays as other older people. Furthermore,
    one out of seven individuals with Alzheimer's or another dementia lives
    alone and up to half do not have an identifiable caregiver. These
    individuals are more likely to need emergency medical services because
    of self-neglect or injury, and are found to be placed into nursing
    homes earlier, on average, than others with dementia. Ultimately,
    supporting individuals with Alzheimer's disease and their families and
    caregivers requires giving them the tools they need to plan for the
    future and ensuring the best quality of life for individuals and
    families impacted by the disease. It is vital that we make the
    investments in Alzheimer's that will fulfill the goals of the National
    Alzheimer's Plan. The Alzheimer's Association urges Congress to support
    an additional $200 million for research activities and priorities
    included in the National Alzheimer's Plan required under Public Law
    111-375.
    Additional Alzheimer's programs
        National Alzheimer's Call Center: The National Alzheimer's Call
    Center, funded by the AoA, provides 24/7, year-round telephone support,
    crisis counseling, care consultation, and information and referral
    services in 140 languages for persons with Alzheimer's, their family
    members and informal caregivers. Trained professional staff and
    master's-level mental health professionals are available at all times.
    In the 12 month period ending July 31, 2013, the Call Center handled
    over 300,000 calls through its national and local partners, and its
    online message board received over 40,000 visits a month. Additionally,
    the Association provides a two-to-one match on the Federal dollars
    received for the call center. The Alzheimer's Association urges
    Congress to support $1.3 million for the National Alzheimer's Call
    Center.
        Healthy Brain Initiative (HBI): The Centers for Disease Control and
    Prevention's (CDC) HBI program works to educate the public, the public
    health community and health professionals about Alzheimer's as a public
    health issue. Although there are currently no treatments to delay or
    stop the deterioration of brain cells caused by Alzheimer's, evidence
    suggests that preventing or controlling cardiovascular risk factors may
    benefit brain health. In light of the dramatic aging of the population,
    scientific advancements in risk behaviors, and the growing awareness of
    the significant health, social and economic burdens associated with
    cognitive decline, the Federal commitment to a public health response
    to this challenge is imperative. The fiscal year 2014 omnibus funding
    bill increased funding for HBI by $1.5 million in order to bolster
    caregiver surveillance. The Alzheimer's Association urges Congress to
    support $3.3 million for the Healthy Brain Initiative.
        Alzheimer's Disease Supportive Services Program (ADSSP): The ADSSP
    at the AoA supports family caregivers who provide countless hours of
    unpaid care, thereby enabling their family members with Alzheimer's and
    dementia to continue living in the community. The program develops
    coordinated, responsive and innovative community-based support service
    systems for individuals and families affected by Alzheimer's. The
    Alzheimer's Association urges Congress to support $13.4 million for the
    Alzheimer's Disease Supportive Services Program.
    Conclusion
        The Association appreciates the steadfast support of the
    Subcommittee and its priority setting activities. We look forward to
    continuing to work with Congress in order to address the Alzheimer's
    crisis. We ask Congress to address Alzheimer's with the same bipartisan
    collaboration demonstrated in the passage of the National Alzheimer's
    Project Act (Public Law 111-375) and with a commitment equal to the
    scale of the crisis.
                                     ______

          Prepared Statement of the Alzheimer's Foundation of America
        On behalf of the Alzheimer's Foundation of America (AFA), a
    national nonprofit organization that unites more than 1,600 member
    organizations nationwide with the goal of providing optimal care and
    services to individuals confronting dementia, and to their caregivers
    and families, we are making the following appropriations requests for
    programs impacting Alzheimer's disease caregiving services and research
    in the fiscal year 2015 budget. These Federal programs and support
    services are vital to providing necessary care supports and promoting
    best practice tools to family caregivers, and advancing promising
    clinical research.
        Specifically, AFA makes the following appropriations requests for
    these specific agencies and programs:
    National Institutes of Health (NIH):
        Adequate investment in scientific research that could lead to new
    treatments and cures is critical in order to reduce long-term
    healthcare costs. We appreciated Congress' efforts in the fiscal year
    2014 budget which provided an additional $80 million for clinical
    research into Alzheimer's disease. AFA urges the Committee to build on
    this modest increase and provide an additional $500 million for
    Alzheimer's disease research and enhanced investments for caregiving
    supports and services in fiscal year 2015. Additional resources will
    fund effective pharmaceutical therapies to prevent, cure or slow the
    progression of Alzheimer's disease, and provide the necessary seed
    money to implement and facilitate the ambitious and laudable goals of
    the ``National Plan to Address Alzheimer's Disease.''
        AFA also urges the Committee to include $32 billion in total
    funding for NIH, as recommended by the Ad Hoc Group for Medical
    Research and a bi-partisan group of Members of Congress including Reps.
    McKinley, Davis, Carson and King. Even if funding remains flat, NIH's
    actual budget will still be effectively cut as spending will not be
    able to keep pace with biomedical inflation.
        --National Institute on Aging (NIA): Since NIA is the primary
    agency responsible for Alzheimer's disease research, AFA urges the
    Committee to include a minimum budget appropriation of $1.7 billion, an
    increase of $500 million for NIA for fiscal year 2015.
        NIA leads the national scientific effort to understand the nature
    of aging in order to promote the health and well-being of older adults,
    whose numbers are projected to rise dramatically in the coming years
    due to increased life expectancy and the aging of the baby boom
    generation.
        This funding is essential to increase the NIA's baseline to a level
    consistent with comparable research initiatives conducted under the
    auspices of NIH, and to support additional research into Alzheimer's
    disease and related dementias. This is particularly vital, as
    Alzheimer's disease holds the infamous position of being the only one
    of the top ten leading causes of death with a rising death rate.
    Administration on Community Living (ACL) programs:
        AFA would like to single out the following programs within the ACL
    that are critical to individuals with Alzheimer's disease and their
    caregivers:
        --National Family Caregiver Support Program (NFCSP): NFCSP provides
    grants to States and territories, based on their share of the
    population aged 70 and over, to fund a range of supportive services
    that assist family and informal caregivers in caring for their loved
    ones at home for as long as possible, thus providing a more person-
    friendly and cost-effective approach than institutional care. Last
    year's appropriation of $146 million cannot possibly keep up with the
    need for respite care as our population ages. AFA urges that $156
    million be appropriated in fiscal year 2015 to support this important
    program.
        --Lifespan Respite Care Program (LRCP): AFA urges the Committee to
    commit $10 million to LRCP in fiscal year 2015. LRCP provides
    competitive grants to State agencies working with Aging and Disability
    Resource Centers and non-profit State respite coalitions and
    organizations to make quality respite care available and accessible to
    family caregivers regardless of age or disability by establishing State
    Lifespan Respite Systems.
        --Alzheimer's Disease Demonstration Grants (ADDG): Existing
    resources for the Alzheimer's population and their caregivers are
    already tapped out, at a time when demand is continuing to rise in line
    with the skyrocketing incidence of this disease. AFA supports funding
    of $9 million for the ADDG program which fosters the development of
    innovative models of care for persons with Alzheimer's disease and
    their caregivers and is designed to improve responsiveness of the home
    and community based care system to persons with dementia including
    underserved minority, rural and low-income persons.
        --Alzheimer's Disease Initiative (ADI): AFA supports the
    President's fiscal year 2015 budget request of $12 million for this
    program that for services such as support for caregivers in the
    community, improving healthcare provider training, and raising public
    awareness. Research shows that education, counseling and other support
    for family caregivers can delay institutionalization of loved ones and
    improve a caregiver's own physical and mental well-being--thus reducing
    costs to families and government. In addition, AFA supports an
    appropriation of $5 million for the Alzheimer's Disease Communications
    Campaign.
    Food and Drug Administration (FDA):
        AFA supports FDA funding in fiscal year 2015 that fully restores
    the agency's base lost in the fiscal year 2013 sequester and provides
    for a modest additional funding above that level. Specifically, we are
    requesting budget authority appropriations of $2.78 billion for FDA,
    $223 million above fiscal year 2014 appropriated spending.
        FDA activities are necessary to ensure proper evaluation and
    testing of pharmaceutical treatments for Alzheimer's disease before
    these drugs enter the market. In addition, with the science of this
    disease becoming more complex, FDA plays an increasingly important and
    often resource-intensive role in pharmaceutical innovation. AFA's
    request is in line with the appropriations request being recommended by
    the Alliance for a Stronger FDA and the Coalition to Accelerate Cure/
    Treatments for Alzheimer's Disease (ACT-AD).
        As we work toward meeting the goal of the historic ``National Plan
    to Address Alzheimer's Disease'' to prevent and effectively treat
    Alzheimer's disease by 2025, adequate resources must be committed to
    meet the pending challenge. Taken together, these programs represent a
    lifeline to families who care for a loved one with Alzheimer's disease
    and provide hope to Americans living with the disease and those who
    face it in the future that there will be funding for a cure.
        AFA thanks the Committee for the opportunity to present its
    recommendations and looks forward to working with you through the
    appropriations process. Please contact me or Eric Sokol, AFA's vice
    president of public policy, at esokol@alzfdn.org if you have any
    questions or require further information.

        [This statement was submitted by Hon. Charles J. Fuschillo, Jr.,
    Chief Executive Officer, Alzheimer's Foundation of America.]
                                     ______

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

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

                      RECOMMENDATIONS FOR FISCAL YEAR 2015
                                                           .................
                   U.S. DEPARTMENT OF LABOR

    Workforce Innovation Fund--with up to $10,000,000 for        $60,000,000
     Pay for Success initiatives.........................
    Agency-Wide Evaluation Set-Aside--1 percent of         .................
     discretionary funds to be used by the Chief
     Evaluation Office for program evaluations...........

         U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Head Start Designation Renewal System--set-aside             $25,000,000
     within the total provided for Head Start............
    Mental Health Service Block Grant Program--at least 5  .................
     percent set-aside for evidence-based programs to
     address the needs of individuals with early serious
     mental illness......................................

                 U.S. DEPARTMENT OF EDUCATION

    First in the World--with $20,000,000 set-aside for          $100,000,000
     minority-serving institutions.......................
    Investing in Innovation (i3)--language directing the        $215,000,000
     Department to provide continuation grants to certain
     current i3 grantees that are demonstrating strong
     interim outcomes but have not had sufficient time to
     achieve their program goals.........................
    Replication and Expansion of High Quality Charter            $75,000,000
     Schools--set-aside within the total provided for the
     Charter School Program..............................
    Title II-A--Effective Teachers and Leaders--language   .................
     requiring the Secretary to set aside 25 percent of
     ESEA Title II-A funds for competitive grants to
     States, high need local school districts, and
     national non-profit organizations, including 10
     percent set-aside for the Supporting Effective
     Educator Development (SEED) program.................
    Titles I and II--language directing States to set-     .................
     aside 1 percent of Title I and II funds, prior to
     distribution to local school districts (LSD), and to
     award these funds on a competitive basis to the 25
     percent of LSD's with the highest poverty levels
     through a tiered funding frame-work.................
    IDEA Results-Driven Accountability Grants--set-aside        $100,000,000
     to implement promising evidence-based reforms.......
    Agency-Wide Evaluation Set-aside--1 percent of         .................
     discretionary funds (not including Pell Grants) for
     program evaluations.................................
    Title II--Whole School Reform--language allowing       .................
     local school districts to use School Improvement
     Grants to implement a whole-school reform strategy
     for a school using an evidence-based strategy that
     ensures whole-school reform is undertaken in
     partnership with a strategy developer offering a
     whole-school reform program that is based on at
     least a moderate level of evidence that the program
     will have a statistically significant effect on
     student outcomes as defined by the Department's
     General Administrative Regulations..................

        CORPORATION FOR NATIONAL AND COMMUNITY SERVICE

    Social Innovation Fund--including up to 20 percent           $80,000,000
     set-aside for Pay for Success initiatives and
     language directing CNCS to (1) provide renewal
     grants to current SIF grantees that are
     demonstrating significant interim outcomes but have
     not had sufficient time to achieve their program
     goals and (2) permit current SIF grantees to be
     eligible to apply for additional SIF funds for
     projects not currently funded by SIF................

                      GENERAL PROVISION

    Performance Partnership Pilot--language establishing   .................
     up to 10 Performance Partnership Pilots to improve
     outcomes for disconnected youth.....................

        [This statement was submitted by Michele Jolin, Managing Partner,
    America Achieves.]
                                     ______

        Prepared Statement of the American Academy of Family Physicians
        The American Academy of Family Physicians (AAFP), representing
    110,600 family physicians and medical students nationwide, urges the
    Senate Appropriations Subcommittee on Labor, Health and Human Services,
    and Education to invest in our Nation's primary care physician
    workforce in the fiscal year 2015 appropriations bill to promote the
    efficient, effective delivery of healthcare by providing these
    appropriations for the Health Resources and Services Administration and
    the Agency for Healthcare Research and Quality:
      --$71 million for Health Professions Primary Care Training and
            Enhancement authorized under Title VII, Section 747 of the
            Public Health Service Act (PHSA);
      --$10 million for Teaching Health Centers development grants (PHSA
            Title VII, Sec. 749A);
      --$4 million for Rural Physician Training Grants (PHSA Title VII,
            Sec. 749B);
      --$100 million for the National Health Service Corps (PHSA Sec. 338A,
            B, & I);
      --$375 million for the Agency for Healthcare Research and Quality
            (PHSA Sec. 487(d)(3), SSA Sec. 1142); and
      --$3 million for the National Health Care Workforce Commission (ACA
            Sec. 5101).
        Founded in 1947, the AAFP is dedicated to preserving and promoting
    the science and art of family medicine and ensuring high-quality, cost-
    effective healthcare for patients of all ages. The AAFP appreciates the
    opportunity to comment on the fiscal year 2015 appropriations levels
    needed to achieve those important goals.
              health resources and services administration (hrsa)
        Our Nation faces a shortage of primary care physicians. The total
    number of office visits to primary care physicians is projected to
    increase from 462 million in 2008 to 565 million in 2025 requiring
    nearly 52,000 additional primary care physicians by 2025.\1\ The Health
    Resources and Services Administration (HRSA) is the Federal agency
    charged with administering the health professions training programs
    authorized under Title VII of the Public Health Services Act and first
    enacted in 1963. We urge the Committee to restore funding for
    discretionary HRSA programs to the fiscal year 2010 level of $7.48
    billion in the fiscal year 2015 bill.
    ---------------------------------------------------------------------------
        \1\ Petterson, S, et al. Projecting U.S. Primary Care Physician
    Workforce Needs: 2010-2015. Ann Fam Med 2012; vol.10 no. 6:503-509.
    ---------------------------------------------------------------------------
        Title VII Health Professions Training Programs.--In the last 50
    years, Congress has revised the Title VII authority in order to meet
    our Nation's changing healthcare workforce needs. We now face
    burgeoning demand for family physicians and must work to increase their
    number in the United States. As the only medical specialty society
    devoted entirely to primary care, the AAFP is gravely concerned that a
    failure to provide adequate funding for the Title VII, Section 747
    Primary Care Training and Enhancement (PCTE) program, will destabilize
    education and training support for family physicians. Between 1998 and
    2008, in spite of persistent primary care physician shortages, family
    medicine lost 46 training programs and 390 residency positions, and
    general internal medicine lost nearly 900 positions.\2\ A study
    published in the Annals of Family Medicine on the impact of Title VII
    training programs found that physicians who work with the underserved
    in Community Health Centers and National Health Service Corps sites are
    more likely to have trained in Title VII-funded programs.\3\ Title VII
    primary care training grants are vital to departments of family
    medicine, general internal medicine, and general pediatrics; they
    strengthen curricula; and they offer incentives for training in
    underserved areas. In the coming years, medical services utilization is
    likely to rise given the increasing and aging population as well as the
    insured status of more people. These demographic trends will exacerbate
    family physician shortages. Although PCTE grants are important to
    family medicine, there has not been a competitive cycle for these
    grants since fiscal year 2010. The AAFP urges the Committee to increase
    the level of Federal funding for primary care training to at least $71
    million in fiscal year 2015 to allow for a robust new grant cycle to
    support family medicine education and training in the new competencies
    required to meet the needs of patients of all ages.
    ---------------------------------------------------------------------------
        \2\ Phillips RL and Turner, BJ. The Next Phase of Title VII Funding
    for Training Primary Care Physicians for America's Health Care Needs.
    Ann Fam Med 2012; vol.10 no. 2:163-168.
        \3\ Rittenhouse DR, et al. Impact of Title VII training programs on
    community health center staffing and national health service corps
    participation. Ann Fam Med 2008; vol. 6 no. 5:397-405.
    ---------------------------------------------------------------------------
        Teaching Health Centers.--The AAFP has long called for reforms to
    graduate medical education programs to encourage the training of
    primary care residents in non-hospital settings where most primary care
    is delivered. An excellent first step is the innovative Teaching Health
    Centers (THC) program authorized under Title VII, Sec. 749A to increase
    primary care physician training capacity that HRSA administers. Federal
    financing of graduate medical education has led to training mainly in
    hospital inpatient settings even though most patient care is delivered
    outside of hospitals in ambulatory settings. The THC program provides
    resources to any qualified community based ambulatory care setting that
    operates a primary care residency. We believe that this program
    requires an investment of $10 million in fiscal year 2015 for planning
    grants.
        Rural Physician Workforce Needs.--HRSA's Office of Rural Health
    focuses on rural health policy issues and administers rural grant
    programs. As the medical specialty most likely to enter rural practice,
    family physicians recognize the importance of dedicating appropriate
    resources to rural health needs. A recent study found that medical
    school rural programs have had a significant impact on rural family
    physician supply and called for wider adoption of that model to
    substantially increase access to care in rural areas compared to a
    greater reliance on international medical graduates or unfocused
    expansion of traditional medical schools.\4\ HRSA's Rural Physician
    Training Grant program will help medical schools recruit students most
    likely to practice medicine in rural communities. This program will
    help provide rural-focused experience and increase the number of
    medical school graduates who practice in underserved rural communities.
    The AAFP recommends that the Committee provide $4 million for Rural
    Physician Training Grants in fiscal year 2015 as called for in the
    President's budget request.
    ---------------------------------------------------------------------------
        \4\ Rabinowitz,HK, et al. Medical School Rural Programs: A
    Comparison With International Medical Graduates in Addressing State-
    Level Rural Family Physician and Primary Care Supply. Academic
    Medicine, Vol. 87, No. 4/April 2012.
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        Primary Care in Underserved Areas.--The National Health Service
    Corps (NHSC) recruits and places medical professionals in Health
    Professional Shortage Areas to meet the need for healthcare in rural
    and medically underserved areas. The NHSC offers scholarships or loan
    repayment as incentives for physicians to enter primary care and
    provide healthcare to Americans in Health Professional Shortage Areas.
    By addressing medical school debt burdens, the NHSC also helps to
    ensure wider access to medical education opportunities. The President's
    budget request includes $810 million for the NHSC, of which $710
    million is mandatory funding. If the NHSC is funded at the President's
    requested level in fiscal year 2015, underserved patients will benefit
    from an NHSC field strength of more than 15,400 primary care clinicians
    compared to the fiscal year 2013 field strength of 8,899. The AAFP
    supports the President's budget request for this important program and
    recommends that the Committee provide an appropriation of $100 million
    for the NHSC in fiscal year 2015 to supplement the authorized and
    requested mandatory funds.
               agency for heatlhcare research and quality (ahrq)
        AHRQ is the only Federal agency responsible for generating evidence
    to make healthcare safer; better; and more accessible, equitable and
    affordable. AHRQ provides the critical evidence reviews that the AAFP
    and other physician specialty societies use to produce clinical
    practice guidelines. These evidence-informed guidelines are important
    to family physicians as well as to patients and their families. AHRQ
    takes the results from the NIH whose research restricts subjects to
    limit the variables in clinical studies and brings the practical
    information to the practicing physicians who treat patients without
    those clinical restrictions. ARHQ supports critical primary care
    investigations through Practice-based Research Networks that examine
    practice transformation, patient quality and safety in non-hospital
    settings, multi-morbidity research, as well as mental and behavioral
    healthcare in communities and primary care practices. The AAFP asks
    that the Committee provide $375 million in base discretionary funding
    for AHRQ in fiscal year 2015.
                   national health care workforce commission
        Appointed on September 30, 2010, the 15-member National Health Care
    Workforce Commission was intended to serve as a resource with a broad
    array of expertise. The Commission was directed to analyze current
    workforce distribution and needs; evaluate healthcare education and
    training; identify barriers to improved coordination at the Federal,
    State, and local levels and recommend ways to address them; and
    encourage innovations. There is broad consensus about the waning
    availability of primary care physicians in the United States, but
    estimates of the severity of the regional and local shortages vary. The
    AAFP supports the work of the Commission to analyze primary care
    shortages and propose innovations to help produce the physicians that
    our Nation needs and will need in the future. We request that the
    Committee provide $4 million in fiscal year 2015 so that this important
    Commission can finally begin this important work.
                                     ______

            Prepared Statement of the American Academy of Pediatrics
        The American Academy of Pediatrics (AAP), a non-profit professional
    organization of 62,000 primary care pediatricians, pediatric medical
    subspecialists, and pediatric surgical specialists dedicated to the
    health, safety, and well-being of infants, children, adolescents, and
    young adults, appreciates the opportunity to submit this statement for
    the record in support of strong Federal investments in children's
    health in fiscal year 2015 and beyond. AAP urges all Members of
    Congress to put children first when considering short and long-term
    Federal spending decisions. AAP supports robust investment in programs
    that help ensure the health, safety and well-being of children,
    including $5 million for the Pediatric Subspecialty Loan Repayment
    Program at the Health Resource Services Administration (HRSA), $21
    million for the Emergency Medical Services for Children (HRSA), $139
    million for the National Center for Birth Defects and Developmental
    Disabilities at the Centers for Disease Control and Prevention (CDC),
    and $160 million for Polio Eradication and $49 million for the Measles
    program within CDC.
        Every adult was once a child. Many adult diseases have their
    origins in childhood. Early and continued investments in our children's
    health are needed to prevent obesity, heart disease, substance use, and
    other chronic conditions that threaten America's health and fiscal
    solvency. As clinicians we not only diagnose and treat our patients, we
    also promote preventive interventions to improve overall health.
    Likewise, as policymakers, you have an integral role in ensuring the
    health of future generations through adequate and sustained funding of
    vital Federal programs.
    Pediatric Subspecialty Loan Repayment Program
        The United States' supply of pediatric subspecialists is inadequate
    to meet children's health needs. Many children must wait more than 3
    months for an appointment with a pediatric subspecialist. Approximately
    1 in 3 children must travel 40 miles or more to receive care from a
    pediatrician certified in adolescent medicine, developmental behavioral
    pediatrics, neurodevelopment disabilities, pulmonology, emergency
    medicine, nephrology, rheumatology, and sports medicine. This problem
    is compounded by the fact that fewer medical residents are choosing
    careers in pediatric subspecialties, and the existing subspecialist
    workforce continues to age. There is also a significant disparity in
    the geographic distribution of pediatric subspecialists across the
    country, resulting in many underserved rural and urban areas.
        The Pediatric Subspecialty Loan Repayment Program (PSLRP) seeks to
    expand children's access to healthcare by creating a more robust
    pediatric work force. In the program, eligible participants must agree
    to practice full-time for not less than 2 years in a pediatric medical
    specialty, surgical specialty, or a child or adolescent mental and
    behavioral subspecialty in a health professional shortage area or a
    medically underserved area. In return, the program will pay up to
    $35,000 in loan repayment for each year of service, for a maximum of 3
    years.
        Fiscal year 2015 Request: $5 million; fiscal year 2014 Level: Not
    Funded.
    Emergency Medical Services for Children
        Established by Congress in 1984 and last reauthorized in 2010, the
    Emergency Medical Services for Children (EMSC) Program is the only
    Federal program that focuses specifically on improving the pediatric
    components of the emergency medical services (EMS) system. Currently
    celebrating its 30th year, the EMSC program has made landmark
    improvements to the emergency care delivered to children all across the
    Nation. EMSC aims to ensure that state of the art emergency medical
    care for the ill and injured child or adolescent is well integrated
    into an EMS system. Every State has received EMSC funds, which they
    have used to ensure that hospitals and ambulances are properly equipped
    to treat pediatric emergencies, to provide pediatric training to
    paramedics and first responders, and to improve the systems that allow
    for efficient, effective pediatric emergency medical care.
        Continued support for EMSC has allowed the program to maintain its
    existing activities, improve pediatric capacity and transport of
    pediatric patients, and address emerging issues such as pediatric
    emergency care readiness and pediatric emergency medical services in
    rural and remote areas.
        Fiscal year 2015 Request: $21 million; fiscal year 2014 Level:
    $20.1 million.
    National Center for Birth Defects and Developmental Disabilities
        The National Center for Birth Defects and Developmental
    Disabilities is a center within CDC that seeks to promote the health of
    babies, children, and adults and enhance the potential for full,
    productive living. According to the CDC, birth defects affect 1 in 33
    babies and are a leading cause of infant death in the United States;
    the center has done tremendous work in the way of identifying the
    causes of birth defects and developmental disabilities, helping
    children to develop and reach their full potential. The center also
    conducts important research on fetal alcohol syndrome, infant health,
    autism, congenital heart defects, and other conditions like Tourette
    Syndrome, Fragile X, Spina Bifida and Hemophilia. NCBDDD has proven to
    be an asset to children and their families and supports extramural
    research in every State.
        Fiscal year 2015 Request: $139 million; fiscal year 2014 Level:
    $122.4 million.
    Global Health at CDC
        The AAP calls on Congress to support and resource Health and Human
    Services to implement the recommendations of the National Vaccine
    Advisory Committee of the Global Immunizations Working Group on
    enhancing the work of the HHS National Vaccine Program in Global
    Immunizations. This includes support for HHS' role in building
    international cooperation for the common goal of reducing the burden of
    vaccine-preventable diseases. HHS has unique and timely opportunities
    to eradicate polio, to reduce measles mortality, and to ensure that the
    routine immunization systems at the front lines of these efforts are
    maintained. The funding that Congress provides to CDC's Global
    Immunization account is also necessary to act on the Advisory
    Committee's recommendations that HHS enhance its ongoing efforts to
    strengthen global immunization systems, enhance global capacity for
    vaccine safety monitoring and post-marketing surveillance, build global
    immunization research and development capacity, and strengthen
    countries' capacity for vaccine decisionmaking.
        Since 1988 a coordinated global immunization campaign has reduced
    the number of polio cases globally by more than 99 percent, saving more
    than 10 million children from paralysis and bringing the disease close
    to eradication. Expanded immunization has reduced the global mortality
    attributed to measles by 74 percent between 2000 and 2010.
        Polio fiscal year 2015 Request: $160 million; fiscal year 2014
    Level: $146 million
        Measles fiscal year 2015 Request: $49 million; fiscal year 2014
    Level: $42.2 million
    America's children deserve better
        Twenty 2 percent of children in the United States now live in
    poverty--up from 17 percent in 2007. Many children suffer from food
    insecurity, unstable housing, family dysfunction, abuse and neglect.
    Such adverse childhood experiences are linked with ``toxic stress,'' a
    biologic phenomenon associated with profound and irreversible changes
    in brain anatomy and chemistry that have been implicated in the
    development of health-threatening behaviors and medical complications
    later in life including drug use, obesity, and altered immune function.
    Adults affected by such adverse childhood experiences are more likely
    to have experienced school failure, gang membership, unemployment,
    violent crime, and incarceration.
    Healthier children, healthier future
        On behalf of the 75 million American children and their families
    that we serve and treat, the Nation's pediatricians expect Congress to
    respond to mounting evidence that child health has life-long impacts
    and put children first during appropriations negotiations. Investing in
    children is not only the right thing to do for the long-term physical,
    mental, and emotional health of the population, but is imperative for
    the Nation's long-term fiscal health as well. In addition to the
    programs we have specifically mentioned in this testimony, Federal
    support for children's health programs, such as early brain and child
    development, parenting and health education, and preventive health
    services, will yield high returns for the American economy. Cuts to
    these areas in the short-term will blunt the possible long-term savings
    these programs could achieve.
        We fully recognize the Nation's fiscal challenges and respect that
    difficult budgetary decisions must be made; however, we do not support
    funding decisions made at the expense of the health and welfare of
    children and families. Rather, a focus on the long-term needs of
    children and adolescents will ensure that the United States can compete
    in the modern, highly-educated global marketplace. Strong and sustained
    financial investments in children's healthcare, research, and
    prevention programs will help keep our children healthy and pay
    dividends for years to come.
        The American Academy of Pediatrics looks forward to working with
    Members of Congress to prioritize the health of our Nation's children
    in fiscal year 2015 and beyond. If we may be of further assistance
    please contact Pat Johnson at the AAP Department of Federal Affairs at
    202-347-8600 or pjohnson@aap.org. Thank you for your consideration.

        [This statement was submitted by James, Perrin, MD, FAAP,
    President, American Academy of Pediatrics.]
                                     ______

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

        [This statement was submitted by Sandy Harding, MSW, Senior
    Director, Federal Advocacy.]
                                     ______

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

        [This statement was submitted by Don Wildman, Host, Travel
    Channel's Mysteries at the Museum, American Alliance of Museums.]
                                     ______

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

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

        [This statement was submitted by Timothy DeRouen, PhD, President,
    American Association for Dental Research.]
                                     ______

     Prepared Statement of the American Association of Colleges of Nursing
        As the national voice for baccalaureate and graduate nursing
    education, the American Association of Colleges of Nursing (AACN)
    represents 750 schools of nursing that educate over 450,000 students
    and employ more than 17,000 full-time faculty members. Collectively,
    these institutions produce approximately half of our Nation's
    Registered Nurses (RNs) and all nurse faculty, Advanced Practice
    Registered Nurses (APRNs), and nurse scientists. AACN requests that
    nursing education, research, and practice are strongly supported in
    fiscal year 2015 through an investment of $251 million for HRSA's
    Nursing Workforce Development programs (authorized under Title VIII of
    the Public Health Service Act [42 U.S.C. 296 et seq.]), $150 million
    for the National Institute of Nursing Research (NINR) within NIH, and
    $20 million in authorized funding for the Nurse-Managed Health Clinics
    (NMHCs) (Title III of the Public Health Service Act). These levels will
    ensure that our Nation's nurses are prepared to care for the growing
    number of patients requiring a complex range of healthcare services.
                            demand for nursing care
        The Bureau of Labor Statistics' (BLS) publication Employment
    Projections for 2012-2022 anticipates significant growth in the nursing
    workforce from 2.71 million in 2012 to 3.24 million by 2022. This surge
    in demand translates to 526,800 nurses, or an increase of 19.4 percent.
    When considering the number of job openings for RNs due to the
    increasing demand for nursing care and replacements in an aging nursing
    workforce, more than one million nurses will be needed by 2022. In
    fact, according to the The U.S. Nursing Workforce: Trends in Supply and
    Education released by HRSA in 2013, over the next 10 to 15 years, the
    nearly 1 million RNs older than age 50--about one-third of the current
    workforce--will reach retirement age. The retirement decisions of these
    experienced RNs may be influenced by the pace of economic recovery and
    have the potential to create a serious deficit in the nursing pipeline.
        Moreover, the BLS projects a need for 47,600 additional Nurse
    Practitioners, Certified Registered Nurse Anesthetists, and Certified
    Nurse-Midwives (or APRNs) to meet the call for more primary and acute
    care services, particularly due to the aging baby boomer population and
    increased access to health insurance coverage. The BLS' Occupational
    Outlook Handbook reported that there will be a 31 percent increase in
    this sector of the workforce between 2012-2022. Investments are
    necessary to educate the RNs and APRNs who will provide the care that
    Americans need now and in the future.
               title viii nursing workforce development programs
        For fifty years, the Nursing Workforce Development programs,
    authorized under Title VIII of the Public Health Service Act, have
    helped build the supply and distribution of qualified nurses to meet
    our Nation's healthcare needs. Between fiscal year 2006 and 2012 alone,
    the Title VIII programs supported over 450,000 nurses and nursing
    students, as well as numerous academic nursing institutions and
    healthcare facilities. The programs bolster nursing education at all
    levels, from entry-level preparation through graduate study, and
    provide support to educate nurses for practice in rural and medically
    underserved communities. Today, the Title VIII programs are essential
    to ensuring that the demand for nursing care is met by supporting
    future practicing nurses and the faculty who educate them.
        However, faculty vacancies have repeatedly been cited as a
    fundamental obstacle to maximizing nursing school enrollment. According
    to the American Association of Colleges of Nursing's 2013-2014
    Enrollment and Graduations in Baccalaureate and Graduate Programs in
    Nursing survey, 78,089 qualified applications were turned away from
    nursing schools in 2013 alone. A primary barrier to accepting all
    qualified students at nursing colleges and universities continues to be
    a shortage of faculty. To counter this disparity, the Title VIII Nurse
    Faculty Loan Program aids in increasing nursing school enrollment
    capacity by supporting students pursuing graduate education, provided
    they serve as faculty for 4 years after graduation.
        The Title VIII programs also increase the number of practicing
    nurses entering the pipeline and the placement of these nurses into
    medically-underserved areas. AACN's Title VIII Student Recipient
    Survey, which gathers information annually about Title VIII funding and
    outcomes related to nursing education and career trajectories, provides
    evidence on the effectiveness of these programs in recruiting more
    students to the nursing profession and, more importantly, practice in
    rural and underserved areas. Results of the 2013-2014 Title VIII
    Student Recipient Survey included responses from 850 students who noted
    that these programs played a critical role in funding their nursing
    education. The survey showed that for 67 percent of respondents, Title
    VIII funding impacted their decision to enter nursing school. Moreover,
    76 percent of the students receiving Title VIII funding are able to
    attend school full-time through this Federal support. By facilitating
    full-time education, the Title VIII programs are helping to ensure that
    students enter the workforce without delay. In addition, personal
    testimony of several survey respondents revealed that many Title VIII
    recipients intend to practice in the community in which they were
    educated--a direct State investment. AACN respectfully requests $251
    million for the Nursing Workforce Development programs authorized under
    Title VIII of the Public Health Service Act in fiscal year 2015.
       national institute of nursing research: advancing nursing science
        The healthcare community is investigating methods to improve the
    delivery of high-quality care in a financially sustainable manner. As
    one of the 27 Institutes and Centers at the NIH, the NINR is dedicated
    to providing the healthcare workforce with evidence-based knowledge and
    the resources needed to accomplish this goal. Research conducted at
    NINR addresses disease prevention and health promotion efforts that
    improve quality of life and alleviate financial burden on individuals
    and the system. Specific areas targeted by NINR include chronic illness
    management, disease prevention, pain management, and care-giver
    support. Nursing research is a critical compliment to biomedical
    research as it investigates how to prevent disease and promote healthy
    living. Moreover, research funded at NINR helps to integrate biology
    and behavior as well as design new technology and tools. At a time when
    healthcare needs are changing, nursing care must be firmly grounded in
    nursing science.
        NINR also allocates a generous 6 percent of its overall budget to
    the education and training of nurse researchers, many of whom dually
    serve as nurse faculty within our Nation's nursing schools. Increased
    investments must be made in the scientists that improve healthcare
    delivery through their groundbreaking discoveries. AACN respectfully
    requests $150 million for the NINR in fiscal year 2015.
             nurse-managed health clinics: expanding access to care
        Managed by APRNs and staffed by an interdisciplinary health
    provider team, NMHCs provide necessary primary care services to
    medically-underserved communities and serve as critical access points
    to keep patients out of the emergency room, saving the healthcare
    system millions of dollars annually. NMHCs provide care to vulnerable
    populations in a host of regions of the country, including rural
    communities, Native American reservations, senior citizen centers,
    elementary schools, and urban housing developments. These communities
    are the most susceptible to developing chronic illnesses that create
    heavy financial burdens on patients and the healthcare system. NMHCs
    aim to reduce disease and create healthier communities through improved
    patient education and health practices.
        Often associated with a school, college, university, department of
    nursing, federally qualified health center, or independent nonprofit
    healthcare agency, NMHCs also serve as clinical education training
    sites for students of nursing, medicine, physical therapy, social work,
    and ancillary healthcare services. Moreover, by serving as clinical
    training sites, NMHCs help foster interprofessional education and
    practice so that patients receive individualized care from an array of
    providers. According to AACN, the lack of clinical training sites is
    often pointed to as a top reason for turning away qualified
    applications in nursing programs. AACN respectfully requests $20
    million for the Nurse-Managed Health Clinics in fiscal year 2015.
        AACN recognizes that the Subcommittee and Congress will need to
    make difficult decisions regarding appropriations for fiscal year 2015.
    AACN respectfully requests Congress to continue a strong investment in
    the health of our Nation by providing $251 million for the Title VIII
    Nursing Workforce Development programs, $150 million for the National
    Institute of Nursing Research, and $20 million for Nurse-Managed Health
    Clinics in fiscal year 2015. If you have any questions, or if AACN can
    be of assistance, please contact AACN's Director of Government Affairs
    and Health Policy, Dr. Suzanne Miyamoto, at Smiyamoto@aacn.nche.edu.
                                     ______

         Prepared Statement of the American Association of Colleges of
                              Osteopathic Medicine
        The American Association of Colleges of Osteopathic Medicine
    (AACOM) strongly supports restoring funding for discretionary Health
    Resources and Services Administration (HRSA) programs to the fiscal
    year 2010 level of $7.48 billion; funding of $520 million for HRSA's
    Title VII and VIII programs under the Public Health Service Act; $10
    million minimally for the Teaching Health Center Graduate Medical
    Education (THCGME) Development Grants; sustainment of student
    scholarship and loan repayment programs; $4 million for the Rural
    Physician Training grants; $3 million for the National Health Care
    Workforce Commission; $32 billion for the National Institutes of Health
    (NIH); and $375 million in base discretionary funding, restoring the
    base to fiscal year 2011 levels for the Agency for Healthcare Research
    and Quality (AHRQ).
        AACOM represents the 30 accredited colleges of osteopathic medicine
    in the United States. These colleges are accredited to deliver
    instruction at 42 teaching locations in 28 States. In the 2013-2014
    academic year these colleges are educating over 23,000 future
    physicians--more than 20 percent of U.S. medical students. Six of the
    colleges are publicly controlled; 24 are private institutions.
        The Title VII health professions education programs, authorized
    under the Public Health Service Act and administered through HRSA,
    support the training and education of health practitioners to enhance
    the supply, diversity, and distribution of the healthcare workforce,
    acting as an essential part of the healthcare safety net and filling
    the gaps in the supply of health professionals not met by traditional
    market forces. Title VII and Title VIII nurse education programs are
    the only Federal programs designed to train clinicians in
    interdisciplinary settings to meet the needs of special and underserved
    populations, as well as increase minority representation in the
    healthcare workforce.
        As demand for health professionals increase in the face of
    impending shortages combined with faculty shortages across health
    professions disciplines, racial and ethnic disparities in healthcare, a
    growing, aging population, and the anticipated demand for increased
    access to care, these needs strain an already fragile healthcare
    system. AACOM appreciates the investments that have been made in these
    programs, and we urge the Subcommittee to fund $520 million for the
    Title VII and VIII programs to include support for the following
    programs in order to include: the Primary Care Training and Enhancement
    (PCTE) Program, the Health Careers Opportunity Program (HCOP), the
    Centers of Excellence (COE), the Geriatric Education Centers (GECs) and
    the Area Health Education Centers (AHECs). We strongly oppose the
    Administration's proposals to eliminate funding for AHECs and the HCOP.
        AACOM has serious concerns with the Administration's budget request
    that would cut nearly $15 billion from Medicare graduate medical
    education (GME). Because GME funding is critical to addressing the
    existing physician workforce shortage and ensuring patient access to
    our Nation's healthcare, AACOM believes that current GME funding should
    not be sacrificed and simply shifted to other healthcare workforce
    programs of importance. Instead, additional investments in GME are
    critical to an already insufficiently-funded system.
        AACOM strongly supports the continuation of the THCGME Program,
    which provides funding to support primary care medical and dental
    residents training in community-based settings. THCs currently train
    more than 350 medical and dental residents and are providing more than
    700,000 primary care visits in underserved rural and urban communities.
    This program will also provide long-term benefits. According to the
    HRSA, physicians who train in THCs are three times more likely to work
    in such centers and more than twice as likely to work in underserved
    areas as physicians who train in other settings. The THCGME Program's
    5-year authorization expires in fiscal year 2015, but the recruitment
    of new residents is being impacted now. We support an investment of $10
    million in fiscal year 2015 for development grants minimally.
        Through scholarships and loan repayment, the National Health
    Service Corps (NHSC) supports the recruitment and retention of primary
    care clinicians to practice in underserved communities. Approximately
    50 million Americans live in communities with a shortage of health
    professionals, lacking adequate access to primary care. The self-
    reported average medical education debt of graduates of colleges of
    osteopathic medicine who borrowed to attend medical school has
    increased by almost $85,000 in the last decade. Today, there are more
    than 23,000 students enrolled at osteopathic medical schools across the
    Nation. Recent graduates report graduating with an average medical
    education debt of $211,423.
        Today, there are nearly 8,900 NHSC members providing culturally
    competent care to more than 9.3 million people. Care is provided at
    5,100 NHSC-approved healthcare sites in urban, rural, and frontier
    areas. In addition to Corps providers currently providing care, nearly
    1,100 students, residents, and health providers receive scholarships or
    participate in the Student to Service Loan Repayment program to prepare
    to practice, which provides loan repayment assistance to medical
    students in their last year of education in return for their commitment
    to practice. AACOM appreciates the Administration's continued
    investment in the NHSC and strongly supports the preservation of
    student scholarship and loan repayment programs. Furthermore, we
    encourage congressional authorizers and appropriators to work together
    before current mandatory funding for the NHSC expires at the end of
    fiscal year 2015. This critical funding works to address the primary
    care workforce shortage and advances innovative models of service.
        HRSA's Rural Physician Training grants will help rural-focused
    training programs recruit and graduate students most likely to practice
    medicine in underserved rural communities. HRSA's Office of Rural
    Health Policy analyzes potential effects of policy on residents of
    rural communities and administers grant programs designed to build
    healthcare capacity at both the local and State levels. Health
    professions workforce shortages are exacerbated in rural areas, where
    communities struggle to attract and keep well-trained providers.
    According to HRSA, approximately 65 percent of primary care health
    professional shortage areas are rural. AACOM supports the President's
    fiscal year 2015 budget request of $4 million for the Rural Physician
    Training grants.
        The National Health Care Workforce Commission was designed to
    develop and evaluate training activities to meet demand for healthcare
    workers. Without funding, the Commission cannot identify barriers that
    may create and exacerbate workforce shortages and improve coordination
    on the Federal, State, and local levels. Having this type of
    coordinating body in place is becoming more critical as more Americans
    have insurance coverage and as the population ages, requiring access to
    care. As the United States struggles to address healthcare provider
    shortages in certain specialties and in rural and underserved areas,
    the country lacks a defined policy to address these critical. For these
    reasons, AACOM recommends that $3 million be appropriated to fund the
    Commission so it can begin its important work.
        Research funded by the NIH leads to important medical discoveries
    regarding the causes, treatments, and cures for common and rare
    diseases, as well as disease prevention. These efforts improve our
    Nation's health and save lives. To maintain a robust research agenda,
    further investment will be needed. AACOM recommends $32 billion for the
    NIH.
        In today's increasingly demanding and evolving medical curriculum,
    there is a critical need for more research geared toward evidence-based
    osteopathic medicine. AACOM believes that it is vitally important to
    maintain and increase funding for biomedical and clinical research in a
    variety of areas related to osteopathic principles and practice,
    including osteopathic manipulative medicine and comparative
    effectiveness. In this regard, AACOM encourages support for the NIH's
    National Center for Complementary and Alternative Medicine (NCCAM) to
    continue fulfilling this essential research role.
        AHRQ supports research to improve healthcare quality, reduce costs,
    advance patient safety, decrease medical errors, and broaden access to
    essential services. AHRQ plays an important role in producing the
    evidence base needed to improve our Nation's health and healthcare. The
    incremental increases for AHRQ's Patient Centered Health Research
    Program in recent years will help AHRQ generate more of this research
    and expand the infrastructure needed to increase capacity to produce
    this evidence; however, more investment is needed. AACOM recommends
    $375 million in base discretionary funding, restoring the base to
    fiscal year 2011 levels for the AHRQ. This investment will preserve
    AHRQ's current programs while helping to restore its critical
    healthcare safety, quality, and efficiency initiatives.
        AACOM is grateful for the opportunity to submit its views and looks
    forward to continuing to work with the Subcommittee on these important
    matters.
        [This statement was submitted by Stephen C. Shannon, D.O., M.P.H.,
    President and Chief Executive Officer, American Association of Colleges
    of Osteopathic Medicine.]
                                     ______

        Prepared Statement of the American Association of Immunologists
        The American Association of Immunologists (AAI), the world's
    largest professional society of research scientists and physicians who
    study the immune system, respectfully submits this testimony regarding
    fiscal year 2015 appropriations for the National Institutes of Health
    (NIH). AAI recommends an appropriation of at least $32 billion for NIH
    for fiscal year 2015 to support important ongoing research, fund a
    reasonable number of outstanding new grant applications, and restore
    NIH funding to a level that can sustain a robust and dynamic biomedical
    research enterprise in the United States.
              nih's crucial role in advancing biomedical research
        NIH is essential to the advancement of biomedical research in the
    United States, where virtually all biomedical scientists rely on NIH
    leadership and funding.\1\ Academic scientists, many of whom conduct
    research while teaching the next generation of doctors and scientists,
    depend on NIH grants to support their research at universities,
    colleges and research institutions all around the country. NIH
    intramural scientists require funding to do their own research as well
    as collaborate with their private sector colleagues.\2\ And scientists
    employed by industry, who generally do not receive NIH grants or
    awards, depend on NIH-funded scientific discoveries to develop products
    that bring research to the bedside. A strong NIH budget, therefore, is
    essential to all sectors of the U.S. biomedical research enterprise,
    and has enabled NIH to remain the key international leader influencing
    biomedical research around the globe.
    ---------------------------------------------------------------------------
        \1\ After a highly competitive peer review process, which includes
    comprehensive review by panels of extramural scientists, NIH awards
    more than 80 percent of its $30.1 billion budget to ``more than
    300,000 researchers at more than 2,500 universities, medical schools,
    and other research institutions in every State and around the world.''
    About 10 percent of its budget supports the work of the approximately
    6,000 scientists who work in NIH's own laboratories. (http://
    www.nih.gov/about/budget.htm).
        \2\ AAI is concerned that a Federal policy limits government
    scientists' ability to attend privately sponsored scientific meetings
    and conferences. (See http://www.hhs.gov/travel/policies/
    2012_policy_manual.pdf AAI believes that ``the rules have had an
    unintended and deleterious effect . . . [and] made government
    scientists feel cut off from the rest of the scientific community,
    wreaked havoc with their ability to fulfill professional commitments,
    and undermined the morale of some of the government's finest minds.''
    Testimony (Amended) of Lauren G. Gross, J.D., on behalf of The American
    Association of Immunologists (AAI), Submitted to the Senate Homeland
    Security and Governmental Affairs Committee for the Hearing Record of
    January 14, 2014: ``Examining Conference and Travel Spending Across the
    Federal Government'' (http://aai.org/Public_Affairs/Docs/2014/
    AAI_Testimony_to_Senate_HSGAC_01142014.pdf).
    ---------------------------------------------------------------------------
          nih budget woes slow research and threaten u.s. preeminence
        The slow growth of the NIH budget in recent years, exacerbated by
    the impact of biomedical research inflation,\3\ has significantly
    reduced NIH's purchasing power, and in turn, the purchasing power of
    its grantees. According to the Congressional Research Service (CRS),
    ``[i]n constant 2003 dollars, fiscal year 2014 funding is 22 percent
    lower than the fiscal year 2003 level.'' \4\ How many avenues of
    research have not been followed because of this reduction? How many
    potential treatments and cures have been delayed or not discovered?
    These are questions that cannot be answered definitively, but we do
    know that NIH budget reductions have already caused real and lasting
    damage: the loss of grant funding, even among the most highly qualified
    scientists; the closure of labs; the termination or interruption of
    important research; and the emigration of talented scientists to other
    countries. And we do know that many scientists are spending too much
    time in a constant chase for funding, rather than conducting research
    and mentoring the Nation's future researchers, inventors and
    innovators. These budget woes threaten America's preeminence in
    advancing basic biomedical research, discovering urgently needed
    treatments and cures, and ``growing'' brilliant young scientists.
    ---------------------------------------------------------------------------
        \3\ The Biomedical Research and Development Price Index (BRDPI)
    ``is developed each year for NIH by the Bureau of Economic Analysis of
    the Department of Commerce. It reflects the increase in prices of the
    resources needed to conduct biomedical research, including personnel,
    services, supplies, and equipment. It indicates how much the NIH budget
    must change to maintain purchasing power.'' Johnson, Judith A., ``A
    History of NIH Funding: Fact Sheet,'' Congressional Research Service,
    R43341, p. 2 (2014).
        \4\ Ibid.
    ---------------------------------------------------------------------------
    research on the immune system: essential to our health, crucial to our
                                     future
        The immune system is the body's primary defense against viruses,
    bacteria, and parasites that cause disease in millions of people every
    year. When the immune system is operating properly, it provides
    powerful protection against a wide variety of illnesses, including
    cancer, Alzheimer's disease, and cardiovascular disease. The immune
    system can, however, perform poorly, leaving the body vulnerable to
    infections, including influenza, HIV/AIDS, tuberculosis, malaria, and
    the common cold. It can also become overactive, damaging normal organs
    and tissues, and causing autoimmune diseases, such as allergy, asthma,
    inflammatory bowel disease, lupus, multiple sclerosis, rheumatoid
    arthritis, and type 1 diabetes. Research scientists and clinicians are
    working to harness this powerful system to protect people and animals
    from infectious diseases, cancer, and many other illnesses, and to
    protect against natural or man-made infectious organisms (including
    plague, smallpox and anthrax) that could be used for bioterrorism.\5\
    ---------------------------------------------------------------------------
        \5\ NIH should robustly fund and primarily rely on individual
    investigator-initiated research, in which researchers working in
    institutions across the Nation submit applications to, and following
    independent peer review, receive grants from, NIH. Biomedical
    innovation and discovery are less likely to be achieved through ``top-
    down'' science, in which the government specifies the type of research
    it wishes to fund.
    ---------------------------------------------------------------------------
          recent immunological advances and their promise for tomorrow
    1. Cancer Immunotherapies: Offering Hope of Conquering Cancer
        NIH-funded scientists recently identified inhibitory receptors
    which suppress immune cell activation. Blocking these receptors can
    allow the immune system to destroy tumor cells.\6\ Today, therapeutics
    targeted against inhibitory receptors like CTLA4 are undergoing
    rigorous clinical trials against a variety of cancers. The success
    rates for these therapies have been astounding and unprecedented: for
    example, rates of tumor regression in patients with metastatic melanoma
    have increased from 10 percent to 50 percent.\7\ With this level of
    success, immunotherapy is one of the most exciting and promising areas
    of cancer treatment.
    ---------------------------------------------------------------------------
        \6\ Couzin-Frankel, Jennifer. ``Cancer Immunotherapy.'' Science
    342.6165 (2013): 1432-433.
        \7\ Wolchok, J. D. et al. ``Nivolumab plus Ipilimumab in Advanced
    Melanoma.'' N Engl J Med 369.2 (2013): 122-33.
    ---------------------------------------------------------------------------
    2. Early Antiretroviral Therapy: Eliminating HIV, Ending AIDS?
        NIH-funded researchers have discovered that early administration of
    antiviral medication, known as anti-retroviral therapy (ART), can have
    lasting effects on an HIV-infected patient's long-term prognosis. In
    one study,\8\ an infant born to an HIV-infected mother began receiving
    ART within hours of birth. The infant tested positive for HIV and
    continued treatment for 18 months. Despite the HIV diagnosis and
    subsequent discontinuation of ART, the child remained virus-free 1 year
    later. A second baby with a similar history also showed an absence of
    HIV.\9\ Together with several additional unconfirmed cases of babies
    ``cured'' of HIV infection, these findings offer hope to the 250,000
    babies born each year infected with HIV.\10\
    ---------------------------------------------------------------------------
        \8\ Deborah, Persaud et al. ``Absence of Detectable HIV-1 Viremia
    after Treatment Cessation in an Infant.'' N Engl J Med 369 (2013):
    1828-835.
        \9\ Conference on Retroviruses and Opportunistic Infections, March
    3--6, 2014, Boston, MA (http://www. croi2014.org/) (See also http://
    www.nytimes.com/2014/03/06/health/second-success-raises-hope-for-a-way-
    to-rid-babies-of-hiv.html).
        \10\ A clinical trial following 60 babies born infected with HIV
    and being treated with antiretroviral medication will begin soon. (See
    http://www.nytimes.com/2014/03/06/health/second-success-raises-hope-
    for-a-way-to-rid-babies-of-hiv.html) A second study found that adult
    HIV-infected patients who were treated with ART within 4 months of
    infection display significantly improved response to treatment. [See
    Le, Tuan, et al. ``Enhanced CD4+ T-Cell Recovery with Earlier HIV-1
    Antiretroviral Therapy.'' N Engl J Med 368 (2013): 218-30].
    ---------------------------------------------------------------------------
    3. Gut (Intestinal) Bacteria: The Microbiome Role in Autoimmune Disease
        NIH-funded research has shown that gut bacteria (the intestinal
    ``microbiome''), which aid in food digestion, may impact the
    development of autoimmune diseases, including rheumatoid arthritis,
    type 1 diabetes, multiple sclerosis and inflammatory bowel
    disorders.\11\ Current research is exploring changes in gut bacteria
    from diet, hormones, antibiotics, and infections, and the effect of gut
    bacteria based therapeutics [for example, the ingestion of healthy gut
    bacteria (probiotics) in yogurt]. One study involving fecal
    transplantation (which includes the transfer of intestinal bacteria
    from one person to another) has found that such transplantation in pill
    form is well tolerated and is 98-100 percent efficacious in curing
    infections with Clostridium difficile, a bacterium linked to 14,000
    diarrheal deaths in the U.S. per year.\12\
    ---------------------------------------------------------------------------
        \11\ Sorini, C., and M. Falcone. ``Shaping the (auto)immune
    Response in the Gut: The Role of Intestinal Immune Regulation in the
    Prevention of Type 1 Diabetes.'' Am J Clin Exp Immunol 2.2 (2013): 156-
    71.
        \12\ Infectious Diseases Society of America. ``Fecal Transplant
    pill knocks out recurrent C. diff infection,'' Science Daily (2013)
    (See http://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html).
    ---------------------------------------------------------------------------
    4. RSV Vaccine: Saving Infants' Lives
        Millions of infants are hospitalized and 160,000 children die each
    year each from pneumonia and other lung diseases caused by respiratory
    syncytial virus (RSV).\13\ Until recently, however, a vaccine for RSV
    has been elusive. In an important breakthrough, scientists at the NIH
    discovered antibodies--protective molecules produced by the immune
    system--that helped identify a key protein for use in vaccine
    development.\14\ The NIH scientists were then able to engineer this
    protein and demonstrate its ability to produce a strong protective
    immune response against RSV in animals.\15\ This molecule is expected
    to be ready soon for testing in humans. Importantly, the approach
    developed in this case can be applied to vaccine design for numerous
    other viruses, such as HIV, hepatitis C, dengue, and West Nile viruses,
    that have evaded the body's protective immune responses, and will
    provide insight into how viruses evade the immune system.
    ---------------------------------------------------------------------------
        \13\ Couzin-Frankel, Jennifer. ``Cancer Immunotherapy.'' Science
    342.6165 (2013): 1432-433.
        \14\ McLellan, J. S. et al. ``Structure of RSV Fusion Glycoprotein
    Trimer Bound to a Pre-fusion Specific Neutralizing Antibody.'' Science
    340.6136 (2013): 1113-117.
        \15\ McLellan, J. S. et al. ``Structure-Based Design of a Fusion
    Glycoprotein Vaccine for Respiratory Syncytial Virus.'' Science
    342.6158 (2013): 592-98.
    ---------------------------------------------------------------------------
                                   conclusion
        AAI thanks the members and staff of the subcommittee for their
    ongoing, strong bipartisan support for biomedical research, and
    recommends an appropriation of at least $32 billion for NIH for fiscal
    year 2015 to fund important ongoing research, strengthen the biomedical
    research enterprise, and ensure that the brightest scientists,
    trainees, and students are able to pursue careers in biomedical
    research in the United States.

        [This statement was submitted by Elizabeth J. Kovacs, Ph.D.,
    American Association of Immunologists.]
                                     ______

      Prepared Statement of the American Association of Nurse Anesthetists

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

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

        [This statement was submitted by Dennis Bless, CRNA, MS, President,
    American Association of Nurse Anesthetists.]
                                     ______

     Prepared Statement of the American Association of Nurse Practitioners
        On behalf of the American Association of Nurse Practitioners
    (AANP), the largest full service professional organization representing
    the 189,000 nurse practitioners across the country, we would like to
    submit the below noted funding requests for fiscal year 2015. Nurse
    Practitioners (NPs) have been providing primary, acute, and specialty
    healthcare to patients of all ages for nearly half a century. As you
    know, in addition to treating acute and chronic illnesses of patients
    coming to them for care, they emphasize health promotion and disease
    prevention in all their undertakings. This includes assessments,
    ordering, performing, supervising and interpreting diagnostic and
    laboratory tests, making diagnoses, initiating and managing treatment
    which includes prescribing medications as well as non-pharmacologic
    treatments, counselling and educating patients, their families and
    communities. They are the healthcare providers of choice for millions
    of patients; in fact last year they conducted over 900 million patient
    visits across the Nation.
        The vast majority of nurse practitioners throughout the United
    States are primary care providers. Eighty 8 percent are prepared to be
    primary care clinicians and nearly seventy percent are currently
    practicing in a primary care setting. As clinicians that blend clinical
    expertise in diagnosing and treating health conditions with an added
    emphasis on disease prevention and health promotion, NPs bring a
    comprehensive perspective to healthcare that enhances health and well-
    being among their patients. Given the demand for primary care
    providers, NPs are and will continue to fill a critical role in the
    American healthcare system. Likewise the need to create and fund more
    nurse managed clinics is critical. As the need for primary care
    services grows, funding such clinics becomes increasingly necessary.
    The need to adequately prepare nurse practitioners and facilitate the
    high quality outcomes of these clinics is clear. Equally clear is the
    need for funding assistance to nurse practitioner educational programs,
    students and nurse managed clinics. We are anxious to include among our
    ranks, students who would not be able to enter our programs without
    assistance as well as clinic sites that serve as clinical education
    sites and meet the unmet healthcare needs of a wide variety of
    populations throughout the country. Therefore we ask that at the very
    least the following funding be appropriated:
        For fiscal year 2015, AANP respectfully requests $251 million for
    the Health Resources and Services Administration's (HRSA) Nursing
    Workforce Development programs (authorized under Title VIII of the
    Public Health Service Act [42 U.S.C. 296 et seq.]), $150 million for
    the National Institute of Nursing Research (NINR) within the National
    Institutes of Health (NIH), and $20 million in authorized funding for
    the Nurse-Managed Health Clinics (Title III of the Public Health
    Service Act). These investments made through the appropriation process
    will help to ensure that our Nation's population receives high quality,
    cost effective healthcare.
        AANP would like to work closely with the committee on areas of
    common interest. We are happy to serve as a resource to the committee
    as you make decisions about these investments. We thank you for the
    opportunity to share our concerns with you and look forward to
    continuing to work with you and your staff on issues affecting our
    profession. Please contact AANP's Federal Government Affairs department
    at: governmentaffairs@aanp.org should you have any questions or need
    further information.
                                     ______

       Prepared Statement of the American Congress of Obstetricians and
                                 Gynecologists
        The American Congress of Obstetricians and Gynecologists (ACOG),
    representing 58,000 physicians and partners in women's healthcare, is
    pleased to offer this statement to the Senate Committee on
    Appropriations, Subcommittee on Labor, Health and Human Services, and
    Education. We thank Chairman Harkin, and the entire Subcommittee for
    the opportunity to provide comments on some of the most important
    programs to women's health.
        Today, the U.S. lags behind many other Nations in healthy births.
    ACOG's Making Obstetrics and Maternity Safer (MOMS) Initiative would
    help improve maternal and infant health through Federal research
    investments, including comprehensive data collection and surveillance,
    biomedical research, and translating research into evidence-based care
    for women and babies. We urge you to make funding of the following
    programs and agencies a top priority in fiscal year 2015.
    Data Collection and Surveillance at the Centers for Disease Control and
            Prevention (CDC)
        In order to conduct robust research, uniform, accurate and
    comprehensive data and surveillance are critical. The National Center
    for Health Statistics is the Nation's principal health statistics
    agency and collects State data from records like birth certificates
    that give us raw, vital statistics. Information from birth and death
    certificates is key to gathering vital information about both mother
    and baby during pregnancy and labor and delivery. Uniform, accurate
    data collection depends on all States and territories using electronic
    birth and death records based on the 2003 US-standard birth and death
    certificates, yet 4 States are still not using the electronic birth
    registries and 12 States are still not using the electronic death
    registries.
        States not using the standard records likely underreport maternal
    and infant deaths and complications from childbirth; causes of these
    deaths remain unknown. Previous appropriations have helped increase the
    number of States using electronic birth and death registries, but NCHS
    needs increased resources to help enroll the remaining States, and to
    improve the accuracy of birth and death data, including through linking
    data from Electronic Health Records to State vital records systems. For
    fiscal year 2015, ACOG requests $182 million for the National Center
    for Health Statistics, $5 million of which we urge you to designate to
    modernize the National Vitals Statistics System, helping States update
    their birth and death records systems.
        The Pregnancy Risk Assessment Monitoring System (PRAMS) at CDC
    extends beyond vital statistics and surveys new mothers on their
    experiences and attitudes during pregnancy, with questions on a range
    of topics, including what their insurance covered, whether they had
    stressful experiences during pregnancy, when they initiated prenatal
    care, and what kinds of questions their doctor covered during prenatal
    care visits. By identifying trends and patterns in maternal health, CDC
    researchers and State health departments are better able to identify
    behaviors and environmental and health conditions that may lead to
    preterm births. Only 40 States use the PRAMS surveillance system today.
    ACOG requests adequate funding to expand PRAMS to all U.S. States and
    territories.
    Biomedical Research at the National Institutes of Health (NIH)
        Biomedical research is critically important to understanding the
    causes of maternal and infant mortality and morbidity, and developing
    effective interventions to lower the incidence of mortality and
    morbidity. The National Institute on Child Health and Human
    Development's (NICHD's) 2012 Scientific Vision identified the most
    promising research opportunities for the next decade. Goals include
    determining the complex causes of prematurity and developing evidence-
    based measures for its prevention within the next 10 years,
    understanding the long term health implications of assisted
    reproductive technology, and understanding the role of the placenta in
    fetal health outcomes. The placenta, one of the least studied human
    organs, is essential to the viability and proper growth of the fetus.
    NICHD's Human Placenta Project will help discover the causes of
    placental failures, and ultimately ways to prevent failure and improve
    maternal and fetal birth outcomes.
        Another major issue that merits attention is that of clinical
    trials involving pregnant women. Pregnant women have historically been
    excluded from most research trials due to concern that trial
    participation could harm the fetus. Although there has been substantial
    progress in the inclusion of women in federally funded research,
    pregnant women are still excluded, even from research that would
    advance our knowledge of medical conditions and treatments in
    pregnancy. Mindful of the important considerations of clinical trials
    on pregnant women, we support establishment of a Federal work group to
    propose how clinical research might be done appropriately in this area.
        Adequate levels of research require a robust research workforce.
    The years of training combined with uncertainty in getting grant
    funding are huge disincentives for students considering a career in
    bio-medical research. This has resulted in a huge gap between the too-
    few women's reproductive health researchers being trained and the
    immense need for research. We urge continued investments in the Women's
    Reproductive Health Research (WRHR) Career Development program,
    Reproductive Scientist Development Program (RSDP), and the Building
    Interdisciplinary Research Careers in Women's Health (BIRCWH) programs
    to address the shortfall of women's reproductive health researchers.
    ACOG supports a minimum of $32 billion for NIH and $1.37 billion within
    that funding request for NICHD in fiscal year 2015.
    Public Health Programs at the Health Resources and Services
            Administration (HRSA) and the Centers for Disease Control and
            Prevention (CDC):
        Projects at HRSA and CDC are integral to translating research
    findings into evidence-based practice changes in communities. Where NIH
    conducts research to identify causes of maternal and infant mortality
    and morbidity, CDC and HRSA help ensure those research findings lead to
    improved maternal and infant health outcomes.
        Maternal Child Health Block Grant (HRSA): The Maternal Child Health
    Block Grant at HRSA is the only Federal program that exclusively
    focuses on improving the health of mothers and children. State and
    territorial health agencies and their partners use MCH Block Grant
    funds to reduce infant mortality, deliver services to children and
    youth with special healthcare needs, support comprehensive prenatal and
    postnatal care, screen newborns for genetic and hereditary health
    conditions, deliver childhood immunizations, and prevent childhood
    injuries.
        These early healthcare services help keep women and children
    healthy, eliminating the need for later costly care. Every $1 spent on
    preconception care for a woman with diabetes can save up to $5.19 by
    preventing costly complications. Over $90 million has been cut from the
    Block Grant since 2003. ACOG requests $639 million for the Block Grant
    in fiscal year 2015 to maintain its current level of services.
        Title X Family Planning Program (HRSA): Family planning and
    interconception care are essential to helping ensure healthy women and
    healthy pregnancies. The Title X Family Planning Program provides
    services to more than 5 million low income men and women who may not
    otherwise have access to these services. Title X clinics accounting for
    $3.4 billion in healthcare savings in 2008 alone. ACOG supports $327
    million for Title X in fiscal year 2015 to sustain its level of
    services.
        Fetal Infant Mortality Review (HRSA): HRSA's Healthy Start Program
    promotes community-based programs to reduce infant mortality and racial
    disparities. These programs are encouraged to use the Fetal and Infant
    Mortality Review (FIMR) which brings together ob-gyn experts and local
    health departments to address local issues contributing to infant
    mortality. Today, more than 220 local programs in 42 States find FIMR a
    powerful tool to help reduce infant mortality and address issues
    related to preterm delivery. For over 20 years, ACOG has partnered with
    the Maternal and Child Health Bureau to sponsor the National FIMR
    Program. ACOG supports $0.5 million in fiscal year 2015 for HRSA to
    increase the number of Healthy Start programs that use FIMR.
        Maternal Health Initiative (HRSA): The Maternal Child Health Bureau
    launched the Maternal Health Initiative to foster the notion of
    ``healthy moms make healthy babies.'' As part of this effort, ACOG has
    convened the National Partnership on Maternal Safety to identify key
    factors to reduce maternal morbidity and mortality. ACOG requests at a
    minimum level funding for MCHB to advance this important work.
        Safe Motherhood, Maternity and Perinatal Collaboratives (CDC): The
    Safe Motherhood Initiative at CDC works with State health departments
    to collect information on pregnancy-related deaths, track preterm
    births, and improve maternal outcomes. Through Safe Motherhood, CDC
    funds State-based Maternity and Perinatal Collaboratives that improve
    birth outcomes by encouraging use of evidence-based care, including
    reducing early elective deliveries. Through the Ohio Perinatal Quality
    Collaborative, started in 2007 with funding from CDC, 21 OB teams in 25
    hospitals have significantly decreased early non-medically necessary
    deliveries, in accordance with ACOG guidelines, reducing costly and
    dangerous pre-term births. Avalere estimated that reducing early
    elective can save from $2.4 million to $9 million a year. The PREEMIE
    Reauthorization Act, enacted in 2013, authorizes funding to increase
    the number of States receiving assistance for perinatal collaboratives.
    ACOG urges you to re-instate the pre-term birth sub-line as authorized
    by PREEMIE and provide an additional $16 million to Safe Motherhood to
    implement PREEMIE and help States expand or establish maternity
    perinatal care collaboratives.
        Again, we would like to thank the Committee for commitment to
    improving women's health, and we urge you to fund programs we've
    identified in our MOMS Initiative in fiscal year 2015.
                                     ______

            Prepared Statement of the American College of Physicians
        The American College of Physicians (ACP) is pleased to submit the
    following statement for the record on its priorities, as funded under
    the U.S. Department of Health & Human Services, for fiscal year 2015.
    ACP is the largest medical specialty organization and the second-
    largest physician group in the United States. ACP members include
    137,000 internal medicine physicians (internists), related
    subspecialists, and medical students. Internal medicine physicians are
    specialists who apply scientific knowledge and clinical expertise to
    the diagnosis, treatment, and compassionate care of adults across the
    spectrum from health to complex illness. As the Subcommittee begins
    deliberations on appropriations for fiscal year 2015, ACP is urging
    funding for the following proven programs to receive appropriations
    from the Subcommittee:
      --Title VII, Section 747, Primary Care Training and Enhancement, at
            no less than $71 million;
      --National Health Service Corps, $810 million in funding, including
            the $310 million in enhanced funding through the Community
            Health Centers Fund;
      --National Health Care Workforce Commission, $3 million;
      --Agency for Healthcare Research and Quality, $375 million; and
      --Centers for Medicare and Medicaid Services, Program Management for
            Marketplaces, $629 million.
        The United States is facing a growing shortage of physicians in key
    specialties, most notably in general internal medicine and family
    medicine--the specialties that provide primary care to most adult and
    adolescent patients. With enactment of the Affordable Care Act (ACA),
    we expect the demand for primary care services to increase with the
    addition of 25 million Americans receiving access to health insurance,
    including an additional 13 million under Medicaid/CHIP, once the law is
    fully implemented. With increased demand, current projections indicate
    there will be a shortage of over 45,000 primary care physicians by
    2020, growing to a shortage of over 65,000 primary care physicians by
    2025. (AAMC Center for Workforce Studies with the Lewin Group. The
    Impact of Health Care Reform on the Future Supply and Demand of
    Physicians Updated Projections Through 2025. June 2010. Accessed at:
    https://www.aamc.org/download/158076/data/updated_projections_through_
    2025.pdf). Without critical funding for vital workforce programs, this
    physician shortage will only grow worse. A strong primary care
    infrastructure is an essential part of any high-functioning healthcare
    system, with over 100 studies showing primary care is associated with
    better outcomes and lower costs of care (http://www.acponline.org/
    advocacy/where_we_stand/policy/primary_shortage.pdf).
        The health professions' education programs, authorized under Title
    VII of the Public Health Service Act and administered through the
    Health Resources and Services Administration (HRSA), support the
    training and education of healthcare providers to enhance the supply,
    diversity, and distribution of the healthcare workforce, filling the
    gaps in the supply of health professionals not met by traditional
    market forces, and are critical in helping institutions and programs
    respond to the current and emerging challenges of ensuring that all
    Americans have access to appropriate and timely health services. Within
    the Title VII program, we urge the Subcommittee to fund the Section
    747, Primary Care Training and Enhancement program at $71 million, in
    order to maintain and expand the pipeline for individuals training in
    primary care. The Section 747 program is the only source of Federal
    training dollars available for general internal medicine, general
    pediatrics, and family medicine. For example, general internists, who
    have long been at the frontline of patient care, have benefitted from
    Title VII training models emphasizing interdisciplinary training that
    have helped prepare them to work with other health professionals, such
    as physician assistants, patient educators, and psychologists. Without
    a substantial increase in funding, for the fourth year in a row, HRSA
    will not be able to carry out a competitive grant cycle for physician
    training; the Nation needs new initiatives supporting expanded training
    in multi-professional care, the patient-centered medical home, and
    other new competencies required in our developing health system.
        The College urges $810 million in funding for the National Health
    Service Corps (NHSC), as requested in the President's fiscal year 2015
    budget; this amount includes the $310 million in enhanced funding the
    Health and Human Services Secretary has been given the authority to
    provide to the NHSC through the Community Health Centers Fund. Since
    the enactment of the ACA, the NHSC has awarded over $1 billion in
    scholarships and loan repayment to healthcare professionals to help
    expand the country's primary care workforce and meet the healthcare
    needs of underserved communities across the country. With field
    strength of nearly 9,000 clinicians, NHSC members are providing
    culturally competent care to more than 10.4 million people at nearly
    14,000 NHSC-approved healthcare sites in urban, rural, and frontier
    areas. The increase in funds would expand NHSC field strength to 15,000
    and would serve the needs of more than 16 million patients, helping to
    address the health professionals' workforce shortage and growing
    maldistribution. The programs under NHSC have proven to make an impact
    in meeting the healthcare needs of the underserved, and with increased
    appropriations, they can do more.
        We urge the Subcommittee to fully fund the National Health Care
    Workforce Commission, as authorized by the ACA, at $3 million. The
    Commission is authorized to review current and projected healthcare
    workforce supply and demand and make recommendations to Congress and
    the Administration regarding national healthcare workforce priorities,
    goals, and polices. Members of the Commission have been appointed, but
    have not begun work due to a lack of funding. The College believes the
    Nation needs a comprehensive workforce policy founded on sound research
    to determine the Nation's current and future needs for physicians by
    specialty and geographic areas; the work of the Commission is
    imperative to ensure Congress is creating the best policies for our
    Nation's needs.
        The Agency for Healthcare Research and Quality (AHRQ) is the
    leading public health service agency focused on healthcare quality.
    AHRQ's research provides the evidence-based information needed by
    consumers, clinicians, health plans, purchasers, and policymakers to
    make informed healthcare decisions. The College is dedicated to
    ensuring AHRQ's vital role in improving the quality of our Nation's
    health and recommends a budget of $375 million. This amount will allow
    AHRQ to help providers help patients by making evidence-informed
    decisions, fund research that serves as the evidence engine for much of
    the private sector's work to keep patients safe, make the healthcare
    market place more efficient by providing quality measures to health
    professionals, and ultimately, help transform health and healthcare.
        Finally, ACP supports $629 million in funding for the Centers for
    Medicare and Medicaid Services, Program Management for Marketplaces as
    requested in the President's fiscal year 2015 budget in order to carry
    out its duties as necessary. Such funding would allow the Federal
    Government to continue to administer the insurance marketplaces as
    authorized by the ACA if a State has declined to establish an exchange
    that meets Federal requirements. CMS now manages and operates some or
    all marketplace activities in over 30 States. If the Subcommittee
    decides to deny the requested funds, it will be much more difficult for
    the Federal Government to operate and manage a federally-facilitated
    exchange in those States, raising questions about where and how their
    residents would obtain and maintain coverage. It is ACP's belief that
    all legal Americans--regardless of income level, health status, or
    geographic location--must have access to affordable health insurance.
        In conclusion, the College is keenly aware of the fiscal pressures
    facing the Subcommittee today, but strongly believes the United States
    must invest in these programs in order to achieve a high performance
    healthcare system and build capacity in our primary care workforce and
    public health system. The College greatly appreciates the support of
    the Subcommittee on these issues and looks forward to working with
    Congress as you begin to work on the fiscal year 2015 appropriations
    process.
                                     ______

       Prepared Statement of the American College of Preventive Medicine
        The American College of Preventive Medicine (ACPM) urges the Senate
    Labor, Health and Human Services, Education, and Related Agencies
    Appropriations Subcommittee to reaffirm its support for training
    preventive medicine physicians and other public health professionals by
    providing $10 million in fiscal year 2015 for preventive medicine
    residency training under the public health and preventive medicine line
    item in Title VII of the Public Health Service Act. We further
    respectfully request that funds allocated for ``public health and
    preventive medicine'' be separated into two distinct line items, with
    separation of funds for preventive medicine residency training from
    other funds allocated to the ``public health and preventive medicine''
    line-item. In conjunction, ACPM also supports the recommendation of the
    Health Professions and Nursing Education Coalition of $520 million in
    fiscal year 2015 to support all health professions and nursing
    education and training programs authorized under Titles VII and VIII of
    the Public Health Service Act.
        In today's healthcare environment, the tools and expertise provided
    by preventive medicine physicians play an integral role in ensuring
    effective functioning of our Nation's public health system. These tools
    and skills include the ability to deliver evidence-based clinical
    preventive services, expertise in population-based health sciences, and
    knowledge of the social and behavioral determinants of health and
    disease. These are the tools employed by preventive medicine physicians
    who practice at the health system level where improving the health of
    populations, enhancing access to quality care, and reducing the costs
    of medical care are paramount. As the body of evidence supporting the
    effectiveness of clinical and population-based interventions continues
    to expand, so does the need for specialists trained in preventive
    medicine.
        Organizations across the spectrum have recognized the growing
    demand for preventive medicine professionals. The Institute of Medicine
    released a report in 2007 calling for an expansion of preventive
    medicine training programs by an ``additional 400 residents per year,''
    and the Accreditation Council on Graduate Medical Education (ACGME)
    recommends increased funding for preventive medicine residency training
    programs. Additionally, the Association of American Medical Colleges
    released statements in 2011 that stressed the importance of
    incorporating behavioral and social sciences in medical education as
    well as announcing changes to the Medical College Admission Test that
    would test applicants on their knowledge in these areas. Such measures
    strongly indicate increasing recognition of the need to take a broader
    view of health that goes beyond just clinical care--a view that is a
    unique focus and strength of preventive medicine residency training.
        In fact, preventive medicine is the only one of the 24 medical
    specialties recognized by the American Board of Medical Specialties
    that requires and provides training in both clinical and population-
    based medicine. Preventive medicine residency training programs provide
    a blueprint on how to train our future physician workforce; physicians
    trained to zoom in on individual patient care needs and zoom out to the
    community and population level to identify and treat the social
    determinants of health. Preventive medicine physicians have the
    training and expertise to advance the population health outcomes that
    public and private payers are increasingly promoting to their
    providers. These physicians have a strong focus on quality care
    improvement and are at the forefront of efforts to integrate primary
    care and public health.
        According to the Health Resources and Services Administration
    (HRSA) and health workforce experts, there are personnel shortages in
    many public health occupations, including epidemiologists,
    biostatisticians, and environmental health workers among others.
    According to the 2012 Physician Specialty Data Book released by the
    Association of American Medical Colleges, preventive medicine had one
    of the biggest decrease (-25 percent) in the number of first-year ACGME
    residents and fellows between 2005 and 2010. ACPM is deeply concerned
    about the shortage of preventive medicine-trained physicians and the
    ominous trend of even fewer training opportunities. This deficiency in
    physicians trained to carry out core public health activities will lead
    to major gaps in the expertise needed to deliver clinical prevention
    and community public health. The impact on the health of those
    populations served by HRSA may be profound.
        Despite being recognized as an underdeveloped national resource and
    in shortage for many years, physicians training in the specialty of
    Preventive Medicine are the only medical residents whose graduate
    medical education (GME) costs are not supported by Medicare, Medicaid
    or other third party insurers. Training occurs outside hospital-based
    settings and therefore is not financed by GME payments to hospitals.
    Both training programs and residency graduates are rapidly declining at
    a time of unprecedented national, State, and community need for
    properly trained physicians in public health and disaster preparedness,
    prevention-oriented practices, quality improvement, and patient safety.
        Currently, residency programs scramble to patch together funding
    packages for their residents. Limited stipend support has made it
    difficult for programs to attract and retain high-quality applicants.
    Support for faculty and tuition has been almost non-existent. Directors
    of residency programs note that they receive many inquiries about and
    applications for training in preventive medicine; however, training
    slots often are not available for those highly qualified physicians who
    are not directly sponsored by an outside agency or who do not have
    specific interests in areas for which limited stipends are available
    (such as research in cancer prevention).
        HRSA--as authorized in Title VII of the Public Health Service Act--
    is a critical funding source for several preventive medicine residency
    programs, as it represents the largest Federal funding source for these
    programs. HRSA funding ($3.8 million in fiscal year 2014) currently
    supports only 55 preventive medicine residents across 8 residency
    training programs. An increase of roughly $6 million will allow HRSA to
    support nearly 120 new preventive medicine residents.
        Of note, the preventive medicine residency programs directly
    support the mission of the HRSA health professions programs by
    facilitating practice in underserved communities and promoting training
    opportunities for underrepresented minorities:
      --Thirty-five percent of HRSA-supported preventive medicine graduates
            practice in medically underserved communities, a rate of almost
            3.5 times the average for all health professionals. These
            physicians are meeting a critical need in these underserved
            communities.
      --Nearly one in five preventive medicine residents funded through
            HRSA programs are under-represented minorities, which is almost
            twice the average of minority representation among all health
            professionals.
      --Fourteen percent of all preventive medicine residents are under-
            represented minorities, the largest proportion of any medical
            specialty.
        In addition to training under-represented minorities and generating
    physicians who work in medically underserved areas, preventive medicine
    residency programs equip our society with health professionals and
    public health leaders who possess the tools and skills needed in the
    fight against the chronic disease epidemic that is threatening the
    future of our Nation's health and prosperity. Correcting the root
    causes of this critical problem of chronic diseases will require a
    multidisciplinary approach that addresses issues of access to
    healthcare; social and environmental influences; and behavioral
    choices. ACPM applauds the initiation of programs such as the Community
    Transformation Grant that take this broad view of the determinants of
    chronic disease. However, any efforts to strengthen the public health
    infrastructure and transform our communities into places that encourage
    healthy choices must include measures to strengthen the existing
    training programs that help produce public health leaders.
        Many of the leaders of our Nation's local and State health
    departments are trained in preventive medicine. Their unique
    combination of expertise in both medical knowledge and public health
    makes them ideal choices to head the fight against chronic disease as
    well as other threats to our Nation's health. Their contributions are
    invaluable. Investing in the residency programs that provide physicians
    with the training and skills to take on these leadership positions is
    an essential part of keeping Americans healthy and productive. As such,
    the American College of Preventive Medicine urges the Labor, Health and
    Human Services, Education, and Related Agencies Appropriations
    Subcommittee to reaffirm its support for training preventive medicine
    physicians and other public health professionals by providing $10
    million in fiscal year 2015 for preventive medicine residency training
    under the public health and preventive medicine line item in Title VII
    of the Public Health Service Act.
                                     ______

            Prepared Statement of the American College of Radiology
        The American College of Radiology (ACR)--a professional
    organization serving more than 35,000 radiologists, radiation
    oncologists, interventional radiologists, nuclear medicine physicians,
    and medical physicists--recommends increased funding for the National
    Institutes of Health (NIH) in fiscal year 2015 appropriations
    legislation. Specifically, the ACR endorses the position of the Ad Hoc
    Group for Medical Research--a coalition of more than 300 patient and
    voluntary health groups, medical and scientific societies, academic and
    research organizations, and industry--that NIH receive at least $32
    billion in fiscal year 2015 as the next step toward a multi-year
    increase in our Nation's investment in medical research. That
    recommended funding level is approximately $1.874 billion above the
    President's Budget request for fiscal year 2015. Additionally, the ACR
    joins the Ad Hoc Group in urging Congress and the Administration to
    work in a bipartisan manner to end sequestration and the continued cuts
    to medical research that squander invaluable scientific opportunities,
    discourage young scientists, jeopardize our economic future, and
    threaten medical progress and continued improvements in our Nation's
    health.
        The value of the NIH to American taxpayers is immeasurable, and
    there have been several recent examples of impactful science in the
    biomedical imaging domain that would not have been realized and
    translated swiftly into patient care without NIH support and
    involvement. For instance, the NIH National Cancer Institute's (NCI)
    nearly decade-long National Lung Screening Trial--conducted by the
    American College of Radiology Imaging Network (ACRIN) and Lung
    Screening Study group--found that computed tomography (CT) screening of
    high risk patients could reduce deaths from lung cancer by 20 percent
    versus chest X-ray screening. Another NCI-supported success, the
    National CT Colonography Trial--also conducted by ACRIN--found that
    virtual colonoscopy was effective as a screening method for colorectal
    cancer thanks to its accuracy, safety, cost-effectiveness, and patient
    acceptability compared to more invasive and potentially intimidating
    screening options. The Radiation Therapy Oncology Group (RTOG) now a
    member of the NRG Oncology Group in the new National Clinical Trials
    Network (NCTN), is the international leader in investigating the
    appropriateness of advanced technologies such as proton therapy and
    intensity modulated radiation therapy (IMRT) in multi-center randomized
    trials examining the safety, effectiveness, and quality of life
    implications of these treatments. Additional ACRIN (now ECOG-ACRIN in
    the NCTN) and NRG activities under NCI's purview promise to advance the
    areas of personalized early cancer detection, identify biomarkers to
    predict treatment effectiveness, reduce the rate of false-positive
    imaging examinations, and improve cancer screening outcomes. However,
    NCI's funding of cooperative groups in the evolved National Clinical
    Trials Network (NCTN) has been severely cut and the groups' planned
    budgets are considerably below expectations. We urge Congress to
    restore the full funding approved by the NCI's Board of Scientific
    Advisors for the organizations that transitioned from the cooperative
    group program into the new NCTN.
        Although smaller than NCI, the NIH National Institute of Biomedical
    Imaging and Bioengineering (NIBIB) has likewise been successful in
    advancing the science behind evolving biomedical imaging technologies
    and techniques. The ACR played a key role in NIBIB's creation through
    co-founding a coalition of likeminded organizations and working with
    Federal policymakers to successfully advance the establishing
    legislation in 2000. Since its inception, NIBIB has been particularly
    effective in supporting training initiatives, educational symposia, and
    international collaborations, as well as fostering future generations
    of biomedical imaging and bioengineering scientists via innovative
    initiatives and communications.
        Without significantly increased funding levels for NIH in fiscal
    year 2015 and beyond, America's leadership in biomedical research will
    decline, scientists will be increasingly discouraged by the lack of
    funding opportunities, and innovative technologies and techniques (such
    as those supported through NCI and NIBIB) will not be appropriately
    researched and translated into patient care. Therefore, the ACR
    endorses the Ad Hoc Group for Medical Research's recommendation that
    NIH receive at least $32 billion in fiscal year 2015 as part of a
    multi-year increase, and that Congress and the Administration work
    together to decisively end sequestration.
        Thank you for your consideration.

        [This statement was submitted by Gloria R. Romanelli, JD, Senior
    Director of Legislative and Regulatory Relations, and Michael Peters,
    Director of Legislative and Regulatory Affairs.]
                                     ______

        Prepared Statement of the American Dental Education Association
        The American Dental Education Association (ADEA), on behalf of all
    65 U.S. dental schools, 700 dental residency training programs, nearly
    600 allied dental programs, as well as more than 12,000 faculty who
    educate and train the nearly 50,000 students and residents attending
    these institutions, submits this statement for the record and for your
    consideration as you begin to prioritize fiscal year 2015 appropriation
    requests. ADEA urges you to protect the funding and fundamental
    structure of Federal programs that provide access to oral healthcare to
    millions of American, train the next generation of healthcare providers
    and fund cutting-edge dental and craniofacial research.
        At ADEA's academic dental institutions, future practitioners and
    researchers are trained and significant dental safety-net care is
    provided. Services are provided through campus and offsite dental
    clinics where students and faculty provide oral healthcare to the
    uninsured and underserved populations. And, in light of the findings
    that good oral health is inextricably linked to good systemic health,
    the need to provide access to oral healthcare is critical. However, in
    order to provide these services, there must be adequate funding.
        We are asking the committee to help ADEA's member institutions
    continue to provide care to all segments of the population by
    maintaining adequate funding for programs focused on access to oral
    healthcare, dental and craniofacial research, and training for oral
    healthcare providers. Specifically we request that you maintain and
    protect funding for Title VII of the Public Health Service Act; the
    National Institutes of Health (NIH) and the National Institute of
    Dental and Craniofacial Research (NIDCR); the Dental Health Improvement
    Act; Part F of the Ryan White HIV/AIDS Treatment and Modernization Act:
    the Dental Reimbursement Program and the Community-Based Dental
    Partnerships Program; and State-Based Oral Health Programs at the
    Centers for Disease Control and Prevention (CDC). These programs
    enhance and sustain State oral health departments, fund public health
    programs proven to prevent oral disease, fund research to eradicate
    dental disease and detect certain cancers, and fund programs to develop
    an adequate workforce of dentists with advanced training to serve
    American citizens including the underserved, the elderly, and those
    suffering from chronic immune-compromised conditions and life-
    threatening diseases.
        We respectfully make the following requests:
      --$32 million for Oral Health Training Programs
        The dental programs in Title VII, Section 748 of the Public Health
    Service Act that provide training in general, pediatric, and public
    health dentistry and dental hygiene are critical. Support for these
    programs will help to ensure there will be an adequate oral healthcare
    workforce. The funding supports pre-doctoral oral health education and
    postdoctoral pediatric, general, and public health dentistry training.
    The investment that Title VII makes not only helps to educate dentists
    and dental hygienists, but also expands access to care for underserved
    communities.
        Additionally, Section 748 addresses the shortage of professors in
    dental schools with the dental faculty loan repayment program and
    faculty development courses for those who teach pediatric, general, or
    public health dentistry or dental hygiene. There are currently almost
    200 open budgeted faculty positions in dental schools. These two
    programs provide schools with assistance in recruiting and retaining
    faculty. ADEA is increasingly concerned that with projected restrained
    funding, the oral health research community will not be able to grow
    and that the pipeline of new researchers will be inadequate to the
    future need.
        Title VII Diversity and Student Aid programs play a critical role
    in helping to diversify the health profession's student body and
    thereby the healthcare workforce. For the last several years, these
    programs have not received adequate funding to sustain the progress
    that is necessary to meet the challenges of an increasingly diverse
    U.S. population. ADEA is most concerned that the Administration did not
    request any funds for the Health Careers Opportunity Program (HCOP).
    This program provides a vital source of support for oral health
    professionals serving underserved and disadvantaged patients by
    providing a pipeline for such individuals from these populations to
    learn about careers in healthcare generally and dentistry specifically
    that is not available through other workforce programs.
        For example, a collaboration between the University of
    Connecticut's Schools of Dental Medicine and Medicine have used HCOP
    grants to perform extensive outreach to colleges and Historically Black
    Colleges and Universities (HBCU); support 30 week and 6 week summer
    science enrichment programs in middle schools; support several high
    school programs, including a Bridge to the Future Science Mentoring,
    support mini dental and medical programs, and in support of a Junior
    and Senior Doctors' Academy program. And at the college level the two
    schools continue the Bridge to the Future Science Mentor program and
    conduct a 7 week Health Disparities Clinical Summer Research Fellowship
    program that explores an introduction to health disparities, cross
    cultural issues, principles of clinical medicine and skills for public
    health research and interventions, techniques for work with diverse
    populate and interventions, techniques for work with diverse
    populations.
        UCONN's program is illustrative of programs that dental schools at
    the University of Iowa, Kansas University, University of Maryland-
    Baltimore, the University of South Alabama, Marquette University, the
    University of Michigan, and many others have sponsored. HRSA reports
    that the average grant is only $670,000 and reaches over 7,100 students
    from underserved and disadvantaged background.
        If policy makers are serious about reversing health disparities and
    providing opportunity for underrepresented minorities and economically
    disadvantaged individuals they will continue this program at current
    levels, if not expand it.
        Another vital program targeted at enhancing high quality culturally
    competent care in community-based interprofessional clinical training
    settings is the Area Health Education Centers (AHEC) program. Again the
    Administration's has not requested any funds. The infrastructure
    development grants and point of service maintenance and expansion
    grants ensure that patients from underserved populations receive
    quality care in a technologically current setting and that health
    professionals receive training in treating such diverse populations.
        The reason given by HRSA in not requesting any appropriations for
    next fiscal year is short-sighted and counterproductive. HRSA states
    that funding priorities is being redirected to programs that directly
    increase the number of primary care health professionals. Increasing
    the number of providers without the adequate opportunities to treat
    underrepresented populations in their communities makes little clinical
    or cultural sense. This is the case especially if the policy goals
    remain to increase the number coming from those populations and
    practicing in rural and underserved areas. Exposure to the rewards and
    professional challenges of such care is a powerful enducement to
    accomplishing the goal. ADEA encourages the Committee, in the strongest
    possible terms, to continue funding the AHEC program.
      --$18 million for Part F of the Ryan White HIV/AIDS Treatment and
            Modernization Act: Dental Reimbursement Program (DRP) and the
            Community-Based Dental Partnerships Program
        Patients with compromised immune systems are more prone to oral
    infections like periodontal disease and tooth decay. By providing
    reimbursement to dental schools and schools of dental hygiene, the
    Dental Reimbursement Program (DRP) provides access to quality dental
    care for people living with HIV/AIDS while simultaneously providing
    educational and training opportunities to dental residents, dental
    students, and dental hygiene students who deliver the care. DRP is a
    cost-effective Federal/institutional partnership that provides partial
    reimbursement to academic dental institutions for costs incurred in
    providing dental care to people living with HIV/AIDS. This program, in
    fiscal year 2013, only reimbursed dental schools for the unreimbursed
    costs at 23 percent of those costs, continuing the shift of the cost
    burden to the schools. This path is not sustainable to provide the
    necessary care. The increase requested would reimburse barely half of
    the dental school's incurred costs of care.
      --$425 million for the National Institute of Dental and Craniofacial
            Research (NIDCR)
        Discoveries stemming from dental research have reduced the burden
    of oral diseases, led to better oral health for millions of Americans,
    and uncovered important associations between oral and systemic health.
    Dental researchers are poised to make breakthroughs that can result in
    dramatic progress in medicine and health, such as repairing natural
    form and function to faces destroyed by disease, accident, or war
    injuries; diagnosing systemic disease from saliva instead of blood
    samples (such as HIV, and certain types of cancer); and deciphering the
    complex interactions and causes of oral health disparities involving
    social, economic, cultural, environmental, racial, ethnic, and
    biological factors. Dental research is the underpinning of the
    profession of dentistry. With grants from NIDCR, dental researchers in
    academic dental institutions have built a base of scientific and
    clinical knowledge that has been used to enhance the quality of the
    Nation's oral health and overall health.
        Also, dental scientists are putting science to work for the benefit
    of the healthcare system through translational research, comparative
    effectiveness research, health information technology, health research
    economics, and further research on health disparities.
      --$19 million for the Division of Oral Health at the Centers for
            Disease Control and Prevention (CDC)
        The CDC Division of Oral Health expands the coverage of effective
    prevention programs. The program increases the basic capacity of State
    oral health programs to accurately assess the needs of the State,
    organize and evaluate prevention programs, develop coalitions, address
    oral health in State health plans, and effectively allocate resources
    to the programs. This strong public health response is needed to meet
    the challenges of oral disease affecting children and vulnerable
    populations.
        The level of funds available in recent fiscal years are below the
    level needed to adequately sustain an appropriately staffed State
    dental program, provide a robust surveillance system to monitor and
    report disease, and support State efforts with other governmental, non-
    profit, and corporate partners. The current path of funding will
    continue to have a negative effect upon the overall health and
    preparedness of the Nation's States and communities.
        Thank you for your consideration of these requests. ADEA looks
    forward to working with you to ensure the continuation of congressional
    support for these critical programs. Also, please feel free to use ADEA
    as a resource on any matter pertaining to academic dentistry under your
    purview.
                                     ______

       Prepared Statement of the American Dental Hygienists' Association
        On behalf of the American Dental Hygienists' Association (ADHA),
    thank you for the opportunity to submit testimony regarding fiscal year
    2015 appropriations. ADHA appreciates the Subcommittee's past support
    of programs that seek to improve the oral health of Americans and to
    bolster the oral health workforce. Oral health is a part of total
    health and authorized oral healthcare programs require appropriations
    support in order to increase the accessibility of oral health services,
    particularly for the underserved. ADHA urges that the block on funding
    for Section 340G-1 of the Public Health Service Act--a much needed
    dental workforce demonstration program--be lifted and that $1.25
    million be appropriated. Lifting the block on this dental workforce
    grants program, officially titled the Alternative Dental Health Care
    Providers Demonstration Program, would send an important signal to
    States and to HRSA that innovation in dental workforce is a meritorious
    undertaking. Importantly, the authorizing language requires that the
    grants be conducted in compliance with State law and that they must
    increase access to dental healthcare in rural and other underserved
    communities. Further, the Institute of Medicine is required to provide
    a qualitative and quantitative evaluation of the grants.
        Congress recognized the need to improve the oral healthcare
    delivery system when it authorized the Alternative Dental Health Care
    Provider Demonstration Grants, Section 340G-1 of the Public Health
    Service Act. The Alternative Dental Health Care Providers Demonstration
    Grants program is a Federal grant program that recognizes the need for
    innovations to be made in oral healthcare delivery to bring quality
    care to the underserved by pilot testing new models. The authorizing
    statute makes clear that pilots must ``increase access to dental care
    services in rural and underserved communities'' and comply with State
    licensing requirements.
        New dental providers are already authorized in Minnesota and are
    under consideration in a number of States, including Connecticut,
    Kansas, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and
    Washington State. Both the W.K. Kellogg Foundation and the PEW
    Charitable Trust Dental Campaign are investing in State efforts to
    increase oral healthcare access by adding new types of dental providers
    to the dental team. Further, the U.S. Federal Trade Commission
    supported dental workforce expansion in December 2013, noting that
    ``expanding the supply of dental therapists . . . is likely to increase
    the output of basic dental services, enhance competition, reduce costs
    and expand access to dental care.'' The National Governors
    Association's January 2014 issue brief on ``The Role of Dental
    Hygienists in Providing Access to Oral Health Care'' found that
    ``innovative State programs are showing that increased use of dental
    hygienists can promote access to oral healthcare, particularly for
    underserved populations, including children'' and that ``such access
    can reduce the incidence of serious tooth decay and other dental
    disease in vulnerable populations.''
        The fiscal year 2014 HHS funding bill included language designed to
    block funding for this important demonstration program. We seek your
    leadership in removing this unjustified prohibition on funding for the
    Alternative Dental Health Care Providers Demonstration Grants. Further,
    because the authorizing language required HRSA to begin the dental
    workforce grant program under Section 340G-1 within 2 years of its 2010
    enactment (i.e., by 2012) and to conclude it within 7 years of
    enactment (2017), language directing HRSA to move forward with Section
    340G-1 grants despite this timeline is needed. ADHA, along with more
    than 60 other oral healthcare organizations, advocated for funding of
    this important program. Without the appropriate supply, diversity and
    distribution of the oral health workforce, the current oral health
    access crisis will only be exacerbated. ADHA recommends funding at a
    level of $1.25 million for fiscal year 2015 to support these vital
    dental workforce demonstration projects.
        Additionally, ADHA joins the American Dental Association, the
    American Dental Education Association and others in the oral health
    community, in recommending $32 million for Title VII Program Grants to
    expand and educate the dental workforce; $19 million for oral health
    programming at CDC, and funding of $425 million for National Institute
    of Dental and Craniofacial Research.
        ADHA urges funding of all authorized oral health programs and
    describes some of the key oral health programs below:
    Title VII Program Grants to Expand and Educate the Dental Workforce--
            Fund at a level of $32 million in fiscal year 2015
        A number of existing grant programs offered under Title VII support
    health professions education programs, students, and faculty. ADHA is
    pleased dental hygienists are recognized as primary care providers of
    oral health services and are included as eligible to apply for several
    of the grants offered under ``General, Pediatric, and Public Health
    Dentistry.'' With millions more Americans eligible for dental coverage
    in coming years, it is critical that the oral health workforce is
    bolstered. Dental and dental hygiene education programs currently
    struggle with significant shortages in faculty and there is a dearth of
    providers pursuing careers in public health dentistry and pediatric
    dentistry. Securing appropriations to expand the Title VII grant
    offerings to additional dental hygienists and dentists will provide
    much needed support to programs, faculty, and students in the future.
    Oral Health Programming within the Centers for Disease Control--Fund at
            a level of $19 million in fiscal year 2015
        ADHA joins with others in the dental community in urging $19
    million for oral health programming within the Centers for Disease
    Control. This funding level will enable CDC to continue its vital work
    to control and prevent oral disease, including vital work in community
    water fluoridation. Federal grants will serve to facilitate improved
    oral health leadership at the State level, support the collection and
    synthesis of data regarding oral health coverage and access, promote
    the integrated delivery of oral health and other medical services,
    enable States to be innovative, and promote a data-driven approach to
    oral health programming.
        National Institute of Dental and Craniofacial Research--Fund at a
    level of $425 million in fiscal year 2015
        The National Institute of Dental and Craniofacial Research (NIDCR)
    cultivates oral health research that has led to a greater understanding
    of oral diseases and their treatments and the link between oral health
    and overall health. Research spurs innovation and efficiency, both of
    which are vital to improving access to oral healthcare services and
    improved oral status of Americans in the future. ADHA joins with others
    in the oral health community to support NIDCR funding at a level of
    $425 million in fiscal year 2015.
        ADHA is the largest national organization representing the
    professional interests of more than 150,000 licensed dental hygienists
    across the country. In order to become licensed as a dental hygienist,
    an individual must graduate from one of the Nation's 335 accredited
    dental hygiene education programs and successfully complete a national
    written and a State or regional clinical examination. Dental hygienists
    are primary care providers of oral health services and are licensed in
    each of the 50 States. Hygienists are committed to improving the
    Nation's oral health, a fundamental part of overall health and general
    well-being. In the past decade, the link between oral health and total
    health has become more apparent and the significant disparities in
    access to oral healthcare services have been well documented. At this
    time, when 130 million Americans struggle to obtain the oral healthcare
    required to remain healthy, Congress has a great opportunity to support
    oral health prevention, infrastructure and workforce efforts that will
    make care more accessible and cost-effective.
    Conclusion
        ADHA appreciates the difficult task appropriators face in
    prioritizing and funding the many meritorious programs and grants
    offered by the Federal Government. ADHA urges the Committee to lift the
    block on funding for Section 340G-1 of the PHSA, dental workforce
    demonstration grants. Lifting the block on funding for these dental
    workforce grants would be an important signal to States and to
    healthcare stakeholders that exploring new ways of bringing oral health
    services to the underserved is a meritorious expenditure of resources.
    In addition to the items listed, ADHA also supports full funding for
    community health centers, and urges HRSA be directed to further bolster
    the delivery of oral health services at community health centers,
    including the use of new types of dental providers. ADHA remains a
    committed partner in advocating for meaningful oral health programming
    that makes efficient use of the existing oral health workforce and
    delivers high quality, cost-effective care.

        [This statement was submitted by Denise Bowers, RDH, PHD,
    President, American Dental Hygienists' Association.]
                                     ______

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

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

        [This statement was submitted by John Madigan, Vice President,
    Public Policy.]
                                     ______

             Prepared Statement of the American Geriatrics Society
        Mr. Chairman and Members of the Subcommittee: We submit this
    testimony on behalf of the American Geriatrics Society (AGS), a non-
    profit organization of over 6,000 geriatrics healthcare professionals
    dedicated to improving the health, independence and quality of life of
    all older Americans. As the Subcommittee works on its fiscal year 2015
    Labor-HHS-Education Appropriations bill, we ask that you prioritize
    funding for the geriatrics education and training programs under Title
    VII and Title VIII of the Public Health Service Act and for research
    funding within the National Institutes of Health/National Institute on
    Aging.
        We ask that the subcommittee consider the following recommended
    funding levels for these programs in fiscal year 2015:
      --$39.7 million for Title VII Geriatrics Health Professions Programs
      --$5.0 million for Title VIII Comprehensive Geriatric Education
            Nursing Program
      --An increase of $500 million for aging research within the National
            Institutes of Health
        While we recognize the fiscal challenges facing our Nation,
    sustained and enhanced Federal investments in these initiatives are
    essential to delivering higher quality, better coordinated and more
    cost effective care to our Nation's seniors. We request that Congress
    provide the additional investments necessary to expand and enhance the
    geriatrics workforce, which is an integral component of the primary
    care workforce, and to foster groundbreaking medical research so that
    our Nation is prepared to meet the unique healthcare needs of the
    rapidly growing population of seniors.
             programs to train geriatrics health care professionals
        Our Nation is facing a critical shortage of geriatrics faculty and
    healthcare professionals across disciplines. This trend must be
    reversed if we are to provide our seniors with the quality care they
    need and deserve. Care provided by geriatric healthcare professionals,
    who are trained to care for individuals who are the most complex and
    frail and who account for 80 percent of our Medicare expenditures, has
    been shown to reduce common and costly conditions that are often
    preventable with appropriate care, such as falls, polypharmacy, and
    delirium.
    Title VII Geriatrics Health Professions Programs ($39.7 million)
        These programs support three initiatives: the Geriatric Academic
    Career Awards (GACAs), the Geriatric Education Center (GEC) program,
    and geriatric faculty fellowships. These are the only programs
    specifically designed to address the well-documented shortage of
    geriatrics healthcare professionals in the U.S. We ask the subcommittee
    to provide a fiscal year 2015 appropriation of $39.7 million for Title
    VII Geriatrics Health Professions Programs.
        Our funding request breaks down as follows:
      --Geriatric Academic Career Awards (GACAs) ($5.5 million)
        GACAs support the development of newly trained geriatric clinicians
    in academic medicine who are committed to teaching geriatrics in
    medical schools across the country. GACA recipients are required to
    provide training in clinical geriatrics, including the training of
    interdisciplinary teams of healthcare professionals. HRSA, through the
    Affordable Care Act, expanded the awards to other disciplines--a change
    long supported by AGS--and requests adequate funding to reflect this.
    In addition, new awardees are only selected every 5 years and we
    believe that these awards should be available annually in order to
    ensure that we have an adequate number of faculty available to provide
    training in the principles of geriatric medicine. Our budget request of
    $5.5 million would support GACA program awardees in their development
    as clinician educators.
        Program Accomplishments.--In Academic Year 2012-2013, the GACA
    program funded 62 full-time junior faculty. These awardees delivered
    over 1,100 different courses, workshops and other types of training
    activities to over 53,000 trainees across the health professions--the
    most common of which included medical school students, residents in
    internal medicine and residents in geriatrics. In addition, GACA
    awardees are highly encouraged to engage in professional development
    and scholarly activities during each academic year as a way of
    advancing the field of geriatrics. Results showed that the awardees
    conducted presentations about their own research and other related
    topics at over 215 conferences at the local, State or national level
    and published a total of 108 peer-reviewed publications.
      --Geriatric Education Centers (GECs) ($20.0 million)
        GECs provide grants to support collaborative arrangements involving
    several health professions, schools and healthcare facilities to
    provide multidisciplinary training in geriatrics, including assessment,
    chronic disease syndromes, care planning, emergency preparedness, and
    cultural competence unique to older Americans. Our funding request of
    $20.0 million includes continued support for the core work of 45 GECs
    ($20.0).
        Program Accomplishments.--In Academic Year 2012-2013, the GECs
    supported various types of geriatrics-specific training for health
    professions students and faculty, as well as for current community-
    based providers--delivering over 1,650 different continuing education
    courses to over 94,000 trainees. This exceeded the program's
    performance target by 58.5 percent. GEC grantees also partnered with
    over 650 healthcare delivery sites across the country to provide
    clinical and experiential training, in areas such as nursing homes and
    chronic and acute disease hospitals, to over 25,000 trainees. It is
    estimated that 2 out of every 5 sites used by GEC grantees for the
    purposes of offering these types of training were primary care settings
    and/or were located in a medically underserved community.
        --Alzheimer 's Disease Prevention, Education, and Outreach
                Program.--Funding for this program was included in the
                President's fiscal year 2015 budget request and allows HRSA
                to expand efforts to provide interprofessional continuing
                education to healthcare practitioners on Alzheimer's
                disease and related dementias through the already existing
                GECs. We are requesting $5.3 million to support this
                program.
      --Geriatric Training for Physicians, Dentists, Behavioral/Mental
            Health Professions ($8.9 million)
        This program is designed to train physicians, dentists, and
    behavioral and mental health professionals who choose to teach
    geriatric medicine, dentistry or psychiatry. The program provides
    fellows with exposure to older adult patients in various levels of
    wellness and functioning, and from a range of socioeconomic and racial/
    ethnic backgrounds. Our funding request of $8.9 million will support
    this important faculty development program.
        Program Accomplishments.--In Academic Year 2012-2013, a total of 64
    physicians, psychiatrists, dentists, and psychologists, were supported
    through this program. These fellows received clinical training in over
    200 different healthcare delivery sites across the country; the most
    common types of sites where fellows trained included Veteran's Affairs
    hospitals and clinics, private hospitals, and academic centers. It is
    estimated that nearly half of the sites (49 percent) where GTPD fellows
    received clinical training were located in a medically underserved
    community. Additionally, results showed that GTPD fellows delivered
    over 275 courses, workshops and other training activities focused on
    topics including oral health, chronic disease management and geriatric
    medicine, among others. It is estimated that over 5,600 trainees were
    trained as a result of these activities--the most common of which
    included medical school students, dental school students, residents in
    geriatrics and residents in geriatric psychiatry.
    Title VIII Comprehensive Geriatric Education Nursing Program ($5.0
            million)
        The American healthcare delivery system for older adults will be
    further strengthened by Federal investments in Title VIII Nursing
    Workforce Development Programs, specifically the comprehensive
    geriatric education grants, as nurses provide cost-effective, quality
    care. This program supports additional training for nurses who care for
    the elderly, development and dissemination of curricula relating to
    geriatric care, and training of faculty in geriatrics. It also provides
    continuing education for nurses practicing in geriatrics. Our funding
    request of $5.0 million includes funds to continue the training of
    nurses caring for older Americans.
        Program Accomplishments.--In Academic Year 2012-2013, the
    Comprehensive Geriatric Education Program (CGEP) supported numerous
    types of geriatric-related training programs and activities for health
    professions students and their faculty, as well as for community-based
    healthcare providers across the country. CGEP grantees offered over 150
    different continuing education (CE) courses to over 11,600 trainees
    across the health professions. In addition, 74 students received
    traineeships--the majority of which (81 percent) are pursuing a Masters
    Degree in Nursing to become Nurse Practitioners in the fields of Adult
    Gerontology or Acute Care in Adult Gerontology.
        Grantees of the CGEP also developed and implemented over 120
    different geriatric-focused training activities to include new
    continuing education courses for current providers, as well as new
    academic courses and clinical rotations for health professions
    students, residents and fellows across the country focused on these
    issues. It is estimated that a total of 4,500 trainees were reached as
    a result of these activities. Lastly, CGEP grantees supported over 40
    different faculty development activities and programs. It is estimated
    that over 300 faculty-level trainees were trained on emerging issues in
    the field of geriatrics (e.g., pain management among the elderly,
    advances in patient engagement, among others) as a result of these
    activities.
     research funding initiatives--national institutes of health/national
                               institute on aging
        The institutes that make up the NIH, and in particular the NIA,
    lead a broad scientific effort to understand the nature of aging and to
    extend the healthy, active years of life. As a member of the Friends of
    the NIA, a broad-based coalition of aging, disease, research, and
    patient groups committed to the advancement of medical research that
    affects millions of older Americans, AGS urges an increase in NIH
    funding of $500 million to support aging research across all
    institutes.
        Considering what the Federal Government spends on the healthcare
    costs associated with age-related diseases, it makes sound economic
    sense to increase Federal resources for aging research. Chronic
    diseases associated with aging afflict 80 percent of the age 65+
    population and account for more than 75 percent of Medicare and other
    Federal health expenditures. Continued Federal investments in
    scientific research, including comparative effectiveness initiatives,
    will ensure that the NIH has the resources to succeed in its mission to
    establish research networks, assess clinical interventions and
    disseminate credible research findings to patients, providers and
    payers of healthcare.
        In closing, geriatrics is at a critical juncture, with our Nation
    facing an unprecedented increase in the number of older patients with
    complex health needs. Strong support such as yours will help ensure
    that every older American is able to receive high-quality healthcare.
        Thank you for your consideration.
                                     ______

              Prepared Statement of the American Heart Association
        Although great progress has been made in prevention and treatment
    of cardiovascular disease, including stroke, there is no cure and CVD
    remains America's No. 1 killer, costing a projected $315 billion in
    medical expenses and lost productivity each year. Stroke, alone, is our
    No. 4 killer, costing an estimated $37 billion a year. Both remain
    major causes of disability.
        Nearly 84 million U.S. adults suffer from some form of CVD. It is
    projected that by the year 2030, more than 44 percent of U.S. adults
    will live with CVD at a cost exceeding $1 trillion annually. So, it is
    disturbing that CVD research, prevention and treatment remain
    disproportionately underfunded with no sustained and stable funding
    from the National Institutes of Health. NIH is key for the U.S. to
    mount an ongoing and effective crusade against these devastating
    diseases.
        We appreciate Congress' and the Administration's partial stay of
    sequestration. These cuts jeopardize the health of tens of millions of
    CVD sufferers and weaken our fragile economy and erode our global
    leadership in medical research. We challenge Congress to appropriate
    stable and sustained funding for CVD research, prevention and
    treatment. NIH funding is not only important for the health of our
    Nation, but also supports our economy through research-related
    employment opportunities it provides.
         funding recommendations: investing in the health of our nation
        Research that could move us closer to a cure for heart disease and
    stroke goes unfunded. Congress must capitalize on 50 years of progress
    or our Nation will pay more in lives lost and healthcare costs. Our
    recommendations tackle the topics in a fiscally responsible way.
    Capitalize on Investment for the National Institutes of Health (NIH)
        AHA is disappointed Congress did not fully restore sequester cuts
    for NIH in Public Law 113-76. NIH funded studies help prevent and cure
    disease, revolutionize patient care, drive economic growth, advance
    innovation, and sustain U.S. leadership in pharmaceuticals and
    biotechnology. NIH is the world's leader of basic research--the
    starting point for all medical progress and an indispensable Federal
    Government role that the private sector cannot fill. The U.S. is in
    jeopardy of losing our competitive edge in scientific research.
        In addition to improving health, NIH creates a solid return on
    investment. In fiscal year 2012, NIH supported 400,000 U.S. jobs and
    produced nearly $60 billion in new economic activity. Every $1 in NIH
    funding produced $2 in economic activity in 2007. Yet, for the past
    decade, the NIH's budget has not kept pace with medical research
    inflation, resulting in more than a 20 percent loss in purchasing
    power. Such reductions, along with only a 50 percent restoration of
    sequester cuts, have occurred during a time of remarkable heightened
    scientific opportunity and when other countries have been increasing
    investment in science--some by double digits. These cutbacks have also
    demoralized early career investigators who, sadly, may leave and never
    return to research. We cannot afford to lose one of our Nation's most
    valuable resources--an innovative biomedical research workforce.
        American Heart Association Advocates: We ask Congress to
    appropriate $32 billion for NIH to restore sequester cuts, provide for
    modest growth, and advance CVD research.
    Enhance Funding for NIH Heart and Stroke Research: A Proven and Wise
            Investment
        Declining death rates from CVD is directly related to NIH research,
    with scientists on the verge of discoveries that could lead to
    groundbreaking treatments and even cures. In addition to saving lives,
    NIH research is cost-effective. For example, the first NIH tPA drug
    trial resulted in a 10-year net $6.47 billion drop reduction in stroke
    healthcare costs.
    Cardiovascular Disease Research: National Heart, Lung, and Blood
            Institute (NHLBI)
        CVD death rates have greatly declined, with much of the reduction
    traced to research emanating from the NHLBI. Stable and sustained NHLBI
    funding is key to capitalize on investments that have led to major
    discoveries. For example, 10 percent of genetic changes leading to
    severe congenital heart disease are new and not passed down by a
    parent; people who maintained ideal health had better brain function in
    mid-life; digestive system bacteria may cause red meat to raise two
    chemicals linked to CVD; and post-traumatic stress disorder may be a
    heart disease risk factor. Sustained funding will allow robust
    implementation of priority CVD strategic plan initiatives.
    Stroke Research: National Institute of Neurological Disorders and
            Stroke (NINDS)
        An estimated 795,000 Americans will suffer a stroke this year and
    more than 129,000 will die. Many of the 7 million survivors face grave
    physical and mental disabilities and emotional trauma. In addition to
    the physical and emotional toll, stroke costs an estimated $37 billion
    in medical expenses and lost productivity each year. Moreover, the
    future looks grim. A study projects that direct costs of stroke will
    triple between 2010 and 2030.
        Stable and sustained NINDS funding is needed to capitalize on
    investments, including one showing aggressive medical treatment is
    better than stents in preventing a second stroke, and to advance the
    BRAIN Initiative. More resources are required to facilitate the NIH
    Stroke Trials Network and other priorities in stroke prevention,
    treatment and recovery research. They include: hastening translation of
    preclinical animal models into clinical studies; preventing vascular
    cognitive damage; expediting comparative effectiveness research trials;
    developing imaging biomarkers; refining clot-busting treatments;
    achieving robust brain protection; targeting early stroke recovery; and
    using neural interface devices.
        American Heart Association Advocates: We recommend that NHLBI be
    funded at $3.2 billion and NINDS at $1.7 billion for fiscal year 2015.
    Increase Funding for the Centers for Disease Control and Prevention
            (CDC)
        Prevention is the best way to promote good health and reduce the
    costs of heart disease and stroke. Yet, proven prevention approaches
    are not implemented due to limited funds. We applaud Congress for
    providing in Public Law 113-76 the Division for Heart Disease and
    Stroke Research with a much needed boost. In addition to supporting
    research and evaluation and developing a surveillance system, the DHDSP
    administers Sodium Reduction Communities and the Paul Coverdell
    National Acute Stroke Registry. DHDSP, with the Centers for Medicare
    and Medicaid Services, implements Million HeartsTM to
    prevent 1 million heart attacks and strokes by 2017.
        DHDSP runs WISEWOMAN, serving uninsured and under-insured, low-
    income women ages 40 to 64. It helps them from becoming heart disease
    and stroke statistics by offering preventive health services, referrals
    to local healthcare, and tailored lifestyle programs to promote lasting
    behavioral change.
        American Heart Association Advocates: We join with the CDC
    Coalition in asking for $7.8 billion for CDC's program level. AHA
    requests $130.188 million for the DHDSP to sustain its participation in
    the State Public Health Actions to Prevent and Control Diabetes, Heart
    Disease, Obesity and Associated Risk Factors and Promote School Health
    and $37 million for WISEWOMAN. We ask for $3 million for Million
    HeartsTM to better control blood pressure.
    Restore Funding for Rural and Community Access to Emergency Devices
            (AED) Program
        About 90 percent of cardiac arrest victims die outside of a
    hospital. Yet, early CPR and use of an automated external defibrillator
    can more than double survival. Communities with full AED programs have
    survival rates near 40 percent. HRSA's Rural and Community AED Program
    awards competitive grants to States to buy AEDs, tactically place them,
    and train lay rescuers and first responders in their use. Nearly 800
    patients were saved from August 1, 2009 to July 31, 2010. But scarce
    resources let only 22 percent of approved applicants in 6 States
    receive funds in fiscal year 2013.
        American Heart Association Advocates: We ask for a fiscal year 2015
    appropriation of $8.927 million to return this life-saving AED program
    to fiscal year 2005 levels when 47 States were funded.
                                   conclusion
        Cardiovascular disease, including stroke, still wreak a deadly,
    disabling and costly toll on Americans. Our recommendations for NIH,
    CDC and HRSA will save lives and slash escalating healthcare costs. We
    challenge Congress to carefully study our requests that signify a wise
    investment for our country and for the health and well-being of this
    and future generations.

        [This statement was submitted by Mariell Jessup, M.D., President,
    American Heart Association.]
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium
        This statement includes the fiscal year 2015 recommendations of the
    Nation's Tribal Colleges and Universities (TCUs), in two areas of the
    Department of Education: Office of Postsecondary Education and Office
    of Vocational Education.
                         higher education act programs
        Strengthening Developing Institutions.--Titles III and V of the
    Higher Education Act support institutions that enroll large proportions
    of financially disadvantaged students and have low per-student
    expenditures. The TCUs, which by any definition are truly developing
    institutions, funded under Title III-A Sec. 316 are providing quality
    higher education opportunities to some of the most rural/isolated,
    impoverished, and historically underserved areas of the country. The
    goal of HEA-Titles III/V programs is ``to improve the academic quality,
    institutional management and fiscal stability of eligible institutions,
    in order to increase their self-sufficiency and strengthen their
    capacity to make a substantial contribution to the higher education
    resources of the Nation.'' The TCU Title III-A program is specifically
    designed to address the critical, unmet needs of their American Indian
    students and communities, in order to effectively prepare them to
    succeed in a globally competitive workforce. Yet, in fiscal year 2011
    this critical program was cut by over 11 percent, by another 4 percent
    in fiscal year 2012, and hit by sequestration--on the lowered
    baseline--in fiscal year 2013. Although sequestration was not imposed
    in fiscal year 2014, the TCUs have not recovered from the earlier cuts
    to this vitally important program. The TCUs urge the Subcommittee to
    restore the discretionary funding for HEA Title III-A, Sec. 316 to
    $30,000,000 in fiscal year 2015.
        TRIO.--Retention and support services are vital to achieving the
    national goal of having the highest proportion of college graduates in
    the world by 2020. TRIO programs, such as Student Support Services and
    Upward Bound, were created out of recognition that college access is
    not enough to ensure advancement and that multiple factors work to
    prevent the successful completion of postsecondary programs for many
    low-income and first-generation students and students with
    disabilities. Therefore, in addition to providing the maximum Pell
    Grant award level, it is critical that Congress also sustain student
    assistance programs, such as Student Support Services and Upward Bound
    so that low-income and minority students have the Federal support
    necessary to allow them to remain enrolled in and ultimately complete
    their higher education degrees.
        Pell Grants.--The importance of Pell Grants to TCU students cannot
    be overstated. Approximately, 80 percent of TCU students receive Pell
    Grants, primarily because student income levels are so low and they
    have far less access to other sources of financial aid than students at
    State-funded and other mainstream institutions. Within the TCU system,
    Pell Grants are doing exactly what they were intended to do--they are
    serving the needs of the lowest income students by helping them gain
    access to quality higher education, an essential step toward becoming
    active, productive members of the workforce. However, the U.S.
    Department of Education has changed its regulations to limit Pell
    eligibility from 18 to 12 full-time semesters, without any
    consideration of those already in the process of earning a
    postsecondary degree. This change in policy has impeded some TCU
    students from completing a postsecondary degree, which is widely
    recognized as being critical for access to, and advancement in, today's
    highly technical workforce.
        TCUs are open enrollment institutions. Recent placement tests
    administered at TCUs to first-time entering students indicated that 74
    percent required remedial math, 54 percent required remedial reading,
    and 57 percent needed remedial writing. These results clearly
    illustrate just how serious this new Pell Grant eligibility limit is to
    the success of TCU students in completing a postsecondary degree.
    Students requiring remediation can use as much as a full year of
    eligibility enhancing their math, and or reading/writing skills,
    thereby hampering their future postsecondary degree plans. A prior
    national goal was to provide access to quality higher education
    opportunities for all students regardless of economic means, at which
    TCUs have been extremely successful. While the new national goal
    intends to produce graduates with postsecondary degrees by 2020, this
    change in policy does not advance that objective. On the contrary, the
    new regulations will cause many low-income students to once again
    abandon their dream of a postsecondary degree, as they will simply not
    have the means to continue to pursue it. The goal of a well-trained
    technically savvy workforce will be greatly compromised. This new
    policy evokes the adage ``penny wise--pound foolish.'' The TCUs urge
    the Subcommittee to continue to fund this essential program at the
    highest possible level, and to direct the Secretary of Education to
    implement a process to waive the very restrictive 12 semester Pell
    Grant eligibility for TCU students.
                perkins career and technical education programs
        Tribally-Controlled Postsecondary Career and Technical
    Institutions.--Section 117 of the Carl D. Perkins Career and Technical
    Education Act provides a competitively awarded grant opportunity for
    tribally chartered and controlled career and technical institutions.
    AIHEC requests $8,200,000 to fund grants under Sec. 117 of the Perkins
    Act.
        Native American Career and Technical Education Program (NACTEP).--
    NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding to
    support American Indian career and technical programs. The TCUs
    strongly urge the Subcommittee to continue to support NACTEP, which is
    vital to the continuation of career and technical education programs
    offered at TCUs that provide job training and certifications to remote
    reservation communities.
      american indian adult and basic education (office of vocational and
                                adult education)
        This program supports adult basic education programs for American
    Indians offered by State and local education agencies, Indian tribes,
    agencies, and TCUs. Despite the absence of dedicated funding, TCUs must
    find a way, often using already insufficient institutional operating
    funds, to continue to provide adult basic education classes for those
    American Indians that the present K-12 Indian education system has
    failed. Before many individuals can even begin the course work needed
    to learn a productive skill, they first must earn a GED or, in some
    cases, even learn to read. The new GED exam, which was instituted in
    January 2014, has a much stronger focus on mathematics. As noted
    earlier, placement tests for TCU entering students reveal a tremendous
    need for math remediation. Additionally, the new GED test is fully
    computerized. While younger GED seekers may be well versed and
    comfortable with computer-based testing, older and poorer citizens may
    not be. These factors indicate a further and growing need for adult
    basic educational programs and GED preparation on Indian reservations.
    TCUs must have sufficient and stable funding to continue to provide
    these essential activities and to ensure their communities residents
    have the same chances to succeed as others throughout the country have.
    TCUs request that the Subcommittee direct that $8,000,000 of the funds
    appropriated annually for the Adult Education State Grants be made
    available to make competitive awards to TCUs to help meet the growing
    demand for adult basic education and remediation program services on
    their respective Reservations.
    further justifications for fiscal year 2015 appropriations requests for
                                      tcus
        Tribal colleges and our students are already being
    disproportionately impacted by ongoing efforts to reduce the Federal
    budget deficit and control Federal spending. The fiscal year 2011
    Continuing Resolution eliminated all of the Department of Housing and
    Urban Development's Minority Serving Institutions (MSIs) community-
    based programs, including a critically needed TCU-HUD facilities
    program. TCUs were able to maximize leveraging potential, often
    securing even greater non-Federal funding to construct and equip Head
    Start and early childhood centers; student and community computer
    laboratories and public libraries; and student and faculty housing in
    rural and remote communities where few and sometimes none of these
    facilities existed. Important STEM programs, administered by the
    National Science Foundation and NASA were cut, and for the first time
    since the NSF program was established in fiscal year 2001, no new TCU-
    STEM awards were made in fiscal year 2011. While NSF-TCUP grants
    resumed in fiscal year 2012, a year of grant opportunity was lost. TCUs
    Additionally, TCUs and their students suffer the realities of cuts to
    programs such as GEAR-UP, TRIO, SEOG, and as noted earlier, are
    seriously impacted by the new highly restrictive Pell Grant eligibility
    criteria more profoundly than mainstream institutions of higher
    education, which can realize economies of scale due to large
    endowments, alternative funding sources, including the ability to
    charge higher tuition rates and enroll more financially stable
    students, and access to affluent alumni. The loss of opportunities that
    cuts to DoEd, HUD, NSF, and NASA programs represent to TCUs, and to
    other MSIs, is magnified by cuts to workforce development programs
    within the Department of Labor, nursing and allied health professions
    tuition forgiveness and scholarship programs operated by the Department
    of Health and Human Services, and an important TCU-based nutrition
    education program planned by USDA. Combined, these cuts strike at the
    most economically disadvantaged and health-challenged Americans.
        We respectfully request that the Members of the Subcommittee
    continue the Federal investment in the Nation's Tribal Colleges and
    Universities and full consideration of our fiscal year 2015
    appropriations needs and recommendations.
                                     ______

            Prepared Statement of the American Physiological Society
        The American Physiological Society (APS) thanks the subcommittee
    for its ongoing support of the National Institutes of Health (NIH).
    Research carried out by the NIH contributes to our understanding of
    health and disease, which allows all Americans to look forward to a
    healthier future. The APS urges you to make every effort to provide the
    NIH with a net funding level of $32 billion in fiscal year 2015. This
    is necessary to prevent further erosion of research capacity.
        Federal investment in research is critically important because
    breakthroughs in basic and translational research are the foundation
    for new drugs and therapies that help patients, fuel our economy, and
    provide jobs. The Federal Government is the primary funding source for
    discovery research through competitive grants awarded by the NIH.
    Although the private sector partners with academic researchers to
    develop research findings into new treatments, industry relies upon
    federally funded research to identify where innovation opportunities
    can be found. This system of public-private partnership has been
    critical to U.S. leadership in the biomedical sciences. However, this
    position of leadership is at risk as other nations, including China,
    increase their investments in research and development while the United
    States investment has lagged in recent years.
        Federal research dollars also have a significant impact at the
    local level: Approximately 85 percent of the NIH budget is awarded
    throughout the country to researchers who use grant funds to pay
    research and administrative staff, purchase supplies and equipment, and
    cover other costs associated with their research.
    NIH funds outstanding science
        As a result of improved healthcare, Americans in the 21st century
    are living longer and healthier lives than ever before. However,
    chronic conditions such as cardiovascular disease, diabetes,
    respiratory illnesses, Alzheimer's and cancer continue to inflict a
    heavy burden in the United States and around the world. As the U.S.
    population ages, the prevalence and cost of these diseases will
    increase exponentially. The NIH invests heavily in basic research to
    understand the physiological mechanisms at work in health and disease.
    This knowledge is crucial to the development of safe and effective
    interventions and prevention strategies.
        Exciting new initiatives are underway at the NIH to advance
    science, including the Brain Research through Advancing Innovative
    Neurotechnologies (``BRAIN'') initiative and the Big Data 2 Knowledge
    project (BD2K). The BRAIN initiative will bring together researchers
    from diverse disciplines to tackle major gaps in current knowledge
    about the brain and brain diseases. BD2K will explore ways to
    capitalize on the immense volume of data being created by biomedical
    scientists, ultimately enhancing the work of the entire community by
    providing new tools and resources to make better use of that data.
    These important projects require significant resources, and at a time
    of constrained budgets, that will further diminish funding for
    investigator-initiated grants. The NIH system of allowing investigators
    to develop and propose ideas which are then evaluated by their peers
    and selected for funding based on their merit has fostered a research
    enterprise that is second to none. Increasing the NIH budget to $32
    billion would provide funding for large projects as described above,
    while also providing resources for individual scientists to pursue
    creative new avenues of research.
    NIH nurtures the biomedical research enterprise
        In addition to supporting research, the NIH must also address
    workforce issues to ensure that our Nation's researchers are ready to
    meet the challenges they will face in the future. The pressures placed
    on the biomedical research enterprise after years of sub-inflationary
    budget increases were severely compounded by sequestration cuts in
    fiscal year 2013. One analysis showed that NIH supported approximately
    1000 fewer investigators in fiscal year 2013 as a result of its
    declining budget.\1\ Researchers who lose their funding face an
    uncertain future as there are few options to sustain their research
    without Federal grants. Losing Federal support puts at risk the
    investment that it took to build those programs over many years. It
    also means that talented individuals working in those labs will have to
    look elsewhere for increasingly scarce jobs. As a result of stagnant
    funding for NIH, scientists at all stages of their careers struggle to
    maintain their research programs.
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        \1\ http://www.asbmb.org/asbmbtoday/201403/PresidentsMessage/
    ---------------------------------------------------------------------------
        Scientists in the early stages of their careers face a particular
    set of challenges as they work to establish themselves during a time of
    dwindling resources. To address some of these problems, the NIH is
    continuing its commitment to fund new investigators at approximately
    the same rate as established investigators. The NIH is also developing
    three new efforts to ensure a diverse and sustainable future biomedical
    workforce. The National Research Mentoring Network (NRMN) and the
    Building Infrastructure Leading to Diversity (BUILD) initiative are
    complementary programs that will develop innovative new mentorship
    programs to engage individuals from diverse backgrounds and help them
    prepare to succeed in biomedical research careers. The Coordination and
    Evaluation Center (CEC) will play a role in coordinating and assessing
    NRMN and BUILD, providing program-wide goals and tools to assess
    progress. These efforts are critical to helping young scientists launch
    their careers. However, to sustain a talented workforce the NIH needs
    predictable and sustainable budget growth. If the current funding
    crisis is not resolved, the continued loss of senior researchers will
    begin to erode the pool of experienced mentors for early career
    scientists on which the BUILD and NRMN programs rely.
        The NIH also uses the Institutional Development Award (IDeA)
    Program to broaden the geographic distribution of NIH funds by
    providing support to researchers and institutions in areas that have
    not previously received significant NIH funding. IDeA builds research
    capacity and improves competitiveness in those States by developing
    shared resources, infrastructure and expertise. Networks established
    through this program expand research opportunities for students and
    faculty at predominantly undergraduate institutions and enhance the
    level of science and technology knowledge of the workforce in IDeA
    States. The program currently serves institutions and researchers in 23
    States and Puerto Rico. The APS believes this program is an important
    way to broaden participation in the scientific workforce.
        The APS appreciates the support of the committee in continuing the
    Science Education Partnership Awards (SEPA) program at the NIH. This
    program was slated for elimination last year under the proposed
    consolidation of science education programs across Federal agencies.
    The SEPA program fosters important connections between biomedical
    researchers and K-12 students and teachers, providing an opportunity
    for students at the earliest levels to learn about STEM careers. No
    other Federal STEM program addresses biomedicine or provides this kind
    of outreach concerning what NIH does to promote the health of our
    citizens. Thus, SEPA programs promote health literacy among young
    individuals, who will increasingly be expected to manage their own
    healthcare. Many of the programs sponsored by SEPA, including those at
    the APS, disproportionately reach underrepresented and disadvantaged
    students. The APS believes that the SEPA program helps establish the
    groundwork to address issues of workforce diversity and health
    literacy.
        The APS is a professional society dedicated to fostering research
    and education as well as the dissemination of scientific knowledge
    concerning how the organs and systems of the body work. The Society was
    founded in 1887 and now has more than 10,000 member physiologists. APS
    members conduct NIH-supported research at colleges, universities,
    medical schools, and other public and private research institutions
    across the U.S.
        The APS joins the Federation of American Societies for Experimental
    Biology (FASEB) in urging that NIH be provided with no less than $32
    billion in fiscal year 2014.\2\
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        \2\ www.faseb.org/fundingreport

        [This statement was submitted by Kim E. Barrett, Ph.D., President,
    American Physiological Society.]
                                     ______

          Prepared Statement of the American Psychological Association
        The American Psychological Association (APA) is the largest
    scientific and professional organization representing psychology in the
    U.S.: its membership includes nearly 130,000 researchers, educators,
    clinicians, consultants and students. APA works to advance the
    creation, communication and application of psychological knowledge to
    benefit society and improve people's lives. Many programs in the Labor-
    HHS-Education bill impact science, education, and the populations
    served by clinical psychologists.
        National Institutes of Health.--The Consolidated Appropriations Act
    of 2014 increase for NIH did not give back all of the funds cut by
    sequestration in fiscal year 2013 nor did it restore the purchasing
    power lost over the past decade. As a member of the Ad Hoc Group for
    Medical Research, APA recommends that NIH receive at least $32 billion
    in fiscal year 2015 as the next step toward a multi-year increase in
    our Nation's investment in health research. APA also urges Congress and
    the Administration to work in a bipartisan manner to end sequestration
    and the continued cuts to health research that squander invaluable
    scientific opportunities, discourage young scientists, threaten or slow
    improvements in our Nation's health, and jeopardize our economic
    future.
        Psychological scientists are supported by research grants or
    training programs in almost all of NIH's 27 institutes and centers.
    They are working with animal models or human participants to improve
    diagnosis and treatment of Alzheimer's disease and autism, to
    understand the mechanisms underlying adoption of healthy behaviors, and
    to help prevent transmission of HIV and unhealthy behaviors such as
    substance abuse. Behavioral research is critical to NIH's mission:
    approximately 40 percent of premature mortality in the U.S. is due to
    behaviors such as smoking, sedentary lifestyle, and alcohol and other
    drug consumption. APA encourages continued support for OppNet, the
    trans-institute initiative funded through the Office of Behavioral and
    Social Sciences Research that has led to some $90 million in funding of
    basic research through fiscal year 2013 on critical issues such as
    sleep, stress, and multisensory perception. As NICHD develops
    initiatives to understand and prevent harmful and costly preterm
    births, APA encourages that institute to enhance research on
    psychological factors that may contribute.
        There remains a disturbing paucity of scientific evidence about the
    effects of sporadic vs. regular use of marijuana, alcohol, nicotine and
    other substances on the developing brain. A large-scale, prospective
    study that (a) includes brain imaging and (b) begins in late childhood
    (prior to substance exposure) and continues into early adulthood is
    urgently needed. Now is the time to begin an in-depth and definitive
    longitudinal study to document the short- and long-term effects of
    substance use and, in particular, the impact on young brains to inform
    future drug policy decisions. By tracking brain development and various
    life outcomes alongside behavioral data on substance use, the study
    would also illuminate the developmental effects of individual
    substances as well as substance interactions, as well as better
    establish the relationship between substance use and other mental
    disorders (e.g., does substance use predispose adolescent users to
    mental illness; do subclinical or premorbid symptoms of mental illness
    lead to substance use; or are associations due to a shared
    vulnerability?). APA urges the NIH to conduct such a study as part of
    the Collaborative Research on Addictions at NIH (CRAN initiative) to
    comprehensively document the biological and behavioral effects of
    substance use on the developing brain by conducting a longitudinal
    naturalistic study monitoring a nationally representative sample of
    10,000 healthy 10-year-old children over the course of 10 years.
        Centers for Disease Control and Prevention.--As a member of the CDC
    Coalition, APA supports at least $7.8 billion for core programs in
    fiscal year 2015. Rather than relying on the Prevention Fund and other
    transfers, APA urges the committee to restore CDC's budget authority.
    As a member of the Friends of NCHS, APA recommends a program level of
    $182 million for the National Center on Health Statistics. APA strongly
    supports the President's request for increased funding for the National
    Injury Prevention and Control Center, including $10 million research
    into the causes and prevention of gun violence, to allow the CDC to
    carry out the critical research agenda developed last year by the
    Institute of Medicine and the National Research Council, and for $23.57
    million for the National Violent Death Reporting System, to allow for
    its expansion to all 50 States and DC. APA is pleased that the
    Committee provided an increase in funding for the Prevention Research
    Centers program in fiscal year 2014, and urges that funding be restored
    for the program to at least $28 million in fiscal year 2015, consistent
    with the fiscal year 2011 funding level, to support research essential
    to the focus on prevention. APA supports the President's request of
    $360.7 million for surveillance, research and programs to support HIV
    prevention in the Division of HIV/AIDS Prevention, an increase of $4.3
    million above fiscal year 2014. Additional resources should be directed
    toward behavioral and social science research that optimizes outcomes
    along the HIV care continuum; implementation science to enhance linkage
    and retention in care; research on adherence to treatment; developing
    and scaling up interventions for most the impacted persons living with
    HIV/AIDS; development, adaptation and implementation of innovative
    strategies to address stigma and discrimination; and research into
    structural and environmental factors that drive the HIV epidemic.
        Substance Abuse and Mental Health Services Administration.--APA
    strongly supports:
      --The National Child Traumatic Stress Network (NCTSN) program. APA
            recommends increased support for the Network's efforts on
            behalf of the recovery of children, families, and communities
            affected by physical and sexual abuse, school and community
            violence, natural disasters, sudden death of a loved one, war's
            impact on military families, and other trauma.
      --Garrett Lee Smith Memorial Act programs--Campus Suicide Prevention,
            State and Tribal Youth Suicide Prevention and the Suicide
            Prevention Resource Center. These effective national programs
            help meet the mental and behavioral health needs of youth and
            young adults through access to prevention, education, and
            outreach services to reduce suicide risk in these populations.
            First authorized in 2004, the Garrett Lee Smith Memorial Act
            has supported youth suicide prevention grants in 49 States, 48
            Tribes or Tribal organizations, and 138 institutions of higher
            education.
      --Minority Fellowship Program. APA remains concerned that while
            minorities represent 30 percent of the population and are
            projected to increase to 40 percent by 2025, only 23 percent of
            recent doctorates in psychology, social work and nursing were
            awarded to minorities. We encourage the Committee to support
            the Administration's $5 million increase for the MFP as
            requested in the fiscal year 2015 budget proposal. The increase
            reflects the need to continually grow the pool of culturally
            competent mental health professionals.
      --Mental Health Care Provider Education in HIV/AIDS Program, in CMHS.
            Continuing education for mental health providers in these
            crucial clinical issues remains a high priority. APA urges
            Congress to maintain level funding in CMHS for the training of
            psychologists, social workers, and psychiatrists in mental
            health and psychosocial issues related to HIV/AIDS.
      --SAMHSA-funded programs providing vital substance abuse and mental
            health services to people with HIV/AIDS.
      --SAMHSA's Safe Schools/Healthy Students program that expands access
            to mental and behavioral health services in schools and reduces
            violence through prevention and early intervention supports.
        Health Resources and Services Administration.--APA recommends
    funding SSA Section 512 regarding services to individuals with a
    postpartum condition. Postpartum Depression (PPD) is one of the most
    common and frequently undiagnosed conditions associated with
    childbirth. In the U.S. approximately one in five women suffers from
    PPD each year. While PPD is a widespread problem, under the current
    USPSTF guidelines, depression screening is available as an Essential
    Health Benefit to all non-pregnant adults, yet excludes the vulnerable
    population of pregnant women. APA supports funding for this as-yet
    unfunded provision that supports PPD research and treatment and the
    incorporation of screening and linkages to behavioral health treatment
    for families affected by this condition. APA encourages the Committee
    to support incorporation of PPD screening into the Title V programs
    administered by HRSA as well as Healthy Start. APA also encourages the
    Committee to urge the Secretary to prioritize the issue of PPD by
    raising awareness, expanding research, and establishing grants for the
    operation and coordination of cost-effective services to afflicted
    women and their families.
        APA recommends continued investments in the mental and behavioral
    health workforce, including $6.9 million for the Graduate Psychology
    Education program to increase the number of health service
    psychologists trained to provide services to high-need and high-demand
    underserved populations in both urban and rural communities. This
    program supports the training of doctoral psychology students, interns
    and postdoctoral residents with other health professionals while they
    provide supervised mental and behavioral health services to underserved
    and vulnerable populations, including: children, older adults, veterans
    and their families, individuals with chronic illnesses, and victims of
    abuse and trauma. In 2010-2011 alone, the GPE program supported the
    training of 620 graduate psychology students and provided mental and
    behavioral health services to over 46,000 underserved persons. APA
    encourages HRSA to maintain a strong emphasis on serving rural veteran
    populations and their families. There is a growing need for highly
    trained mental and behavioral health professionals to deliver evidence-
    based services to the rapidly aging population. APA encourages HRSA to
    reinstate the geropsychology component, and help integrate health
    service psychology trainees at federally Qualified Health Centers.
        HHS programs on aging.--Given that approximately 20-25 percent of
    older adults have a mental or behavioral health problem, and older
    white males (age 85 and over) currently have the highest rates of
    suicide of any group in the U.S. APA supports an expanded effort to
    address the mental and behavioral health needs of older adults
    including implementation of the mental and behavioral health provisions
    in the Older Americans Act Amendments of 2006, grants to States for the
    delivery of mental health screening, and treatment services for older
    individuals and programs to increase public awareness and reduce the
    stigma associated with mental disorders in older individuals.
        APA also recommends continued support of the HHS's Lifespan Respite
    Program. Respite care can provide family caregivers with relief
    necessary to maintain their own health, bolster family stability and
    well-being, and avoid or delay more costly nursing home or foster care
    placements.
        Department of Education.--APA supports strengthening our Federal
    investment in gifted and talented education and encourages Congress to
    fund the Javits Gifted and Talented Education Program in fiscal year
    2015, funded last year at $5 million. And, as a member of the Friends
    of the Institute of Education Sciences (IES), APA supports $202.3
    million for IES's research, development and dissemination portfolio,
    consistent with the Administration's 2013 and 2014 requests. This would
    support critical investments to provide evidence-based information on
    effective educational practices to parents, teachers and schools, and
    new research to fill gaps in knowledge.
        Thank you for the opportunity to submit testimony for the record in
    support of critical program areas funded by the Labor-Health and Human
    Services-Education appropriations bill.
                                     ______

          Prepared Statement of the American Public Health Association
        The American Public Health Association is a diverse community of
    public health professionals who champion the health of all people and
    communities. We are pleased to submit our request to fund the Centers
    for Disease Control and Prevention at $7.8 billion and the Health
    Resources and Services Administration at $7.48 billion in fiscal year
    2015. We urge you to take our recommendations to restore funding to at
    least fiscal year 2010 levels into consideration as you move forward
    with writing the fiscal year 2015 Labor-HHS-Education Appropriations
    bill.
    Centers for Disease Control and Prevention
        APHA believes Congress should support CDC as an agency, not just
    the individual programs that it funds. Given the challenges and burdens
    of chronic disease and disability, public health emergencies, new and
    reemerging infectious diseases and other unmet public health needs, we
    urge a funding level of $7.8 billion for CDC's programs in fiscal year
    2015. We appreciate some of the important new investments in President
    Obama's fiscal year 2015 budget proposal; however, under the
    president's proposal, CDC's total budget would be cut by nearly $243
    million compared to fiscal year 2014. CDC's budget authority under the
    president's budget is lower than fiscal year 2003 levels. State and
    local health departments continue to operate on tight budgets and with
    a smaller workforce, losing more than 50,000 public health jobs since
    2008. These cuts will reduce the ability of CDC and its State and local
    grantees to investigate and respond to public health emergencies,
    ensure adequate immunization rates and track environmental hazards.
        By translating research findings into effective intervention
    efforts, CDC is a critical source of funding for many of our State and
    local programs that aim to improve the health of communities. Perhaps
    more importantly, Federal funding through CDC provides the foundation
    for our State and local public health departments, supporting a trained
    workforce, laboratory capacity and public health education
    communications systems. It is notable that more than 70 percent of
    CDC's budget supports public health and prevention activities by State
    and local health organizations and agencies, national public health
    partners and academic institutions.
        CDC also serves as the command center for our Nation's public
    health defense system against emerging and reemerging infectious
    diseases. With the potential onset of a worldwide influenza pandemic
    and the many other natural and man-made threats that exist in the
    modern world, CDC has become the Nation's--and the world's--expert
    resource and response center, coordinating communications and action
    and serving as the laboratory reference center. States and communities
    rely on CDC for accurate information and direction in a crisis or
    outbreak.
        CDC serves as the lead agency for bioterrorism and other public
    health emergency preparedness and response programs and must receive
    sustained support for its preparedness programs in order for our Nation
    to meet future challenges. Given the challenges of terrorism and
    disaster preparedness, and our many unmet public health needs and
    missed prevention opportunities we urge you to provide adequate funding
    for State and local capacity grants. Unfortunately, this is not a
    threat that is going away.
        CDC plays a significant role in addressing chronic diseases such as
    heart disease, stroke, cancer, diabetes and arthritis that continue to
    be the leading causes of death and disability in the United States.
    These diseases, many of which are preventable, are also among the most
    costly to our health system. CDC's National Center for Chronic Disease
    Prevention and Health Promotion provides critical funding for State
    programs to prevent chronic disease, conducts surveillance to collect
    data on disease prevalence and monitor intervention efforts and
    translates scientific findings into public health practice in our
    communities.
        CDC's National Center for Environmental Health is essential to
    protecting the health and well being of the public by helping to
    control asthma, protect from threats associated with climate change and
    reduce exposure to lead and other hazards. We urge the subcommittee to
    provide adequate funding for NCEH which has been significantly cut in
    recent years.
    Health Resources and Services Administration
        HRSA operates programs in every State and U.S. territory and is a
    national leader in improving the health of Americans through the
    delivery of quality health services and supporting a well prepared
    workforce. The agency serves the health needs of people who are
    medically vulnerable, low-income and geographically isolated. The
    Nation faces a shortage of health professionals and continues to
    experience an ever growing, aging and increasingly diverse population,
    alongside health professionals that are nearing retirement age. We are
    deeply concerned that since fiscal year 2010, HRSA's discretionary
    budget authority has been cut by 19 percent in nominal dollars and 25
    percent when adjusted for inflation. Funding for HRSA is far too low
    and keeping austerity measures in place will threaten the agency's
    ability to address the present and growing health needs of the U.S. To
    respond to the needs of our Nation, APHA recommends restoring funding
    to the fiscal year 2010 level of $7.48 billion for discretionary HRSA
    programs in fiscal year 2015.
        HRSA programs have a strong history of providing quality care to
    keep people healthy and improve health equity for those living outside
    of the economic and medical mainstream. HRSA has contributed to the
    decrease in infant mortality rate, a widely used indicator of the
    Nation's health, which is now at an all-time low. Most recently,
    preliminary data indicates that the infant mortality rate for black
    infants has decreased, resulting in a narrowing of the gap that exists
    between racial groups. HIV/AIDS programs administered by HRSA provide
    access to regular care and ensure adherence to antiretroviral treatment
    for people living with HIV, which reduces HIV transmission by 96
    percent and greatly contributes to the prevention of new HIV
    infections. A committed investment from Congress is required to
    continue achieving the health improvements HRSA has made and to pave
    the way for new achievements.
        Our recommendation is based on the need to continue improving the
    health of Americans by supporting critical HRSA programs, including:
      --Health Professions supports the education and training of a broad
            range of health professionals. With a focus on primary care and
            training in interdisciplinary, community-based settings, these
            are the only Federal programs focused on filling the gaps in
            the supply of health professionals, as well as improving the
            distribution and diversity of the workforce so health
            professionals are well-equipped to care for the growing and
            changing population.
      --Primary Care supports 9,200 health sites in every State and U.S.
            territory, improving access to care for more than 21 million
            patients in geographically isolated and economically distressed
            communities. Close to half of these health centers serve rural
            populations. In addition, health centers target populations
            with special needs, including migrant and seasonal farm
            workers, homeless individuals and families and those living in
            public housing.
      --Maternal and Child Health including the Title V Maternal and Child
            Health Block Grant, Healthy Start and others support
            initiatives designed to promote optimal health, reduce
            disparities, combat infant mortality, prevent chronic
            conditions and improve access to quality healthcare for more
            than 43 million women and children, including children with
            special healthcare needs.
      --HIV/AIDS provides assistance to States and communities most
            severely affected by HIV/AIDS. The programs deliver
            comprehensive care, prescription drug assistance and support
            services for about half of the total population--1.1 million
            people--living with HIV/AIDS in the U.S. Additionally, the
            programs provide education and training for health
            professionals treating people with HIV/AIDS and work toward
            addressing the disproportionate impact of HIV/AIDS on racial
            and ethnic minorities.
      --Family Planning Title X services ensure access to a broad range of
            reproductive, sexual and related preventive healthcare for over
            5 million poor and low-income women, men and adolescents at
            nearly 4,400 health centers nationwide. This program helps
            improve maternal and child health outcomes and promotes healthy
            families.
      --Rural Health improves access to care for the nearly 50 million
            people living in rural areas that experience a persistent
            shortage of healthcare services. These programs are designed to
            support community-based disease prevention and health promotion
            projects, help rural hospitals and clinics implement new
            technologies and strategies and build health system capacity in
            rural and frontier areas.
    Conclusion
        In closing, we emphasize that the public health system requires
    stronger financial investments at every stage. This funding makes up
    less than 1 percent of Federal spending and continued austerity
    measures that cut funding for public health and prevention programs
    will not balance our budget and will only lead to increased costs to
    our healthcare system. Successes in biomedical research must be
    translated into tangible prevention opportunities, screening programs,
    lifestyle and behavior changes and other population-based interventions
    that are effective and available for everyone. Without a robust and
    sustained investment in our public health agencies, we will fail to
    meet the mounting health challenges facing our Nation.

        [This statement was submitted by Georges Benjamin, MD, Executive
    Director American Public Health Association.]
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM), the largest single
    life science Society with over 39,000 members, wishes to submit a
    statement in support of increased funding in the fiscal year 2015
    budget for the Centers for Disease Control and Prevention (CDC). As the
    Nation's health protection Agency, the CDC's programs are critical to
    preventing disease and injury. The CDC conducts scientific
    investigations, develops public health guidelines and provides
    information and expertise in response to threats against public health
    in the United States and worldwide.
        The ASM urges Congress to approve the requested budget of $445.3
    million for the National Center for Emerging and Zoonotic Infectious
    Diseases (EZID), an overall increase of $54.9 million over fiscal year
    2104. The EZID budget includes an increase of $31 million for Core
    Infectious Diseases. A funding level of $30 million is included for
    Advanced Molecular Detection (AMD), year 2 of the 5 year initiative to
    enhance CDC's microbiology and bioinformatics capabilities to detect
    and respond to infectious disease outbreaks. The AMD initiative will
    improve pathogen identification and detection; adapt new diagnostics to
    meet evolving public health needs; help States meet future reference
    testing needs in a coordinated manner; implement enhanced, sustainable
    and integrated laboratory information systems; and develop prediction
    modeling and early recognition tools. Advances in biotechnology and
    computing must be part of CDC efforts against the threat of infectious
    diseases. Because of the need for better molecular sequencing tools and
    bioinformatics, last year CDC proposed the AMD initiative, integrating
    cutting edge laboratory and computer tools to enhance infectious
    disease prevention and control. A 2013 pilot study tracking a Listeria
    outbreak demonstrated that AMD technologies and methods could detect
    outbreaks sooner, halting disease faster. The study used whole genome
    sequencing with diagnostic testing for the first time to help clarify
    which patients' illnesses were related to a listeriosis outbreak linked
    to contaminated cheese. Listeria ranks third as a cause of death from
    foodborne pathogens in the United States and sickens about 1,600 people
    each year.
        The EZID budget includes a $10 million increase for CDC's Food
    Safety program. This increase is essential to enhance national
    surveillance outbreak detection and response and food safety prevention
    efforts. It will help modernize PulseNet and apply advanced DNA
    technology and expand sites for FoodCORE to improve outbreak detection
    and response. It will improve foodborne disease tracking, detection and
    response through the Integrated Food Safety Center of Excellence. Food
    safety is one of CDC's foremost strategic goals and heavily reliant
    upon state of the art surveillance. Last year, the CDC published first
    ever estimates of which food types were causing foodborne illnesses in
    the United States. These attribution estimates guide regulators,
    industry and consumers toward more precise and effective measures to
    prevent food contamination. In June, a new CDC report identified the
    key demographic groups most affected by Listeria bacteria infections.
    During 2009--2011, twelve Listeria outbreaks sickened people in 38
    States. CDC partnerships with other public health agencies clearly
    extend the CDC's ability to prevent disease. For example, data from the
    Foodborne Diseases Active Surveillance Network (FoodNet) are the source
    for CDC's most recent annual food safety report, which showed that 2012
    rates of infection for two foodborne pathogens (Campylobacter and
    Vibrio) had increased significantly when compared to 2006--2008, while
    rates of most others have not changed during the same period. FoodNet
    involves CDC, ten State health departments, the Department of
    Agriculture and the Food and Drug Administration.
        The ASM strongly supports the fiscal year 2015 EZID budget request
    of $30 million for the Antibiotic Resistance (AR) Strategy, which will
    speed up outbreak detection through regional labs, support development
    of new antibiotics and diagnostics and improve infection prevention and
    antibiotic prescribing. With a $30 million annual funding for 5 years,
    the AR initiative could achieve reductions in many infections,
    including C. difficile, carbapenem resistant Enterobacteriaceae (CRE),
    Multidrug Resistant (MDR) Pseudomosas, Invasive Methicillin-resistant
    Staphylococcus aureus (MRSA) and MDR Salmonella.
        CDC efforts have intensified against microbial pathogens that have
    evolved resistance against known drug therapies. In September, a
    landmark CDC report warned that antimicrobial resistant infections
    infect more than two million people in the United States every year,
    causing at least 23,000 deaths. CDC ranked AR threats into three
    categories: urgent, serious and concerning. Infections classified as
    urgent include CRE, drug resistant gonorrhea and Clostridium difficile,
    a diarrheal infection that causes about 250,000 U.S. hospitalizations
    and at least 14,000 deaths annually. Last year, CDC data showed more
    patients at hospitals and long term care facilities are being diagnosed
    with CRE infections; other AR reports are equally alarming.
        In November, CDC joined with the American Academy of Pediatrics to
    slow AR expansion with new guidelines, ``Principles of Judicious
    Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections
    in Pediatrics.'' Every year, up to 10 million children in the United
    States risk side effects from antibiotic prescriptions unlikely to help
    their respiratory symptoms. Many of these infections are caused by
    viruses not treatable by antibiotics. Antibiotic use is the single most
    important factor in antibiotic resistance, with up to 50 percent of
    prescriptions unnecessary or prescribed inappropriately. Studies
    estimate that AR adds $20 billion in excess direct health costs, with
    additional costs to Society for lost productivity as high as $35
    billion a year.
        CDC guidelines that include science based prevention protocols can
    be very effective, for example, the ongoing battle against healthcare
    acquired infections (HAIs). About 1 in every 20 hospitalized patients
    develops an infection caused by receiving medical care. Many of these
    are drug resistant (e.g., three quarters of Staphylococcus aureus
    infections in hospital ICUs are methicillin resistant MRSA). CDC
    aggressively promotes use of prevention protocols in all facilities in
    the United States. In 2013, CDC found that bloodstream infections in
    patients with central IV lines had decreased by over 40 percent and
    surgical site infections by 20 percent since 2008 and that following
    CDC protocols could cut dialysis related bloodstream infections in
    half. Another CDC coauthored report last fall concluded that there were
    an estimated 30,800 fewer invasive MRSA infections in 2011 compared
    with 2005. More than 12,000 healthcare facilities now track HAI
    infections using CDC's National Healthcare Safety Network (NHSN).
    Surveillance and Response
        CDC depends upon extensive surveillance networks and unique rapid
    response mobilization. Sustaining these CDC capabilities is critical to
    detect health threats, halt outbreaks and prevent illness and injury.
    Familiar threats like hepatitis and HIV/AIDS continue to affect lives.
    Public health institutions also are repeatedly challenged by emerging
    infectious diseases (EIDs), unexpected and often dangerous. CDC
    regularly confronts new threats, including the following EIDs in the
    past year:
      --CDC scientists traced the newly discovered Heartland virus that
            infected two men from Missouri to lone star ticks in the
            region, adding another tick borne disease to those the CDC
            monitors.
      --NCEZID helped identify a novel poxvirus (the same genus as
            smallpox) afflicting shepherds in the Republic of Georgia and
            is developing new diagnostic tests.
      --International travel advisories released by CDC address threats
            posed by the new coronavirus MERS-CoV, first reported by Saudi
            Arabia in 2012. CDC is working with health departments,
            hospitals and other partners to prepare for possible cases in
            the United States.
      --CDC is monitoring new reports of the mosquito borne chikungunya
            virus among residents of St. Martin in the Caribbean, the first
            time the disease has been detected among non-travelers in the
            Western Hemisphere.
        In 2013, CDC updated new surveillance results on several infectious
    diseases with serious healthcare and economic consequences in the
    United States:
      --Each year there are about 19 to 21 million cases of norovirus
            illness, about 570 to 800 people die, and many thousands more
            are hospitalized or visit emergency rooms and outpatient
            clinics. Another CDC study found that the contagious stomach
            virus is now the leading cause of acute gastroenteritis among
            children less than 5 years of age who seek medical care. It
            caused nearly one million U.S. pediatric visits in 2009--2010.
      --About 300,000 people are diagnosed with Lyme disease each year in
            the United States, making it the most commonly reported tick
            borne illness. The early estimate is based on findings from
            three ongoing CDC studies. It suggests that the total number is
            roughly 10 times higher than the number reported to CDC by
            healthcare providers.
      --Valley Fever, a fungal respiratory infection, dramatically
            increased in several southwestern States, from 2,265 in 1998 to
            more than 22,000 in 2011. CDC is investigating whether the
            increase is related to changes in weather, rising populations
            or changes in the way the disease is detected and reported to
            the States or CDC.
        Each year, CDC gives financial support to all 50 State health
    departments, six local departments, and eight territories or
    affiliates. Since 2010, CDC has provided funds to 57 State, local and
    territorial health departments to increase the use of electronic lab
    reporting (ELR). About 10,400 labs send reportable data to health
    agencies but many do not report electronically.
    Global Health
        With globalization of our food supply and frequent travel to and
    from the United States, health security threats can come from anywhere.
    CDC's Center for Global Health and Office of Infectious Diseases
    oversee Agency efforts to prevent, detect and respond to outbreaks in
    other countries. There are more than 1,600 CDC employees located in
    over 60 countries. At present, only 1 in 5 countries can rapidly
    detect, respond to or prevent global health threats caused by emerging
    infections. Improvements overseas, such as strengthening surveillance
    and lab systems or training investigators, make both the United States
    and the rest of the world more secure against infectious disease.
        In January, CDC reported results from pilot projects in Uganda and
    Vietnam to improve disease detection and response capabilities. Work in
    Uganda modernized diagnostic testing, developed real time information
    systems for faster outbreak response and improved emergency operations
    procedures. It focused on three priority diseases, drug resistant
    tuberculosis, cholera and viral hemorrhagic fever caused by Ebola
    virus. The Vietnam project trained Vietnamese health officials in
    advanced PCR techniques to detect H7N9 influenza, enterovirus 71 and
    respiratory viruses.
        The ASM strongly urges Congress to increase CDC's budget in fiscal
    year 2015 to the highest level possible and approve funding increases
    for infectious diseases.
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM), the largest single
    life science Society with over 39,000 members, wishes to submit the
    following comments and recommendations for the record on the fiscal
    year 2015 budget for the National Institutes of Health (NIH). The ASM
    commends Congress for passage of the fiscal year 2014 Omnibus
    Appropriations Bill which represents a step in the right direction
    although funding for NIH remains too low in view of the gaps in our
    knowledge of disease and the abundance of scientific opportunities that
    cannot be pursued because of lack of funding. The ASM recommends that
    NIH receive at least $32 billion in fiscal year 2015 as the next step
    toward a multi-year increase in the Nation's investment in medical
    research.
        The ASM is very concerned about the future of biomedical research
    in the United States. NIH support for basic research is critical to
    health and security, job creation and growing the U.S. economy. In
    fiscal year 2013, the success rate for NIH research grant applicants
    fell to an historic low 16.8 percent. The average size of research
    project grants (RPGs) decreased to the lowest ever since 1999. During
    last year's sequestration, there were reports of delayed research
    projects, enforced layoffs of technical staff and waning innovation.
    Such stagnation undercuts biomedical research progress in the United
    States at a time when the opportunities are great and other Nations are
    growing their investment in basic and translational biomedical
    research.
        NIH is the primary supporter of biomedical research in the Nation.
    In 2012 alone, NIH funding supported more than 402,000 jobs and $57.8
    billion in new economic activity nationwide. Among NIH's investments
    are those in the rapidly advancing field of genomics. A recent report
    from the nonprofit United for Medical Research (UMR) spotlighted the
    economics of Federal investment in the human genome project, which has
    generated $965 billion in economic impact, more than 53,000 direct
    genomics related jobs and $293 billion in personal income.
        Current trends in the Nation's R&D investments clearly do not bode
    well for future innovation and global competition. Federal R&D
    expenditures declined by 16.3 percent between fiscal years 2010 and
    2013, while China's investment jumped more than 400 percent over the
    past decade. Since 2001, the U.S. share of global R&D performed has
    decreased from 37 percent to 30 percent. The Science Coalition Report
    in 2013 highlighted the importance of federally funded university
    research in creating new companies and R&D jobs. The report profiles
    R&D companies launched by relatively small Federal investment in
    university research, including NIH grants funding rapid pathogen
    detection technologies, vaccine development and advances in food and
    water safety.
        Several UMR reports from last year underscore how NIH supported
    research can propel private sector growth and innovation. U.S. biotech
    companies catalyzed by NIH funding illustrate the productive
    collaborations among NIH, university research scientists and the
    private sector. These companies are reshaping lucrative R&D sectors
    like gene sequencing and therapeutics for human disease, taking basic
    research to the marketplace. NIH support is responsible for several of
    Science magazine's top ten 2013 discoveries, all expected to return
    huge dividends, including the ``breakthrough of the year'' cancer
    immunotherapy, the new gene editing CRISPR technique and the
    astoundingly important human microbiome project.
        Also included was the first use of structural biology techniques to
    custom design a powerful immunogen with vaccine potential, in this case
    against respiratory syncytial virus (RSV). Worldwide, about 64 million
    cases of RSV infection occur each year, responsible for 160,000 deaths,
    making it the most common cause of severe respiratory illness in
    infants and young children. There is no approved vaccine, but the team
    led by NIAID Vaccine Research Center identified 3-D structures of
    attachment sites on the virus surface and potent antibodies against
    those sites, offering new tools to develop new or improved vaccines.
        NIH investments build the scientific foundation for the Nation's
    valuable biomedical R&D sector, which employs 7 million and exports $90
    billion in goods and services. In 2013, all three recipients of the
    Nobel Prize in Physiology or Medicine and all three winners of the
    Nobel Prize in Chemistry had at some point received NIH funding (for a
    total of 144 NIH supported Nobel laureates). Four NIH funded scientists
    also won prestigious 2013 Lasker Foundation awards.
        As the Nation's largest funder of biomedical research, NIH leads
    the Nation's efforts to discover new cures, preventions and therapies
    for difficult disease challenges by funding intramural and extramural
    projects to combat infectious diseases that kill millions of people
    worldwide. The National Institute of Allergy and Infectious Diseases
    (NIAID) and the National Institute of General Medical Sciences (NIGMS)
    contribute to new, paradigm shifting technologies like high throughput
    genomic sequencing, as well as new multidisciplinary research
    approaches like systems biology.
        NIAID funded scientists have discovered therapies, vaccines,
    diagnostic tests and other biomedical tools that improve human health.
    Lifesaving examples are vaccines for rabies, meningitis, whooping
    cough, hepatitis A and B, chickenpox and pneumococcal pneumonia.
    Developing new influenza vaccines is a high priority for NIAID, which
    has supported a health provider consortium for clinical trials since
    the 1960s. The NIAID Vaccine Research Center's influenza research has
    produced multiple promising advances like a DNA vaccine against H5N1
    avian influenza and it helped establish the Southeast Asia Influenza
    Clinical Research Network to address global influenza threats. Ongoing
    NIAID research is making progress toward the highly significant goal of
    a universal influenza vaccine that would confer decades long protection
    from any flu virus strain.
        In February, NIAID reported on its latest contributions in the
    battle to halt antimicrobial resistance (AR) spreading among pathogens,
    which is creating ever more dangerous diseases like multidrug resistant
    gonorrhea and extensively drug resistant tuberculosis. Each year, there
    are 2 million drug resistant infections and 23,000 deaths in the United
    States. Annual costs are an estimated $20 billion in added healthcare
    and $35 billion in lost productivity. NIAID leads U.S. research against
    drug resistant pathogens, making major investments in basic,
    translational and clinical research. Results include advances in
    prevention, diagnosis and treatment of AR infections, as well as
    greater support for new drug discovery. The agency has helped support
    R&D of at least 25 percent of the antibiotics currently in clinical
    testing. Basic AR research funded by NIAID is detailing the ways that
    pathogens evade host defenses, to identify new therapeutic and
    diagnostic targets. Using the latest in technological tools, NIAID
    supported researchers are developing novel diagnostics platforms for
    more rapid and accurate detection of emerging AR infections. NIAID's
    expansive AR portfolio also includes vaccine development against
    increasingly common AR threats like drug resistant staph and gonorrhea
    bacteria.
        One of NIAID's greatest challenges for the 21st century is
    developing defenses against familiar enemies, the world's three
    greatest microbial killers, HIV/AIDS, malaria and tuberculosis. Recent
    research advances include the following:
      --A novel compound, from a new class of potential antimalarial drugs,
            appears effective against multiple life stages of the malaria
            causing Plasmodium parasite. Most antimalarials only target the
            parasite as it grows in the host's bloodstream, giving the
            parasite more chances to spread and acquire drug resistance.
      --After designing nanoparticles loaded with copies of mutated HIV
            selected via computerized screening, scientists have activated
            host immune cells to produce VRC01 neutralizing antibodies. The
            approach offers a new tool to potentially reverse engineer
            neutralizing antibodies against HIV and other viruses.
      --Using a systems biology approach, scientists have identified
            interactions among genetic regulators in Mycobacterium
            tuberculosis (Mtb), the bacterium that causes tuberculosis
            (TB). The results help explain how Mtb lies latent for long
            periods in otherwise healthy people, then becomes active and
            transmissible TB. About one third of the world's population is
            infected, making Mtb switches between different stages crucial
            to public health.
        Research strategies clearly rely upon previous scientific
    successes. Ever shifting influenza viruses and steady evolution of AR
    pathogens illustrate how any effort must build upon the past, respond
    to the present and plan for the future. New microbial threats emerge as
    old threats persist, the recent spread of dengue fever, detection of
    influenza H7N9 last year and the newly emerging coronavirus caused
    Middle East respiratory syndrome (MERS). First identified in 2012,
    MERS-CoV infection has been implicated in 181 cases (as of February 4)
    and 79 deaths. With high mortality and no treatments, the disease's
    spread from the Middle East to Europe has health officials concerned.
    NIAID funded researchers now have reported some laboratory success
    using potential MERS-CoV therapy that combines two licensed antiviral
    drugs routinely used to treat diseases such as hepatitis C.
        At NIGMS, microbial genetics and cell/molecular biology are
    principal research emphases, recognition that microbiology not only
    provides insights to human health and biology in general, but also
    stimulates innovation in U.S. biotechnology. Each year, NIGMS awards
    more than 4,500 research grants and supports one fourth (4,000) of the
    NIH supported technical trainees.
        NIGMS funded research has generated high value technologies like
    PCR, high throughput DNA sequencing, and the human genome project. The
    latest exciting biotech tool to emerge is CRISPR technology (Clustered
    Regularly Interspaced Short Palindromic Repeats, DNA loci in bacterial
    genomes), innovation that evolved from basic research in both phage
    biology and advanced computing genomics. With huge potential for
    improved genome editing essential to the biotech industry, today the
    CRISPR system is increasingly used in gene cutting and other customized
    gene targeting.
        Without sustained NIH funding in diverse fields like microbiology,
    ASM strongly believes there will be fewer new discoveries and
    innovation in the United States. We urge Congress to build on
    bipartisan efforts to replace the random cuts of sequestration that
    have been devastating to basic research in the United States and to
    increase funding for the National Institutes of Health. Increased
    investment will enable the scientific progress that is needed to
    improve the health, security and economic growth of the country.
                                     ______

            Prepared Statement of the American Society for Nutrition
        Dear Chairwoman Mikulski and Ranking Member Shelby: Thank you for
    the opportunity to provide testimony regarding fiscal year 2015
    appropriations. The American Society for Nutrition (ASN) respectfully
    requests $32 billion dollars for the National Institutes of Health
    (NIH) and $182 million dollars for the Centers for Disease Control and
    Prevention/National Center for Health Statistics (CDC/ NCHS) in Fiscal
    Year 2015. ASN is dedicated to bringing together the world's top
    researchers to advance our knowledge and application of nutrition, and
    has more than 5,000 members working throughout academia, clinical
    practice, government, and industry.
    National Institutes of Health (NIH)
        The NIH is the Nation's premier sponsor of biomedical research and
    is the agency responsible for conducting and supporting 86 percent of
    federally-funded basic and clinical nutrition research. Although
    nutrition and obesity research makes up less than eight percent of the
    NIH budget, some of the most promising nutrition-related research
    discoveries have been made possible by NIH support. NIH nutrition-
    related discoveries have impacted the way clinicians prevent and treat
    heart disease, cancer, diabetes and other chronic diseases. For
    example, U.S. death rates from heart disease and stroke have decreased
    by more than 60 percent, and the proportion of older adults with
    chronic disabilities has dropped by one-third. With additional support
    for NIH, additional breakthroughs and discoveries to improve the health
    of all Americans will be made possible.
        Investment in biomedical research generates new knowledge, improved
    health, and leads to innovation and long-term economic growth. A decade
    of flat-funding, followed by sequestration cuts, has taken a
    significant toll on NIH's ability to support research. Such economic
    stagnation is disruptive to training, careers, long-range projects and
    ultimately to progress. Increasing the NIH budget to $32 billion
    dollars would fully restore the funding that was lost to sequestration
    and support at least 600 additional competing research project grants.
    As a first step toward sustainable growth, ASN recommends a minimum of
    $32 billion dollars for NIH in fiscal year 2015. NIH needs sustainable
    and predictable budget growth in order to fulfill the full potential of
    biomedical research, including nutrition research, and to improve the
    health of all Americans.
    Centers for Disease Control and Prevention National Center for Health
            Statistics (CDC NCHS)
        The National Center for Health Statistics, housed within the
    Centers for Disease Control and Prevention, is the Nation's principal
    health statistics agency. ASN recommends a fiscal year 2015 funding
    level of $182 million dollars for NCHS, consistent with the President's
    budget request, to help ensure uninterrupted collection of vital health
    and nutrition statistics, and help cover the costs needed for
    technology and information security maintenance and upgrades that are
    necessary to replace aging survey infrastructure. More than half of
    NCHS's budget is supported through the evaluation tap. Therefore, ASN
    does not support efforts to eliminate the evaluation tap--in part or in
    full--unless a viable alternative funding mechanism is put in place to
    continue these important functions.
        The NCHS provides critical data on all aspects of our health care
    system, and it is responsible for monitoring the Nation's health and
    nutrition status through surveys such as the National Health and
    Nutrition Examination Survey (NHANES), that serve as a gold standard
    for data collection around the world. Nutrition and health data,
    largely collected through NHANES, are essential for tracking the
    nutrition, health and well-being of the American population, and are
    especially important for observing nutritional and health trends in our
    Nation's children.
        Nutrition monitoring conducted by the Department of Health and
    Human Services in partnership with the U.S. Department of Agriculture/
    Agricultural Research Service is a unique and critically important
    surveillance function in which dietary intake, nutritional status, and
    health status are evaluated in a rigorous and standardized manner.
    Nutrition monitoring is an inherently governmental function and
    findings are essential for multiple government agencies, as well as the
    public and private sector. Nutrition monitoring is essential to track
    what Americans are eating, inform nutrition and dietary guidance
    policy, evaluate the effectiveness and efficiency of nutrition
    assistance programs, and study nutrition-related disease outcomes.
    Funds are needed to ensure the continuation of this critical
    surveillance of the Nation's nutritional status and the many benefits
    it provides.
        Through learning both what Americans eat and how their diets
    directly affect their health, the NCHS is able to monitor the
    prevalence of obesity and other chronic diseases in the U.S. and track
    the performance of preventive interventions, as well as assess
    `nutrients of concern' such as calcium, which are consumed in
    inadequate amounts by many subsets of our population. Data such as
    these are critical to guide policy development in the area of health
    and nutrition, including food safety, food labeling, food assistance,
    military rations and dietary guidance. For example, NHANES data are
    used to determine funding levels for programs such as the Supplemental
    Nutrition Assistance Program (SNAP) and the Women, Infants, and
    Children (WIC) clinics, which provide nourishment to low-income women
    and children.
        To continue support for the agency and its important mission, ASN
    recommends an FY 2015 funding level of $162 million for NCHS. Sustained
    funding for NCHS can help to ensure uninterrupted collection of vital
    health and nutrition statistics, and will help to cover the costs
    needed for technology and information security upgrades that are
    necessary to replace aging survey infrastructure.
        Thank you for the opportunity to submit testimony regarding fiscal
    year 2015 appropriations for the National Institutes of Health and the
    CDC/National Center for Health Statistics. Please contact John E.
    Courtney, Ph.D., Executive Officer, if ASN may provide further
    assistance.

        [This statement was submitted by Gordon M. Jensen, M.D., Ph.D.,
    2013-2014 ident, American Society for Nutrition.]
                                     ______

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

        [This statement was submitted by James S. Bernstein, Director,
    Government and Public Affairs, American Society for Pharmacology &
    Experimental Therapeutics.]
                                     ______

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

        [This statement was submitted by Clifford A. Hudis, MD, FACP,
    President, American Society of Clinical Oncology.]
                                     ______

            Prepared Statement of the American Society of Hematology
        The American Society of Hematology (ASH) thanks the Subcommittee
    for the opportunity to submit written testimony on the fiscal year 2015
    Departments of Labor, Health and Human Services, and Education
    Appropriations bill.
        ASH represents more than 15,000 clinicians and scientists committed
    to the study and treatment of blood and blood-related diseases. These
    diseases encompass malignant disorders such as leukemia, lymphoma, and
    myeloma; life-threatening conditions, including thrombosis and bleeding
    disorders; and congenital diseases such as sickle cell anemia,
    thalassemia, and hemophilia. In addition, hematologists have been
    pioneers in the fields of bone marrow transplantation, stem cell
    biology and regenerative medicine, gene- and immunotherapy, and the
    development of many drugs for the prevention and treatment of heart
    attacks and strokes.
    Funding for Hematology Research: An Investment in the Nation's Health
        Over the past 60 years, American biomedical research has led the
    world in probing the nature of human disease. This research has led to
    new medical treatments, saved innumerable lives, reduced human
    suffering, and spawned entire new industries. This research would not
    have been possible without support from the National Institutes of
    Health (NIH).
        Funding for hematology research has been an important component of
    this investment in the Nation's health. Most of the research that
    produced cures and treatments for hematologic diseases has been funded
    by the NIH. The study of blood and its disorders is a trans-NIH issue
    involving many institutes at the NIH, including the National Heart,
    Lung and Blood Institute (NHLBI), the National Cancer Institute (NCI),
    the National Institute of Diabetes, Digestive and Kidney Diseases
    (NIDDK), and the National Institute on Aging (NIA).
        With the advances gained through an increasingly sophisticated
    understanding of how the blood system functions, hematologists have
    changed the face of medicine through their dedication to improving the
    lives of patients. As a result, children are routinely cured of acute
    lymphoblastic leukemia (ALL); more than 90 percent of patients with
    acute promyelocytic leukemia (APL) are cured with a drug derived from
    vitamin A; older patients suffering from previously lethal chronic
    myeloid leukemia (CML) are now effectively treated with well-tolerated
    pills; and patients with multiple myeloma are treated with new classes
    of drugs.
        Additionally, as NIH Director Francis Collins recently noted in his
    testimony to the Subcommittee, researchers are ``aiming to harness the
    body's own immune system to fight cancer.'' One such method, known as
    chimeric antigen receptor (CAR) cell engineering, extracts T cells
    (naturally occurring immune cells) from the blood of a cancer patients
    and modifies the cells to produce special proteins on their surface.
    With these new engineered features, the T cells are injected back into
    the patient, now primed to seek and destroy cancer cells. Preliminary
    studies have found that this process may generate responses in as many
    as two-thirds of cases in which all other treatment options have
    failed. Further, because the cells are derived from the patient, there
    is an inherently lower risk of toxicity because the cells are less
    likely to attack the host tissue than cells introduced from a foreign
    body. Promising results in patients with leukemia prompted Science
    magazine to name this its 2013 ``Breakthrough of the Year.''
        Hematology advances also help patients with other types of cancers,
    heart disease, and stroke. Even modest investments in hematology
    research have yielded large dividends for other disciplines. Basic
    research on blood has aided physicians who treat patients with heart
    disease, strokes, end-stage renal disease, cancer, and AIDS. Blood
    thinners effectively treat or prevent blood clots, pulmonary embolism,
    and strokes. Death rates from heart attacks are reduced by new forms of
    anticoagulation drugs.
    Sequestration Threatens Scientific Momentum
        ASH is particularly concerned about the impact of continued cuts on
    biomedical research supported by the NIH. NIH's ability to continue
    current research capacity and encourage promising new areas of science
    is, and will be, significantly limited. At a time when we should be
    investing more in research to save lives, research funding remains in
    serious jeopardy. Trials to find new therapies and cures for millions
    of Americans with blood cancers, bleeding disorders, clotting problems,
    and genetic diseases are just a few of the important projects that
    could be delayed unless NIH continues to receive predictable and
    sustained funding.
        Additionally, perhaps one of the greatest concerns is the obstacle
    these continued cuts will present to the next generation of scientists,
    who will see training funds slashed and the possibility of sustaining a
    career in research diminished. The Society is especially concerned
    about the number of scientists who have abandoned research careers;
    continued cuts will exacerbate this exodus, forcing researchers to
    abandon potentially life-enhancing research.
    Fiscal year 2015 NIH Funding Request
        ASH appreciates the welcome and much needed funding increase for
    the NIH that Congress provided in the Consolidated Appropriations Act
    of 2014. However, this increase did not give back all of the funds cut
    by sequestration in fiscal year 2013 nor did it restore the purchasing
    power lost over the past decade. ASH supports the Ad Hoc Group for
    Medical Research recommendation that NIH receive at least $32 billion
    in fiscal year 2015 as the next step toward a multi-year increase in
    our Nation's investment in medical research. ASH also urges Congress
    and the Administration to work in a bipartisan manner to end
    sequestration and the continued cuts to medical research that squander
    invaluable scientific opportunities, discourage young scientists,
    threaten medical progress and continued improvements in our Nation's
    health, and jeopardize our economic future.
    Centers for Disease Control and Prevention (CDC) Public Health Response
            for Blood Disorders
        The Society also recognizes the important role of the Centers for
    Disease Control and Prevention (CDC) in preventing and controlling
    clotting, bleeding, and other hematologic disorders. Blood disorders--
    such as sickle cell disease, anemia, blood clots, and hemophilia--are a
    serious public health problem and affect millions of people each year
    in the United States, cutting across the boundaries of age, race, sex,
    and socioeconomic status. Men, women, and children of all backgrounds
    live with the complications associated with these conditions, many of
    which are painful and potentially life-threatening.
        CDC is uniquely positioned to reduce the public health burden
    resulting from blood disorders by contributing to a better
    understanding of these conditions and their complications; ensuring
    that prevention programs are developed, implemented, and evaluated;
    ensuring that information is accessible to consumers and healthcare
    providers; and encouraging action to improve the quality of life for
    people living with or affected by these conditions. The Society is
    concerned that the Division of Blood Disorders was cut by nearly $6
    million in the Consolidated Appropriations Act of 2014 and the
    President's Budget for fiscal year 2015 did not restore this funding.
    ASH respectfully requests that the Division of Blood Disorders be
    funded in fiscal year 2015 at $19 million to assure that the programs
    funded by the Division for Hemophilia, Thalassemia, Sickle Cell
    Disease, and DVT/PE can be maintained. This funding will allow CDC to
    improve health outcomes and limit complications to those who are risk
    or currently have blood disorders, by promoting a comprehensive care
    model; identifying and evaluating effective prevention strategies; and
    increasing public and healthcare provider awareness of bleeding and
    clotting disorders such as such as hemophilia and thrombosis, and
    hemoglobinopathies, including sickle cell disease and thalassemia.
        Thank you again for the opportunity to submit testimony. Please
    contact Tracy Roades, ASH Legislative Advocacy Manager, at
    troades@hematology.org, if you have any questions or need further
    information concerning hematology research or ASH's fiscal year 2015
    funding request.
                                     ______

            Prepared Statement of the American Society of Nephrology
        The American Society of Nephrology (ASN) is the world's largest
    kidney health professional organization in the world, representing
    15,000 physicians, other healthcare providers, and scientists, and
    committed to advancing research, prevention, and treatment options for
    the more than 20 million adults, children, and adolescents with kidney
    disease in the United States today. The society requests at least
    $2.066 billion for the National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK) at the National Institutes of Health (NIH). The
    society also requests an additional $150 million/year over 10 years for
    kidney research above current funding for NIDDK.
        ASN believes these are crucial and necessary investments for
    preventing illness and maintaining fiscal responsibility. Investing in
    research to slow the progression of kidney disease and identify new
    therapies will save Medicare spending for the End-Stage Renal Disease
    (ESRD) Program in the long run.
        In 1972, Congress made a commitment to treat all Americans with
    kidney failure through the Medicare ESRD Program--the only health
    entitlement program that provides coverage regardless of age or
    disability. Today, ESRD patients account for less than 1 percent of the
    Medicare population but 7 percent of the Medicare budget. Meanwhile, at
    approximately $650 million per year, total Federal funding for kidney
    research is equivalent to less than 1 percent of the nearly $77 billion
    Medicare spends annually for the care of patients with kidney disease.
        Given that the Medicare ESRD Program is unique in that it covers
    treatment for all patients with kidney failure regardless of age or
    disability, preventing kidney disease and improving therapy--starting
    with innovative research at NIDDK--would yield significant savings to
    the Centers for Medicare and Medicaid Services.
        The vast majority of Federal research leading to advances in the
    care and treatment of patients with kidney disease is funded by NIDDK.
    Examples of critical discoveries arising from NIDDK-funded research are
    numerous.
        For instance, investigative studies supported by NIDDK led to a
    groundbreaking discovery that helps explain racial and ethnic
    disparities that increase risks for kidney disease, which can lead to
    earlier detection and treatment. The finding that African Americans
    with two variants of the APOL1 gene are likely to progress to kidney
    failure faster than other ethnicities paves the way for future research
    to unlock better preventive therapies and gene-based cures.
        Recent findings from NIDDK's Chronic Renal Insufficiency Cohort
    (CRIC) Study led to the discovery that the progression of kidney
    disease is associated with less efficient pumping of blood by the
    heart. Further research exploring the mechanisms for this development
    could lead to new interventions that could slow down the progression of
    kidney disease.
        Scientists supported by NIDDK have pursued cutting-edge basic,
    clinical, and translational research. While ASN fully understands the
    difficult economic environment, the society firmly believes that
    funding NIDDK is a sound investment to create jobs, support the next
    generation of investigators, and ultimately provide quality care that
    is less expensive in order to improve the public health of Americans.
        Medical research is a major force in the economic health of
    communities nationwide: every dollar invested in medical research
    generates $2.60 in economic activity. America must continue to
    capitalize on previous investments to drive research progress, train
    the next generation of scientists, create new jobs, promote economic
    growth, and maintain leadership in the global innovation economy--
    particularly as other countries increase their investments in
    scientific research. Most important, a failure to maintain and
    strengthen NIDDK's ability to support the groundbreaking work of
    researchers across the country carries a palpable human toll, denying
    hope to the millions of patients awaiting the possibility of a
    healthier tomorrow.
        ASN urges Congress to uphold its longstanding legacy of bipartisan
    support for biomedical research. Should you have any questions or wish
    to discuss NIDDK or kidney research in more detail, please contact ASN
    Manager of Policy and Government Affairs Rachel Meyer at (202) 640-4659
    or rmeyer@asn-online.org.
                                   about asn
        The American Society of Nephrology (ASN) is a 501(c)(3) non-profit,
    tax-exempt organization that leads the fight against kidney disease by
    educating the society's 15,000 physicians, scientists, and other
    healthcare professionals, sharing new knowledge, advancing research,
    and advocating the highest quality care for patients. For more
    information, visit ASN's website at www.asn-online.org.
                                     ______

         Prepared Statement of the American Society of Plant Biologists
        On behalf of the American Society of Plant Biologists (ASPB), we
    would like to thank the Subcommittee for its support of the National
    Institutes of Health (NIH). ASPB and its members strongly believe that
    sustained investments in scientific research will be a critical step
    toward economic recovery and job creation in our Nation. ASPB supports
    the maximum fiscal year 2015 appropriation for NIH and asks that the
    Subcommittee Members encourage increased support for plant-related
    research within the agency; 25 percent of our medicines originate from
    discoveries related to plant natural products, and such research has
    contributed in innumerable ways to improving the lives and health of
    Americans and people throughout the world.
        ASPB is an organization of some 4,500 professional plant biology
    researchers, educators, students, and postdoctoral scientists with
    members across the Nation and throughout the world. A strong voice for
    the global plant science community, our mission--achieved through work
    in the realms of research, education, and public policy--is to promote
    the growth and development of plant biology, to encourage and
    communicate research in plant biology, and to promote the interests and
    growth of plant scientists in general.
    Plant Biology Research and America's Future
        Among many other functions, plants form much of the base of the
    food chain upon which all life depends. Importantly, plant research is
    also helping make many fundamental contributions in the area of human
    health, including that of a sustainable supply and discovery of plant-
    derived pharmaceuticals, nutriceuticals, and alternative medicines.
    Plant research also contributes to the continued, sustainable,
    development of better and more nutritious foods and the understanding
    of basic biological principles that underpin improvements in the health
    and nutrition of all Americans.
    Plant Biology and the National Institutes of Health
        Plant science and many of our ASPB member research activities have
    enormous positive impacts on the NIH mission to pursue ``fundamental
    knowledge about the nature and behavior of living systems and the
    application of that knowledge to extend healthy life and reduce the
    burdens of illness and disability.'' In general, plant research aims to
    improve the overall human condition--be it food, nutrition, medicine or
    agriculture--and the benefits of plant science research readily extend
    across disciplines. In fact, plants are often the ideal model systems
    to advance our ``fundamental knowledge about the nature and behavior of
    living systems'' as they provide the context of multi-cellularity while
    affording ease of genetic manipulation, a lesser regulatory burden, and
    maintenance requirements that are less expensive than those required
    for the use of animal systems.
        Many fundamental biological components and mechanisms (e.g., cell
    division, viral and bacterial invasion, polar growth, DNA methylation
    and repair, innate immunity signaling and circadian rhythms) are shared
    by both plants and animals. For example, a process known as RNA
    interference, which has potential application in the treatment of human
    disease, was first discovered in plants. Subsequent research eventually
    led to two American scientists, Andrew Fire and Craig Mello, earning
    the 2006 Nobel Prize in Physiology or Medicine. More recently
    scientists engineered a class of proteins called TALENs capable of
    precisely editing genomes to potentially correct mutations that lead to
    disease. That these therapeutic proteins are derived from others
    initially discovered in a plant pathogen exemplifies the application of
    plant biology research to improving human health. These important
    discoveries again reflect the fact that some of the most important
    biological discoveries applicable to human physiology and medicine can
    find their origins in plant-related research endeavors.
        Health and Nutrition--Plant biology research is also central to the
    application of basic knowledge to ``extend healthy life and reduce the
    burdens of illness and disability.'' Without good nutrition, there
    cannot be good health. Indeed, a World Health Organization study on
    childhood nutrition in developing countries concluded that over 50
    percent of child deaths under the age of five could be attributed to
    malnutrition's effects in weakening the immune system and exacerbating
    common illnesses such as respiratory infections and diarrhea.
    Strikingly, most of these deaths were not linked to severe
    malnutrition, but chronic nutritional deficiencies brought about by
    overreliance on single crops for primary staples. Plant researchers are
    working today to address the root cause of this problem by balancing
    the nutritional content of major crop plants to provide the full range
    of essential micronutrients in plant-based diets.
        By contrast to developing countries, obesity, cardiac disease, and
    cancer take a striking toll in the developed world. Research to improve
    and optimize concentrations of plant compounds known to have, for
    example, anti-carcinogenic properties, will hopefully help in reducing
    disease incidence rates. Ongoing development of crop varieties with
    tailored nutraceutical content is an important contribution that plant
    biologists can and are making toward realizing the long-awaited goal of
    personalized medicine, especially for preventative medicine.
        Drug Discovery--Plants are also fundamentally important as sources
    of both extant drugs and drug discovery leads. In fact, 60 percent of
    anti-cancer drugs in use within the last decade are of natural product
    origin--plants being a significant source. An excellent example of the
    importance of plant-based pharmaceuticals is the anti-cancer drug
    taxol, which was discovered as an anti-carcinogenic compound from the
    bark of the Pacific yew tree through collaborative work involving
    scientists at the NIH National Cancer Institute and plant natural
    product chemists. Taxol is just one example of the many plant compounds
    that will continue to provide a fruitful source of new drug leads.
        While the pharmaceutical industry has largely neglected natural
    products-based drug discovery in recent years, research support from
    NIH offers yet another paradigm. Multidisciplinary teams of plant
    biologists, bioinformaticians, and synthetic biologists are being
    assembled to develop new tools and methods for natural products
    discovery and creation of new pharmaceuticals. We appreciate NIH's
    current investment into understanding the biosynthesis of natural
    products through transcriptomics and metabolomics of medicinal plants.
    The recently released ``Genomes to Natural Products'' funding
    opportunity is also to be applauded as a potential avenue for new
    plant-related medicinal research, and we strongly encourage the
    continuation of these types of investments and other plant-related
    initiatives which can help further achievement of the NIH mission.
    Conclusion
        Although NIH does recognize that plants serve many important roles,
    the boundaries of plant-related research are expansive and integrate
    seamlessly and synergistically with many different disciplines that are
    also highly relevant to NIH. As such, ASPB asks the Subcommittee to
    provide the maximum appropriation and direction to NIH to support
    additional plant research in order to continue to pioneer new
    discoveries and new methods with applicability and relevance in
    biomedical research.
        Thank you for your consideration of ASPB's testimony. For more
    information about ASPB, please see www.aspb.org.

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

              Prepared Statement of the American Thoracic Society

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

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

        [This statement was submitted by Thomas Ferkol, MD, President,
    American Thoracic Society.]
                                     ______

        Prepared Statement of the Americans for Nursing Shortage Relief
        The organizations of the ANSR Alliance greatly appreciate the
    opportunity to submit written testimony recommending $251 million in
    fiscal year 2015 for the Title VIII Nursing Workforce Development
    Programs at the Health Resources and Services Administration (HRSA) and
    $20 million for the Nurse Managed Health Clinics as authorized under
    Title III of the Public Health Service Act. We represent a diverse
    cross-section of healthcare and other related organizations, healthcare
    providers, and supporters of nursing issues (http://
    www.ansralliance.org/Members.html) that have united to address the
    national nursing shortage. ANSR stands ready to work with Congress to
    advance programs and policy that will ensure our Nation has a
    sufficient and adequately prepared nursing workforce to provide quality
    care to all well into the 21st century.
    The Nursing Shortage
        Nursing is the largest healthcare profession in the United States
    and work in a variety of settings, including primary care, public
    health, long-term care, surgical care facilities, schools, and
    hospitals. In the Bureau of Labor Statistics (BLS) Employment
    Projections for 2012-2022, the total employment of registered nurses
    (RNs) and advanced practice registered nurses (APRNs) will increase by
    574,400 jobs. With upcoming RN retirements in the mix, the Nation will
    need to produce 1.13 million new RNs by 2022 to fill those jobs.
    Because of the retirements, the projected number of RNs needed to fully
    staff healthcare facilities is virtually double the number of increased
    jobs due to expanded demand from new patients coupled with the aging
    baby boomer population wanting healthcare services. More new RNs are
    graduating from nursing programs than had been observed in the early
    2000's but not sufficient numbers to make up the difference over the
    long-term. The Title VIII Nursing Workforce Education Programs will
    help fill these vacancies by supporting training programs designed to
    meet these healthcare needs.
        The Title VIII Nursing Workforce and Education programs provide
    training for entry-level and advanced degree nurses to improve the
    access to, and the quality of, healthcare in underserved areas. These
    programs provide the largest source of Federal funding for nursing
    education, providing loans, scholarships, traineeships, and
    programmatic support that, between fiscal year 2005 and 2010, supported
    over 400,000 nurses and nursing students as well as numerous academic
    nursing institutions and healthcare facilities.
    The Desperate Need for Nurse Faculty
        Nursing vacancies exist throughout the entire healthcare system,
    including long-term care, home care and public health. Government
    estimates indicate that this situation only promises to worsen due to
    an insufficient supply of individuals matriculating in nursing schools,
    an aging existing workforce, and the inadequate availability of nursing
    faculty to educate and train the next generation of nurses. At the
    exact same time that the nursing shortage is expected to worsen, the
    baby boom generation is aging and the number of individuals with
    serious, life-threatening, and chronic conditions requiring nursing
    care will increase.
        Each year, nursing schools turn away tens of thousands of qualified
    applications at all degree levels due to an insufficient number of
    faculty, clinical sites, classroom space, clinical preceptors, and
    budget constraints. Securing and retaining adequate numbers of faculty
    is essential to ensure that all individuals interested in--and
    qualified for--nursing school can matriculate in the year that they are
    accepted.
        ANSR supports the need for sustained attention on the efficacy and
    performance of existing and proposed programs to improve nursing
    practices and strengthen the nursing workforce. The support of research
    and evaluation studies that test models of nursing practice and
    workforce development is integral to advancing healthcare for all in
    America. Investments in research and evaluation studies have a direct
    effect on the caliber of nursing care. Our collective goal of improving
    the quality of patient care, reducing costs, and efficiently delivering
    appropriate healthcare to those in need is served best by aggressive
    nursing research and performance and impact evaluation at the program
    level.
    The Nursing Supply Impacts the Nation's Health and Economic Safety
        The demand for primary care services in the US is expected to
    increase over the next few years, particularly with the aging and
    growth of the population. One study projects that by the year 2019, the
    demand for primary care in the United States will increase by between
    15 million and 25 million visits per year. HRSA estimates that more
    than 35.2 million people living within the 5,870 Health Professional
    Shortage Areas nationwide do not currently receive adequate primary
    care services. Research suggests that nurses and other health
    professionals are trained to and already do deliver many primary care
    services and may therefore be able to help increase access to primary
    care, particularly in underserved areas.
        ANSR applauds the subcommittee's bipartisan efforts to recognize
    that a strong nursing workforce is essential to a health policy that
    provides high-value care for every dollar invested in capacity building
    for a 21st century nurse workforce. For 50 years, the Title VIII
    Nursing Workforce Development Programs have responded to the Nation's
    evolving workforce needs by providing education and training
    opportunities to nurses. These programs are the only Federal programs
    focused on filling gaps in the supply of nurses not met by traditional
    market forces, as well as producing a workforce prepared to care for
    the Nation's increasingly diverse and aging population. Numerous
    studies have demonstrated that the Title VIII programs graduate more
    minority and disadvantaged students more likely to serve in community
    health centers as well as rural and underserved areas. In a difficult
    economy, the Title VIII Nursing Workforce Education Programs help
    schools offer scholarships and affordable loans to nursing students,
    making such educational opportunities available to aspiring nurses of
    all backgrounds. By guiding job seekers to high-demand nursing jobs,
    the programs fulfill both their individual career goals and a
    community's health needs.
    Summary
        HRSA's Title VIII Nursing Workforce Education programs contribute
    to a sufficient nursing workforce to meet the demands of a highly
    diverse and aging population is an essential component to improving the
    health status of the Nation and reducing healthcare costs. While the
    ANSR Alliance understands the immense fiscal pressures facing the
    Nation, we respectfully urge support for $251 million in funding for
    Nursing Workforce Development Programs under Title VIII of the Public
    Health Service Act at HRSA and $20 million for the Nurse Managed Health
    Clinics under Title III of the Public Health Service Act in fiscal year
    2015. We look forward to working with the Subcommittee to prioritize
    the Title VIII programs in fiscal year 2015 and the future.
                            ansr alliance co-chairs
    Christine Murphy, ANSR Alliance Co-Chair
    Senior Public Policy Specialist
    National League for Nursing

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

                                     ______

     Prepared Statement of the Animal Protection of New Mexico and Animal
                               Protection Voters
        On behalf of the board, staff, members and supporters of Animal
    Protection of New Mexico (APNM) and Animal Protection Voters (APV), we
    sincerely appreciate the opportunity to provide testimony on our top
    NIH funding priority for the House Labor, Health and Human Services,
    Education and Related Agencies Appropriations Subcommittee in fiscal
    year 2015.
       capacity for federally-owned chimpanzees retired by the national
                              institutes of health
        APNM and APV request NIH be given authority to use $5 million of
    funds appropriated in this and subsequent appropriations bills for
    extramural construction and renovation within the National Chimpanzee
    Sanctuary System.
        In 2013, NIH announced their plan to retire hundreds of government
    owned chimpanzees to sanctuary. This decision followed years of
    scientific review that determined chimpanzees are not necessary for
    research to advance human health along with broad public outcry over
    the ethics of holding chimpanzees in labs. Additional sanctuary
    construction is needed to enable NIH to move forward with their plan to
    retire the vast majority of government owned chimpanzees. Even taking
    into account upfront construction expenditures, the sooner the
    construction is completed and the chimpanzees are moved to sanctuary,
    the more the government will save over the lifetimes of the
    chimpanzees--which can be 60 years or more.
        Detailed information on the request follows.
    Background information
        In June of 2010, the National Institutes of Health proposed a plan
    to move 202 aging, sick chimpanzees from a facility New Mexico where
    they had not been used for invasive research for years to a laboratory
    in Texas for further research. Intense public scrutiny over the animal
    cruelty issues and taxpayer waste of this plan was bolstered by
    involvement from New Mexico Governor Bill Richardson, Dr. Jane Goodall,
    and many more. In December 2010 U.S. Senators Tom Udall, Tom Harkin,
    and Jeff Bingaman requested an independent study from the National
    Academy of Sciences on whether chimpanzees are necessary as invasive
    research subjects.
        The December 2011 Institute of Medicine study found that
    chimpanzees are not necessary for the vast majority of research and
    noted the serious ethical objections raised by keeping chimps in
    research labs. Immediately following the announcement of the IOM study
    results, NIH accepted the findings and assembled a panel of experts to
    advise them on the best way to implement the IOM findings. NIH accepted
    nearly all of the expert panel's recommendations in their final
    decision. In June of 2013, the National Institutes of Health announced
    their plan to retire all but 50 government-owned chimpanzees to
    sanctuary, significantly curtail the use of chimps in NIH funded
    studies and not to revitalize breeding of chimpanzees for research.
        NIH had already begun the transfer of the 110 government owned
    chimpanzees at the New Iberia Research Center in Louisiana to Chimp
    Haven (the National Chimpanzee Sanctuary), also located in Louisiana.
    This transfer is on schedule to be completed by the end of fiscal year
    2014. At that point, approximately 350 government-owned chimpanzees
    will remain in laboratories--300 of whom are slated for retirement to
    sanctuary per NIH's plan.
        In late November of 2013, the President signed into law amendments
    to the Chimpanzee Health Improvement Maintenance and Protection (CHIMP
    Act) which continued funding for the care, maintenance and
    transportation of federally owned chimpanzees over the next 5 years.
    These amendments have enabled NIH to provide funds for basic care for
    chimpanzees the agency already approved into sanctuary and also set the
    stage for NIH to move forward with their plan to retire hundreds more
    chimpanzees.
    Costs in laboratories vs. sanctuary
        Accredited sanctuaries provide the highest welfare standards for
    chimps at a lower cost to taxpayers than housing chimpanzees in
    research laboratories (see attached chart). It is estimated that
    transferring the 300 government-owned chimpanzees who are slated for
    retirement from the laboratories where they are currently housed to the
    national sanctuary will save taxpayers $1.7 million to $2.7 million per
    year in care and maintenance costs.
        Construction to house more chimpanzees in sanctuary will require an
    upfront expenditure. However, due to the lower per diem cost in
    sanctuary, retiring chimpanzees to sanctuary will still yield a
    significant savings to taxpayers. The sooner construction is completed
    and the chimpanzees are moved to sanctuary, the more the taxpayers will
    save.
    We respectfully request the subcommittee to consider the following
            language for inclusion in the appropriations bill:
        Of the funds appropriated to NIH, $5,000,000 shall be for grants or
    contracts for construction, renovation, or repair of the sanctuary
    system established by Section 404K of the Public Health Service Act.
        Estimated Costs Related to Care and Maintenance of Government Owned
    Chimpanzees:

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

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

        We appreciate the opportunity to share this testimony with the
    Labor, Health and Human Services, Education and Related Agencies
    Appropriations Act for fiscal year 2015. We hope the Committee will be
    able to accommodate this request. Thank you for your consideration.
                                     ______

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

        [This statement was submitted by Barbara Duffy Stewart, MPH,
    Executive Director, Association of American Cancer Institutes.]
                                     ______

       Prepared Statement of the Association of American Medical Colleges
        The Association of American Medical Colleges (AAMC) is a not-for-
    profit association representing all 141 accredited U.S. and 17
    accredited Canadian medical schools; nearly 400 major teaching
    hospitals and health systems; and nearly 90 academic and scientific
    societies. Through these institutions and organizations, the AAMC
    represents 128,000 faculty members, 75,000 medical students, and
    110,000 resident physicians. The AAMC requests the following for
    Federal priorities essential in assisting medical schools and teaching
    hospitals to fulfill their missions of education, research, and patient
    care: at least $32 billion for the National Institutes of Health (NIH);
    $375 million for the Agency for Healthcare Research and Quality (AHRQ);
    $520 million for the Title VII and VIII health professions workforce
    programs the Health Resources and Services Administration (HRSA)'s
    Bureau of Health Professions; and student aid through the Department of
    Education and HRSA's National Health Service Corps. The AAMC
    appreciates the Subcommittee's longstanding, bipartisan efforts to
    strengthen these programs.
        National Institutes of Health--Congress's long-standing bipartisan
    support for medical research through the NIH has created a scientific
    enterprise that is the envy of the world and has contributed greatly to
    improving the health and well-being of all Americans. The foundation of
    scientific knowledge built through NIH-funded research drives medical
    innovation that improves health through new and better diagnostics,
    improved prevention strategies, and more effective treatments.
        Nearly 84 percent of NIH research funding is awarded to more than
    2,500 research institutions in every state. At least half of this
    funding supports life-saving research at America's medical schools and
    teaching hospitals, where scientists, clinicians, fellows, residents,
    medical students, and trainees work side-by-side to improve the lives
    of Americans through research. This successful partnership between the
    Federal Government and academic medicine not only lays the foundation
    for improved health and quality of life, it also strengthens the
    Nation's long-term economy.
        The Consolidated Appropriations Act of 2014 included a welcome and
    much needed increase for NIH. However, this increase did not restore
    the funding cut from sequestration in fiscal year 2013 or the
    purchasing power lost over the past decade. The AAMC hopes fiscal year
    2014 represents a first step toward restoring our Nation's preeminence
    in medical research. The AAMC supports the Ad Hoc Group for Medical
    Research recommendation that NIH receive at least $32 billion in fiscal
    year 2015 as the next step toward a multi-year increase in our Nation's
    investment in medical research. The AAMC also urges Congress and the
    Administration to work in a bipartisan manner to end sequestration and
    the continued cuts to medical research that squander invaluable
    scientific opportunities, discourage young scientists, threaten medical
    progress and continued improvements in our Nation's health, and
    jeopardize our economic future.
        The AAMC thanks the Subcommittee for its efforts to retain the
    limit on salaries that can be drawn from NIH extramural awards at
    Executive Level II of the Federal Executive Pay Scale. Medical schools'
    and teaching hospitals' discretionary funds from clinical revenues and
    other sources have become increasingly constrained and less available
    to invest in research. If institutions and departments divert funds to
    compensate for a reduction in the salary limit, they have less funding
    for critical activities such as bridge funding to investigators between
    grants and start-up packages to young investigators to launch their
    research programs. A lower salary cap also will disproportionately
    affect physician investigators, who will be forced to make up salaries
    from clinical revenues, thus leaving less time for research. This may
    serve as a deterrent to their recruitment into research careers. The
    AAMC urges the Subcommittee to continue its efforts to retain the limit
    at Executive Level II.
        Agency for Healthcare Research and Quality--Complementing the
    medical research supported by NIH, AHRQ sponsors health services
    research designed to improve the quality of healthcare, decrease
    healthcare costs, and provide access to essential healthcare services
    by translating research into measurable improvements in the healthcare
    system. The AAMC firmly believes in the value of health services
    research as the Nation continues to strive to provide high-quality,
    evidence-based, efficient, and cost-effective healthcare to all of its
    citizens. The AAMC joins the Friends of AHRQ in recommending $375
    million in base discretionary funding for the agency in fiscal year
    2015.
        As the only Federal agency with the sole purpose of generating
    evidence to make healthcare safer; higher quality; and more accessible,
    equitable, and affordable, AHRQ also works to ensure such evidence is
    available across the continuum of healthcare stakeholders, from
    patients to payers to providers. These research findings will better
    guide and enhance consumer and clinical decisionmaking, provide
    improved healthcare services, and promote efficiency in the
    organization of public and private systems of healthcare delivery.
        Health Professions Funding--HRSA's Title VII health professions and
    Title VIII nursing education programs are the only Federal programs
    designed to improve the supply, distribution, and diversity of the
    Nation's primary care workforce. Through loans, loan guarantees, and
    scholarships to students, and grants and contracts to academic
    institutions and non-profit organizations, the Title VII and Title VIII
    programs fill the gaps in the supply of health professionals not met by
    traditional market forces.
        Titles VII and VIII are structured to allow grantees to test
    educational innovations, respond to changing delivery systems and
    models of care, and address timely topics in their communities. By
    assessing the needs of the communities they serve and emphasizing
    interprofessional education and training, Title VII and VIII programs
    bring together knowledge and skills across disciplines to provide
    effective, efficient and coordinated care. Further, numerous studies
    demonstrate that the programs graduate more minority and disadvantaged
    students and prepare providers that are more likely to serve in
    Community Health Centers (CHC) and the National Health Service Corps
    (NHSC).
        The AAMC joins the Health Professions and Nursing Education
    Coalition (HPNEC) in recommending $520 million for these important
    workforce programs in fiscal year 2015. This funding level is necessary
    to ensure continuation of all Title VII and Title VIII programs while
    also supporting promising initiatives such as the Pediatric
    Subspecialty Loan Repayment program, the Clinical Training in
    Interprofessional Practice program, the Rural Physician Training
    Grants, and other efforts to bolster the workforce.
        The AAMC strongly objects to the Administration's proposal to
    eliminate the Area Health Education Centers (AHEC), which, in 2012
    alone, trained more than 20,000 health professions students in
    community-based settings, and the Health Careers Opportunity Program
    (HCOP), which research shows has helped students from disadvantaged
    backgrounds achieve higher grade point averages and matriculate into
    health professions programs. Continued support for these and the full
    spectrum of Title VII and programs is essential to prepare our next
    generation of medical professionals to adapt to the evolving healthcare
    needs of the changing population.
        In addition to funding for Title VII and Title VIII, HRSA's Bureau
    of Health Professions also supports the Children's Hospitals Graduate
    Medical Education (CHGME) program. This program provides critical
    Federal graduate medical education support for children's hospitals to
    prepare the future primary care and specialty care workforce for our
    Nation's children. At a time when the Nation faces a critical physician
    shortage, the AAMC has serious concerns about the proposed elimination
    of the CHGME program in the president's budget. We strongly support
    full funding for the Children's Hospitals Graduate Medical Education
    program at $300 million in fiscal year 2015.
        Student Aid and the National Health Service Corps (NHSC)--The AAMC
    urges the committee to sustain student loan and repayment programs for
    graduate and professional students at the Department of Education. The
    average graduating debt of medical students is currently $175,000, and
    typical repayment can range from $326,000 to $492,000.
        The AAMC urges Congress to reauthorize the National Health Service
    Corps (NHSC) Fund, created under the Affordable Care Act (ACA, Public
    Law 111-142 and Public Law 111-152) and set to expire at the end of
    fiscal year 2015. In the absence of continued mandatory funding, the
    committee must address the NHSC funding shortfall in the already
    strained Labor-HHS spending bill. To date, the steady, sustained, and
    certain growth established by this mandatory funding for the NHSC has
    resulted in program expansion and innovative pilots such as the Student
    to Service (S2S) Loan Repayment Program that incentivizes fourth-year
    medical students to practice primary care in underserved areas after
    residency training.
        Once again, the AAMC appreciates the opportunity to submit this
    statement for the record and looks forward to working with the
    Subcommittee as it prepares its fiscal year 2015 spending bill.
                                     ______

         Prepared Statement of the Association of Independent Research
                                   Institutes
        The Association of Independent Research Institutes (AIRI) thanks
    the Subcommittee for its long-standing and bipartisan leadership in
    support of the National Institutes of Health (NIH). We continue to
    believe that science and innovation are essential if we are to continue
    to improve our Nation's health, sustain our leadership in medical
    research, and remain competitive in today's global information and
    innovation-based economy. The Consolidated Appropriations Act of 2014
    included a welcome and much needed increase for NIH. However, this
    increase did not give back all of the funds cut by sequestration in
    fiscal year 2013 nor did it restore the purchasing power NIH has lost
    over the past decade. We hope fiscal year 2014 represents a first step
    toward restoring our Nation's preeminence in medical research. AIRI
    recommends that NIH receive at least $32 billion in fiscal year 2015 as
    the next step toward a multi-year increase in our Nation's investment
    in medical research.
        AIRI is a national organization of more than 80 independent, non-
    profit research institutes that perform basic and clinical research in
    the biological and behavioral sciences. AIRI institutes vary in size,
    with budgets ranging from a few million to hundreds of millions of
    dollars. In addition, each AIRI member institution is governed by its
    own independent Board of Directors, which allows our members to focus
    on discovery-based research while remaining structurally nimble and
    capable of adjusting their research programs to emerging areas of
    inquiry. Researchers at independent research institutes consistently
    exceed the success rates of the overall NIH grantee pool, and they
    receive about 10 percent of NIH's peer-reviewed, competitively-awarded
    extramural grants.
        The partnership between NIH and America's scientists, research
    institutions, universities, and medical schools is a unique and highly-
    productive relationship, leveraging the full strength of our Nation's
    research enterprise to foster discovery, improve our understanding of
    the underlying cause of disease, and develop the next generation of
    medical advancements that deliver more treatments and cures to
    patients. Not only is NIH research essential to advancing health, it
    also plays a key economic role in communities nationwide. Approximately
    84 percent of the NIH's budget goes to more than 300,000 research
    positions at over 2,500 universities and research institutions located
    in every State.
        The Federal Government has an irreplaceable role in supporting
    medical research. No other public, corporate or charitable entity is
    willing or able to provide the broad and sustained funding for the
    cutting edge research necessary to yield new innovations and
    technologies of the future. NIH supports long-term competitiveness for
    American workers, forming one of the key foundations for U.S.
    industries like biotechnology, medical device and pharmaceutical
    development, and more. Unfortunately, continued erosion of the national
    commitment to medical research threatens our ability to support a
    medical research enterprise that is capable of taking full advantage of
    existing and emerging scientific opportunities.
        The NIH model for conducting biomedical research, which involves
    supporting scientists at universities, medical centers, and independent
    research institutes, provides an effective approach to making
    fundamental discoveries in the laboratory that can be translated into
    medical advances that save lives. AIRI member institutions are private,
    stand-alone research centers that set their sights on the vast
    frontiers of medical science. AIRI institutes are specifically focused
    on pursuing knowledge around the biology and behavior of living systems
    and applying that knowledge to improve human health and reduce the
    burdens of illness and disability. Additionally, AIRI member institutes
    have championed (and very frequently are called upon to lead)
    technologies and research centers to collaborate on biological research
    for all diseases. Using shared resources--specifically, advanced
    technology platforms or ``cores,''--as well as genomics, next-
    generation sequencing, electron and light microscopy, high-throughput
    compound screening, bioinformatics, imaging, and other technologies,
    AIRI researchers advance therapeutics development and drug discovery.
        AIRI member institutes are especially vulnerable to reductions in
    the NIH budget, as they do not have other reliable sources of revenue
    to make up the shortfall. In addition to concerns over funding, AIRI
    member institutes oppose legislative provisions--such as directives to
    reduce the salary limit for extramural researchers--which would harm
    the integrity of the research enterprise and disproportionately affect
    independent research institutes. Such prescriptive policies hinder AIRI
    members' research missions and their ability to recruit and retain
    talented researchers. AIRI also does not support legislative language
    limiting the flexibility of NIH to determine how to most effectively
    manage its resources while funding the best scientific ideas.
        AIRI member institutes' flexibility and research-only missions
    provide an environment particularly conducive to creativity and
    innovation. Independent research institutes possess a unique
    versatility and culture that encourages them to share expertise,
    information, and equipment across research institutions, as well as
    neighboring universities. These collaborative activities help minimize
    bureaucracy and increase efficiency, allowing for fruitful partnerships
    in a variety of disciplines and industries. Also, unlike institutes of
    higher education, AIRI member institutes focus primarily on scientific
    inquiry and discovery, allowing them to respond quickly to the research
    needs of the country.
        AIRI members are located in 25 States, including many smaller or
    less-populated States that do not have major academic research
    institutions. In many of these regions, independent research institutes
    are major employers and local economic engines, and they exemplify the
    positive impact of investing in research and science.
        The biomedical research community depends upon a knowledgeable,
    skilled, and diverse workforce to address current and future critical
    health research questions. While the primary function of AIRI member
    institutions is research, most are highly involved in training the next
    generation of biomedical researchers, ensuring that a pipeline of
    promising scientists is prepared to make significant and potentially
    transformative discoveries in a variety of areas. AIRI supports
    policies that promote the ability of the United States to maintain a
    competitive edge in biomedical science. The NIH initiatives focusing on
    career development and recruitment of a diverse scientific workforce
    are important to innovation in biomedical research and public health.
        AIRI thanks the Subcommittee for its important work dedicated to
    ensuring the health of the Nation, and we appreciate this opportunity
    to urge the Subcommittee to provide $32 billion for NIH in the fiscal
    year 2015 appropriations bill. AIRI also urges Congress and the
    Administration to work in a bipartisan manner to end sequestration and
    the continued cuts to medical research that squander valuable
    scientific opportunities, discourage young scientists, threaten medical
    progress and continued improvements in our Nation's health, and
    jeopardize our economic future.
                                     ______

        Prepared Statement of the Association of University Programs in
                         Occupational Health and Safety
        On behalf of the Association of University Programs in Occupational
    Health and Safety (AUPOHS), an organization representing the 18
    multidisciplinary, university-based Education and Research Centers
    (ERCs) and the ten Agricultural Centers for Disease and Injury
    Research, Education, and Prevention funded by the National Institute
    for Occupational Safety and Health (NIOSH), we respectfully request
    that the fiscal year 2015 Labor, Health and Human Services
    Appropriations bill include level funding of $27 million for the
    Education and Research Centers and $24 million for the Agriculture,
    Forestry and Fishing (AFF) Program within the NIOSH budget.
        NIOSH is the Federal agency responsible for supporting education,
    training, and research for the prevention of work-related injuries and
    illnesses in the United States. The ERCs are regional resources for
    parties involved with occupational health and safety--industry, labor,
    government, academia, and the public. Collectively, the ERCs provide
    training and research resources to every Public Health Region in the
    United States. ERCs contribute to national efforts to reduce losses
    associated with work-related illnesses and injuries by offering:
      --Prevention Research: Developing the basic knowledge and associated
            technologies to prevent work-related illnesses and injuries.
      --Professional Training: ERCs support 86 graduate degree programs in
            Occupational Medicine, Occupational Health Nursing, Safety
            Engineering, Industrial Hygiene, and other related fields to
            provide qualified professionals in essential disciplines.
      --Research Training: Preparing doctoral-trained scientists who will
            respond to future research challenges and who will prepare the
            next generation of occupational health and safety
            professionals.
      --Continuing Education: Short courses designed to enhance
            professional skills and maintain professional certification for
            those who are currently practicing in occupational health and
            safety disciplines. These courses are delivered throughout the
            regions of the 18 ERCs, as well as through distance learning
            technologies.
      --Regional Outreach: Responding to specific requests from local
            employers and workers on issues related to occupational health
            and safety.
        Occupational injury and illness represent a striking burden on
    America's health and well-being. Despite significant improvements in
    workplace safety and health over the last several decades, each year
    nearly 1.2 million workers are injured seriously enough to require time
    off work and, daily, an average of 11,000 U.S. workers sustain
    disabling injuries on the job, 13 workers die from an injury suffered
    at work, and 146 workers die from work-related diseases. This burden
    costs industry and citizens an estimated $4 billion per week--$250
    billion dollars per year. This is an especially tragic situation
    because work-related fatalities, injuries and illnesses are preventable
    with effective, professionally directed, health and safety programs.
        The rapidly changing workplace continues to present new health
    risks to American workers that need to be addressed through
    occupational safety and health research. For example, between 2000 and
    2015, the number of workers 55 years and older will increase 72 percent
    to over 31 million. Work related injury and fatality rates increase at
    age 45, with rates for workers 65 years and older nearly three times
    greater than younger workers. In addition to changing demographics, the
    rapid development of new technologies (e.g., nanotechnology) poses many
    unanswered questions with regard to workplace health and safety that
    require urgent attention.
        The heightened awareness of terrorist threats, and the increased
    responsibilities of first responders and other homeland security
    professionals, illustrates the need for strengthened workplace health
    and safety in the ongoing war on terror. The NIOSH ERCs play a crucial
    role in preparing occupational safety and health professionals to
    identify and mitigate vulnerabilities to terrorist attacks and to
    increase readiness to respond to biological, chemical, or radiological
    attacks. In addition, occupational health and safety professionals have
    worked for several years with emergency response teams to minimize
    disaster losses. For example, NIOSH took a lead role in protecting the
    safety of 9/11 emergency responders in New York City and Virginia, with
    ERC-trained professionals applying their technical expertise to meet
    immediate protective needs and to implement evidence-based programs to
    safeguard the health of clean-up workers.
        Additionally, NIOSH is now administering grants to provide health
    screening of World Trade Center responders. We need manpower to address
    these challenges and it is the NIOSH ERCs that train the professionals
    who fill key positions in health and safety programs, regionally and
    around the Nation. And because ERCs provide multi-disciplinary
    training, ERC graduates protect workers in virtually every walk of
    life. Despite the success of the ERCs in training such qualified
    professionals, the country continues to have ongoing manpower
    shortages.
        The Agricultural Safety and Health Centers program was established
    by Congress in 1990 (Public Law 101-517) in response to evidence that
    agricultural workers were suffering substantially higher rates of
    occupational injury and illness than other U.S. workers.
        Today the NIOSH Agriculture, Forestry, and Fishing (AFF) Initiative
    includes nine regional Centers for Agricultural Disease and Injury
    Research, Education, and Prevention and one national center to address
    children's farm safety and health. The AFF program is the only
    substantive Federal effort to meet the obligation to ensure safe
    working conditions for workers in this most vital production sector.
    While agriculture, forestry, and fishing constitute one of the largest
    industry sectors in the U.S. (DOL 2011), most AFF operations are
    themselves small: nearly 78 percent employ fewer than 10 workers, and
    most rely on family members and/or immigrants, part-time, contract and
    seasonal labor. Thus, many AFF workers are excluded from labor
    protections, including many of those enforced by OSHA.
        In 2012 the AFF sector had a work-related fatality rate of 22 per
    100,000 workers, the highest of any sector in the Nation. More than 1
    in 100 AFF workers incur nonfatal injuries resulting in lost work days
    each year. These reported figures do not even include men, women, and
    youths on farms with fewer than 11 full-time employees. In addition to
    the harm to individual men, women, and families, these deaths and
    injuries inflict serious economic losses including medical costs and
    lost capital, productivity, and earnings. The life-saving, cost-
    effective work of the NIOSH AFF program is not replicated by any other
    agency:
      --State and Federal OSHA personnel rely on NIOSH research in the
            development of evidence-based standards for protecting
            agricultural workers and would not be able to fulfill their
            mission without the NIOSH AFF program.
      --While committed to the well-being of farmers, the USDA has little
            expertise in the medical or public health sciences. USDA no
            longer funds, as it did historically, land grant university-
            based farm safety specialists.
      --Staff members of USDA's National Institute of Food and Agriculture
            interact with NIOSH occupational safety and health research
            experts to keep abreast of cutting-edge research and new
            directions in this area.
        NIOSH Agricultural Center activities include:
      --AFF research has shown that the use of rollover protective
            structures (ROPS or rollbars) and seatbelts on tractors can
            prevent 99 percent of overturn-related deaths. A New York
            program has increased the installation of ROPS by 10-fold and
            recorded over 140 close calls with no injuries among farmers
            who had installed ROPS. 99 percent of program participants said
            they would recommend the program to other farmers.
      --Working in partnership with producers and farm owners, the NIOSH
            AFF Centers have developed evidence-based solutions for
            reducing exposure to pesticides and other farm chemicals among
            farmers, farm workers and their children.
      --Commercial Fishing had a reported annual fatality rate 58 times
            higher than the rate for all U.S. workers in 2009. Research has
            shown that knowledge of maritime navigation rules and emergency
            preparedness means survival. A NIOSH AFF-funded team produced
            an interactive navigation training CD in three languages,
            demonstrated the effectiveness of refresher survival drill
            instruction, and assisted the US Coast Guard's revision of
            regulations requiring commercial fishing vessel captains
            complete navigation training.
      --The Centers have partnered with producers, employers, the Federal
            migrant health program, physicians, nurses, and Internet
            Technology specialists to educate farmers, employers, and
            healthcare providers about the best way to treat and prevent
            agricultural injury and illness.
      --In 2010, the logging industry had a reported fatality rate of 91.9
            deaths per 100,000 workers (preliminary data), a rate more than
            25 times higher than that of all US workers. NIOSH AFF Centers,
            including the Southeast and the Northwest, are uniquely
            positioned to ensure the safety of our Nation's 86,000 workers
            in forestry & logging.
        Thank you for the opportunity to present testimony on behalf of the
    many individuals committed to working to improve the safety and well
    being of others in our communities.
                                     ______

          Prepared Statement of the Association of Zoos and Aquariums
        Thank you Chairman Harkin and Ranking Member Moran for allowing me
    to submit testimony on behalf of the Nation's 213 U.S. accredited zoos
    and aquariums. Specifically, I want to express my support for the
    inclusion of $38.6 million for the Institute of Museum and Library
    Services' (IMLS) Office of Museum Services in the fiscal year 2015
    Labor, Health and Human Services, Education, and Related Agencies
    appropriations bill.
        Founded in 1924, the Association of Zoos and Aquariums (AZA) is a
    nonprofit 501c(3) organization dedicated to the advancement of zoos and
    aquariums in the areas of conservation, education, science, and
    recreation. Accredited zoos and aquariums annually see more than 182
    million visitors, collectively generate more than $21 billion in annual
    economic activity, and support more than 204,000 jobs across the
    country. Over the last 5 years, AZA-accredited institutions supported
    more than 4,000 field conservation and research projects with
    $160,000,000 annually in more than 100 countries. In the last 10 years,
    accredited zoos and aquariums formally trained more than 400,000
    teachers, supporting science curricula with effective teaching
    materials and hands-on opportunities. School field trips annually
    connect more than 12,000,000 students with the natural world.
        Aquariums and zoological parks are defined by the ``Museum and
    Library Services Act of 2003'' (Public Law 108-81) as museums. The
    Office of Museum Services awards grants to museums to support them as
    institutions of learning and exploration, and keepers of cultural,
    historical, and scientific heritages. Grants are awarded in several
    areas including educational programming, professional development, and
    collections management, among others.
        The Nation's accredited zoos and aquariums, even while facing
    budget limitations, are thriving during these uncertain economic times.
    As valued members of local communities, zoos and aquariums offer a
    variety of programs ranging from unique educational opportunities for
    schoolchildren to conservation initiatives that benefit both local and
    global species. The competitive grants offered by the IMLS Office of
    Museum Services ensure that many of these programs, which otherwise may
    not exist because of insufficient funds, positively impact local
    communities and many varieties of species.
        For example, with a 2013 Museums for America--Collections
    Stewardship grant the Toledo Zoo will obtain new life support systems
    for an interactive visitor touch tank containing invertebrates and
    another holding sharks and stingrays. The exhibits provide multi-
    sensory experiences that connect people with animals, while the systems
    ensure the animals are properly cared for. Through its 2012 Museums for
    American grant, the Birmingham Zoo supported its Africa Zoo School
    program, which is serving 1,200 students over 2 years. Partnering with
    Birmingham City School, seventh-grade students from low-performing
    schools attend a week-long ``Zoo School'' session, where they learn
    about the crisis of the elephant species' survival in Africa, the
    cultures of people in Africa, and the scientific and engineering
    research involved in sustaining these populations. Finally, a 2011
    Museums for America grant enabled The National Aquarium in Baltimore to
    create a more robust volunteer program by developing and testing new
    techniques to attract, train, engage, and retain a new generation of
    more diverse volunteers.
        Unfortunately, current funding has allowed IMLS to fund only a
    small fraction of all highly-rated grant applications. Despite this
    funding shortfall, zoo and aquarium attendance has increased and the
    educational services zoos and aquariums provide to schools and
    communities are in greater demand than ever. Zoos and aquariums are
    essential partners at the Federal, State, and local levels in providing
    education and cultural opportunities that adults and children may
    otherwise never enjoy.
        As museums, zoos and aquariums share the same mission of preserving
    the world's great treasures, educating the public about them, and
    contributing to the Nation's economic and cultural vitality. Therefore,
    I strongly encourage you to include $38.6 million for the Institute of
    Museum and Library Services' Office of Museum Services in the fiscal
    year 2015 Labor, Health and Human Services, Education, and Related
    Agencies appropriations bill.
        Thank you.
        [This statement was submitted by Jim Maddy, President and CEO,
    Association of Zoos and Aquariums.]
                                     ______

         Prepared Statement of the Brain Injury Association of America
        Chairman Harkin and Ranking Member Moran, thank you for the
    opportunity to submit this written testimony with regard to the fiscal
    year 2015 Labor-HHS-Education appropriations bill. This testimony is on
    behalf of the Brain Injury Association of America (BIAA), our network
    of State affiliates, and hundreds of local chapters and support groups
    from across the country.
        In the civilian population alone every year, more than 2.5 million
    people sustain brain injuries from falls, car crashes, assaults and
    contact sports. Males are more likely than females to sustain brain
    injuries. Children, teens and seniors are at greatest risk.
        Increasing numbers of service members returning from the conflicts
    in Iraq and Afghanistan with TBI and their families are seeking
    resources for information to better understand TBI and to obtain vital
    support services to facilitate successful reintegration into their
    communities.
        Since 1997, Congress has provided minimal funding through the
    Health Resources and Services Administration (HRSA) Federal TBI Program
    to assist States in developing services and systems to help individuals
    with brain injuries and their families who have a broad range of
    service and support needs. . Similarly, Congress has appropriated funds
    to HRSA for grants to State Protection and Advocacy Systems to assist
    individuals with TBI in accessing services through education, legal and
    advocacy remedies, but the program is woefully underfunded.
    Rehabilitation, community support and long-term care systems are still
    developing in many States, while stretched to capacity in others.
    Additional numbers of individuals with TBI as the result of war-related
    injuries only adds more stress to these inadequately funded systems.
        BIAA respectfully urges you to provide States with the resources
    they need to address both the civilian and military populations that
    look to them for much needed support in order to live and work in their
    communities.
        With broader regard to all of the programs authorized through the
    TBI Act, BIAA specifically requests:
      --$10 million (+ $4 million) for the Centers for Disease Control and
            Prevention TBI Registries and Surveillance, Brain Injury Acute
            Care Guidelines, Prevention and National Public Education/
            Awareness
      --$12 million (+ $1 million) for the Health Resources and Services
            Administration (HRSA) Federal TBI State Grant Program
      --$4 million (+ $1 million) for the HRSA Federal TBI Protection &
            Advocacy (P&A) Systems Grant Program
        CDC--National Injury Center--The Centers for Disease Control and
    Prevention's National Injury Center is responsible for assessing the
    incidence and prevalence of TBI in the United States. The CDC estimates
    that 2.5 million TBIs occur each year and 5.3 million Americans live
    with a life-long disability as a result of TBI. The TBI Act as amended
    in 2008 requires the CDC to coordinate with the Departments of Defense
    and Veterans Affairs to include the number of TBIs occurring in the
    military. This coordination will likely increase CDC's estimate of the
    number of Americans sustaining TBI and living with the consequences.
        CDC also funds States for TBI registries, creates and disseminates
    public and professional educational materials, for families, caregivers
    and medical personnel, and has recently collaborated with the National
    Football League and National Hockey League to improve awareness of the
    incidence of concussion in sports. CDC plays a leading role in helping
    standardize evidence based guidelines for the management of TBI and $1
    million of this request would go to fund CDC's work in this area.
        HRSA TBI State Grant Program--The TBI Act authorizes HRSA to award
    grants to (1) States, American Indian Consortia and territories to
    improve access to service delivery and to (2) State Protection and
    Advocacy (P&A) Systems to expand advocacy services to include
    individuals with traumatic brain injury. Since 1997, the HRSA Federal
    TBI State Grant Program has supported State efforts to address the
    needs of persons with brain injury and their families and to expand and
    improve services to underserved and unserved populations including
    children and youth; veterans and returning troops; and individuals with
    co-occurring conditions
        In fiscal year 2009, HRSA reduced the number of State grant awards
    to 21, in order to increase each monetary award from $118,000 to
    $250,000. This means that many States that had participated in the
    program in prior years have now been forced to close down their
    operations, leaving many individuals with brain injury and their
    families unable to access needed care and supports.
        Increasing the program to $8 million will provide funding necessary
    to sustain the grants for the 21 States currently receiving funding
    along with the three additional States added this year and to ensure
    funding for four additional States. Steady increases over 5 years for
    this program will provide for each State including the District of
    Columbia and the American Indian Consortium and territories to sustain
    and expand State service delivery; and to expand the use of the grant
    funds to pay for such services as Information & Referral (I&R), systems
    coordination and other necessary services and supports identified by
    the State.
        HRSA TBI P&A Program--Similarly, the HRSA TBI P&A Program currently
    provides funding to all State P&A systems for purposes of protecting
    the legal and human rights of individuals with TBI. State P&As provide
    a wide range of activities including training in self-advocacy,
    outreach, information & referral and legal assistance to people
    residing in nursing homes, to returning military seeking veterans
    benefits, and students who need educational services.
        Effective Protection and Advocacy services for people with
    traumatic brain injury is needed to help reduce government expenditures
    and increase productivity, independence and community integration.
    However, advocates must possess specialized skills, and their work is
    often time-intensive. A $4 million appropriation would ensure that each
    P&A can move towards providing a significant PATBI program with
    appropriate staff time and expertise.
        NIDRR TBI Model Systems of Care--Funding for the TBI Model Systems
    in the Department of Education is urgently needed to ensure that the
    Nation's valuable TBI research capacity is not diminished, and to
    maintain and build upon the 16 TBI Model Systems research centers
    around the country.
        The TBI Model Systems of Care program represents an already
    existing vital national network of expertise and research in the field
    of TBI, and weakening this program would have resounding effects on
    both military and civilian populations. The TBI Model Systems are the
    only source of non-proprietary longitudinal data on what happens to
    people with brain injury. They are a key source of evidence-based
    medicine, and serve as a ``proving ground'' for future researchers.
        In order to make this program more comprehensive, Congress should
    provide $13 million (+ $1.5 million) in fiscal year 2015 for NIDRR's
    TBI Model Systems of Care program, in order to add two new
    Collaborative Research Projects. In addition, given the national
    importance of this research program, the TBI Model Systems of Care
    should receive ``line-item'' status within the broader NIDRR budget.
        We ask that you consider favorably these requests for the CDC, the
    HRSA Federal TBI Program, and the NIDRR TBI Model Systems Program to
    further data collection, increase public awareness, improve medical
    care, assist States in coordinating services, protect the rights of
    persons with TBI, and bolster vital research.
                                     ______

        Prepared Statement of the California Association of Psychiatric
                                  Technicians
                                  introduction
        On behalf of approximately 14,000 California Licensed Psychiatric
    Technicians representing the Nation's ``gold standard'' in direct-care
    nursing services for people with developmental disabilities and mental
    illnesses, I am writing to respectfully request that the Subcommittee,
    Committee and Congress as a whole end the practice of using Federal
    funds to downsize and close federally regulated and accredited homes
    for Americans with developmental disabilities.
          individuals and families caught in a federal web of ironies
        In recent years, the national demand for developmental centers'
    closure has come perhaps most strongly--and, perhaps, most
    surprisingly--from the Federal Government: the very Federal Government
    which requires developmental centers to meet its own regulatory
    standards.
        To be federally certified through the U.S. Centers for Medicare and
    Medicaid Services, State developmental centers must meet eight major
    criteria on management, client protections, facility staffing, active
    treatment, client behavior and facility practices, healthcare services,
    physical environment and dietetic services. To meet all of these major
    criteria, developmental centers must comply with 378 specific Federal
    standards and elements. Failure to comply with any one of these
    hundreds of requirements or to swiftly correct any deficiencies means
    the loss of Federal certification as well as Federal Medicaid funding.
        But in an interesting twist, other Federal funds go to support the
    efforts of the Protection and Advocacy system. Created by Congress,
    this federally mandated system acts as a legally based advocacy
    provider for people with developmental disabilities and other mental
    and physical disabilities throughout the Nation. Each State has a P&A
    branch to investigate allegations of discrimination, abuse or other
    concerns affecting Americans with disabilities, wherever they reside.
        The P&A system and other Federal laws arose as responses to
    widespread concerns of neglect and abuse at an unlicensed New York
    developmental center called Willowbrook State School more than 40 years
    ago. The system and laws are the bases for the regulations that today's
    developmental centers must follow to achieve and continue Federal
    accreditation. However, nothing in this system or laws require the
    closure of developmental centers. In the case of the Federal law which
    creates P&As--the Developmental Disabilities Assistance and Bill of
    Rights Act (often called the ``DD Act'')--P&As' board charge is to
    ``protect and advocate'' for people with disabilities regardless of
    where they reside. In the DD Act's legislative history, Congress
    expressly cautioned against interpreting the act as mandating closures:
    ``The goals expressed in this act to promote the greatest possible
    integration and independence for some individuals with developmental
    disabilities may not be read as a Federal policy supporting the closure
    of residential institutions... .'' This Congressional intent is
    reinforced in the act itself, where individuals and their families, and
    no one else, are named as the ``primary decisionmakers'' regarding
    services (including residential supports) and policies.
                 u.s. supreme court supports residential choice
        To add to the paradox, another Federal group--none other than the
    U.S. Supreme Court--made key points in its touchstone 1999 Olmstead
    ruling:
        ``We emphasize that nothing in the [Americans with Disabilities
    Act] or its implementing regulations condone termination of
    institutional settings for persons unable to handle or benefit from
    community settings...Nor is there any Federal requirement that
    community-based treatment be imposed on patients who do not desire
    it.''
        The overall tragic irony of this Kafkaesque situation is not lost
    on those advocating for loved ones to have the choice of living in
    federally regulated and certified facilities. Adding to the personal
    and emotional toll of advocating to keep their loved ones'
    developmental-center homes open, family members must use their own
    personal funds to fight the deep pockets of federally funded P&A and
    DOJ attorneys seeking center closures that families and residents often
    do not wish. Federal funds are being used by one Federal agency to sue
    another Federal agency for the purpose of evicting our Nation's most
    vulnerable people from their homes. In addition to wasting taxpayer
    dollars, it defies common sense and human decency.
                       what does `most integrated' mean?
        Those taking aim at developmental centers, in the Federal
    Government or elsewhere, feel that the centers are not the most
    integrated settings possible for those with developmental disabilities.
    But the ADA defines ``most integrated setting'' to be ``a setting that
    enables individuals with disabilities to interact with non-disabled
    persons to the fullest extent possible [emphasis added].''
        Families with loved ones in developmental centers who wish to
    continue their services strongly disagree with any interpretation that
    their family members are, in any way, restricted. They feel that the
    many on-site services offered at a developmental center provide the
    most integrated environments possible, allowing their loved ones live
    securely and to meet their fullest potentials.
        Professional developmental-center staff also echo families'
    concerns about how many group homes and placements with less safety and
    oversight and fewer programs can be less ``restrictive.'' Developmental
    centers are required by Federal and State regulations to have dozens
    and dozens of federally regulated state-of-the-art therapeutic and
    rehabilitative programs in place, right there on grounds as well as in
    the broader community; but somehow a developmental center is always
    painted as ``less integrated'' and ``more restrictive'' than a house on
    a busy street with a postage-stamp yard, occasional visits by licensed
    staff, few or no programs and infrequent and pre-announced visits by
    State regulators.
        California's Licensed Psychiatric Technicians are not ```anti-
    ``community'''--in fact, we actively advocate for group-home placements
    when it is in the clients' best interests and is what they and their
    families wish. However, when taken as a whole, how is having more
    space, more programs both on and off the center campus, higher
    regulatory standards and a whole community of professionals there to
    help Americans enjoy the healthiest, happiest and most active life
    possible necessarily ``more restrictive?''
         end the paradox: stop funding restrictions on federal choices
        On behalf of CAPT and its dedicated professional membership, I wish
    to respectfully request that the Subcommittee and Congress as a whole
    end the use of Federal appropriations to discourage, downsize and close
    federally regulated developmental centers (``ICF/DDs and ICF/MRs'')
    throughout the country. It is the legal and moral choice and right for
    people with developmental disabilities and their loved ones to make
    decisions on their individual residential, service and support needs,
    and the choice of federally regulated developmental centers and related
    congregate settings should remain an option for them. Our Federal
    Government should not play a role in restricting or eliminating any
    viable, recognized and desired option for Americans with developmental
    disabilities.

        [This statement was submitted by Juan Nolasco, PT, State President,
    California Association of Psychiatric Technicians.]
                                     ______

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

        [This statement was submitted by Theresa DeBell, R.N., California
    Association of State Hospital Parent Councils for the Retarded.]
                                     ______

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

        [This statement was submitted by Donald Hoppert, Director,
    Government Relations, American Public Health Association.]
                                     ______

       Prepared Statement of the Children's Environmental Health Network
        The Children's Environmental Health Network (CEHN or the Network)
    is pleased to have this opportunity to submit testimony on fiscal year
    2015 appropriations for the following programs and activities that
    safeguard the health and future of all of our children:
      --Centers for Disease Control and Prevention ($7.8 billion),
            especially the National Center for Environmental Health ($181.1
            million) and its programs, including:
        --Healthy Homes and Lead Poisoning Prevention Program ($29 million)
        --National Asthma Control Program ($28 million)
        --National Environmental Public Health Tracking Program ($40
                million)
      --National Institute of Environmental Health Sciences (NIEHS) ($717.7
            million), especially the Children's Environmental Health
            Research Centers ($33 million)
      --Pediatric Environmental Health Specialty Units (PEHSUs) ($2
            million)
        The Children's Environmental Health Network (CEHN) was created more
    than 20 years ago by concerned pediatricians and researchers with a
    goal of protecting the developing child from environmental health
    hazards and to promote a healthy environment.
        Today's children are facing the distressing possibility that they
    may be the first generation to see a shorter life expectancy than their
    parents due to poor health. Key contributors to this trend are the
    modern pediatric epidemics of obesity, asthma, learning disabilities,
    and autism. For all of these conditions, the child's environment plays
    a role in causing, contributing to or mitigating these chronic
    conditions. The estimated costs of environmental disease in children
    (such as lead poisoning, childhood cancer, and asthma) were $76.6
    billion in 2008.\1\
    ---------------------------------------------------------------------------
        \1\ Trasande, Liu Y. ``Reducing The Staggering Costs Of
    Environmental Disease In Children, Estimated At $76.6 Billion In 2008,
    Health Affairs. No. (2011): doi: 10.1377/hlthaff.2010.1239.
    ---------------------------------------------------------------------------
        Investments in programs that protect and promote children's health
    will be repaid by healthier children with brighter futures.
        Additionally, protecting our children--those born as well as those
    yet to be born--from environmental hazards is truly a national security
    issue. When we protect children from harmful chemicals in their
    environment, we help to assure that they will reach their full
    potential. We have a responsibility to our Nation's children, and to
    the Nation that they will someday lead, to provide them with a healthy
    environment. American competitiveness depends on having healthy,
    educated children who grow up to be healthy productive adults. Thus it
    is vital that the Federal programs and activities that protect children
    from environmental hazards receive adequate resources. We strongly urge
    the Committee to support and expand children's environmental health
    programs. Key programs in your jurisdiction deserving your support
    include:
    Centers for Disease Control and Prevention (CDC)
        As the Nation's leader in public health promotion and disease
    prevention, the CDC should receive top priority in Federal funding. CDC
    continues to be faced with unprecedented challenges and
    responsibilities. CEHN applauds your support for CDC in past years and
    urges you to support a funding level of $7.8 billion for CDC's core
    programs in fiscal year 2015.
        The National Center for Environmental Health (NCEH) is particularly
    important in protecting the environmental health of young children.
    Current research is uncovering the extensive role that environment
    plays in human health and development. As a result, NCEH partners with
    public health agencies and a wide range of other organizations to bring
    their expertise and support to an expanding scope of environmental-
    human health challenges. NCEH's programs are key national assets. Yet
    in recent years, NCEH funding has been drastically cut. We urge the
    Subcommittee to at least restore NCEH to its fiscal year 2010 funding
    level of $181.1 million.
        We were deeply concerned with the fiscal year 2012 gutting of the
    Healthy Homes and Lead Poisoning Prevention Program and we commend you
    for the substantial increase the program received in fiscal year 2014.
    This program helps to prevent lead poisoning and helps children who
    have already been exposed to lead. Much more needs to be done just to
    return it to fiscal year 2011 levels. Millions of American children
    remain at risk of lead poisoning and need this program, which supports
    effective local and State efforts. As evidence increasingly
    demonstrates no safe level of lead exposure for children, this funding
    is all the more essential. We join with the National Safe and Healthy
    Housing Coalition to urge a funding level of $29 million in fiscal year
    2015.
        NCEH's National Asthma Control Program not only has greatly
    increased data collection about this rampant epidemic but it also
    encourages States to use evidence-based approaches to reduce costs and
    improve outcomes for people living with asthma. Asthma is an epidemic
    in the U.S., affecting 10 percent of our Nation's children. We urge the
    Committee to fund this vital program at $28 million in fiscal year
    2015.
        Public health officials need integrated health and environmental
    data so that they can protect the public's health. The CDC's National
    Environmental Public Health Tracking Program helps to track
    environmental hazards and the diseases they may cause and to coordinate
    and integrate local, State and Federal health agencies' collection of
    critical health and environmental data. Participation in the tracking
    network development will decline under further cuts and erase the
    progress we have made across the country to better link data with
    public health action.
    National Institute of Environmental Health Science (NIEHS)
        NIEHS is the leading institute conducting research to understand
    how the environment influences human health. Unlike other NIH
    Institutes focused on one disease or one body system, NIEHS is charged
    with all diseases, all human health and body systems, as they are
    affected by the environment--a vital and monumental charge. NIEHS plays
    a critical role in our efforts to understand how to protect children,
    whether it is identifying and understanding the immediate impact of
    chemical substances or understanding childhood exposures that may not
    affect health until decades later. CEHN recommends that $717.7 million
    be provided for NIEHS' fiscal year 2015 budget.
    Children's Environmental Health Research Centers of Excellence
        The Children's Environmental Health & Disease Prevention Research
    Centers, jointly funded by the NIEHS and the U.S. Environmental
    Protection Agency (EPA) and located at research institutions across the
    Nation, play a vital role in providing the scientific basis for
    protecting children from environmental hazards. With their modest
    budgets, these centers are generating invaluable research. For example,
    these centers conducted the recent research that found links between
    prenatal exposures to either a common air pollutant or a common
    pesticide to lower IQs and poorer working memory at age 7.
        Several Centers have established longitudinal cohorts, which in
    some cases are more than 10 years old. The ability to look for linkages
    between exposures and health outcomes in infants, toddlers, and, now,
    adolescents, is vital. If these cohorts are disbanded due to funding
    cuts, at best it will take years and untold resources before it is
    possible to replicate them. Few if any longitudinal cohort studies on
    adolescents, puberty and environmental exposures exist. The Network is
    concerned that inadequate funding may result in the loss of these
    valuable cohorts. We urge the Subcommittee to support these centers at
    $33 million in fiscal year 2015.
    Pediatric Environmental Health Specialty Units
        Pediatric Environmental Health Specialty Units (PEHSUs) form a
    valuable resource network for parents and clinicians around the Nation.
    They are funded jointly by the Agency for Toxic Substances and Disease
    Registry (ATSDR) and the EPA with a very modest budget. PEHSU
    professionals provide medical consultation to healthcare professionals
    from individual cases of exposure to advice regarding large-scale
    community issues. PEHSUs also provide information and resources to
    school, child care, health and medical, and community groups and help
    inform policymakers by providing data and background on local or
    regional environmental health issues and implications for specific
    populations or areas. We urge the Subcommittee to fully fund ATSDR's
    portion of this program in fiscal year 2015.
        In conclusion, our Nation's future will depend upon its future
    leaders. Protecting children from harmful chemicals in their
    environment will result in healthier children with brighter futures, an
    outcome we can all support. Thank you for the opportunity to testify.
                                     ______

           Prepared Statement of the Children's Hospital Association
        The Children's Hospital Association advances child health through
    innovation in the quality, cost and delivery of care. Representing more
    than 220 children's hospitals, the Association is the voice of
    children's hospitals nationally. As institutions dedicated to
    protecting and advancing the health of America's children, we thank the
    Subcommittee for its longstanding bipartisan support of the Children's
    Hospital Graduate Medical Education program (CHGME).
        CHGME is an essential investment in our children's healthcare--in
    promoting prevention and primary care, expanding healthcare for
    vulnerable and underserved children, and ensuring access to care for
    all children. The Children's Hospitals Association urges the
    Subcommittee to protect this important program and provide $300 million
    in funding for CHGME in fiscal year 2015.
        The CHGME program protects children's access to high-quality
    medical care by providing independent children's hospitals with funding
    to support the training of pediatric providers, much as Medicare
    supports training in adult teaching hospitals. CHGME funding has had a
    tremendous impact, enabling children's hospitals to increase their
    overall training by more than 45 percent since the program began in
    1999. In addition, the CHGME program has accounted for more than 74
    percent of the growth in the number of new pediatric subspecialists
    being trained nationwide.
        Today, the 55 hospitals that receive CHGME, less than 1 percent of
    all hospitals, train over 6,000 residents annually, and 49 percent of
    all pediatric residents in the country, including 45 percent of general
    pediatricians and 51 percent of pediatric specialists. CHGME benefits
    all children, supporting the training of doctors who go on to care for
    children living in every State--in cities, rural communities, suburbs
    and everywhere in between. Furthermore, CHGME is an example of a well-
    functioning public-private partnership; each of the participating
    children's hospitals invests significant resources into the success of
    their training programs along with the Federal dollars they receive.
        Since the program's beginning, CHGME has enjoyed strong, bipartisan
    support in Congress, under both Republican and Democratic leadership.
    Congress created CHGME because it recognized that the absence of
    dedicated GME support for independent children's teaching hospitals
    created gaps in the training of pediatric providers, which potentially
    threatened access to care for children. At that time, independent
    children's hospitals were effectively left out of Federal GME support
    provided through Medicare because children's hospitals treat children
    and not the elderly, and received less than 0.5 percent of the GME
    support of other teaching hospitals.
        CHGME has helped close the gap, but support for training of
    pediatric providers in children's hospitals still lags significantly
    behind Medicare support for graduate medical education. Analysis
    commissioned by the Children's Hospitals Association shows that in 2014
    CHGME provides children's hospitals, on a per-resident basis, about 45
    percent of the support Medicare provides to adult teaching hospitals.
        Continued funding is essential to maintaining the gains that have
    been achieved under CHGME and strengthening the pediatric workforce
    pipeline. While much has been achieved, much remains to be done, as
    serious shortages persist in many pediatric specialties. The shortages
    affect children and their families' ability to receive timely,
    appropriate care, including surgery. Children's hospital clinics use a
    two-week benchmark when scheduling non-emergency appointments, but
    certain pediatric specialties experiencing physician shortages have
    wait times of 14.5 weeks or more, far exceeding the two-week standard.
        Unfortunately, funding for the CHGME program has been significantly
    reduced in recent years, from $317.5 million in fiscal year 2010 to
    $265 million in 2014, a 17 percent reduction. These cuts hurt the
    ability of children's hospitals to train enough pediatricians and
    pediatric specialists to keep up with growing demand at local, State
    and national levels.
        Furthermore, there are no adequate substitutes for CHGME. Other
    potential sources of support, such as Medicaid GME or competitive
    grants, are not available to many children's hospitals and cannot come
    close to supporting training on the scale necessary to meet workforce
    needs. Failing to adequately support CHGME would take us back to the
    same flawed system that was not meeting the needs of America's
    children.
        The White House's fiscal year 2015 budget proposes eliminating
    funding for CHGME and incorporating support for training at children's
    hospitals into a new competitive grant program under the Health
    Resources and Services Administration (the program would have to be
    created by Congress), funded from Medicare trust fund dollars, with
    $100 million set aside specifically for children's hospitals in fiscal
    year 2015 and fiscal year 2016. While we recognize that the White House
    includes funding for training in children's hospitals in the budget,
    the administration's proposal continues to underfund pediatric
    training. Furthermore, children's hospitals have strong concerns that
    replacing the current system with competitive grants that are limited
    in duration puts at risk the gains that have been made for children's
    health under CHGME. Children's hospitals welcome the idea of engaging
    with the administration and Congress on ways to strengthen the
    pediatric workforce for the future. In the present, however, financial
    support for GME in children's hospitals needs to be uninterrupted and
    undiminished.
        We recognize that the current budget climate is extraordinarily
    challenging and that Congress has a responsibility to carefully
    consider the Nation's spending priorities. However, now is not the time
    to take a step backwards in pediatric medicine. The CHGME program is
    critical to protecting gains in pediatric health and ensuring access to
    care for children nationwide.
        We respectfully request that the Subcommittee continue its history
    of bipartisan support for the CHGME program and include $300 million in
    funding in the fiscal year 2015 Labor-HHS appropriations bill for this
    vital program.
        The Children's Hospital Association, and the children and families
    we serve, thank you for your past support for this critical program and
    your leadership in protecting children's health.
        The Children's Hospital Association advances child health through
    innovation in the quality, cost and delivery of care. Representing more
    than 220 children's hospitals, the Association is the voice of
    children's hospitals nationally. The Association champions public
    policies that enable hospitals to better serve children and is the
    premier resource for pediatric data and analytics, driving improved
    clinical and operational performance of member hospitals. Formed in
    2011, Children's Hospital Association brings together the strengths and
    talents of three organizations: Child Health Corporation of America
    (CHCA), National Association of Children's Hospitals and Related
    Institutions (NACHRI) and National Association of Children's Hospitals
    (N.A.C.H.). The Children's Hospital Association has offices in
    Washington, DC, and Overland Park, KS.
                                     ______

      Prepared Statement of the Coalition for Clinical and Translational
                                    Science
        Chairman Harkin and distinguished members of the Subcommittee,
    thank you for your time and your consideration of the priorities of the
    clinical and translational research community as you work to craft the
    fiscal year 2015 Labor, Health and Human Services Appropriations Bill.
    The community would like to thank you for your past support of the full
    spectrum of medical research.
           about the coalition for clinical and translational science
        Coalition for Clinical and Translational Science (CCTS) is the
    unified voice of the clinical and translational science research
    community. CCTS is a nationwide, grassroots network of dedicated
    individuals who work together to educate Congress and the
    Administration about the value and importance of Federal clinical and
    translational research and research training and career development
    activities. CCTS's goals are to ensure that the full spectrum of
    medical research is adequately funded, the next generation of
    researchers is well-prepared, and the regulatory and public policy
    environment facilitates ongoing expansion and advancement of the field
    of clinical and translational science.
    Association for Clinical and Translational Science (ACTS)
        ACTS supports investigations that continually improve team science,
    integrating multiple disciplines across the full translational science
    spectrum: from population based and policy research, through patient
    oriented and human subject clinical research, to basic discovery. Our
    goal is to improve the efficiency with which health needs inform
    research and new therapies reach the public.
        ACTS is the academic home for the disciplines of research
    education, training, and career development for the full spectrum of
    translational scientists. Through meetings, publications, and
    collaborative efforts, ACTS will provide a forum for members to
    develop, implement, and evaluate the impact of research education
    programs.
        ACTS provides a strong voice to advocate for translational science,
    clinical research, patient oriented research, and research education
    support. We will engage at the local, State, and Federal levels and
    coordinate efforts with other professional organizations.
        ACTS will promote investigations and dissemination of effective
    models for mentoring future generations of translational scientists.
    Through collaborative efforts, ACTS will provide a forum for members to
    share studies, promote best practices, and optimize professional
    relationships among trainees and mentors.
    The Clinical Research Forum (CRF)
        CRF was formed in 1996 to discuss unique and complex challenges to
    clinical research in academic health centers. Over the past decade, it
    has convened leaders in clinical research annually and has provided a
    forum for discussing common issues and interests in the full spectrum
    of research. Through its activities, the Forum has enabled sharing of
    best clinical practices and increasingly has played a national advocacy
    role in support of the boarder interests and needs of clinical
    research.
        Governed by a Board of Directors constituted of clinical
    researchers from thirteen member institutions, CRF has grown to sixty
    members from academia, industry, and volunteer health organizations.
    CRF engages leaders in the clinical research enterprise including
    leaders from government, foundations, other not-for-profit
    organizations, and industry in addressing the challenges and
    opportunities facing the clinical research enterprise.
        Parallel with our widening focus upon the broad needs of the entire
    national clinical research enterprise, CRF is committed to working in
    those areas where it is uniquely positioned to have a significant
    impact. Collaboration with other organizations with similar goals and
    synergizing with their efforts strengthens all approaches to the issues
    facing clinical research.
                                 sequestration
        Thank you for providing sequestration relief in fiscal year 2014
    and fiscal year 2015.
        Federal medical research programs form the cornerstone of our
    Nation's biotech sector. In addition to undermining active and emerging
    research projects, across the board funding cuts create widespread
    disruption. Due to a number of factors, this disruption compounds
    significant challenges facing the clinical and translational research
    training and career development pipeline.
        Recent years of near-level funding have curtailed NIH's ability to
    issue funding opportunities. As a result, the pay line at NIH has
    decreased substantially while the average age of an investigator
    receiving their first award has increased significantly. This dynamic
    creates a strong disincentive for young people to pursue a career in
    this field. Prior to sequestration, NIH would often discuss the decline
    in young investigators entering the research training and career
    development pipeline.
        Beyond public health, our country needs to ensure that we are
    adequately preparing the next generation of medical investigators for
    reasons related to both the economy and national security. Last year,
    China announced a $300 billion 5-year investment in medical research;
    this amount is double the current NIH budget over the same period of
    time. With strong competition from foreign countries, we run the risk
    of a researcher brain-drain from the U.S. to other Nations. Scientific
    breakthroughs and innovation will continue, but our loss in this area
    will mean gains for other Nations. Foreign economies will benefit from
    the significant return-on-investment that occurs through robust support
    of research.
        Sequestration has the potential to severely exacerbate an already
    difficult task of recruiting and training the next generation of
    scientific investigators. In order to ensure that the U.S. maintains a
    strong research training and career development pipeline, please
    eliminate the threat of sequestration and further support key
    activities.
                         national institutes of health
        This Nation has a proud history as a global leader in medical
    research and biotechnology. This leadership has provided our country
    with cutting-edge patient care, high-quality jobs, and meaningful
    economic growth. The Milliken Institute recently calculated that every
    dollar invested in NIH returns about a $1.70 in economic output in the
    short term and as much as $3.20 long-term. Crucially, through a robust
    external research program, NIH resources flow out to the States where
    the benefit of the funding infusion is felt on the local level.
        NIH's impact on public health has been profound. Conditions once
    considered a death-sentence can now be managed, survival rates for
    patients with life-threatening diseases have increased dramatically,
    and additional innovative therapies and diagnostic tools come to market
    each year. NIH has been successful, but much more can be done. Please
    provide NIH with at least $32 billion in fiscal year 2015 so ongoing
    research projects can be adequately supported and new research
    activities can be initiated.
    Clinical and Translational Science Awards (CTSA)
        NIH's CTSA Program, which is housed within the National Center for
    Advancing Translational Sciences (NCATS), is transforming the
    efficiency and effectiveness of clinical and translational research.
    Since its establishment with 13 centers, the CTSA program has expanded
    to 62 medical research institutions located across the country. These
    centers are linked together and work in concert to improve human health
    by energizing the research and training environment to innovate and
    enhance the quality of clinical and translational research.
        Last year, the Institute of Medicine (IOM) released a review of the
    CTSA program. The report entitled, The CTSA Program at NIH:
    Opportunities for Advancing Clinical and Translational Research, spoke
    favorably of the CTSA effort and made the following recommendations to
    improve the program:
        (1) Strengthen NCATS leadership of the CTSA program, (2)
    reconfigure and streamline the CTSA Consortium, (3) build on the
    strengths of individual CTSAs across the spectrum of clinical and
    translational research, (4) formalize and standardize evaluation
    processes for individual CTSAs and the CTSA Program, (5) advance
    innovation in education and training programs, (6) ensure community
    engagement in all phases of research, (7) strengthen clinical and
    translational research relevant to child health.
        CCTS supports the recommendations of the IOM report and the
    organization is hopeful these changes will be implemented quickly.
    Further, when the CTSA program was authorized, Congress indicated that
    the consortium would be considered fully-funded when it received an
    annual appropriation of $750 million. For fiscal year 2015, as part of
    an overall funding increase for NIH, please provide CTSAs with at least
    $500 million to ensure the program can continue to grow and advance.
    Additionally, we hope you will continue working over the coming years
    to provide CTSAs with $750 million to fully fund the program and
    establish a robust home for clinical and translational research.
    Additional Programs
        In recent years, Congress and NIH have made important investments
    to support the full spectrum of medical research. Key clinical and
    translational research programs at NIH include Research Centers at
    Minority Institutions (RCMI), Institutional Development Awards (IDeA),
    and the new Accelerating Medicine Partnership (AMP). Supporting the
    full spectrum of medical research encourages outcomes-oriented
    investigation where breakthroughs in basic science are translated to
    new diagnostic tools and treatments that improve health and lower
    healthcare expenses. In recognition of the future of the overall field
    of medical research, most individual NIH Institutes and Centers now
    provide some level of support for translational and clinical research
    activities.
        In order to ensure that clinical and translational research
    programs at NIH have adequate support to facilitate ongoing growth,
    please provide $32 billion for NIH in fiscal year 2015 with
    proportional increases for individual Institutes, Centers, and Offices.
           federal research training and career development programs
        As we discussed previously, the future of our Nation's biomedical
    research enterprise relies heavily on the maintenance and continued
    recruitment of promising young investigators. The ``T'' and ``K''
    series awards at NIH and AHRQ provide much-needed support for the
    career development of young investigators. As clinical and
    translational medicine takes on increasing importance, there is a great
    need to grow these programs. Career development grants are crucial to
    the recruitment of promising young investigators, as well as to the
    continuing education of established investigators. Reduced commitment
    to the K and T awards would have a devastating impact on our pool of
    highly trained clinical researchers. CCTS urges you to support the
    ongoing commitment to research training through adequate funding for T
    and K series awards and a meaningful fiscal year 2015 funding increase
    for AHRQ.
        Thank you for the opportunity to present the views and
    recommendations of the clinical and translational research and research
    training and career development community.
                                     ______

        Prepared Statement of the Coalition for Usher Syndrome Research
        My name is Mark Dunning from the State of Massachusetts. As
    Chairman of the Coalition for Usher Syndrome Research, I am here on
    behalf of the Usher syndrome community to respectfully request this
    committee encourage NIH to prioritize research that will eventually
    expand treatment options for individuals suffering from the severe
    hearing and vision loss related to Usher syndrome. We also respectfully
    request that the committee direct NIH to move expeditiously to direct
    additional resources to respond to any deficiencies in the funding
    level or the manner in which various ICs coordinate on common goals and
    objectives related to Usher syndrome.
        Usher syndrome is the leading cause of deaf-blindness. In the
    United States, it is estimated that about 45,000 people have this rare
    genetic disorder. My fifteen year old daughter Bella is one of them.
    She has Usher syndrome type 1b. She was born profoundly deaf and now
    she is losing her vision to retinitis pigmentosa. She also suffers from
    the severe balance issues common in her type of Usher syndrome.
        Imagine yourself as a fifteen year old girl. Adulthood stands
    before you. You dream of getting your driver's license, of the freedom
    it provides, of the limits it removes. We live in a small town. There
    is no public transportation. A car is the only way to get to work, to
    visit friends, to shop for food. But Bella's vision is too poor for
    driving. How will she survive?
        Or imagine yourself as a sophomore in high school. You dream of
    college, of the freedom it provides, of the limitless career
    opportunities. Only hard work and desire stand between you and your
    dreams. Unless, like Bella, you have Usher syndrome. Then you also face
    the barriers of access to information. You cannot hear the professor or
    see the board as well as your peers. You work many times harder to get
    the same grades. And some trades are closed to you before you start.
    Can you be an architect if you are losing your vision? Can you be a
    salesperson if you have no hearing? Can you dare to dream of an
    unfettered future? Is the American dream available to you if you have
    Usher syndrome?
        My daughter is an asset to this country. She is kind and
    empathetic. She puts all others before herself. She is hard working and
    fearless. She has been honored with a John F. Kennedy award for
    leadership and a StayClassy award for philanthropy. She is the type of
    fifteen year old we should be grooming as a future leader in the
    country.
        But Bella has Usher syndrome. She was born profoundly deaf and she
    is going blind. She will fight it every step of the way, but without
    increased Federal funding, she will eventually lose. And when Bella
    loses, we all lose. Kids like Bella are our future. Unless they have
    Usher syndrome. Then they are not, and we are all the worse for it.
        People with Usher syndrome share the same range of intelligence and
    work ethic as any other slice of America. Yet they suffer from an 82
    percent unemployment rate. People with Usher syndrome are born with the
    same emotional strength as any other American. Yet they have a suicide
    rate that is 2\1/2\ times greater than the general population. People
    with Usher syndrome not only have the capacity to contribute to
    America's future, they thirst for it. They want to be active members of
    society. Yet our country spends an estimated $139 billion annually in
    direct and indirect costs for people with eye disorders and vision
    loss.\1\ That doesn't even include the costs associated with hearing
    impairment.
    ---------------------------------------------------------------------------
        \1\ Wittenborn, John S. & Rein, David B. ``Cost of Vision Problems:
    The Economic Burden of Vision Loss and Eye Disorders in the United
    States.'' NORC at the University of Chicago. Prepared for Prevent
    Blindness America, Chicago, IL. June 11, 2013.
    http://costofvision.preventblindness.org.
    ---------------------------------------------------------------------------
        In my role as the Chairman of the Coalition for Usher Syndrome
    Research, I have spoken with or met hundreds of people who are
    determined, focused, and working everyday to help themselves, their
    loved one, or in some cases complete strangers, figure out how to treat
    this syndrome. Usher genes are complex, long protein cells which
    require significant investment in research if we are ever to find a
    cure or treatment. We can't do it alone.
        Through the Coalition, we have brought the Usher community and
    researchers together by:
      --Establishing a registry of individuals with Usher syndrome which is
            available for research or clinical trials at no cost. Our
            registry currently has families from each of the 50 States and
            29 countries.
      --Sponsoring an International Symposium on Usher Syndrome at the
            Harvard Medical School in July 2014 to develop a roadmap for
            future research projects to bring us closer to viable clinical
            trials.
      --Sponsoring annual family conferences, webinars and monthly
            conferences that provide information and support to all of
            those living with Usher.
        With this in place, we have begun bringing brilliant researchers
    together who are working on developing treatments every day.
    Researchers like those in Oregon and Pennsylvania who are working on
    gene therapy treatments, one of which began clinical trials last year.
    Researchers in Louisiana, who have been able to rescue the hearing in
    mice with Usher syndrome using a drug therapy that holds promise for
    rescuing vision as well. Researchers in Iowa, California, Nebraska,
    Massachusetts, Florida, Texas, and many other States, who are
    collaborating with each other and with families through the Coalition
    to advance all kinds of Usher syndrome research.
        But still this is not enough. We cannot help any of the tens of
    thousands who have Usher, or countless others that will be born in the
    future with this devastating genetic disorder without Federal support.
    There are dozens of different mutations that cause Usher syndrome, and
    the pace of research is slowed dramatically by the lack of researchers
    and funding. The infrastructure is there to find treatments, but the
    significant financial support is not. We are asking you to supply this
    last critical resource to help us find a cure.
        When you review the report on categorical spending by the NIH,
    Usher syndrome is not even listed. Rare diseases with similar incident
    rates average around $50 million annually. These investments have
    resulted in significant discoveries for these diseases and there is
    reason to believe that we can see these same results or better for
    Usher syndrome. We do not ask that the committee throw dollars at the
    problem. Only that they ensure the appropriate funding is available.
    The researchers are there, waiting to discover what now is just a
    dream. All we are asking for is a chance; a chance for deaf children
    and adults who are going blind, a chance to see. With your help, my
    daughter and others like her can once again dare to dream.
        I will leave you with the words of America's most famous deaf-blind
    person, Helen Keller. ``Alone we can do so little; together we can do
    so much.'' Only together can we find a way to end deaf-blindness. I
    thank you on behalf of all those with Usher syndrome, their families,
    and most importantly to me, my daughter Bella.

        [This statement was submitted by Mark Dunning, Chairman, Coalition
    for Usher Syndrome Research.]
                                     ______

         Prepared Statement of the Coalition of Northeastern Governors
        The Coalition of Northeastern Governors (CONEG) is pleased to share
    with the Subcommittee on Labor, Health and Human Services, Education,
    and Related Agencies its views regarding the fiscal year 2015
    appropriations for the Low-Income Home Energy Assistance Program
    (LIHEAP).
        The CONEG Governors appreciate the Subcommittee's long-standing
    support for this vital program, and recognize the difficult fiscal
    decisions that face the Subcommittee. In recognition of the on-going
    challenges that the most vulnerable low-income households in our region
    face in heating their homes, the Governors urge the Subcommittee to
    fund the LIHEAP core block program in fiscal year 2015 at the
    authorized level of $5.1 billion but not less than $4.7 billion. In
    addition, the Governors request sufficient contingency funds to address
    unforeseen energy emergencies such as prolonged severe weather or price
    spikes in home heating fuels. Adequate, predictable and timely Federal
    funding is essential for LIHEAP to provide a vital lifeline to those
    households struggling to afford the basic necessity of home energy. The
    Governors urge the Subcommittee to provide these funds in a manner
    consistent with the LIHEAP statutory objective: ``to assist low-income
    households, particularly those with the lowest incomes that pay a high
    proportion of household income for home energy, primarily in meeting
    their immediate home energy needs.''
        LIHEAP funds are targeted to those households with the greatest
    energy burden. Most LIHEAP assistance is targeted to households whose
    income is less than 150 percent of the Federal poverty level, which for
    a two-person household is $23,595 in 2014. However the majority of
    LIHEAP recipients have incomes far below that level. Many of these
    households live on fixed incomes and are not likely to benefit from
    improvements in the job market and the national economy. More than
    ninety percent of LIHEAP households have at least one vulnerable
    member--the elderly or disabled and young children--for whom
    temperature extremes could have serious health and safety consequences.
    Approximately 20 percent of LIHEAP households contain at least one
    member who is a military veteran.
        Low-income households across the Nation spend a disproportionate
    amount of their income on home energy, often over three times more than
    non-low-income households. The AARP estimates low-income senior
    households (age 65 and older) heating with fuel oil will spend almost
    20 percent of household income on heating costs, while all other
    households heating with fuel oil will spend roughly 5 percent of their
    income to heat their homes. In the colder climates of the Northeast,
    the average household typically uses 800 gallons of heating oil per
    winter. At EIA's projected average cost of $3.83 per gallon, an elderly
    LIHEAP recipient whose primary income is a Social Security check would
    need to spend almost 3 months of income to heat her home this winter.
    Many seniors will spend more than one-third of their monthly income
    just to get the minimum 100-gallon delivery of heating oil.
        The energy burden faced by low-income households is particularly
    acute in the Northeast. This region experiences some of the Nation's
    highest home heating bills due to a combination of the extended winter
    heating season and heating fuel expenditures that typically exceed
    national averages. According to the Energy Information Administration
    (EIA), the average consumer expenditures for heating fuels in the
    Northeast have consistently and significantly exceeded similar
    expenditures in all other regions regardless of the type of fuel used--
    natural gas, heating oil, propane, or electricity.
        Low-income households in the Northeast experience another aspect of
    ``energy burden''. More than any other region of the country, Northeast
    households are dependent upon delivered fuels--heating oil, propane and
    kerosene. The 30 percent of Northeast households that rely upon
    delivered fuels account for approximately 80 percent of the homes
    nationwide that use home heating oil. These heating fuels are also the
    most expensive and volatile in price. The EIA estimates that households
    using heating oil can expect to pay $2,243 to keep warm this winter.
    The EIA also finds that households using delivered fuels see any change
    in wholesale prices reflected in their energy bills almost immediately,
    unlike natural gas and electricity retail customers. These ``delivered
    fuel'' households experience another vulnerability compared to natural
    gas and electricity customers. Low-income households that use delivered
    fuels are less likely to have the option of payment plans, access to
    utility assistance programs, and the protection of utility service
    shut-off moratoria during the heating season. If LIHEAP funds are not
    available to these households, the fuel delivery truck simply does not
    come.
        The Northeast has some of the country's oldest homes and coldest
    climates. Reducing home energy costs presents unique challenges to
    northeast states. State LIHEAP programs, often working with their
    Weatherization Assistance Programs, help low-income households take
    steps to reduce their energy use and lower their energy bills. Unlike
    the Federal weatherization program, LIHEAP funds can be used to provide
    repair or replace inefficient, unsafe and non-working home heating
    systems--improvements that enhance the safety and reduce the energy use
    of low-income households.
        Even with these programs to reduce energy use, many of the lowest
    income families that benefit from LIHEAP have limited options to reduce
    their energy bills. Some older homes, especially older manufactured
    homes, have structural issues that make them ineligible for
    weatherization assistance. Throughout the region, many LIHEAP
    households have limited ability to switch to more energy efficient
    heating systems due to the lack of adequate resources for the upfront
    costs and the lack of access to less expensive heating fuels. For
    example, natural gas may provide a less expensive energy source to heat
    homes, but conversion is neither simple nor affordable for low-income
    households. The New England Fuel Institute estimates that converting a
    complete home heating system from oil to natural gas can cost as much
    as $10,000. In addition, homes in rural and metropolitan areas
    throughout the Northeast are not served by natural gas infrastructure.
        State LIHEAP programs continue to seek innovative and efficient
    ways to ``do more with less'' and stretch scarce LIHEAP dollars to
    ensure that meaningful assistance can be provided to those households
    with the greatest needs. For example, LIHEAP funds are frequently
    leveraged by utility assistance programs for low-income households.
    States in the Northeast have worked with utilities to develop payment
    plans to reduce arrearages and lessen the prospect of utility shut-offs
    after the heating season ends. They have negotiated with fuel dealers
    to receive discounts on deliverable fuels, and have entered into
    agreements to purchase fuel in the summer when prices are lowest.
    LIHEAP is one of the most efficiently run programs with low overhead
    costs. Even after taking significant cost-cutting steps, States have
    had to take actions such as tightening program eligibility, closing the
    program early, and reducing benefit levels.
        In summary, the CONEG Governors appreciate the Subcommittee's
    continued support for LIHEAP, and urge you to fund the core block grant
    at the authorized level of $5.1 billion, but not less than $4.7
    billion, and sufficient contingency funds to address unforeseen energy
    emergencies.
                                     ______

        Prepared Statement of the College on Problems of Drug Dependence
        Mr. Chairman and Members of the Subcommittee, thank you for the
    opportunity to submit testimony to the Subcommittee in support of the
    National Institute on Drug Abuse. The College on Problems of Drug
    Dependence (CPDD), a membership organization with over 1000 members,
    has been in existence since 1929. It is the longest standing group in
    the United States addressing problems of drug dependence and abuse. The
    organization serves as an interface among governmental, industrial and
    academic communities maintaining liaisons with regulatory and research
    agencies as well as educational, treatment, and prevention facilities
    in the drug abuse field. CPDD also often works in collaboration with
    the World Health Organization.
        Recognizing that so many health research issues are inter-related,
    we request that the subcommittee provide at least $32 billion for the
    National Institutes of Health (NIH) and within that amount a
    proportionate increase for the National Institute on Drug Abuse, in
    your Fiscal 2015 Labor, Health and Human Services, Education and
    Related Agencies Appropriations bill. We also respectfully request the
    inclusion of the following NIDA specific report language.
        Marijuana Research. Efforts to legalize or ``medicalize'' marijuana
    continue across the United States. The Committee understands that
    research from different areas of science is converging on the fact that
    regular marijuana use by young people can have a long-lasting negative
    impact on the structure and function of their brains, resulting in
    lower educational achievement, reduced IQ, etc. Research clearly
    demonstrates that marijuana has the potential to cause problems in
    daily life or make a person's existing problems worse. NIDA is
    encouraged to continue to fund research on preventing and treating
    marijuana abuse and addiction, and the possible health and policy
    implications of proposals to implement ``medical marijuana'' or
    marijuana legalization programs across the U.S.
        Opiate Abuse and Addiction. The Committee is concerned about the
    continued crisis of prescription drug abuse in the U.S. In particular,
    the June 2011 IOM report on pain indicates that abuse and misuse of
    prescription opioid drugs resulted in an annual estimated cost to the
    Nation of $72,500,000,000. Further, the Committee is very concerned
    with the potential rise in heroin abuse and addiction as a result of
    successful efforts to combat the prescription drug side of this issue.
    The Committee urges NIDA to 1) continue funding research on medications
    to alleviate pain, including the development of pain medications with
    reduced abuse liability; 2) as appropriate, work with private companies
    to fund innovative research into such medications; and 3) report on
    what we know regarding the transition from opiate analgesics to heroin
    abuse and addiction within affected populations.
        Medications Development. The Committee recognizes that next-
    generation pharmaceuticals will surely take advantage of new
    technologies. In the context of NIDA funding, chief among these are
    NIDA's current approaches to develop viable immunotherapeutic or
    biologic (e.g., bioengineered enzymes) approaches for treating
    addiction. The goal of this active area of research is the development
    of safe and effective vaccines or antibodies that target specific
    drugs, like nicotine, cocaine, and heroin, or drug combinations. The
    Committee is excited by this approach--if successful, immunotherapies,
    alone or in combination with other medications, behavioral treatments,
    or enzymatic approaches, stand to revolutionize how we treat, and,
    maybe even someday, prevent addiction. The Committee looks forward to
    hearing more about work in this area.
        Nurturing Talent and Innovation in Research. The Committee commends
    NIDA for its continued support of innovative research on drug addiction
    and related health problems such as pain and HIV/AIDS, and the
    Institute's effort to be at the forefront of training the next
    generation of innovative researchers. The 6 year-old Avant-Garde award
    is a good example of a program that stimulates high-impact research
    that could lead to groundbreaking opportunities for the prevention and
    treatment of HIV/AIDS in drug abusers. The Committee understands that
    NIDA is now crafting a new kind of award, which would blend NIH's
    Pioneer and New Innovator award mechanisms. This new opportunity,
    called ``AVENIR'' awards, is designed to attract creative young
    investigators into HIV/drug abuse public health research. The Committee
    strongly supports this effort, and asks the Institute to report on its
    progress in future appropriations and related requests.
        Research to Assist Military Personnel, Veterans, and Their
    Families. The Committee recognizes the significant health challenges,
    including substance abuse and addiction, faced by military personnel,
    veterans, and their families. Many of these individuals need help
    confronting war-related problems including traumatic brain injury,
    PTSD, depression, anxiety, sleep disturbances, and substance abuse and
    addiction. The Committee commends NIDA for its successful efforts to
    coordinate and support research with the Department of Veterans
    Affairs, Department of Defense, and other NIH Institutes focusing on
    these populations, and strongly urges NIDA to continue work in this
    area.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment. The Committee is very pleased
    with NIDAMed, an initiative designed to reach out to physicians,
    physicians in training, and other healthcare professionals. The
    Committee urges the Institute to continue its focus on activities to
    provide physicians and other medical professionals with the tools and
    skills needed to incorporate drug abuse screening and treatment into
    their clinical practices.
        Drug abuse is costly to Americans; it ruins lives, while tearing at
    the fabric of our society and taking a huge financial toll on our
    resources. Beyond the unacceptably high rates of morbidity and
    mortality, drug abuse is often implicated in family disintegration,
    loss of employment, failure in school, domestic violence, child abuse,
    and other crimes. Placing dollar figures on the problem; smoking,
    alcohol and illegal drug use results in an exorbitant economic cost on
    our Nation, estimated at over $600 billion annually. We know that many
    of these problems can be prevented entirely, and that the longer we can
    delay initiation of any use, the more successfully we mitigate future
    morbidity, mortality and economic burdens.
        Over the past three decades, NIDA-supported research has
    revolutionized our understanding of addiction as a chronic, often-
    relapsing brain disease --this new knowledge has helped to correctly
    situate drug addiction as a serious public health issue that demands
    strategic solutions. By supporting research that reveals how drugs
    affect the brain and behavior and how multiple factors influence drug
    abuse and its consequences, scholars supported by NIDA continue to
    advance effective strategies to prevent people from ever using drugs
    and to treat them when they cannot stop.
        NIDA supports a comprehensive research portfolio that spans the
    continuum of basic neuroscience, behavior and genetics research through
    medications development and applied health services research and
    epidemiology. While supporting research on the positive effects of
    evidence-based prevention and treatment approaches, NIDA also
    recognizes the need to keep pace with emerging problems. We have seen
    encouraging trends--significant declines in a wide array of youth drug
    use--over the past several years that we think are due, at least in
    part, to NIDA's public education and awareness efforts. However, areas
    of significant concern include the recent increase in lethalities due
    to heroine, as well as the continued abuse of prescription opioids and
    the recent increase in designer drugs availability and their
    deleterious effects. The need to increase our knowledge about the
    effects of marijuana is most important now that decisions are being
    made about its approval for medical use and/or its legalization. We
    support NIDA in its efforts to find successful approaches to these
    difficult problems.
        The Nation's previous investment in scientific research to further
    understand the effects of abused drugs on the body has increased our
    ability to prevent and treat addiction. As with other diseases, much
    more needs be done to improve prevention and treatment of these
    dangerous and costly diseases. Our knowledge of how drugs work in the
    brain, their health consequences, how to treat people already addicted,
    and what constitutes effective prevention strategies has increased
    dramatically due to support of this research. However, since the number
    of individuals continuing to be affected is still rising, we need to
    continue the work until this disease is both prevented and eliminated
    from society.
        We understand that the fiscal year 2015 budget cycle will involve
    setting priorities and accepting compromise, however, in the current
    climate we believe a focus on substance abuse and addiction, which
    according to the World Health Organization account for nearly 20
    percent of disabilities among 15-44 year olds, deserves to be
    prioritized accordingly. We look forward to working with you to make
    this a reality. Thank you for your support for the National Institute
    on Drug Abuse.
                                     ______

      Prepared Statement of the Consortium of Social Science Associations
        Mr. Chairman and Members of the Subcommittee, the Consortium of
    Social Science Associations (COSSA) appreciates and welcomes the
    opportunity to comment on the fiscal year 2015 appropriations for the
    National Institutes of Health (NIH), Centers for Disease Control and
    Prevention (CDC) and the Agency for Healthcare Research and Quality
    (AHRQ). COSSA joins the Ad Hoc Group for Medical Research in
    recommending that NIH receive at least $32 billion in fiscal year 2015
    as the next step toward a multi-year increase in our Nation's
    investment in medical research. As a member of the CDC Coalition, COSSA
    requests $7.8 billion in funding for the CDC in fiscal year 2015. We
    join the Friends of AHRQ in requesting a funding level of $375 million
    for AHRQ in fiscal year 2015.
        COSSA is an advocacy group for the social and behavioral sciences
    supported by more than 100 professional associations, scientific
    societies, universities and research centers. It serves as a bridge
    between the academic research and Washington policy-making community.
    Our organizations are appreciative of the Subcommittee's and the
    Congress' continued support of NIH, CDC, and AHRQ. Strong, sustained
    funding for these agencies is essential to the national priorities of
    better health and economic revitalization.
                  nih behavioral and social sciences research
        As this Committee knows, the NIH mission is to support
    scientifically rigorous, peer/merit-reviewed, investigator-initiated
    research, including basic and applied behavioral and social science
    research in fulfilling its mission: ``Science in pursuit of fundamental
    knowledge about the nature and behavior of living systems and the
    application of that knowledge to enhance health, lengthen life and
    reduce illness and disability.''
        The fundamental understanding of how disease works, including the
    impact of social environment on these disease processes, underpins our
    ability to conquer devastating illnesses. Perhaps the grandest
    challenge we face is to understand the brain, behavior, and society--
    from responding to short-term pleasures to self-destructive behavior,
    such as addiction, to lifestyle factors that determine the quality of
    life, infant mortality rate and longevity. And while Americans have
    achieved very high levels of health over the past century and are
    healthier than people in many other Nations, according to the 2013
    National Academies' (NAS) report, U.S. Health in International
    Perspective: Shorter Lives, Poorer Health, ``a growing body of research
    suggests that the health of the U.S. population is not keeping pace
    with the health of people in other economically advanced, high-income
    countries.''
        Nearly 125 million Americans are living with one or more chronic
    conditions, including heart disease, cancer, diabetes, kidney disease,
    arthritis, asthma, mental illness and Alzheimer's disease. At the same
    time, healthcare spending in the United States is being driven up by
    the aging of the U.S. population and the rapid rise in chronic
    diseases, many of which are caused or exacerbated by behavioral
    factors--including, obesity, caused by sedentary behavior and poor
    diet, and addictions resulting from health problems caused by tobacco
    and other drug use. As the NAS report notes, ``the United States is
    losing ground in the control of diseases, injuries, and other sources
    of morbidity.''
        The behavioral and social sciences regularly make important
    contributions to the well-being of this Nation. Due in large part to
    the behavioral and social science research sponsored by the NIH, we are
    now aware of the enormous role behavior plays in our health. At a time
    when genetic control over disease is tantalizingly close but not yet
    possible, knowledge of the behavioral influences on health is a crucial
    component in the Nation's battles against the leading causes of
    morbidity and mortality: obesity, heart disease, cancer, AIDS,
    diabetes, age-related illnesses, accidents, substance abuse, and mental
    illness.
        As a result of the strong Congressional commitment to the NIH in
    years past, our knowledge of the social and behavioral factors
    surrounding chronic disease health outcomes is steadily increasing. The
    NIH's behavioral and social science portfolio has emphasized the
    development of effective and sustainable interventions and prevention
    programs targeting those very illnesses that are the greatest threats
    to our health, but the work is just beginning. This includes NIH's
    support of economic research, specifically, research on the linkages
    between socioeconomic status and health outcomes in the elderly and
    achievement and health outcomes in children. This research has been an
    integral part of the interdisciplinary science NIH has historically
    supported. Accordingly, the agency's investment has yielded key data,
    methodologies and substantive insights on some of the most important
    and pressing issues facing the U.S. For example, NIH-funded surveys
    such as the Health and Retirement Survey, the Panel Study of Income
    Dynamics (PSID), parts of the National Longitudinal Survey of Labor
    Market Experiences, and surveys on international aging and retirement
    provide data necessary to monitor and detect changes in important
    socioeconomic trends in health. This in turn allows NIH to support
    research that will provide the greatest return on its investment when
    it comes to the health of our citizens.
                   cdc behavioral and social science research
        As the country's leading health protection and surveillance agency,
    the Centers for Disease Control and Prevention (CDC) works with State,
    local, and international partners to protect Americans from infectious
    diseases; prevent the leading causes of disease, disability, and death;
    protect Americans from natural and bioterrorism threats; monitor health
    and ensure laboratory excellence; keep Americans safe from
    environmental and work-related hazard; and ensure global disease
    protection.
        Social and behavioral science research plays a crucial role in
    helping the CDC carry out its mission. Scientists in fields ranging
    from psychology, sociology, anthropology, and geography to health
    communications, social work, and demography work in every CDC Center to
    design, analyze, and evaluate behavioral surveillance systems, public
    health interventions, and health promotion and communication programs
    using a variety of both quantitative and qualitative methods. These
    scientists play a key role in the CDC's surveillance and monitoring
    efforts, which collect and analyze data to better target public health
    prevention efforts. Another vital contribution of the social and
    behavioral sciences to CDC activities is in identifying and
    understanding health disparities. Finally, the social and behavioral
    sciences play an important role in the evaluation of CDC programs,
    helping policymakers make informed, evidence-based decisions on how to
    prioritize in a resource-scarce environment.
        The CDC is also the home of the Nation's principal health
    statistics agency, the National Center for Health Statistics (NCHS).
    NCHS collects data on chronic disease prevalence, healthcare
    disparities, emergency room use, teen pregnancy, infant mortality,
    causes of death and rates of insurance, to name a few. It provides
    critical data on all aspects of our healthcare system through data
    cooperatives and surveys that serve as the gold standard for data
    collection around the world. Data from NCHS surveys like the National
    Health Interview Survey (NHIS), the National Health and Nutrition
    Examination Survey (NHANES) and the National Vital Statistics System
    (NVSS) are used by agencies across the Federal Government, State and
    local governments, public health officials, Federal policymakers, and
    demographers, epidemiologists, health services researchers, and other
    scientists.
                         ahrq health services research
        AHRQ's sole purpose is to improve healthcare in America. Just as
    biomedical research helps us find cures for disease, the health
    services research AHRQ supports helps find ways to cure our healthcare
    system--improving its quality, safety, and efficiency for the benefit
    of patients. AHRQ's research identifies what works and what doesn't in
    healthcare to improve patient care and provide policymakers and other
    healthcare leaders with the information needed to make critical
    healthcare decisions.
        AHRQ helps providers help patients. AHRQ's research generates
    valuable evidence to help providers help patients make the right
    healthcare decisions for themselves and their loved ones. The science
    funded by AHRQ ensures patients receive high quality, appropriate care
    every time they walk through the hospital, clinic, and medical office
    doors. AHRQ's research provides the basis for protocols that prevent
    medical errors and reduce healthcare-associated infections (HAIs), and
    improve patient experiences and outcomes. AHRQ helps healthcare
    providers--from private practice physicians to large hospital systems--
    understand how to deliver the best care most efficiently. The breadth
    of evidence available from AHRQ empowers healthcare providers to
    understand not just how they compare to their peers, but also how to
    improve their performance to be more competitive.
        COSSA expects this testimony to be only the beginning of an ongoing
    conversation between the Subcommittee and stakeholders on the fiscal
    year 2015 funding needs of these agencies.
        We would be pleased to provide any additional information.
                                     ______

         Prepared Statement of the Corporation for Public Broadcasting
        Chairman Harkin and distinguished members of the subcommittee,
    thank you for allowing me to submit this testimony on behalf of
    America's public media service--public television and public radio--on-
    air, online and in the community. The Corporation for Public
    Broadcasting (CPB) requests level funding of $445 million for fiscal
    year 2017 and $27.3 million for the Department of Education's Ready To
    Learn program in fiscal year 2015.
        Forty-six years after passage of the Public Broadcasting Act, this
    uniquely American public-private partnership is keeping its promise to
    the American people by providing a safe place where children can learn
    on-air and online; providing high-quality educational content for
    teachers in the classroom and children schooled at home; providing
    reliable and trusted news and information; and providing emergency
    alert services. Either by looking at each station individually or
    public media as a whole, this public-private partnership is making a
    big difference in the lives of individuals and communities.
        Today we are a system that comprises more than 1,400 locally owned
    and locally operated public radio and television stations serving rural
    and urban communities throughout the country. More than 98 percent of
    the American people turn to American public media for high quality
    content that educates, informs, inspires and entertains. Public media's
    commitment to early and lifelong learning, available to all citizens,
    helps strengthen our civil society and our democracy. Our trusted,
    noncommercial services available for free to all Americans is
    especially important to those living in rural communities where the
    local public media station is sometimes the only source of broadcast
    news, information and educational programming.
        I understand that this committee is faced with the challenging task
    of allocating scarce Federal resources to a number of organizations,
    all doing worthy and important work. The financial support for the
    public broadcasting system that is derived from the Federal
    appropriation is the essential investment keeping public media free and
    commercial free for all Americans. Former President Ronald Reagan said,
    ``Government should provide the spark and the private sector should do
    the rest.'' And what stations do, with the spark of Federal dollars
    that amounts to approximately 10 to 15 percent of a stations' budget,
    results in a uniquely entrepreneurial and American public media system
    with a track record of proven benefits delivered through stations to
    the American people.
        The Federal investment through CPB is the foundation on which the
    entire system is built. These critical funds leverage vital investments
    from other sources. Undermining this foundation would put the entire
    structure in jeopardy. While private donations and existing funding
    sources can help defray considerable costs for the much-honored
    programs of public television and radio--nonFederal funding represents
    five of every six dollars invested annually in public broadcasting--the
    Federal investment is indispensable to sustaining the operations of
    public broadcasting stations, the public service mission they pursue,
    local community-based accountability, and the universal service to
    which the Public Broadcasting Act aspires.
        Further, it is this initial investment in public media that keeps
    it commercial free and available to all Americans for free. However,
    smaller stations serving rural, minority and other underserved
    communities are hard pressed to raise six times the Federal
    appropriation, which can represent as much as 40 percent of their
    budget.
        Public media's contribution to education--from early childhood
    through adult learning--is well documented. We are America's largest
    classroom, with proven content available to all children, including
    those who cannot afford preschool. Our content is repeatedly regarded
    as ``most trusted'' by parents, caregivers and teachers.
        CPB's work with the Department of Education's Ready To Learn
    program is an excellent example of how public media brings together
    high-quality educational content with on-the-ground work in local
    communities. We also invest in research that demonstrates and promotes
    the effectiveness of this content in formal and informal educational
    settings.
        We talk a lot about content that matters and engagement that
    counts, further defining public media from commercial media. An example
    of this is CPB's ``American Graduate: Let's Make it Happen''
    Initiative, which tells the story behind the statistic of one million
    American young people failing to graduate every year from high school.
    Our stations told the stories and communities throughout the country
    responded. More than 75 public media stations located in 33 States with
    at-risk communities are working with more than 1000 national and
    community-based partners to bring together diverse stakeholders and
    community organizations; filling gaps in information, resources and
    solutions; sharing best practices for teacher training and student
    engagement; creating local programming around the dropout issue unique
    to their communities, and leveraging digital media and technology to
    engage students in an effort to keep them on the path to graduation.
    Those numbers are now declining because what our stations do, counts.
    But American Graduate is just one example of how public media stations
    are using their spectrum for the public good.
        Building on our education commitment, CPB recently announced that
    it will expand on these successful models to bring meaningful impact
    and change to more communities at risk. Through the recently created
    $20 million American Graduate/PBS KIDS Fund, CPB and PBS will invest in
    the development of new tools to help parents better prepare their
    children ages 2-8 for educational success, to support teacher
    development, and to engage middle and high school youth to improve
    learning.
        Public media is utilizing today's technology to provide content of
    value to millions of citizens who trust us to deliver content that
    matters and is relevant to their lives today. CPB strategically focuses
    investments through the lens of what we refer to as the ``Three D's''
    --Digital, Diversity and Dialogue. This refers to support for
    innovation on digital platforms, extending public media's reach and
    service over multiple platforms; content that is for, by and about
    Americans of all backgrounds; and services that foster dialogue between
    the American people and the public service media organizations that
    serve them.CPB funding enables stations to provide content of
    consequence and to keep faith with the visions of political,
    educational, philanthropic and community leaders who have seen in
    public broadcasting the potential to strengthen our nation by promoting
    lifelong learning and an informed citizenry.
        As the steward of these important taxpayer dollars, CPB ensures
    that 95 cents of every dollar received goes to support local stations
    and the programs and services they offer to their communities; no more
    than five cents of every dollar goes to the administration of funding
    programs and overhead.
        The Public Broadcasting Act ensures diversity in this programming
    by requiring CPB to fund independent and minority producers. CPB
    fulfills this obligation, in part, by funding the Independent
    Television Service, the five Minority Consortia entities in television
    (African American, Latino, Asian American, Native American and Pacific
    Islander), several public radio consortia (Latino Public Radio
    Consortia, African American Public Radio Stations, and Native Public
    Media) and numerous minority public radio stations. In addition, CPB,
    through its Diversity and Innovation fund, makes direct investments in
    the development of diverse primetime and children's broadcast programs
    as well as innovative digital content.
        As newspapers across the country have scaled back their operations,
    public media has stepped into the void. Local stations have been
    working to fill the gap with creative ventures and partnerships, such
    as our seven multimedia local journalism centers (LJCs) that are
    providing their communities with much-needed local, regional and
    statewide coverage.
        For an investment of approximately $1.35 per American per year,
    public media stations are able to train teachers and help educate
    America's children; provide in-depth journalism that informs citizens
    about issues in their neighborhoods, their country, and around the
    globe; make the arts accessible to all Americans; and provide emergency
    alert services for their communities.
        CPB's fiscal year 2017 request of $445 million balances the fiscal
    reality facing our nation with our statutory mandate to provide a
    valuable and trusted service to all Americans. Today, the challenges we
    face are more complex than ever and require new levels of thinking,
    innovation, and collaboration. Community organizations often work in
    isolation, shouldering the burden of solving societal problems. But
    public media is the essential link, uniquely poised to add real value.
    CPB's fiscal year 2017 request will allow stations to enhance their
    role as a trusted source of information and as a convener, help
    communities understand issues, and mobilize them toward positive,
    sustainable outcomes.
        Mr. Chairman and members of the subcommittee, this is only part of
    the story of our public media system in America. Public media is a
    national treasure that is available and accessible to all Americans.
    Every day public media works to strengthen and advance our civil
    society. I thank you for allowing me to submit this testimony and urge
    you to consider our request for funding.

        [This statement was submitted by Patricia Harrison, President and
    CEO, Corporation for Public Broadcasting.]
                                     ______

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

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

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

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

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

        [This statement was submitted by Grant Hoekzema, MD, Chair, Council
    of Academic Family Medicine.]
                                     ______

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

        [This statement was submitted by Dr. Darla Spence Coffey,
    President, Council on Social Work Education.]
                                     ______

      Prepared Statement of the Crohn's and Colitis Foundation of America
                  summary of fiscal year 2015 recommendations
    _______________________________________________________________________

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

        Thank you for the opportunity to submit testimony to the
    Subcommittee. CCFA has remained committed to its mission of finding a
    cure for Crohn's disease and ulcerative colitis and improving the
    quality of life of children and adults affected by these diseases for
    over 46 years. Impacting an estimated 1.4 million Americans, 30 percent
    of whom are diagnosed in their childhood years, Inflammatory Bowel
    Diseases (IBD) are chronic disorders of the gastrointestinal tract
    which cause abdominal pain, fever, and intestinal bleeding. IBD
    represents a major cause of morbidity from digestive illness and has a
    devastating impact on both patients and their families.
        The social and economic impact of digestive disease is enormous and
    difficult to grasp. Digestive disorders afflict approximately 65
    million Americans. This results in 50 million visits to physicians,
    over 10 million hospitalizations, collectively 230 million days of
    restricted activity. The total cost associated with digestive diseases
    has been conservatively estimated at $60 billion a year.
        The CCFA would like to thank the subcommittee for its past support
    of digestive disease research and prevention programs at the National
    Institutes of Health (NIH) and the Centers for Disease Control and
    Prevention (CDC).
        Specifically the CCFA recommends:
      --$32 billion for the NIH.
      --$2.16 billion for the National Institute of Diabetes and Digestive
            and Kidney Disease (NIDDK).
        We at the CCFA respectfully request that any increase for NIH does
    not come at the expense of
        other Public Health Service agencies. With the competing and the
    challenging budgetary constraints the Subcommittee currently operates
    under, the CCFA would like to highlight the research being accomplished
    by NIDDK which warrants the increase for NIH.
                           inflammatory bowel disease
        In the United States today about one million people suffer from
    Crohn's disease and ulcerative colitis, collectively known as IBD.
    These are serious diseases that affect the gastrointestinal tract
    causing bleeding, diarrhea, abdominal pain, and fever. Complications
    arising from IBD can include anemia, ulcers of the skin, eye disease,
    colon cancer, liver disease, arthritis, and osteoporosis. The cause of
    IBD is still unknown, but research has led to great breakthroughs in
    therapy.
        In recent years researchers have made significant progress in the
    fight against IBD. The CCFA encourages the subcommittee to continue its
    support of IBD research at NIDDK and NIAID at a level commensurate with
    the overall increase for each institute. The DDNC would like to applaud
    the NIDDK for its strong commitment to IBD research through the
    Inflammatory Bowel Disease Genetics Research Consortium. The CCFA urges
    the Consortium to continue its work in IBD research.
          centers for disease control and prevention ibd epidemiology
        CDC, in collaboration with a nationwide, geographically diverse
    network of large managed healthcare delivery systems, has led an
    epidemiological study of IBD to understand IBD incidence, prevalence,
    demographics, and healthcare utilization. The group, comprised of
    investigators at the Massachusetts General Hospital in Boston, Rhode
    Island Hospital, the Crohn's and Colitis Foundation of America, and
    CDC, has piloted the Ocean State Crohn's and Colitis Registry (OSCAR),
    which includes both pediatric and adult patients. Since 2008, the OSCAR
    investigators have recruited 22 private-practice groups and hospital
    based physicians in Rhode Island and are that enrolling newly diagnosed
    patients into the registry. This study found an average annual
    incidence rate of 8.4 per 100,000 people for Crohn's disease and 12.4
    per 100,000 for Ulcerative Colitis; published in Inflammatory Bowel
    Disease Journal, April 2007.
      --Over the course of the initial 3-year epidemiologic collaboration,
            CDC laboratory scientists and epidemiologists worked to improve
            detection tools and epidemiologic methods to study the role of
            infections (infectious disease epidemiology) in pediatric IBD,
            collaborating with extramural researchers who were funded by a
            National Institutes of Health (NIH) research award.
      --Since 2006, CDC epidemiologists have been working in conjunction
            with the Crohn's and Colitis Foundation of American and a large
            health maintenance organization to better understand the
            natural history of IBD and factors that predict the course of
            disease.
        The Crohn's and Colitis Foundation of America encourages the CDC to
    continue to support a nationwide IBD surveillance and epidemiological
    program in fiscal year 2014.
                          colorectal cancer prevention
        Colorectal cancer is the third most commonly diagnosed cancer for
    both men and woman in the United States and the second leading cause of
    cancer-related deaths. Colorectal cancer affects men and women equally.
        The CCFA recommends a funding level of $50 million for the CDC's
    Colorectal Cancer Screening and Prevention Program. This important
    program supports enhanced colorectal screening and public awareness
    activities throughout the United States. The DDNC also supports the
    continued development of the CDC-supported National Colorectal Cancer
    Roundtable, which provides a forum among organizations concerned with
    colorectal cancer to develop and implement consistent prevention,
    screening, and awareness strategies.
                                   conclusion
        The CCFA understands the challenging budgetary constraints and
    times we live in that this Subcommittee is operating under, yet we hope
    you will carefully consider the tremendous benefits to be gained by
    supporting a strong research and education program at NIH and CDC.
    Millions of Americans are pinning their hopes for a better life, or
    even life itself, on digestive disease research conducted through the
    National Institutes of Health. Mr. Chairman, on behalf of our patients,
    we appreciate your consideration of our view. We look forward to
    working with you and your staff.
                                     ______

              Prepared Statement of the Cystic Fibrosis Foundation
        On behalf of the Cystic Fibrosis Foundation (CFF) and the 30,000
    people with cystic fibrosis (CF) in the United States, we submit the
    following testimony to the Senate Appropriations Committee's
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies on our funding requests for fiscal year 2015. The
    Foundation requests the highest possible funding level for the National
    Institutes of Health (NIH), particularly the National Center for
    Advancing Translational Sciences (NCATS) and programs under its
    jurisdiction, including the Cures Acceleration Network (CAN) and the
    Clinical and Translational Science Awards (CTSA).
    Collaboration and Innovation: The Future of Drug Development
        NIH uses appropriated funds wisely and effectively by supporting
    programs that promote efficiency and innovation in drug discovery and
    encouraging collaboration across sectors. Many of these effective,
    collaborative ventures aim to translate basic research into promising
    potential treatments, speeding the discovery of therapies for those
    with serious illnesses like cystic fibrosis. We urge you to ensure that
    these critical programs are sufficiently funded and receive the support
    they need. For those with rare genetic diseases like CF, treatments and
    cures cannot wait.
        As an example of the NIH's cooperative, innovative approach, in
    February the agency announced the establishment of the Accelerating
    Medicines Partnership (AMP), a joint venture between NIH,
    pharmaceutical companies, and several non-profit organizations to
    characterize biomarkers and distinguish biological targets that are
    most likely to respond to new therapies. The AMP will begin with three
    to five year pilot projects in Alzheimer's disease, type 2 diabetes,
    rheumatoid arthritis and systemic lupus erythematosus.
        Through this cross-sector partnership, NIH and industry partners
    share expertise, resources, and data in order to speed the development
    of treatments. Furthermore, industry partners have agreed to make AMP
    data and analyses available to the biomedical community for use in
    future study.
        Drug development is risky, expensive, and time-consuming, and there
    is a 95 percent failure rate for drug candidates. This kind of cross-
    sector partnership aims to reduce the time, cost, and risk of drug
    development by sharing resources so diseases can be analyzed in ways
    that drug companies have not been able to do on their own.
        Importantly, industry will fund one-half of the $230 million budget
    while NIH will provide the other half. The Federal money used for this
    project acts as seed money, a jumping off point for private sector
    investment in drug discovery for serious diseases. This type of
    cooperative approach saves taxpayer funds in the long run and can save
    lives.
        While AMP is not administered by the National Center for Advancing
    Translational Sciences (NCATS), this NIH center spearheads similarly
    innovative programs that encourage collaboration, improve the process
    by which diagnostics and therapeutics are developed, and improve the
    efficiency of the translation of basic scientific discoveries into new
    therapies.
        For example, the Cures Acceleration Network (CAN), a program under
    the umbrella of NCATS, funds a variety of initiatives designed to
    address scientific and technical challenges that hinder transitional
    research. For instance, CAN provides funding for the Tissue Chip for
    Drug Screening Initiative, a joint project with the Defense Advanced
    Research Projects Agency (DARPA) and the Food and Drug Administration
    (FDA) to develop 3-D human tissue chips. These chips, composed of
    diverse human cells and tissues, mimic how drugs interact with the
    human body. If successful, these chips could make drug safety and
    efficacy assessments possible at an earlier stage in drug development,
    enabling investigators to concentrate on the most promising new drugs.
        Unfortunately, CAN has been chronically underfunded. Since its
    inception as part of the Patient Protection and Affordable Care Act in
    2010, it has been funded at approximately $10 million per year for
    fiscal years 2012, 2013, and 2014. We urge the Committee to provide at
    least the funding level requested in the President's fiscal year 2015
    budget--$29.8 million. CAN needs additional funding for projects that
    will help move new treatments to patients.
        Similarly, the Clinical and Translational Science Awards (CTSA)
    program in the NCATS Division of Clinical Innovation demonstrates
    NCATS' innovative, collaborative approach. This program supports a
    national consortium of more than 60 medical research institutions that
    work together on research. Its goals are to accelerate the process of
    translating laboratory discoveries into treatments for patients, train
    a new generation of researchers, and engage communities in clinical
    research efforts.
        Institutional CTSA awards provide academic homes for translational
    sciences and support research resources needed by local and national
    research communities to improve the quality and efficiency of all
    phases of translational research. They also support the training of
    clinical and translational scientists and the development of all
    disciplines needed for a robust translational research workforce.
        CTSA funds have the potential to be used in new ways. For example,
    CTSA's academic homes can serve as a platform for sharing patient
    registry data. As the CF Foundation has seen with its Therapeutics
    Development Network of clinical trial sites, the sharing of patient
    registry information, including demographics and health outcomes, among
    sites is integral to conducting CF research. This strategy could be
    beneficial in the wider disease community.
    A Culture of Collaboration: The Cystic Fibrosis Model
        The Cystic Fibrosis Foundation has long been engaged in
    partnerships with industry and supports a collaborative network of care
    centers and clinical trial sites. As such, CFF knows firsthand that
    this type of cooperation can lead to the targeted treatments that
    change the face of many life-threatening diseases.
        Because drug research and development is a lengthy, expensive and
    risky process, CFF pioneered a successful ``venture philanthropy''
    business model to drive drug development for this rare disease. By
    collaborating with pharmaceutical companies and providing financial,
    scientific, and clinical support in order to ``de-risk'' the
    development process, CFF speeds development of much-needed treatments.
        Through its venture philanthropy model, the Foundation is able to
    invest in promising CF research and a robust pipeline of potential
    therapies that target the disease from every angle. Nearly every CF
    drug available today was made possible because of the Foundation's
    support and ongoing work with researchers and the pharmaceutical
    industry to find a cure.
        In January 2012, the Food and Drug Administration approved
    Kalydeco, a groundbreaking cystic fibrosis drug developed by Vertex
    Pharmaceuticals in partnership with the CF Foundation. This targeted
    drug is the first to address the underlying genetic cause of cystic
    fibrosis in a subset of the CF population.
        Kalydeco was approved in only 3 months, one of the fastest
    approvals in the FDA's history. According to Margaret A. Hamburg, M.D.,
    Commissioner of the FDA, ``The unique and mutually beneficial
    partnership that led to the approval of Kalydeco serves as a great
    model for what companies and patient groups can achieve if they
    collaborate on drug development.''
        Throughout Kalydeco's review, the Cystic Fibrosis Foundation and
    renowned CF experts worked closely with Vertex Pharmaceuticals and the
    FDA, providing valuable insight on specific issues related to CF,
    clinical research on CF treatments, and other issues related to the
    product and its review. We believe that this collaborative process
    contributed to a more efficient evaluation, and is a testament to what
    can be achieved when stakeholders collaborate across sectors on
    critical drugs for patients.
        Akin to AMP, the Cystic Fibrosis Foundation also recognizes the
    profound importance of data sharing, which is a critical way to enable
    efficient drug development. The Cystic Fibrosis Foundation Therapeutics
    Development Network (TDN) of clinical trial centers has accumulated
    data from over 40 cystic fibrosis studies in the last 15 years. This
    data resides in a repository specifically meant to facilitate sharing
    among our research community.
                                     * * *
        As the Committee determines its funding levels for fiscal year
    2015, we request your attention to the critical nature of NIH's work
    and the innovation it supports, and urge robust funding for this
    important agency. The CF Foundation stands ready to work with the
    Committee, NIH, and Congressional leaders on the challenges ahead.
    Thank you for your consideration.
                                     ______

         Prepared Statement of the Digestive Disease National Coalition
                  summary of fiscal year 2015 recommendations
    _______________________________________________________________________

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

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

           Prepared Statement of Dystonia Medical Research Foundation
                summary of recommendations for fiscal year 2015
    _______________________________________________________________________

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

    _______________________________________________________________________

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

        [This statement was submitted by Janet Hieshetter, Executive
    Director, Dystonia Medical Research Foundation.]
                                     ______

               Prepared Statement of the Elder Justice Coalition
        Chairman Harkin, Ranking Member Moran: On behalf of the Elder
    Justice Coalition, a bipartisan 3000 member organization, we thank you
    for the opportunity to testify in support of the Department of Health
    and Human Services' proposed Elder Justice Initiative in the amount of
    $25 million.
        Our topic has been and must always be a bipartisan issue:
    preventing elder abuse, neglect and exploitation. We ask this
    Subcommittee to provide the necessary funding in a bipartisan fashion
    as part of the solution to the real national disgrace of elder abuse.
        There are more than six million victims of elder abuse; roughly one
    of every ten persons over 60. Victims of elder financial abuse lose an
    estimated $2.9 billion a year which can include entire life savings.
    Other data points to a 16 percent increase in reported cases. However,
    a New York State study said for every elder abuse case known to
    agencies, twenty-four were unknown.
        The $25 million requested in the President's fiscal year 2015
    budget for an Elder Justice Initiative which if approved by Congress
    would be the first direct appropriation for the bipartisan Elder
    Justice Act sponsored in the Senate by Senators Breaux, Hatch and
    Baucus.
        The funding request includes:
      --$13.8 million for Adult Protective Services, including an APS
            National Data System and Technical Assistance and national
            demonstration grants to both enhance APS data systems and
            development of program standards as well as an full evaluation
            of APS practices.
      --$11.2 million for research including elder abuse screening and to
            establish a better knowledge base about elder abuse, neglect
            and exploitation.
        Data collection is important. The lack of good data has hurt the
    elder abuse field and our ability to target efforts to prevent abuse.
    Data often drives dollars. For elder abuse to compete effectively for
    resources, we must have a good system to collect and analyze data. This
    appropriation will also help assess the most likely perpetrators and
    victims and direct resources to those most vulnerable.
        We support the development of APS program standards. Interventions
    for victims of elder abuse are far more complicated than for younger
    victims of abuse and family violence. To be effective, APS programs
    must have consistency and quality on a national basis. Elder abuse is
    happening in all States and districts and in some cases an older person
    can be victimized in more than one State.
        This initial investment of $25 million means existing Federal
    resources could be used more efficiently while also responding to elder
    abuse with a systematic approach. This and slowing future victimization
    is a solid return on investment.
        Why else is this an investment? According to the National Center on
    Elder Abuse, the direct medical costs associated with elder abuse now
    exceed $5 billion. Victims often end up having to turn to other Federal
    programs, especially Medicare and Medicaid, and for financial abuse
    victims they may require other assistance including income support.
    Some of this can clearly be avoided and savings achieved for these
    programs if we make this investment today.
        Elder abuse victims are household names like Mickey Rooney or the
    late Brooke Astor. We testify for them today but also for those who are
    not household names. The voices we don't hear are the ones who need a
    voice that you can listen to today.
        We say that elder justice is a bipartisan issue. Leaders have
    included Senator Hatch, Representative King, as well as former Senator
    Lincoln and Representative Emanuel to name a few. Again on a bipartisan
    basis this Congress reauthorized the Violence Against Women Act. The
    reality is that elder abuse is also a women's issue. The average victim
    is an older woman living alone between 75 and 80 at a time when the
    Census reports that almost 50 percent of all women over 75 now live
    alone--another reason to act now to get resources into elder abuse
    prevention.
        If one in ten seniors in your State were victims of crime, you
    would likely respond by seeking more support for law enforcement as
    first responders in the fight against crime. Elder abuse hits one out
    of every ten seniors. Let us give needed support to Adult Protective
    Services who are the first responders for elder abuse.
        Our Coalition also supports funding the Social Services Block Grant
    the only funding source for Adult Protective Services today at the
    level proposed in the President's budget.
        Just as 40 years ago when witnesses came to this Subcommittee
    seeking initial funding for the Child Abuse Prevention and Treatment
    Act of 1974 we come today asking for this initial $25 million for elder
    justice. What is common? A victim of child abuse, like a victim of
    elder abuse, is never the same. The role of government should always be
    to help the vulnerable of all ages.
        Elder justice warrants considerably more than the requested $25
    million. The Elder Justice Act also includes increased support for long
    term care ombudsmen assisting nursing home residents and funding
    forensic centers important to the prosecution of abusers. Since these
    are not included, please view the $25 million as a floor to build on,
    not a ceiling. We look forward to working with you on ensuring that
    this first time appropriations for elder justice provides us with the
    best possible value and positive outcomes.
                                     ______

             Prepared Statement of the Eldercare Workforce Alliance
        Mr. Chairman, Ranking Member Moran, and Members of the
    Subcommittee: We are writing on behalf of the Eldercare Workforce
    Alliance (EWA), which is comprised of 30 national organizations united
    to address the immediate and future workforce crisis in caring for an
    aging America. As the Subcommittee begins consideration of funding for
    programs in fiscal year 2015, the Alliance\**\ urges you to provide
    adequate funding for programs designed to increase the number of
    healthcare professionals prepared to care for America's growing senior
    population and to support family caregivers in the essential role they
    play in this regard.
    ---------------------------------------------------------------------------
        \**\ The positions of the Eldercare Workforce Alliance reflect a
    consensus of 75 percent or more of its members. This testimony reflects
    the consensus of the Alliance and does not necessarily represent the
    position of individual Alliance member organizations.
        The Eldercare Workforce Alliance is a project of The Advocacy Fund.
    ---------------------------------------------------------------------------
        Today's healthcare workforce is inadequate to meet the special
    needs of older Americans, many of whom have multiple chronic physical
    and mental health conditions and cognitive impairments. It is estimated
    that an additional 3.5 million trained healthcare workers will be
    needed by 2030 just to maintain the current level of access and
    quality. Without a national commitment to expand training and
    educational opportunities, the workforce will be even more constrained
    in its ability to care for the growth in the elderly population as the
    baby boom generation ages. Reflecting this urgency, the Health
    Resources and Services Administration (HRSA) has identified ``enhancing
    geriatric/elder care training and expertise'' as one of its top five
    priorities.
        Of equal importance is supporting the legions of family caregivers
    who annually provide billions of hours of uncompensated care that
    allows older adults to remain in their homes and communities. The
    estimated economic value of family caregivers' unpaid care was
    approximately $450 billion in 2009.
        The number of Americans over age 65 is expected to reach 70 million
    by 2030, representing a 71 percent increase from today's 41 million
    older adults. That is why Title VII and Title VIII geriatrics programs
    and Administration for Community Living (ACL) programs that support
    family caregivers are so critical to ensure that there is a skilled
    eldercare workforce and knowledgeable, well-supported family caregivers
    available to meet the complex and unique needs of older adults.
        We hope you will support a total of $44.7 million in funding for
    geriatrics programs in Title VII and Title VIII of the Public Health
    Service Act, $172.9 million in funding for programs administered by the
    Administration on Aging that support the vital role of family
    caregivers in providing care for older adults, and $3 million to
    convene a White House Conference on Aging. Specifically, we recommend
    the following levels:
      --$39.7 million for Title VII Geriatrics Health Professions Programs;
      --$5 million for Title VIII Comprehensive Geriatric Education
            Programs;
      --$172.9 million for Family Caregiver Support Programs; and
      --$3 million for a White House Conference on Aging.
        Geriatrics health profession training programs are integral to
    ensuring that America's healthcare workforce is prepared to care for
    the Nation's rapidly expanding population of older adults.
        In light of current fiscal constraints, EWA specifically requests
    $44.7 million in funding for the following programs administered
    through the Health Resources and Services Administration (HRSA) under
    Title VII and VIII of the Public Health Service Act. In the 2012-2013
    Academic Year, these geriatrics and gerontology programs provided
    training to more than 200,000 individuals.
    Title VII Geriatrics Health Professions: Appropriations Request: $39.7
            Million
        Title VII Geriatrics Health Professions programs are the only
    Federal programs that seek to increase the number of faculty with
    geriatrics expertise in a variety of disciplines. These programs offer
    critically important training for the healthcare workforce overall to
    improve the quality of care for America's elders.
      --Geriatric Academic Career Awards (GACA).--The goal of this program
            is to promote the development of academic clinician educators
            in geriatrics. Program Accomplishments: In the In the Academic
            Year 2012-2013, the GACA program funded 62 full-time junior
            faculty. These awardees delivered over 1,100 interprofessional
            continuing education courses specific to geriatric-related
            topics to over 53,000 students and providers. Additionally,
            they presented on research and other topics at 215 local, State
            and national conference and published 108 peer-reviewed
            publications. HRSA, through the Affordable Care Act (ACA),
            expanded the awards to be available to more disciplines. EWA
            strongly supports this expansion and requests adequate funding
            to reflect this change. Currently, new awardees are selected
            only every 5 years. To meet the need for clinician educators in
            all disciplines, EWA believes that awards should be made
            available to clinical educators annually in order to develop an
            adequate number of faculty that can provide geriatric
            instruction and training. EWA's fiscal year 2015 request of
            $5.5 million will support GAC Awardees in their development as
            clinician educators.
      --Geriatric Education Centers (GEC).--The goal of Geriatric Education
            Centers is to provide high quality interprofessional geriatric
            education and training to current members of the health
            professions workforce, including geriatrics specialists and
            non-specialists. Program Accomplishments: In Academic Year
            2012-2013, the 45 GEC grantees developed and provided over
            1,650 different continuing education and clinical training
            offerings to more than 135,000 health professionals, students,
            faculty, and practitioners, significantly exceeding the
            program's performance target. Three quarters of the continuing
            education offerings were interprofessional in focus. Of the
            sites that offered clinical training sessions, 2 out of every 5
            of these sites were in a medically underserved community and/or
            Health Professional Shortage Area. The GECs provide much needed
            education and training. Our funding request of $20 million
            includes support for the core work of these 45 GECs.
      --Alzheimer's Disease Prevention, Education, and Outreach Program
            (GECs).--These funds, included in the President's fiscal year
            2015 budget request, allow HRSA to expand efforts to provide
            interprofessional continuing education to healthcare
            practitioners on Alzheimer's disease and related dementias,
            utilizing the already existing Geriatric Education Centers
            (GECs). EWA Requests $5.3 million.
      --Geriatric Training Program for Physicians, Dentists, (GTPD) and
            Behavioral and Mental Health Professions.--The goal of the GTPD
            program is to increase the number and quality of clinical
            faculty with geriatrics and cultural competence, including
            retraining mid-career faculty in geriatrics. Program
            Accomplishments: In Academic Year 2012-2013, a total of 64
            physicians-including psychiatrists-, dentists, and
            psychologists, were supported through this fellowship program.
            Fellows delivered over 275 courses to 5,600 trainees. This
            program supports training additional faculty in medicine,
            dentistry, and behavioral and mental health so that they have
            the expertise, skills, and knowledge to teach geriatrics and
            gerontology to the next generation of health professionals in
            their disciplines. EWA's funding request of $8.9 million will
            support this important faculty development program.
    Title VIII Geriatrics Nursing Workforce Development Programs:
            Appropriations Request: $5 million
        Title VIII programs, administered by the HRSA, are the primary
    source of Federal funding for advanced education nursing, workforce
    diversity, nursing faculty loan programs, nurse education, practice and
    retention, comprehensive geriatric education, loan repayment, and
    scholarship.
      --Comprehensive Geriatric Education Program.--The goal of this
            program is to provide quality geriatric education and training
            to individuals caring for the elderly. Program Accomplishments:
            In Academic Year 2012-2013, a total of 18 00Comprehensive
            Geriatric Education Program (CGEP) grantees provided a variety
            of services, including over 150 different continuing education
            courses to over 11,600 trainees. This program supports
            additional training for nurses who care for the elderly;
            development and dissemination of curricula relating to
            geriatric care; training of faculty in geriatrics; and
            continuing education for nurses practicing in geriatrics.
      --Traineeships for Advanced Practice Nurses.--Through the ACA, the
            Comprehensive Geriatric Education Program was expanded to
            include advanced practice nurses who are pursuing long-term
            care, geropsychiatric nursing, or other nursing areas that
            specialize in care of older adults. In Academic Year 2012-2013,
            a total of 74 grantees were awarded traineeships. One in every
            4 grantee is considered an underrepresented minority in their
            prospective profession. EWA's funding request of $5 million
            will support the education and training of individuals who
            provide geriatric care.
    Administration for Community Living Family Caregiver Support and White
            House Conference on Aging: Appropriations Request: $175.9
            million
        These programs support caregivers, elders, and people with
    disabilities by providing critical respite care and other support
    services for family caregivers, training and recruitment of care
    workers and volunteers, information and outreach, counseling, and other
    supplemental services.
      --Family Caregiver Support Services.--This program provides a range
            of support services to approximately 700,000 family and
            informal caregivers annually in States, including counseling,
            respite care, training, and assistance with locating services
            that help family caregivers in caring for their loved ones at
            home for as long as possible. EWA requests $154.5 million.
      --Native American Caregiver Support.--This program provides a range
            of services to Native American caregivers, including
            information and outreach, access assistance, individual
            counseling, support groups and training, respite care and other
            supplemental services. EWA requests $6.4 million.
      --Alzheimer's Disease Support Services:.--One critical focus of this
            program is to support the family caregivers who provide
            countless hours of unpaid care, thereby enabling their family
            members with dementia to continue living in the community.
            Funds go towards evidence-based interventions and expand the
            dementia-capable home and community-based services, enabling
            older adults to remain in the community for as long as
            possible. EWA requests $9.5 million.
      --Lifespan Respite Care.--This program funds grants to improve the
            quality of and access to respite care for family caregivers of
            children or adults of any age with special needs. EWA requests
            $2.5 million.
      --White House Conference on Aging.--As recommended by the bi-partisan
            Commission on Long-Term Care, the President's fiscal year 2015
            budget request includes $3 million for the convening of a
            decennial White House Conference on Aging to bring together
            stakeholders and consumers from across the country to discuss
            the range of aging issues they face. EWA requests $3 million.
        On behalf of the members of the Eldercare Workforce Alliance, we
    commend you on your past support for geriatrics workforce programs and
    ask that you join us in supporting the eldercare workforce at this
    critical time--for all older Americans deserve quality care, now and in
    the future. Thank you for your consideration.

        [This statement was submitted by Nancy Lundebjerg, MPA, and Michele
    Saunders, DMD, MS, MPH, Alliance Co-Convener.]
                                     ______

             Prepared Statement of the Emergency Nurses Association
        The Emergency Nurses Association (ENA), with more than 40,000
    members worldwide, is the only professional nursing association
    dedicated to defining the future of emergency nursing and emergency
    care through advocacy, expertise, innovation, and leadership. Founded
    in 1970, ENA develops and disseminates education and practice standards
    and guidelines, and affords consultation to both private and public
    entities regarding emergency nurses and their practice. ENA has a great
    interest in the work of the Senate Labor, Health and Human Services,
    Education Subcommittee and especially its efforts to improve the
    quality of emergency care for patients in the United States.
        For fiscal year 2015, ENA respectfully requests $28 million for
    Trauma and Emergency Care Programs (HHS; ASPR/HRSA), $251 million for
    Nursing Workforce Development programs (HHS; HRSA), $21.116 million for
    the Emergency Medical Services for Children program (HHS; HRSA), $30.1
    million to fund poison control centers (HHS; HRSA), $150 million for
    the National Institute of Nursing Research (HHS; NIH), and $8.927
    million for Rural Health--Access to Emergency Devices (HHS; HRSA).
                       trauma and emergency care programs
        Trauma is the leading cause of death for persons younger than 44
    and the fourth-leading cause of death for all ages. In States with an
    established trauma system, patients are 20 percent more likely to
    survive a traumatic injury. Victims of traumatic injury treated at a
    Level I trauma center are 25 percent more likely to survive than those
    treated at a general hospital.
        Our trauma and emergency medical systems are designed to transport
    seriously injured individuals to trauma centers quickly. However, due
    to a lack of financial resources, 45 million Americans do not have
    access to a major trauma center within the ``golden hour'' following an
    injury when chances of survival are highest.
        Trauma and emergency care programs, which are authorized under the
    Public Health Service Act, provide much-needed money to the States to
    develop and enhance of trauma systems. These programs are critical to
    the efficient delivery of services through trauma centers, as well as
    to the development of regionalized systems of trauma and emergency care
    that ensure timely access for injured patients to appropriate
    facilities. This modest investment can yield substantial returns in
    terms of cost efficiencies and, most importantly, saved lives.
        Therefore, ENA respectfully requests $28 million in fiscal year
    2015 for trauma and emergency care programs.
                     nursing workforce development programs
        The nursing profession faces significant challenges to ensure that
    there will be an adequate number of qualified nurses to meet the
    growing healthcare needs of Americans. It is estimated that 80 million
    Baby Boomers turned 65 last year. This growing elderly population will
    seek healthcare services in a multitude of settings and the care they
    depend upon will require a highly educated and skilled nursing
    workforce. A 2014 projection from the U.S. Bureau of Labor Statistics'
    2013-2014 Employment Outlook Handbook anticipates that the number of
    practicing RNs will grow 19 percent by 2022.
        The aging of the Baby Boom generation will deplete the nursing
    ranks as well. During the next 10 to 15 years, approximately one-third
    of the current nurse workforce will reach retirement age. The
    retirement of these experienced nurses has the potential to create a
    serious deficit in the nursing pipeline. At the same time, our colleges
    cannot keep up with the demand for new nurses. According to the
    American Association of Colleges of Nursing's (AACN) 2013-2014
    Enrollment and Graduations in Baccalaureate and Graduate Programs in
    Nursing survey, 78,089 qualified applications were turned away from
    nursing schools in 2013 alone.
        Title VIII Nursing Workforce Development programs address these
    factors and help support the training of qualified nurses. They not
    only enhance nursing education at all levels, from entry-level to
    graduate study, but they also support nursing schools that educate
    nurses for practice in rural and medically underserved communities.
    Another important part of Title VIII is the Faculty Loan Program which
    is critical to alleviating the large shortage in nursing faculty.
    Overall, more than 80,000 nurses and nursing students were trained and
    educated last year with the help of Title VIII nursing workforce
    development programs.
        Therefore, ENA respectfully requests $251 million in fiscal year
    2015 for the Nursing Workforce Development programs authorized under
    Title VIII of the Public Health Service Act.
                    emergency medical services for children
        The Emergency Medical Services for Children (EMSC) program is the
    only Federal program that focuses specifically on improving the
    pediatric components of the emergency medical services (EMS) system.
    EMSC aims to ensure state-of-the-art emergency medical care for ill and
    injured children or adolescents; that pediatric services are well
    integrated into an EMS system backed by optimal resources; and that the
    entire spectrum of emergency services is provided to children and
    adolescents no matter where they live, attend school, or travel.
        The Federal investment in the EMSC program produces a wide array of
    benefits to children's health through EMSC State Partnership Grants,
    EMSC Targeted Issue Grants, the Pediatric Emergency Care Applied
    Research Network, and the National EMSC Data Analysis Resource Center.
        Therefore, ENA respectfully requests $21.116 million in fiscal year
    2015 for the EMSC program.
                             poison control centers
        Poisoning is the second most common form of unintentional death in
    the United States. In 2009, 31,768 deaths nationwide were attributed to
    unintentional poisoning. Children are especially vulnerable to injury
    by poisoning and each day 300 children are treated for poisoning in
    emergency departments across the country and two die.
        The Nation's 56 poison control centers handle 3.4 million calls
    each year, including approximately 680,000 calls from nurses and
    doctors who rely on poison centers for an immediate assessment and
    expert advice on poisoning cases.
        Not only are America's network of poison centers invaluable for
    treating victims of poisonings, but the work of the centers also
    results in substantial savings to our healthcare system. About 90
    percent of people who call with poison emergencies are treated at home
    and do not have to visit an emergency department. In more severe
    poisoning cases, the expertise provided by poison control centers can
    decrease the length of hospital stays. It has been estimated that every
    dollar spent on America's poison control centers saves $13.39 in
    healthcare costs and lost productivity. The positive impact to the
    Federal budget is also significant. A 2012 study by the Lewin Group
    found that poison control centers resulted in $313.5 million in savings
    to Medicare and $390.2 million in savings to Medicaid.
        Therefore, ENA respectfully requests $30.1 million in fiscal year
    2015 for poison control centers
               the national institute of nursing research (ninr)
        As one of the 27 Institutes and Centers at the NIH, NINR funds
    research that lays the groundwork for evidence-based nursing practice.
    NINR's mission is to promote and improve the health of individuals,
    families, communities, and populations. The Institute supports and
    conducts clinical and basic research on health and illness to build the
    scientific foundation for clinical practice, prevent disease and
    disability, manage and eliminate symptoms caused by illness, and
    improve palliative and end-of-life care.
        NINR nurse-scientists examine ways to improve care models to
    deliver safe, high-quality, and cost-effective health services to the
    Nation. Our country must look toward prevention as a way of reducing
    healthcare expenditures and improving outcomes. The work of NINR is an
    important part of this effort.
        Moreover, NINR helps to provide needed faculty to support the
    education of future generations of nurses. Training programs at NINR
    develop future nurse-researchers, many of whom also serve as faculty in
    our Nation's nursing schools.
        Therefore, ENA respectfully requests $150 million in fiscal year
    2015 for the NINR.
            rural and community access to emergency devices program
        Fewer than 10 percent of people who suffer a cardiac arrest outside
    of a hospital setting survive. According to a 2011 study published in
    the New England Journal of Medicine, immediate CPR and prompt
    defibrillation using an automated external defibrillator (AED) can more
    than double a patient's chance of survival.
        The Health Resources and Services Administration (HRSA)'s Rural and
    Community Access to Emergency Devices Program saves lives of patients
    with cardiac arrest. Between August 1, 2008, and July 31, 2010, nearly
    800 cardiac arrest victims were reportedly saved through this program.
    Funding for this initiative is used to buy AEDs, locate them in public
    places where cardiac arrests are more likely to happen, and instruct
    lay rescuers and first responders in their use. Between March 1, 2010,
    and Feb. 28, 2011, 3,928 AEDs were placed and 28,776 people were
    trained in their use.
        Therefore, ENA respectfully requests $8.927 million in fiscal year
    2015 for the Rural and Community Access to Emergency Devices Program.
                                     ______

                  Prepared Statement of The Endocrine Society
        The Endocrine Society is pleased to submit the following testimony
    regarding fiscal year 2015 Federal appropriations for biomedical
    research, with an emphasis on appropriations for the National
    Institutes of Health (NIH). The Endocrine Society is the world's
    largest and most active professional organization of endocrinologists
    representing more than 17,000 members worldwide. Our organization is
    dedicated to promoting excellence in research, education, and clinical
    practice in the field of endocrinology. The Society's membership
    includes thousands of basic and clinical scientists who receive Federal
    support from the NIH to fund endocrine-related research on topics such
    as diabetes, cancer, fertility, aging, obesity and bone disease. The
    Society's membership also includes clinicians who depend on new
    scientific advances to better treat and cure their patients' diseases.
    As a result of Federal investment in endocrine research, individuals
    with diabetes have made dramatic improvements in managing their
    disease, and the obesity rate for children age 2 to 5 years old has
    dropped 43 percent.\1,2\ The Endocrine Society recommends that the NIH
    receive at least $32 billion in fiscal year 2015. This funding
    recommendation represents the minimum investment necessary to avoid
    further erosion of national research priorities and global preeminence,
    while allowing the NIH's budget to keep pace with biomedical inflation.
    ---------------------------------------------------------------------------
        \1\ Casagrande et al., ``The Prevalence of Meeting A1C, Blood
    Pressure, and LDL Goals Among People With Diabetes, 1988-2010.''
    Diabetes Care, Aug 36;8 (2013) 2271-9.
        \2\ Sabrina Tavernise, ``Obesity Rate for Young Children Plummets
    43 percent in a Decade.'' The New York Times. Feb 25, 2014.
    ---------------------------------------------------------------------------
        Sustained investment by the United States Federal government in
    biomedical research has dramatically advanced the health and improved
    the lives of the American people. The United States' NIH-supported
    scientists represent the vanguard of researchers making fundamental
    biological discoveries and developing applied therapies that advance
    our understanding of, and ability to treat human disease. In the past
    year NIH funded scientists have made fundamental insights into how mild
    traumatic brain injury causes brain damage; identified potential drug
    targets for Parkinson's disease; and identified a safe and protective
    candidate malaria vaccine.\3\ In the field of endocrinology, NIH-funded
    researchers have made remarkable contributions in areas of critical
    national interest, for example:
    ---------------------------------------------------------------------------
        \3\ ``2013 Research Highlights''. December 23, 2013. http://
    www.nih.gov/researchmatters/january2014/researchmatters2013recap.htm
    Accessed March 23, 2013.
    ---------------------------------------------------------------------------
      --Endocrinologists have made insightful discoveries describing newly
            understood contributors to body weight and obesity.\4\ Obesity
            is a growing national concern, with related medical costs in
            the United States as high as $190 billion in 2005 alone.\5\
    ---------------------------------------------------------------------------
        \4\ Mathur et al., ``Methane and hydrogen positivity on breath test
    is associated with greater body mass index and body fat.'' J Clin
    Endocrinol Metab. 98;4 (2013) 698-702.
        \5\ Cawley and Meyerhoefer. ``The medical care costs of obesity: an
    instrumental variables approach.'' J Health Econ. 31;(2012) 219-30.
    ---------------------------------------------------------------------------
      --Endocrinologists have discovered that higher vitamin D levels are
            associated with increased mobility and physical function in
            older individuals. As the population of the United States
            increasingly lives longer, this research has the potential to
            dramatically improve the quality of life for Americans.\6\
    ---------------------------------------------------------------------------
        \6\ Wohl et al., ``Vitamin D status is associated with functional
    limitations and functional decline in older individuals.'' J Clin
    Endocrinol Metab. 98;9 (2013) 1483-90.
    ---------------------------------------------------------------------------
      --Endocrinologists are also at the leading edge of research on
            testosterone therapy and maintaining appropriate levels of sex
            hormones. For instance, endocrinologists are investigating
            links between testosterone levels and heart disease in men.\7\
    ---------------------------------------------------------------------------
        \7\ Ruige et al., ``Beneficial and Adverse Effects of Testosterone
    on the Cardiovascular System in Men.'' J Clin Endocrinol Metab. 98;11
    (2013) 4300-10.
    ---------------------------------------------------------------------------
        These discoveries represent but a fraction of the contributions
    made by endocrinologists and other NIH funded scientists in the past
    year. The foundation for these research products are the NIH research
    grants that support the basic and clinical research done by scientists.
    Since 2004, the number of NIH research grants to scientists in the
    United States has been declining. Consequently, the likelihood of a
    scientist with a highly-regarded grant application successfully being
    awarded a grant has dropped from 31.5 percent in 2000 to an historic
    low of 16.8 percent in 2013.\8\ This means that experienced scientists
    are increasingly spending time writing grant applications instead of
    applying their expertise to productive research. Additionally, younger
    scientists struggle to find a job in the United States that makes use
    of the unique skills generated during graduate training.
    ---------------------------------------------------------------------------
        \8\ Salley Rockey, ``fiscal year 2013 By The Numbers: Research
    Applications, Funding, and Awards,'' Rock Talk, January 10, 2014.
    http://nexus.od.nih.gov/all/2014/01/10/fy2013-by-the-numbers/Accessed
    March 20, 2014.
    ---------------------------------------------------------------------------
        The lack of sustained government support compounded by austerity
    measures such as sequestration has created an environment that is
    leading to a ``brain drain'' as brilliant scientists pursue other
    careers or leave the United States to develop impactful research
    products elsewhere. In 2013, the number of NIH supported scientists
    declined significantly, with nearly 1,000 NIH scientists dropping out
    of the workforce.\9\ NIH scientists run labs that support high-quality
    jobs and education while generating breakthrough innovations. In 2011,
    the NIH directly or indirectly supported over 432,000 jobs across the
    country.\10\ As a result of sequestration, States such as Georgia and
    Connecticut lost $62 million and $32 million respectively.\11\
    ---------------------------------------------------------------------------
        \9\ Jeremy Berg ``The impact of the sequester: 1,000 fewer funded
    investigators.'' ASBMB Today. March (2014). https://www.asbmb.org/
    asbmbtoday/201403/PresidentsMessage/Accessed March 20, 2014.
        \10\ Everett Ehrlich ``Engine Stalled: Sequestration's Impact on
    NIH and the Biomedical Research Enterprise.'' United for Medical
    Research. (2012).
        \11\ ``NIH State Information Factsheets.'' http://www.faseb.org/
    Policy-and-Government-Affairs/Advocacy-on-Capitol-Hill/Advocacy-
    Resources-for-Scientists/NIH-State-Information-Factsheets.aspx.
    Federation of American Societies for Experimental Biology. Accessed
    March 19, 2014.
    ---------------------------------------------------------------------------
        We may never be able to quantify the opportunities we have missed
    to improve the health and economic status of the United States due to
    persistent underinvestment in research. We do know however, that when
    ``laboratories lose financing, they lose people, ideas, innovations and
    patient treatments.'' \12\ Based on the personal stories of researchers
    who have been forced to curtail research programs, we know that
    research programs to understand how genetics can influence heart
    disease, develop therapeutic treatments for Parkinson's disease, and
    evaluate the effect of metal contaminants on reproductive health; among
    many others, are delayed or terminated.\13\
    ---------------------------------------------------------------------------
        \12\ Teresa K. Woodruff ``Budget Woes and Research.'' The New York
    Times. September 10, 2013.
        \13\ Sequester Profiles: How Vast Budget Cuts to NIH are Plaguing
    U.S. Research Labs. United for Medical Research. http://
    www.unitedformedicalresearch.com/advocacy_reports/sequestration-
    profiles/Accessed March 20, 2014.
    ---------------------------------------------------------------------------
        As the world's largest source of funding for medical research, the
    NIH is vitally important to the United States' global preeminence in
    research. However, this global preeminence is being tested due to flat
    funding that has reduced the inflation-adjusted budget of the NIH to a
    level that is nearly 22 percent below the NIH budget in fiscal year
    2003.\14\ As a consequence of this underinvestment, the United States'
    global share of pharmaceutical industry output has declined, our global
    share of biopharmaceutical patents has declined, and our trade balance
    in pharmaceutical products is worsening.\15\ While the Bipartisan
    Budget Act of 2013 and omnibus appropriations bill have provided some
    much needed additional resources, overall levels of funding remain well
    below the $32 billion required for adequate, sustainable growth in
    biomedical research.
    ---------------------------------------------------------------------------
        \14\ ``Budget Cuts in 2013 Reduced Biomedical Research'' Federation
    of American Societies
    for Experimental Biology. http://www.faseb.org/
    pdfviewer.aspx?loadthis=http%3A%2F%2F
    www.faseb.org%2FPortals%2F2%2FPDFs%2Fopa%2F2014%2F1.21.14%2520NIH%2520Fu
    nding
    %2520Cuts%25202-pager.pdf Accessed March 19, 2014.
        \15\ Atkinson et al., ``Leadership in Decline, Assessing U.S.
    International Competitiveness in Biomedical Research.'' The Information
    Technology and Innovation Foundation and United for Medical Research.
    May 2012.
    ---------------------------------------------------------------------------
        We live during an age of tremendous scientific opportunity that can
    only be realized through Federal funding of biomedical research.
    Researchers are only beginning to harness the power of big data to
    solve complicated problems. Innovative new experiments and clinical
    research hold promise to solve some of the United States' greatest
    medical challenges and discover new ways to improve our quality of
    life. Government support is critical to these opportunities, and we
    encourage the Appropriations Committee to actively support promising
    and innovative research.
        As the Appropriations Committee considers funding for the NIH, the
    Endocrine Society also asks the Committee to encourage the NIH to look
    at ways to increase data reporting to address gaps in gender and sex
    differences in research. Sex differences need to be acknowledged as a
    critical biological variable.\16\ In addition to including more women
    in clinical research, the Endocrine Society believes sex differences
    should be c as part of the design of all basic biological studies and
    clinical research. If the NIH required researchers to consider sex
    differences in grant applications when appropriate, and incorporate
    data on sex as a biological variable in animal and human studies, more
    appropriate conclusions could be drawn from basic research, and
    clinical research would provide more representative data on safety and
    efficacy of drugs.\17\
    ---------------------------------------------------------------------------
        \16\ Woodruff et al., ``'Leaning in' to Support Sex Differences in
    Basic Science and Clinical Research.'' Endocrinology. 155;4 (2014)
    1181-3
        \17\ Kim et al., ``Sex Bias in Trials and Treatment Must End.''
    Nature. 465;7299 (2010) 688-9.
    ---------------------------------------------------------------------------
        The Endocrine Society remains deeply concerned about the future of
    biomedical research in the United States without sustained support from
    the Federal government. Flat funding in recent years, combined with the
    impact of sequestration, threaten the Nation's scientific enterprise
    and make adequate fiscal year 2015 appropriations for the NIH
    increasingly important. The Society strongly supports increased Federal
    funding for biomedical research in order to provide the additional
    resources needed to enable American scientists to address scientific
    opportunities and maintain the country's status as the preeminent
    research engine. The Endocrine Society therefore asks that the NIH
    receive at least $32 billion in fiscal year 2015.

        [This statement was submitted by Teresa K. Woodruff, PhD,
    President, The Endocrine Society.]
                                     ______

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

        [This statement was submitted by Frank G. Zalom, PhD, President,
    Entomological Society of America.]
                                     ______

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

        [This statement was submitted by Carole L. Sherman, Arkansas'
    statewide parent-guardian association.]
                                     ______

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

                       Prepared Statement of Cheryl Felak
        Dear Committee Members: Thank you very much for the opportunity to
    submit personal and professional testimony to this committee.
        I am writing as a healthcare professional with an abundance of
    experience working with clients and family members who experience life
    with developmental disabilities. I am also the parent of a young man
    who has profound developmental disabilities due to a rare genetic
    condition which is similar to pediatric Alzheimer's.
        I would like you to be aware that many of the advocacy agencies in
    this country (The Arc and it's many State and local chapters),
    Developmental Disability Councils and affiliates, all who receive
    Federal funds for advocacy, are forgetting that our citizens with
    developmental disabilities live on a continuum and have a large
    variation in support needs.
        It is shameful that these so-called advocacy groups forget about
    those with the most profound needs, misinterpret the 1999 U.S. Supreme
    Court Olmstead decision on choice and community, and force their
    opinions regarding these issues discriminatory practices.
        It is a fact that people need communities--yet why are these so
    called advocacy groups allowed to determine what ``community'' is for
    those with developmental disabilities. Rather than allowing choice and
    opportunities, they are restricting choice and opportunities to this
    group of people. This is discrimination.
        I am not aware of any other population which has ``community''
    defined for them, which has funds for housing, medical care, education,
    vocational support tied to the artificial definition of ``community''
    which is made up for people with developmental disabilities.
        I believe it is time to go back and really read the Olmstead
    Decision--not just take for granted what is heard because what is heard
    is not what the decision States. We need to honor this decision and
    stop discriminating against our most vulnerable citizens.
        Thank you very much.

        [This statement was submitted by Cheryl Felak, RN, BSN, Because We
    Care--Beyond Inclusion.]
                                     ______

    Prepared Statement of the Friends of the Health Resources and Services
                                 Administration
        The Friends of HRSA is a non-partisan coalition of more than 170
    national organizations representing millions of public health and
    healthcare professionals, academicians and consumers invested in HRSA's
    mission to improve health and achieve health equity. For fiscal year
    2015, we recommend restoring HRSA's discretionary budget authority to
    the fiscal year 2010 level of $7.48 billion. We are deeply concerned
    that since fiscal year 2010, HRSA's discretionary budget authority has
    been cut by 19 percent in nominal dollars and 25 percent when adjusted
    for inflation. Funding for HRSA is far too low and keeping austerity
    measures in place will threaten the agency's ability to address the
    present and growing health needs of the U.S. Of additional concern,
    cuts will be compounded by the fact that multiple mandatory programs
    are set to expire at the end of fiscal year 2015. In the absence of
    continued mandatory funding for the National Health Service Corps Fund
    and Community Health Center Fund, the committee will be faced with
    addressing these shortfalls in the following Labor-HHS-Education
    appropriations bill.
        The Nation faces a shortage of health professionals and continues
    to experience an ever growing, aging and increasingly diverse
    population, alongside health professionals that are nearing retirement
    age. Additionally, national estimates of workforce shortages are often
    masked by significant distributional disparities--particularly in rural
    and certain inner-city populations that experience greater shortages.
    By restoring funding to HRSA, the agency will be able to more
    effectively fill the primary and preventive care gaps for people living
    outside of the medical and economic mainstream through supporting a
    well prepared workforce and high-quality health services.
        HRSA operates programs in every State and U.S. territory and is a
    national leader in improving the health of Americans. HRSA programs
    have reduced AIDS-related deaths through providing drug treatment
    regimens for people living with HIV and have the potential to prevent
    the spread of HIV by 96 percent by ensuring that people living with HIV
    have access to regular care and adhere to their antiretroviral
    medications. Less than 10 percent of people who experience a cardiac
    arrest outside of a hospital setting survive. HRSA provides rural
    communities with training and access to emergency devices which can
    more than double a patient's chance of survival. HRSA has contributed
    to the decrease in infant mortality rate, a widely used indicator of
    the Nation's health, which is now at an all-time low. Most recently,
    preliminary data indicates that the infant mortality rate for black
    infants has decreased, resulting in a narrowing of the gap that exists
    between racial groups.
        Now is the time to make a strong investment in a robust workforce
    and to improve access to care to continue achieving the health
    improvements HRSA has made and to pave the way for new achievements.
    The Nation only stands to benefit from a healthier population through a
    thriving workforce and reduced healthcare costs. Our recommendation is
    based on the need to continue improving the health of Americans by
    supporting critical HRSA programs including:
      --Health professions programs support the education and training of
            primary care physicians, nurses, oral health professionals,
            optometrists, physician assistants, nurse practitioners,
            clinical nurse specialists, public health personnel, mental and
            behavioral health professionals, pharmacists and other allied
            health providers. With a focus on primary care and training in
            interdisciplinary, community-based settings, these are the only
            Federal programs focused on filling the gaps in the supply of
            health professionals, as well as improving the distribution and
            diversity of the workforce so health professionals are well-
            equipped to care for the Nation's growing, aging and
            increasingly diverse population. Additionally, HRSA provides
            interdisciplinary training to health professionals to
            accurately screen, diagnose and treat children with autism and
            other developmental disabilities.
      --Primary care programs support nearly 9,200 service delivery sites
            in every State and territory, improving access to preventive
            and primary care to more than 21 million patients in
            geographically isolated and economically distressed
            communities. Close to half of the health centers serve rural
            populations. The health centers coordinate a full spectrum of
            health services including medical, dental, behavioral and
            social services--often delivering the range of services in one
            location. In addition, health centers target populations with
            special needs, including agricultural workers, homeless
            individuals and families and those living in public housing.
            Following health insurance reform in Massachusetts, health
            centers experienced a substantial increase in newly-insured
            patients. We expect the same will be true nationally, as health
            insurance expands to millions of Americans who were previously
            uninsured. Health centers and other programs administered by
            HRSA will remain vital sources of care for patients and
            continue to reduce costs to the health system.
      --Maternal and child health programs, including the Title V Maternal
            and Child Health Block Grant, Healthy Start and others, support
            initiatives designed to promote optimal health, reduce
            disparities, combat infant mortality, prevent chronic
            conditions and improve access to quality healthcare for 43
            million women and children. MCH programs help assure that
            nearly all babies born in the U.S. are screened for a range of
            serious genetic or metabolic diseases and that a community-
            based system of family centered services is available for
            coordinated long-term follow up for babies with a positive
            screen and for all children with special healthcare needs.
      --HIV/AIDS programs provide the largest source of Federal
            discretionary funding assistance to States and communities most
            severely affected by HIV/AIDS. The Ryan White HIV/AIDS Program
            delivers comprehensive care, prescription drug assistance and
            support services for more than half a million low-income people
            impacted by HIV/AIDS, which accounts for about half of the
            total population living with the disease in the U.S.
            Additionally, the programs provide education and training for
            health professionals treating people with HIV/AIDS and work
            toward addressing the disproportionate impact of HIV/AIDS on
            racial and ethnic minorities.
      --Family planning Title X services ensure access to a broad range of
            reproductive, sexual and related preventive healthcare for over
            5 million poor and low-income women, men and adolescents at
            nearly 4,400 health centers nationwide. Healthcare services
            include patient education and counseling, cervical and breast
            cancer screening, sexually transmitted disease prevention
            education, testing and referral, as well as pregnancy diagnosis
            and counseling. This program helps improve maternal and child
            health outcomes and promotes healthy families. Often, Title X
            service sites provide the only continuing source of healthcare
            and education for many individuals.
      --Rural health programs improve access to care for the nearly 50
            million people living in rural areas that experience a
            persistent shortage of healthcare services. The Office of Rural
            Health Policy serves as the Nation's primary voice for programs
            and research on rural health issues. Rural Health Outreach and
            Network Development Grants, Rural Health Research Centers,
            Rural and Community Access to Emergency Devices Program and
            other programs are designed to support community-based disease
            prevention and health promotion projects, help rural hospitals
            and clinics implement new technologies and strategies and build
            health system capacity in rural and frontier areas.
      --Special programs include the Organ Procurement and Transplantation
            Network, the National Marrow Donor Program, the C.W. Bill Young
            Cell Transplantation Program and National Cord Blood Inventory.
            These programs maintain and facilitate organ marrow and cord
            blood donation, transplantation and research, along with
            efforts to promote awareness and increase organ donation rates.
            Special programs also include the Poison Control Program, the
            Nation's primary defense against injury and death from
            poisoning. For every dollar spent on the poison center system,
            $13.39 is saved in medical costs and lost productivity,
            totaling more than $1.8 billion every year in savings.
        While the Bipartisan Budget Act of 2013 and Consolidated
    Appropriations Act of 2014 provided modest and temporary relief from
    sequestration, austerity measures remain firmly in place, which pose
    serious threats for the viability of HRSA's important programs and
    compromise the agency's ability to address our Nation's health needs.
    We urge you to consider HRSA's central role in strengthening the
    Nation's health and advise you to adopt our fiscal year 2015 request of
    $7.48 billion for HRSA's discretionary budget authority. Thank you for
    the opportunity to submit our recommendation to the subcommittee.
                                     ______

    Prepared Statement of Friends of the National Institute of Child Health
                             and Human Development
        My name is Kate Ryan. I currently serve as Co-Chair of the Friends
    of the National Institute of Child Health and Human Development
    (NICHD). On behalf of the Friends, I urge the Labor, Health and Human
    Services, Education Appropriations Subcommittee to support at least $32
    billion for the NIH, including $1.37 billion for NICHD for fiscal year
    2015. Our coalition includes over 100 organizations representing
    scientists, physicians, healthcare providers, patients and parents
    concerned with the health and welfare of women, children, families, and
    people with disabilities. We are pleased to support the extraordinary
    work of the Eunice Kennedy Shriver National Institute of Child Health
    and Human Development (NICHD).
        Since its establishment in 1963, NICHD has achieved great success
    in meeting the objectives of its broad biomedical and behavioral
    research mission, which includes research on child development before
    and after birth; maternal, child, and family health; learning and
    language development; women's health and reproductive biology;
    population issues; and medical rehabilitation. With sufficient
    resources, NICHD could build upon the promising initiatives described
    in this testimony and produce new insights into human development and
    solutions to health and developmental problems throughout the world,
    including for women, children and families in your districts.
    Scientific breakthroughs supported by NICHD serve to prevent and treat
    many of the Nation's most devastating health problems including infant
    mortality and low birthweight, birth defects, intellectual and
    developmental disabilities, and the reproductive and gynecologic health
    of women throughout their lifespan, among others. Some of these
    research areas are described below.
        Preterm Birth.--NICHD supports a comprehensive research program to
    study the causes of preterm birth and prevention strategies and
    treatment regimens. Pre-term birth costs our Nation $26 billion
    annually and is a leading cause of infant mortality and intellectual
    and physical disabilities. Continued prioritization of extramural
    preterm birth prevention research, the Maternal-Fetal Medicine Units
    Network, the Neonatal Research Network and intramural research program
    related to prematurity are necessary to further this work. Resources
    also should be available to support transdisiplinary science as
    recommended in NICHD's Scientific Vision to study and identify the
    complex causes of preterm birth.
        NICHD supports research on the causes of preterm birth with the
    goal of discovering effective ways to prevent it. In the U.S., the rate
    of preterm birth is approximately 12 percent, one of the highest rates
    in all industrialized countries, resulting in neonatal death, infant
    mortality and severe neurological disability, including cerebral palsy,
    mental retardation, and visual/auditory problems. Preterm birth also
    significantly impacts families emotionally and financially. Although
    research has identified some factors that influence preterm birth
    (e.g., multiple gestation, infections, diabetes, high blood pressure),
    it cannot be fully explained by physical health. There is growing
    evidence of the role of psychological factors such as pregnancy-related
    anxiety and stress, behavioral issues such as substance abuse, and
    sociological issues such as cultural disparities. Thus, support is
    needed for research on the complex interaction of factors including
    psychological, behavioral, social, and environmental factors in
    addition to genetic and biological influences, with the ultimate goal
    of developing efficacious interventions to decrease this country's
    epidemic of babies being born far too soon.
        National Children's Study (NCS).--The NCS is the largest and most
    comprehensive study of children's health and development ever planned
    in the United States. The Friends of NICHD thank the Committee for its'
    longstanding support of the NCS. The Friends look forward to roll-out
    of the main study that includes a science-based design and recruitment
    strategy. When fully implemented, this study will inform the work of
    scientists in universities and research organizations, helping them
    identify precursors to disease and to develop new strategies for
    prevention and treatment. Identifying the root causes of many childhood
    diseases and conditions, including preterm birth, developmental delay,
    asthma, obesity, heart disease, injury and diabetes, will reduce
    healthcare costs and improve the health of children. NCS also provides
    an opportunity to collect data on social and behavioral aspects of
    child and adolescent health, such as important information on the
    sexual and reproductive health of adolescents
        Contraceptive Research and Development.--NICHD's Contraceptive
    Discovery and Development Branch supports basic, applied and clinical
    research on contraceptive methods, including mechanisms of action, the
    effects of contraceptive hormones and drugs, and optimal formulations
    of contraceptive agents. Through its investment in contraceptive
    evaluation research, NICHD plays a key leadership role in ensuring
    acceptability and effective use of existing products in various
    settings and populations and in addressing behavioral issues related to
    fertility and contraceptive use. Specific opportunities and research
    priorities in the area of contraceptive evaluation include evaluation
    of the safety and effectiveness of hormonal contraceptive options for
    women who are overweight or obese. The Institute's investment in
    contraceptive research and development is critical for producing new
    contraceptive modalities that are more effective, affordable,
    acceptable, and easier to deliver, by, for example, offering couples
    options with fewer side-effects and addressing women's other concerns
    about contraceptive use. Specific opportunities and research priorities
    in the area of contraceptive research and development include the need
    for non-hormonal contraception, pericoital contraception, and
    multipurpose prevention technologies that would prevent both pregnancy
    and sexually transmitted infections.
        Reproductive Sciences.--Through its investment in reproductive
    science, NICHD conducts research to improve women's health by
    developing innovative medical therapies and technologies and improving
    existing treatment options for gynecological conditions affecting
    overall health and fertility. The Institute's reproductive science
    research makes a vital contribution to women's health by focusing on
    serious conditions that have been overlooked and underfunded, despite
    the fact that they impact many women. Future work could focus on
    infertility research into the need for treatments for disorders such as
    endometriosis, polycystic ovarian syndrome (PCOS) and uterine fibroids
    which can prevent couples from achieving desired pregnancies.
        Pelvic Floor Disorders Network (PFDN).--Female pelvic floor
    disorders (PFD) represent an under-appreciated but major public health
    burden with high prevalence, impaired quality of life and substantial
    economic costs affecting approximately 25 percent of American women.
    The PFDN is conducting research to improve treatment of these extremely
    painful gynecological conditions. Current research is aimed at
    improving female urinary incontinence outcome measures and ensuring
    high quality patient-centered outcomes.
        Development of the Research Workforce.--Adequate levels of research
    require a robust research workforce. The years of training combined
    with uncertainty in getting grant funding are huge disincentives for
    students considering a career in bio-medical research. This has
    resulted in a huge gap between the too-few women's reproductive health
    researchers being trained and the immense need for research. NICHD's
    Women's Reproductive Health Research (WRHR) Program and Reproductive
    Scientist Development Program (RSDP), both aimed at obstetrician-
    gynecologists to further their education and experience in basic,
    translational, and clinical research, provide training grants to
    hundreds of researchers and provide new insight into a host of
    diseases, such as ovarian cancer. Continued investment in these
    training programs is critical to helping ensure future scientific
    advances in women's health research.
        Population Research.--The NICHD Population Dynamics branch supports
    a diverse portfolio of scientific research and research training
    programs, exploring the social, economic and health-related impacts of
    population change on families, children, and communities. The branch is
    well respected for investing wisely in the development of longitudinal,
    representative surveys, providing scientists with reliable data that
    can be used to examine the influence of early life course events on
    long-term health and achievement outcomes in particular. As an example,
    in 2012, NICHD-supported demographers using data from the Panel Study
    of Income Dynamics survey found that growing up in poor neighborhoods
    throughout the entire childhood life course can have a devastating
    effect on educational attainment. In another study, using data from the
    National Study of Adolescent Health, researchers found that women who
    are overweight or obese years during the transition from adolescence to
    adulthood are more likely to later deliver babies with a higher birth
    weight, putting the next generation at a higher risk of obesity-related
    health outcomes.
        Sex Differences in Research.--The Friends encourages NICHD to look
    at ways to increase data reporting to address gaps in gender and sex
    differences in research. Sex differences need to be acknowledged as a
    critical biological variable. In addition to including more women in
    clinical research, we believe sex differences should be included as
    part of the design of all basic biological studies and clinical
    research. If the researchers were to consider sex differences in the
    design of basic science studies, and incorporate data on sex as a
    biological variable in animal and human studies, more appropriate
    conclusions could be drawn from basic research, and clinical research
    would provide more representative data on safety and efficacy of drug.
        Clinical Trials in Pregnant Women.--Pregnant women have
    historically been excluded from most research trials due to concern
    that trial participation could harm the fetus. Although there has been
    substantial progress in the inclusion of women in federally funded
    research, pregnant women are still excluded, even from research that
    would advance our knowledge of medical conditions and treatments in
    pregnancy. Mindful of the important considerations of clinical trials
    on pregnant women, we support establishment of a Federal work group to
    propose how clinical research might be done appropriately in this area.
        Data on Pediatric Enrollment in NIH Trials.--NIH policy mandates
    the inclusion of women, minorities, and children in clinical trials
    whenever appropriate. While NIH collects enrollment data on sex/gender
    and race, it does not collect enrollment data broken down by age. We
    urge NIH, with leadership from NICHD, to improve data collection and
    reporting on pediatric enrollment sufficient to determine if children
    are appropriately represented in trials with relevance to child health.
        Best Pharmaceuticals for Children Act (BPCA).--NICHD funds
    meaningful research into pediatric pharmacology through the BPCA
    program. This program provides for the study of drug products that are
    important to children but have been inadequately studied in pediatric
    populations. We urge continued funding and support for this important
    research, as well as for training the next generation of pediatric
    clinical investigators.
        Brain Development.--Research on learning disabilities--neurological
    disorders that can make it difficult to acquire certain academic and
    social skills--shows that they can be prevented through effective
    evidence-based programs in school and that when children improve their
    reading and math skills, brain function normalizes.
        Rehabilitation Science.--The National Center for Medical
    Rehabilitation Research (NCMRR) currently resides within NICHD, yet
    there is a strong need for elevating the stature of NCMRR. We recommend
    moving the NCMRR to an independent Institute or Center reporting
    directly to the NIH Director, or to establish a new Office of
    Rehabilitation Research within the Office of the NIH Director.
    Implementation of this structural recommendation would require a
    statutory change. Elevation of NCMRR has been viewed from the start as
    a critical step in achieving sufficient critical mass to coordinate
    rehabilitation science across all the Independent Centers at NIH that
    conduct and support research directly addressing or related to
    rehabilitation science.
        These research efforts have made significant contributions to the
    well-being of all Americans, but there is still much to discover. We
    support the NICHD's recently released Scientific Vision and urge you to
    support NICHD at funding levels that meet current needs for addressing
    health issues across the lifespan. Thank you for your consideration and
    we look forward to working with you on these critical issues.
                                     ______

     Prepared Statement of the Friends of the National Institute of Dental
                           and Craniofacial Research
        Mr. Chairman, Ranking Member, and distinguished Members of the
    Subcommittee, the members of the Friends of the National Institute of
    Dental and Craniofacial Research (FNIDCR), a leading broad-based
    consortium of individuals, academic institutions, patient advocate
    groups, dental societies, and corporations, that understands the
    importance of dental, oral and craniofacial health to our society, are
    requesting fiscal year 2015 funding under section 301 and Title IV of
    the Public Health Service Act for the National Institute of Dental and
    Craniofacial Research (NIDCR) to be appropriated at a recommended level
    of 1.33 percent of the National Institutes of Health's (NIH's) total
    fiscal year 2015 funding level.
        The fiscal year 2014 level enacted by the omnibus bill is $398.65
    million for NIDCR. After transfers, NIDCR's total amount for obligation
    in fiscal year 2014 is $397.10 million. President Barack Obama's fiscal
    year 2015 budget proposal for NIDCR, $397.13, is at best stagnate if
    compared to total obligations, and at worse, a decrease of $1,519,000
    if compared to the level Congress appropriated in the fiscal year 2014
    omnibus bill. The end result is ongoing diminished grant opportunities
    that will only discourage young and talented researchers. Also,
    stagnated funding means NIDCR will not be able to keep up with the
    increasing rate of medical inflation.
    Background
        From 1998 to 2011, NIDCR's percentage of total NIH funding
    decreased from 1.53 percent to 1.33 percent, its lowest percentage,
    amid a period when NIH's budget doubled. Save for a slight bump in
    2012, this percentage remains at 1.33 percent. The Friends of NIDCR has
    been working to reverse this troublesome trend--and return NIDCR
    research to a percentage of total NIH funding that is more appropriate
    and proper. For fiscal year 2014, NIDCR's percentage of total NIH
    funding is 1.33 percent.
      --If Congress enacts the president's fiscal year 2015 budget figures
            for NIH and NIDCR, then NIDCR's percentage of total NIH funding
            would be at an all-time low, 1.31 percent.
        The Friends of NIDCR would welcome the opportunity to work with
    members of this Subcommittee to ensure NIDCR funding realizes a
    percentage of total NIH funding that is appropriate, yet realistic. The
    research performed by NIDCR justifies this approach. This is why the
    Friends of NIDCR recommends a modest increase in NIDCR's percentage of
    total NIH funding for fiscal year 2015 of 1.33 percent based upon the
    president's fiscal year 2015 budget request. This is also a consistent
    recommendation based upon the level enacted by Congress for fiscal year
    2014.
    NIDCR: A Renown Leader in Research
        For 66 years, NIDCR has been the leading sponsor of research and
    research training in biomedical and behavioral sciences. Its mission is
    to ``improve oral, dental and craniofacial health through research,
    research training, and the dissemination of health information.''
        NIDCR meets its mission by:
      --Performing and supporting basic and clinical research;
      --Conducting and funding research training and career development
            programs to ensure an adequate number of talented, well-
            prepared and diverse investigators is sustained;
      --Coordinating and assisting relevant research and research-related
            activities among all sectors of the research community; and
      --Promoting the timely transfer of knowledge gained from research and
            its implications for health to the public, health
            professionals, researchers, and policy-makers.
        In addition, NIDCR's Gold Standard Peer Review System ensures that
    taxpayers' dollars are being utilized in a wise, effective and
    productive manner.
    NIDCR Research Benefits All Americans
        Proper Federal funding of NIDCR will transform the future of
    medical and dental practice to the benefit of our society and ease the
    burden on our Nation's healthcare system. Examples of where NIDCR
    research has and will benefit society are:
        Tooth Decay: Fluorides and sealants have cut the rate of the number
    of American adults, aged 45 and older, who are without teeth by more
    than half since the 1950s. Government investment in oral health
    research saved Americans $3 for every $1 invested.
        Oral Cancer Detection: Oral cancer affects 38,000 Americans each
    year and approximately 22 Americans die each day from it. Survival
    rates are among the lowest of all the major cancers. It is difficult to
    detect and hard to predict its outcome. However, if detected in early
    stages, the 5-year survival rate is 83 percent. NIDCR-supported
    research has yielded initial success with developing new diagnostic
    techniques that can lead to early detection and life-saving
    interventions. For example, oral cancer is the first cancer to have its
    biomarkers mapped using Salivary Diagnostics and the presence of these
    biomarkers resulted in an early diagnosis of oral cancer 93 percent of
    the time. Furthermore, as a testament to scientific discoveries, oral
    researchers have confirmed that oral cancer (traditionally thought of
    as being driven by extensive use of tobacco and alcohol) possesses a
    strong and growing link to Human Papilloma Virus (HPV). HPV is now the
    cause of more oral cancers than smoking. NIDCR supports research aimed
    to gain a clearer take on HPV-related oral cancers, including their
    incidence, risk factors, natural history and biology.
        Craniofacial Biology. Scientists are defining the genetics that
    underlie the formation of the head and skull, and researchers are
    identifying the key areas for craniofacial malformations. For example,
    NIDCR-supported research has detected proteins associated with
    craniosynostosis, which is the premature fusion of a baby's skull bones
    that causes asymmetric skull growth. NIDCR believes this research could
    provide the foundation for the development of early detection methods
    and more effective treatments.
        Genome-wide Association Studies. NIDCR supports the first genome-
    wide association studies (``GWAS'') of cleft lip and/or palate and
    dental caries. The studies offer significant potential for
    understanding the molecular and genetic basis of cleft lip and/or
    palate and dental caries with the goal of improving the ability to
    predict and manage them by providing the first comprehensive
    compilation of the biological instructions required to construct the
    middle region of the human face and to define the genetics that create
    its developmental disorders, according to NIDCR. The dental caries GWAS
    revealed areas of the genome that make an individual more likely to
    develop decay. Moreover, NIDCR researchers have identified six areas of
    the genome that may put a person at risk for moderate or severe
    periodontal disease and patients afflicted with Sjogren's Syndrome and
    TMJD can benefit from this program.
        Moreover, NIDCR research benefits millions of Americans with:
      --Periodontal Disease,
      --Chronic Dry Mouth,
      --Chronic Facial and Oral Pain, such as TMJD, and
      --Bone and Cartilage Regeneration.
    How NIDCR Research Makes a Difference
        Because Friends of NIDCR is a broad-based coalition of members, we
    are able to share first-hand perspectives from across the spectrum of
    the oral health community.
        The TMJ Association:
        During the past decade, NIDCR-funded research directed toward
    Temporomandibular Disorders has been a ``game changer.'' Previously
    thought to be a condition about teeth and jaws, research has
    demonstrated that this is a complex condition mediated by genes, sex,
    age, and epigenetics. We now also know that for many, TMD is a chronic
    pain condition and that in addition these patients also present with
    other comorbid pain conditions that co-occur more than by chance. These
    findings have truly revolutionized the way that these conditions are
    researched and will ultimately be treated. It is important to note that
    the National Institutes of Health are the only sources of funding of TM
    Disorders in the United States. We rely on their resources to improve
    the healthcare and quality of life for the 35 million TMJ patients in
    this country. Our hope is in science and the NIH, through its
    Institutes such as NIDCR, provides us with that hope.
        Ostrow School of Dentistry of the University of Southern
    California:
        NIDCR funding is essential to the success of several areas of
    research at USC that directly impact millions of people in the U.S. and
    worldwide. First, thanks to the NIDCR, we have made progress in
    understanding cleft lip and palate, craniosynostosis, and other birth
    defects of the craniofacial region. According to the CDC, the lifetime
    cost of treating the children born each year in the U.S. with cleft lip
    or palate is $697 million. Every day, our researchers come closer to
    better treatments and preventive measures to help reduce this cost and
    improve quality of life. Moreover, we are working to leverage the
    dramatic potential of stem cells to regenerate bone and other tissues
    that may be lost due to birth defects, trauma, or disease. The NIDCR
    also funds our efforts to prevent dental caries, which is a major
    global health concern affecting 92 percent of American adults. Finally,
    the NIDCR supports our community outreach program in California's
    diverse population, through which we are investigating how to improve
    oral health for everyone in America.
    Research Drives the Economy, Innovates
        Despite the fact 54 percent of Americans thought Federal spending
    for medical and health research should be exempt from across-the-board
    cuts outlined in the Budget Control Act of 2011 \1\, the ramifications
    of sequestration still linger. However, Friends of NIDCR maintains that
    investment in medical research powers our innovation economy and
    provides life-saving treatments and cures. For example, a typical NIH
    grant supports the salaries of about seven high-tech jobs. Moreover,
    cuts or stagnate funding will only set the U.S. back at a time when
    other countries are rapidly increasing investment in research. Eighty-
    five percent of likely voters are concerned about the impact of a
    decreased Federal investment in research, including the possibility of
    scientists leaving their profession or moving abroad to countries with
    a stronger investment in research.\2\ NIDCR-funded grants contribute to
    our Nation's economy and keep scientists from looking abroad for work.
    fiscal year 2013 NIDCR-funded grants had a presence in 120
    congressional districts (often multiple awards for a congressional
    district) in 43 States and territories. This equates to 75 percent of
    NIDCR-funded research being distributed to grantees at universities,
    dental schools, and medical schools, primarily in the U.S. Therefore, a
    significant portion of NIDCR-funded research occurs away from the NIH
    campus. However, this nationwide NIDCR presence will surely decline
    with decreased investment in research.
    ---------------------------------------------------------------------------
        \1\ ``More than Half of Americans Doubt U.S. Global Leadership in
    2020,'' Research!America press release, March 14, 2012, http://
    www.researchamerica.org/release --14march12--poll.
        \2\ 2 Ibid.
    ---------------------------------------------------------------------------
    Health Disparities Research Program
        Finally, through the NIDCR Health Disparities Research Program, a
    difference is being made in meeting the health needs of our Nation's
    low-income, underserved, and high-risk populations. Sadly, this need
    was made apparent with the tragic passing of 12-year-old Deamonte
    Driver who died from a tooth infection in 2007. As a result of the
    program, tailored interventions to prevent dental caries and oral
    cancer are being tested in community settings such as urban public
    housing, community health centers, rural Project Head Start centers,
    low-income senior housing facilities, and primary medical care offices.
                                 recommendation
        Eighty-five percent of Americans are concerned about stagnate
    funding for medical research.\3\ Proper funding of medical and health
    research is essential to the overall health and well-being of our
    fellow Americans. We firmly contend that medical discoveries and
    advances from NIDCR funding lead to improvements in dental practices
    and change the scope of public health policies across the Nation.
    Whether it is detecting a clear link between bacteria in the mouth and
    heart disease--or discovering early stages of oral cancer--or searching
    for breakthroughs to help combat facial and oral pain--we all benefit
    when we make NIDCR a priority. Therefore, based upon the merits of the
    research conducted by NIDCR, and its demonstrated benefits to the lives
    of countless Americans, we respectfully request the Subcommittee to
    fund NIDCR at 1.33 percent of NIH's funding level, so that it can
    realize the full potential of its worthy mission and sustain its
    beneficial scientific research.
    ---------------------------------------------------------------------------
        \3\ ``America Speaks,'' Poll Data Summary Volume 13,
    Research!America, http://www.researchamerica.org/uploads/
    AmericaSpeaksV13.pdf.
    ---------------------------------------------------------------------------
        Thank you for the opportunity to present our written testimony
    before the Subcommittee.

        [This statement was submitted by Christian Stohler, D.D.S.,
    DrMedDent, President, Friends of the National Institute of Dental and
    Craniofacial Research.]
                                     ______

      Prepared Statement of the Friends of the National Institute on Drug
                                     Abuse
        Mr. Chairman and Members of the Subcommittee, thank you for the
    opportunity to submit testimony to the Subcommittee in support of the
    National Institute on Drug Abuse (NIDA). The Friends of the National
    Institute on Drug Abuse is a coalition of over 150 scientific and
    professional societies, patient groups, and other organizations
    committed to preventing and treating substance use disorders as well as
    understanding their causes through the research agenda of the National
    Institute on Drug Abuse (NIDA).
        We are pleased to provide testimony in support of the work carried
    out by scholars around the country whose work is supported by NIDA.
    Recognizing that so many health research issues are inter-related, we
    request that the subcommittee provide at least $32 billion for the
    National Institutes of Health (NIH) and within that amount a
    proportionate increase for the National Institute on Drug Abuse, in
    your Fiscal 2015 Labor, Health and Human Services, Education and
    Related Agencies Appropriations bill. We also respectfully request the
    inclusion of the following NIDA specific report language.
        Marijuana Research. Efforts to legalize or ``medicalize'' marijuana
    continue across the United States. The Committee understands that
    research from different areas of science is converging on the fact that
    regular marijuana use by young people can have a long-lasting negative
    impact on the structure and function of their brains, resulting in
    lower educational achievement, reduced IQ, etc. Research clearly
    demonstrates that marijuana has the potential to cause problems in
    daily life or make a person's existing problems worse. NIDA is
    encouraged to continue to fund research on preventing and treating
    marijuana abuse and addiction, and the possible health and policy
    implications of proposals to implement ``medical marijuana'' or
    marijuana legalization programs across the U.S.
        Opiate Abuse and Addiction. The Committee is concerned about the
    continued crisis of prescription drug abuse in the U.S. In particular,
    the June 2011 IOM report on pain indicates that abuse and misuse of
    prescription opioid drugs resulted in an annual estimated cost to the
    nation of $72,500,000,000. Further, the Committee is very concerned
    with the potential rise in heroin abuse and addiction as a result of
    successful efforts to combat the prescription drug side of this issue.
    The Committee urges NIDA to 1) continue funding research on medications
    to alleviate pain, including the development of pain medications with
    reduced abuse liability; 2) as appropriate, work with private companies
    to fund innovative research into such medications; and 3) report on
    what we know regarding the transition from opiate analgesics to heroin
    abuse and addiction within affected populations.
        Medications Development. The Committee recognizes that next-
    generation pharmaceuticals will surely take advantage of new
    technologies. In the context of NIDA funding, chief among these are
    NIDA's current approaches to develop viable immunotherapeutic or
    biologic (e.g., bioengineered enzymes) approaches for treating
    addiction. The goal of this active area of research is the development
    of safe and effective vaccines or antibodies that target specific
    drugs, like nicotine, cocaine, and heroin, or drug combinations. The
    Committee is excited by this approach--if successful, immunotherapies,
    alone or in combination with other medications, behavioral treatments,
    or enzymatic approaches, stand to revolutionize how we treat, and,
    maybe even someday, prevent addiction. The Committee looks forward to
    hearing more about work in this area.
        Nurturing Talent and Innovation in Research. The Committee commends
    NIDA for its continued support of innovative research on drug addiction
    and related health problems such as pain and HIV/AIDS, and the
    Institute's effort to be at the forefront of training the next
    generation of innovative researchers. The 6 year-old Avant-Garde award
    is a good example of a program that stimulates high-impact research
    that could lead to groundbreaking opportunities for the prevention and
    treatment of HIV/AIDS in drug abusers. The Committee understands that
    NIDA is now crafting a new kind of award, which would blend NIH's
    Pioneer and New Innovator award mechanisms. This new opportunity,
    called ``AVENIR'' awards, is designed to attract creative young
    investigators into HIV/drug abuse public health research. The Committee
    strongly supports this effort, and asks the Institute to report on its
    progress in future appropriations and related requests.
        Research to Assist Military Personnel, Veterans, and Their
    Families. The Committee recognizes the significant health challenges,
    including substance abuse and addiction, faced by military personnel,
    veterans, and their families. Many of these individuals need help
    confronting war-related problems including traumatic brain injury,
    PTSD, depression, anxiety, sleep disturbances, and substance abuse and
    addiction. The Committee commends NIDA for its successful efforts to
    coordinate and support research with the Department of Veterans
    Affairs, Department of Defense, and other NIH Institutes focusing on
    these populations, and strongly urges NIDA to continue work in this
    area.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment. The Committee is very pleased
    with NIDAMed, an initiative designed to reach out to physicians,
    physicians in training, and other healthcare professionals. The
    Committee urges the Institute to continue its focus on activities to
    provide physicians and other medical professionals with the tools and
    skills needed to incorporate drug abuse screening and treatment into
    their clinical practices.
        Drug abuse is costly to Americans; it ruins lives, while tearing at
    the fabric of our society and taking a huge financial toll on our
    resources. Beyond the unacceptably high rates of morbidity and
    mortality, drug abuse is often implicated in family disintegration,
    loss of employment, failure in school, domestic violence, child abuse,
    and other crimes. Placing dollar figures on the problem; smoking,
    alcohol and illegal drug use results in an exorbitant economic cost on
    our nation, estimated at over $600 billion annually. We know that many
    of these problems can be prevented entirely, and that the longer we can
    delay initiation of any use, the more successfully we mitigate future
    morbidity, mortality and economic burdens.
        Over the past three decades, NIDA-supported research has
    revolutionized our understanding of addiction as a chronic, often-
    relapsing brain disease --this new knowledge has helped to correctly
    situate drug addiction as a serious public health issue that demands
    strategic solutions. By supporting research that reveals how drugs
    affect the brain and behavior and how multiple factors influence drug
    abuse and its consequences, scholars supported by NIDA continue to
    advance effective strategies to prevent people from ever using drugs
    and to treat them when they cannot stop.
        NIDA supports a comprehensive research portfolio that spans the
    continuum of basic neuroscience, behavior and genetics research through
    medications development and applied health services research and
    epidemiology. While supporting research on the positive effects of
    evidence-based prevention and treatment approaches, NIDA also
    recognizes the need to keep pace with emerging problems. We have seen
    encouraging trends--significant declines in a wide array of youth drug
    use--over the past several years that we think are due, at least in
    part, to NIDA's public education and awareness efforts. However, areas
    of significant concern include the recent increase in lethalities due
    to heroine, as well as the continued abuse of prescription opioids and
    the recent increase in designer drugs availability and their
    deleterious effects. The need to increase our knowledge about the
    effects of marijuana is most important now that decisions are being
    made about its approval for medical use and/or its legalization. We
    support NIDA in its efforts to find successful approaches to these
    difficult problems.
        The Nation's previous investment in scientific research to further
    understand the effects of abused drugs on the body has increased our
    ability to prevent and treat addiction. As with other diseases, much
    more needs be done to improve prevention and treatment of these
    dangerous and costly diseases. Our knowledge of how drugs work in the
    brain, their health consequences, how to treat people already addicted,
    and what constitutes effective prevention strategies has increased
    dramatically due to support of this research. However, since the number
    of individuals continuing to be affected is still rising, we need to
    continue the work until this disease is both prevented and eliminated
    from society.
        We understand that the fiscal year 2015 budget cycle will involve
    setting priorities and accepting compromise, however, in the current
    climate we believe a focus on substance abuse and addiction, which
    according to the World Health Organization account for nearly 20
    percent of disabilities among 15-44 year olds, deserves to be
    prioritized accordingly. We look forward to working with you to make
    this a reality. Thank you for your support for the National Institute
    on Drug Abuse.
                                     ______

                  Prepared Statement of the FSH Society, Inc.
        Honorable Chairwoman Mikulski and Ranking Member Harkin, thank you
    for the opportunity to submit this testimony. Facioscapulohumeral
    muscular dystrophy (FSHD), is one of the most common adult muscular
    dystrophies with a prevalence of 1:15,000--1:20,000.\1 2\ For a half-
    million men, women, and children worldwide the major consequence of
    inheriting this genetic form of muscular dystrophy is a lifelong
    progressive loss of all skeletal muscles. FSHD is a crippling and life
    shortening disease. No one is immune. It is both genetically and
    spontaneously transmitted to children. It can affect multiple
    generations and entire families.
    ---------------------------------------------------------------------------
        \1\ Flanigan KM, et al. Genetic characterization of a large,
    historically significant Utah kindred with facioscapulohumeral
    dystrophy. Neuromuscul Disorders 2001;11:525--529.
        \2\ Mostacciuolo ML, et al. Facioscapulohumeral muscular dystrophy:
    epidemiologicaland molecular study in a north-east Italian population
    sample. Clinical Genetics 2009;75:550--555.
    ---------------------------------------------------------------------------
        With FSHD there is a loss of muscle strength that ranges between
    one and 4 percent a year during a lifetime. In terms of functional
    impairment, 20 percent of FSHD-affected individuals over age fifty will
    require the use of a wheelchair. FSHD also has very specific non-
    muscular manifestations; hearing-loss, restrictive lung disease,
    supraventricular arrhythmias (rare), and retinal vasculopathy. 95
    percent of individuals with FSHD have the FSHD1 (FSHD1A OMIM: 158900)
    genetic variation--caused by the contraction of DNA macrosatellite
    repeat units, termed D4Z4 repeats, on chromosome 4, leading to the
    release of transcriptional repression of a retrogene (DUX4) believed to
    be associated with the cause of disease. Of the 5 percent of FSHD
    individuals remaining, 80 percent of those are the FSHD2 (FSHD1B OMIM:
    158901) genetic variation--caused by mutations in the SMCHD1 gene on
    chromosome 18 that helps to maintain the structure of the D4Z4 repeats
    on the long arm of chromosome 4.
        The National Institutes of Health (NIH) is the principal source of
    funding of research on FSHD currently at the $5 million level. For
    nearly two decades, this Committee has supported the incremental growth
    in funding for FSHD research. I am pleased to report that this modest
    investment has produced huge scientific returns.
        1. Congress has made a major difference in muscular dystrophy. I
    have testified many times before Congress, nearly fifty. When I first
    testified, we did not know the mechanism of this disease. Now we do.
    When I first testified, we assumed that FSHD was a rare form of
    muscular dystrophy. Now we understand it to be one of the most
    prevalent forms of muscle disease, if not the most prevalent muscle
    disease based on new ways of evaluating the disease clinically within
    families. Congress is responsible for this success, through its
    sustaining support of the NIH and the enactment of the Muscular
    Dystrophy CARE Act. We are aware that MD Care Act does not set the
    amount of spending on FSHD or the other dystrophies at the NIH and we
    recognize that funding levels are determined in the appropriations
    process and the numbers of grant applications received and funded by
    the NIH on FSHD. Even though it is a technically separate legislative
    process, the reauthorization of the MD Care Act does raise the
    visibility of all the muscular dystrophies which can be of help in the
    appropriations process--and we thank you for your support of the MD
    Care Act. Further, we recognize and feel at this time in FSHD research
    that there are additional efforts and pathways that Congress can
    request and the NIH can enact to increase the amount of research
    funding on FSHD in the NIH portfolio that neither increases the NIH
    budget required nor takes money from another area of research.
        2. Quantum leaps in our understanding of FSHD have occurred in past
    three and a half years. The past three and a half years have seen
    remarkable contributions made by researchers funded by NIH.
      --On August 19, 2010, American and Dutch researchers published a
            paper which dramatically expanded our understanding of the
            mechanism of FSHD.\3\ A front page story in the New York Times
            quoted the NIH Director Dr. Francis Collins saying, ``If we
            were thinking of a collection of the genome's greatest hits,
            this would go on the list.'' \4\
    ---------------------------------------------------------------------------
        \3\ Lemmers, RJ, et al, A Unifying Genetic Model for
    Facioscapulohumeral Muscular Dystrophy Science 24 September 2010: Vol.
    329 no. 5999 pp. 1650-1653.
        \4\ Kolata, G., Reanimated `Junk' DNA Is Found to Cause Disease.
    New York Times, Science. Published online: August 19, 2010 http://
    www.nytimes.com/2010/08/20/science/20gene.html.
    ---------------------------------------------------------------------------
      --Two months later, another paper was published that made a second
            critical advance in determining the cause of FSHD.\5\ The
            research shows that FSHD is caused by the inefficient
            suppression of a gene that may be normally expressed only in
            early development.
    ---------------------------------------------------------------------------
        \5\ Snider, L., Geng, L.N., Lemmers, R.J., Kyba, M., Ware, C.B.,
    Nelson, A.M., Tawil, R., Filippova, G.N., van der Maarel, S.M.,
    Tapscott, S.J., and Miller, D.G. (2010). Facioscapulohumeral dystrophy:
    incomplete suppression of a retrotransposed gene. PLoS Genet. 6,
    e1001181.
    ---------------------------------------------------------------------------
      --On January 17, 2012, an international team of researchers based out
            of Seattle discovered a stabilized form of a normally
            suppressed gene called DUX4 required to develop chromosome 4
            linked FSHD.\6\
    ---------------------------------------------------------------------------
        \6\ Geng et al., DUX4 Activates Germline Genes, Retroelements, and
    Immune Mediators: Implications for Facioscapulohumeral Dystrophy,
    Developmental Cell (2012), doi:10.1016/j.devcel.2011.11.013.
    ---------------------------------------------------------------------------
      --Six months later, another high profile paper produced by a Senator
            Paul A. Wellstone Cooperative Research Center of the NIH, used
            sufficiently ``powered'' large collections of genetically
            matched FSHD cell lines generated by the NIH center that are
            both unique in scope and shared with all researchers worldwide,
            to improve on the Seattle group's finding by postulating that
            DUX4-fl expression is necessary but not sufficient by itself
            for FSHD muscle pathology.\7\ This work was also supported by a
            NIH cooperative research center grant mandated by MD CARE Act.
    ---------------------------------------------------------------------------
        \7\ Jones TI, et al, Facioscapulohumeral muscular dystrophy family
    studies of DUX4 expression: evidence for disease modifiers and a
    quantitative model of pathogenesis. Hum Mol Genet. 2012 Oct
    15;21(20):4419-30. Epub 2012 Jul 13.
    ---------------------------------------------------------------------------
      --On July 13, 2012, a team of researchers from the, United States,
            Netherlands and France identified mutations in a gene causing
            80 percent of another form of FSHD. This paper furthers our
            understanding of the molecular pathophysiology of FSHD. This
            work too was supported in part by a program project grant from
            NIH.\8\
    ---------------------------------------------------------------------------
        \8\ Lemmers, RJ, et al, Digenic inheritance of an SMCHD1 mutation
    and an FSHD-permissive D4Z4 allele causes facioscapulohumeral muscular
    dystrophy type 2. Nat Genet. 2012 Dec;44(12):1370-4. doi: 10.1038/
    ng.2454. Epub 2012 Nov 11.
    ---------------------------------------------------------------------------
      --In 2013 and continuing into 2014, papers have been published
            clearly documenting functional impairment in FSHD, clinical and
            genetic features of hearing loss FSHD, restrictive lung disease
            and respiratory insufficiency, Coats syndrome and vision loss
            in FSHD, high-throughput screening that identify inhibitors of
            DUX4-induced myoblast toxicity, better definition of epigenetic
            features of FSHD, Pain and FSHD, MRI/MRS studies, biomarkers
            for FSHD, the demonstration that although the transcription of
            the toxic protein DUX4 occurs in only a limited number of
            nuclei, the resulting protein diffuses into nearby nuclei
            within the myotubes, thus spreading aberrant gene expression
            throughout a muscle, to name a few.
        Many of these researchers have started their efforts in FSHD with
    seed funding from the FSH Society and have received continued support
    from the FSH Society, the NIH, and the Muscular Dystrophy Association
    and other partners.
        3. Remarkable progress in FSHD research and the need to keep moving
    forward. Last October, nearly 100 researchers from around the world
    gathered under the direction of Massachusetts Institute of Technology
    professor, David Housman, PhD, Chair of the FSH Society's Scientific
    Advisory Board, at the David H. Koch Center for Integrative Cancer
    Research on the campus of M.I.T. for the annual FSH Society
    International Research Consortium meeting; there was a palpable feeling
    of FSHD research having ``arrived'' in the big time. The general
    discussion of day two covered four major areas. With respect to the
    first area, called DUX4, the unanimous conclusion of the general
    discussion was that over-expression of the toxic transcription factor
    DUX4 is at the root of FSHD1 and FSHD2 and that DUX4 expression is
    necessary but not always sufficient to cause FSHD. Research should
    focus on upstream and downstream molecular pathways and mechanisms as
    they form the most plausible intervention targets. The group also
    discussed needs and priorities in three additional areas: disease
    models, intervention, clinical studies and trial readiness. The
    priorities stated for 2014, at the October 21-22, 2013, FSH Society
    FSHD IRC meetings are as follows: \9\
    ---------------------------------------------------------------------------
        \9\ 2013 FSH Society FSHD International Research Consortium, held
    October 22-23, 2013 co-sponsored by DHHS NIH NICHD University of
    Massachusetts School of Medicine Senator Paul D. Wellstone MD CRC for
    FSHD. To read the expanded summary and recommendations of the group
    see: http://www.fshsociety.org/pages/sciConsortium.html.
    ---------------------------------------------------------------------------
      --The DUX4 interactome
      --Understanding DUX4 manifestation and variation
      --Additional genetic heterogeneity; non-FSHD1 and FSHD2
      --Disease models
      --Well documented natural history with reliable endpoints; modulating
            mechanisms/genes
      --Increasing data depth of patient databases with extensive (follow-
            up) clinical data
      --Prepare for clinical trials: reliable and meaningful outcome
            measures; with access to discreet patient populations and
            disease mechanism of action classes.
      --Therapy; proof-of-principle experiments
      --Focus on translational research; from clinic to bench and back
      --Understanding pathophysiology of FSHD: connection to DUX4,
            heterogeneity, asymmetry, role of inflammation; infiltrates and
            etiology
        Given the recent developments, there is a need to ramp up the
    preclinical enterprise and build/organize infrastructure needed to
    conduct clinical trials. Our immediate priorities should be to confirm
    the new hypotheses and targets. We need to be prepared for this new era
    in the science of FSHD. Many leading experts are now turning to work on
    FSHD not only because it is one of the most complicated and challenging
    problems seen in science, but because it represents the potential for
    great discoveries, insights into stem cells, transcriptional processes,
    new ways of thinking about disease of epigenetic etiology, and for
    treating diseases.
        4. NIH Funding for Muscular Dystrophy. Mr. Chairman, these major
    advances in scientific understanding and epidemiological surveillance
    are not free. They come at a cost. Since Congress passed the MD CARE
    Act, research funding at NIH for muscular dystrophy has increased 4-
    fold. While FSHD research funding has increased 12-fold during this
    period, the level of funding is still anemic and, for FSHD, has been
    astonishingly flat for the past 6 years.

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

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

        [This statement was submitted by Daniel Paul Perez, President &
    CEO, FSH Society.]
                                     ______

          Prepared Statement of the GBS/CIDP Foundation International
        Chairman Harkin and distinguished members of the Subcommittee,
    thank you for your time and your consideration of the priorities of the
    community of individuals impacted by Guillain-Barre Syndrome (GBS),
    Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), and related
    conditions as you work to craft the fiscal year 2015 Labor, Health and
    Human Services Appropriations Bill.
                               about gbs and cidp
    Guillain-Barre Syndrome
        GBS is an inflammatory disorder of the peripheral nerves outside
    the brain and spinal cord. It's also known as Acute Inflammatory
    Demyelinating Polyneuropathy and Landry's Ascending Paralysis.
        The cause of GBS is unknown. We do know that about 50 percent of
    cases occur shortly after a microbial infection (viral or bacterial),
    some as simple and common as the flu or food poisoning. Some theories
    suggest an autoimmune trigger, in which the patient's defense system of
    antibodies and white blood cells are called into action against the
    body, damaging myelin (nerve covering or insulation), leading to
    numbness and weakness.
        GBS in its early stages is unpredictable, so except in very mild
    cases, most newly diagnosed patients are hospitalized. Usually, a new
    case of GBS is admitted to ICU (Intensive Care) to monitor breathing
    and other body functions until the disease is stabilized. Plasma
    exchange (a blood ``cleansing'' procedure) and high dose intravenous
    immune globulins are often helpful to shorten the course of GBS. The
    acute phase of GBS typically varies in length from a few days to
    months, with over 90 percent of patients moving into the rehabilitative
    phase within four weeks. Patient care involves the coordinated efforts
    of a team such as a neurologist, physiatrist (rehabilitation
    physician), internist, family physician, physical therapist,
    occupational therapist, social worker, nurse, and psychologist or
    psychiatrist. Some patients require speech therapy if speech muscles
    have been affected.
        Recovery may occur over 6 months to 2 years or longer. A
    particularly frustrating consequence of GBS is long-term recurrences of
    fatigue and/or exhaustion as well as abnormal sensations including pain
    and muscle aches. These can be aggravated by `normal' activity and can
    be alleviated by pacing activity and rest.
    Chronic Inflammatory Demyelinating Polyneuropathy
        CIDP is a rare disorder of the peripheral nerves characterized by
    gradually increasing weakness of the legs and, to a lesser extent, the
    arms.
        It is the gradual onset as well as the chronic nature of CIDP that
    differentiates it from GBS. Fortunately, CIDP is even rarer than GBS.
    The incidence of new cases is estimated to be between 1.5 and 3.6 in a
    million people (compare to GBS: 1-2 in 100,000).
        Like GBS, CIDP is caused by damage to the covering of the nerves,
    called myelin. It can start at any age and in both genders. Weakness
    occurs over two or more months.
        Unlike GBS, CIDP is not self-limiting (with an end to the acute
    phase). Left untreated, 30 percent of CIDP patients will progress to
    wheelchair dependence. Early recognition and treatment can avoid a
    significant amount of disability.
        Post-treatment life depends on whether the disease was caught early
    enough to benefit from treatment options. Patients respond in various
    ways. The gradual onset of CIDP can delay diagnosis by several months
    or even years, resulting in significant nerve damage that may take
    several courses of treatment before benefits are seen. The chronic
    nature of CIDP differentiates long-term care from GBS patients.
    Adjustments inside the home may need to be made to facilitate a return
    to normal life.
                              about the foundation
        The Foundation's vision is that every person afflicted with GBS,
    CIDP, or variants has convenient access to early and accurate
    diagnosis, appropriate and affordable treatments, and dependable
    support services.
        The Foundation's mission is to improve the quality of life for
    individuals and families across America affected by GBS, CIDP, and
    their variants by:
      --Providing a network for all patients, their caregivers and families
            so that GBS or CIDP patients can depend on the Foundation for
            support, and reliable up-to-date information.
      --Providing public and professional educational programs worldwide
            designed to heighten awareness and improve the understanding
            and treatment of GBS, CIDP and variants.
      --Expanding the Foundation's role in sponsoring research and engaging
            in patient advocacy.
                                 sequestration
        We have heard from the medical research community that
    sequestration and deficit reduction activities have created serious
    issues for Federal funding opportunities and the career development
    pipeline. In order to ensure that research into GBS, CIDP, and related
    disorders can continue to move forward, and, more importantly, to
    ensure that our country is adequately preparing the next generation of
    young investigators, we urge you to avert, mitigate, or otherwise
    eliminate the specter of sequestration. While the Foundation has
    anecdotal accounts of the harms of sequestration, the Federated
    American Societies for Experimental Biology has reported:
      --In constant dollars (adjusted for inflation), the NIH budget in
            fiscal year 2013 was $6 billion (22.4 percent) less than it was
            in fiscal year 2003.
      --The number of competing research project grants (RPGs) awarded by
            NIH has also fallen sharply since fiscal year 2003. In fiscal
            year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3
            percent) fewer than in fiscal year 2003.
      --Awards for R01-equivalent grants, the primary mechanism for
            supporting investigator-initiated research, suffered even
            greater losses. The number awarded fell by 2,528 (34 percent)
            between fiscal year 2003 and fiscal year 2013.
        The pay line for some NIH funding mechanisms has fallen from 18
    percent to 10 percent while the average age for a researcher to receive
    their first NIH-funded grant has climbed to 42. These are strong
    disincentives to choosing a career as a medical researcher. Our
    scaling-back is occurring at a time when many foreign countries are
    investing heavily in their biotechnology sectors. China alone plans to
    dedicate $300 million to medical research over the next 5 years; this
    amount is double the current NIH budget over the same period of time.
    Scientific breakthroughs will continue, but America may not benefit
    from the return-on-investment of a robust biotechnology sector. For the
    purposes of economic and national security, as well as public health,
    the Foundation asks that you work with your colleagues to eliminate
    sequestration and recommit to supporting this Nation's biomedical
    research enterprise.
                   centers for disease control and prevention
        CIDP is a progressive condition with serious health impacts.
    Patients can end up almost completely paralyzed and on a ventilator.
    The key to limiting serious health impacts is an early and accurate
    diagnosis. The time it takes for a CIDP patient to begin therapy is
    linked to the length of therapy and the seriousness of the health
    impacts. An early diagnosis can mean the difference between a 3 month
    or 18 month hospital stay, or no hospitalization at all. For the
    Federal healthcare system, there is an economic incentive to ensure
    early and accurate diagnosis as longer hospitalizations equate to
    higher costs.
        CDC and NCCDPHP have resources that could be brought to bear to
    improve public awareness and recognition of CIDP and related
    conditions. In order to initiate new, potentially cost-saving programs,
    CDC requires meaningful funding increases to support crucial
    activities.
                         national institutes of health
        NIH hosts a modest research portfolio focused on GBS, CIDP, and
    related conditions. This research has led to important scientific
    breakthroughs and is well positioned to vastly improve our
    understanding of the mechanism behind these conditions. In fact, NINDS,
    NIAID, and the Office of Rare Diseases Research (ORDR) housed within
    NCATS have expressed interest in hosting a State-of-the-Science
    Conference on autoimmune peripheral neuropathies. This conference would
    allow intramural and extramural researchers to develop a roadmap that
    would lead research into these conditions into the next decade. While
    such a conference would not require additional appropriations, the
    Foundation urges you to provide NIH with meaningful funding increases
    to facilitate growth in the GBS, CIDP, and related conditions research
    portfolio.
        Thank you for your time and your consideration of the community's
    requests.
                                     ______

                  Prepared Statement of Girl Scouts of the USA
        As the preeminent leadership development organization for girls,
    Girl Scouts of the USA (Girl Scouts) serves over two million girls each
    year, ages 5 to 17, from every corner of the United States and its
    territories, with value placed on diversity and inclusiveness. We also
    serve nearly 17,000 American girls living outside of the United States
    in over 90 countries. Through our 112 councils and USA Girl Scouts
    Overseas, and more than 800,000 dedicated volunteers, we continue to
    deliver the Girl Scout Leadership Experience (GSLE)--the world's most
    comprehensive and best program for girls' leadership development.
                           building girls leadership
        Girl Scout experiences through GSLE are, as much as possible, girl-
    led and encourage hands-on and cooperative learning. Our framework
    specifies 15 outcomes--behaviors, attitudes, skills and values--that
    develop girls of courage, confidence and character. We provide
    significant financial assistance to vulnerable girls who cannot afford
    to pay to belong to Girl Scouts. In many communities, Girl Scouts is
    the single most visible and viable positive choice for these girls as
    opposed to negative behavior. Girl Scouts plays a major role in helping
    girls find their voice in a positive and productive way.
        Women today are well educated but still underrepresented in high-
    paying positions and positions of leadership, facing societal barriers
    to leading and achieving success in everything from technology and
    science to business and industry. With this in mind, we need a bold
    policy shift so that girls are able to achieve their full leadership
    potential now and later in life, as women. Girl Scouts is eager to work
    with policymakers to create opportunities and environments that foster
    girls' leadership development.
                                 pension relief
        Under Department of Labor, General Provisions, Girl Scouts
    respectfully requests the insertion of the following language as our
    highest priority request:
        Sec.--Election Not To Be Treated as an Eligible Charity Plan.--A
    plan sponsor of an eligible charity plan (as defined in subsection (d)
    of section 104 of the Pension Protection Act of 2006) may elect,
    effective for the first plan year beginning after December 31, 2013, to
    have section 104 of such Act not apply to such plan. In the case of
    such an election, solely for plan years beginning after December 31,
    2013, section 430(c) of the Internal Revenue Code of 1986 and section
    303(c) of the Employee Retirement Income Security Act of 1974 shall
    apply as if such sections had applied to the first two plan years
    beginning after December 31, 2009, and as if the plan sponsor had
    elected to apply section 430(c)(2)(D)(iii) of such Code and section
    303(c)(2)(D)(iii) of such Act with respect to those two plan years.
        The proposed language, which would only affected eligible charities
    and thus should not have an associated cost, would modify the rule
    established by section 202(b) of the Preservation of Access to Care for
    Medicare Beneficiaries and Pension Relief Act of 2010, Public Law 111-
    192. The effect of the proposed language is similar in effect to
    section 2 of H.R. 4915, as passed by the Senate in December of 2010,
    which also allowed a plan sponsor of an eligible charity plan not to
    have section 104 of the Pension Protection Act of 2006 apply.
        Girl Scouts organization, on behalf of the millions of girls we
    serve, respectfully requests this technical fix. The language simply
    says that as of 2014, we, and all similarly structured charities, be
    permitted to elect in to the Pension Protection Act funding rules,
    which are the Federal pension rules applicable to corporate America.
    In addition to our request pertaining to pension relief, the following
            are the key policy priority areas where we can offer research
            and programmatic success stories:
                                 stem education
        As the preeminent organization for girls and a leader on informal
    STEM education, Girl Scouts is committed to ensuring that every girl
    has the opportunity to explore and build an interest in science,
    technology, engineering and mathematics. The strength of our Nation
    depends on increasing girls' involvement in STEM, to develop critical
    thinking, problem solving and collaboration skills that are important
    throughout life.
        In 2012, the Girl Scout Research Institute released Generation
    STEM: What Girls Say about Science, Technology, Engineering and Math,
    which found girls are interested in STEM and aspire to STEM careers,
    but need further exposure and education about what STEM careers can
    offer and how STEM can help girls make a difference in the world.
        Among some of Generation STEM's other findings:
      --74 percent of teen girls are interested in the field of STEM and
            STEM subjects. Girls like the process of learning, asking
            questions, and problem solving.
      --Girls who are interested in STEM are significantly better students,
            have higher confidence in their abilities, and higher academic
            goals.
      --But while 81 percent say they are interested in pursuing STEM
            careers, only 13 percent say it's their first choice. About
            half of all girls feel that STEM isn't a typical career path
            for girls. 57 percent of girls say that if they went into a
            STEM career, they'd have to work harder than a man just to be
            taken seriously.
      --African American and Hispanic girls have high interest in STEM,
            high confidence and work ethic, but say they have fewer
            supports and less STEM exposure than Caucasian girls.
        Research shows that girl-only settings not only provide a sense of
    belonging, but are more effective environments for personal
    development, including learning new skills and building self-
    confidence. In emotionally and physically safe environments, like those
    provided by Girl Scouts, girls partner with positive role models in a
    range of activities not limited by gender stereotypes. Girl Scout
    programs also emphasize partnerships, public education campaigns,
    mentorship programs, career exploration, traditional badges, and
    innovative new programming.
      --As Congress considers consolidations and a redesign of existing
            Federal STEM programs, we urge you to invest more of a focus on
            engaging and motivating girls in STEM, in particular girls in
            underrepresented minorities and at younger ages before their
            interest wanes in middle school. Strategies include introducing
            girls to diverse role models and mentors; promoting proven
            techniques for engaging girls in STEM including, single-gender
            learning; and, hands-on and experiential learning opportunities
            in after-school or out-of-school environments.
                               financial literacy
        The world's current economic challenges have made financial
    literacy skills matter now more than ever. Girl Scouts offers a
    financial literacy program at every grade level from K-12. Through our
    Girl Scout financial education programming, girls learn to handle money
    and the basics of budgeting, banking, saving, using credit and planning
    for retirement and even practicing philanthropy.
        Additionally, the Girl Scout Cookie Program is often girls' first
    introduction to business planning and entrepreneurship. The $790
    million Girl Scout Cookie Program is the largest girl-led business in
    the country.
        While lack of financial literacy is a growing concern, relatively
    little research has been conducted on how girls think about and
    experience money and finances. To address this gap, the Girl Scout
    Research Institute recently conducted a study, Having It All: Girls and
    Financial Literacy, with girls and their parents. It found girls need
    and want financial literacy skills to help them achieve their dreams,
    with 90 percent saying it is important for them to learn how to manage
    money; however, just 12 percent of girls surveyed feel very confident
    about making financial decisions.
      --To be successful and sustainable, financial education must begin
            early, continue throughout elementary and secondary education,
            and be relevant. And although 93 percent of the public believes
            all high school students should be required to take a class in
            financial education, only four States have made a semester-long
            course in financial literacy a graduation requirement.\1\ In
            addition to providing teachers with training and materials, we
            believe policy support for after-school and community-based
            programs is critical if girls are to learn money-management
            skills and have real-world financial literacy experiences that
            will serve them throughout their lives.
    ---------------------------------------------------------------------------
        \1\ Back to School Survey Shows Americans Want Personal Finance
    Taught in the Classroom, Visa, July 20, 2010.
    ---------------------------------------------------------------------------
               healthy living--bullying and relational aggression
        As exemplified through our program experience and research, Girl
    Scouts understands the complex issue of healthy living and what
    motivates youth--especially girls--to adopt healthy lifestyles.
    Improving youths' physical health and emotional well-being are not
    mutually exclusive. Youth, especially girls, experience them in an
    interrelated fashion. Girls place the same or even greater emphasis on
    social and emotional health as physical health.
        The Girl Scout Research Institute's original research report,
    Feeling Safe: What Girls Say, found that nearly half (46 percent) of
    girls define safety as not having their feelings hurt, and
    approximately one-third of all girls worry about being teased, bullied,
    threatened, or having their feelings hurt when spending time with
    peers, participating in groups, and trying new things. Our report, The
    New Normal? What Girls Say About Healthy Living, tells us that a girl's
    relationships with her peers are critical components of her health and
    safety.
        Our BFF (Be a Friend First) curriculum is focused on middle-school
    girls and designed to easily integrates into existing health or
    character education classes, or can even serve as an after-school
    program in the community.
      --As the Department of Education has proposed a safe schools
            initiative that includes a positive school climate focus, Girl
            Scouts supports this kind of effort that embraces a holistic
            definition of health that addresses both the physical health
            and emotional wellness of youth. National youth serving
            organizations such as Girl Scouts, should be seen as vital
            partners for schools in developing relevant solutions such as
            policies to address relational aggression and evaluating and
            implementing programs that prevent relational aggression and
            build healthy relationships.
                                    closing
        We look forward to being a partner with Congress as you make
    difficult funding decisions in the areas of supporting healthy living,
    improving financial education of our youth, and building a pipeline of
    girls and underrepresented minorities in STEM careers. Thank you, and
    please consider us a resource in these areas.

        [This statement was submitted by Anna Maria Chavez, Girl Scouts of
    the USA.]
                                     ______

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

        [This statement was submitted by Kaitlin Christenson, Coalition
    Director, Global Health Technologies Coalition.]
                                     ______

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

        [This statement was submitted by Katy Beh Neas, Senior Vice
    President, Government Relations Easter Seals, Inc.]
                                     ______

               Prepared Statement of the Harm Reduction Coalition
        We are requesting $5 million for the Substance Abuse and Mental
    Health Services Administration at the Center for Substance Abuse
    Treatment, and $5 million for the Centers for Disease Control and
    Prevention at the office of Unintentional Injury Prevention, to address
    the opioid overdose epidemic.
        The opioid overdose epidemic has reached crisis proportions in
    recent years. The Centers for Disease Control and Prevention reports
    that in 2010, opioids--including both prescription painkillers and
    heroin--were responsible for nearly 20,000 overdose deaths. While
    prescription painkillers continue to account for the majority of opioid
    overdoses, deaths from heroin overdose increased by 45 percent between
    2006 and 2010, fueling concerns in several parts of the country that
    progress in reducing prescription painkiller misuse is being offset by
    a dramatic rise in heroin use and its attendant social and health
    consequences, including addiction, hepatitis C, and overdose. For
    example, in Kentucky, a State on the forefront of comprehensive
    approaches to the prescription drug overdose epidemic, the Kentucky
    Injury Prevention and Research Center recently reported that while
    overall drug overdose deaths have leveled off from 2011 to 2012 after a
    decade of dramatic increases, promising declines in the number of
    prescription painkiller deaths have been accompanied by a 207 percent
    increase in heroin-related overdose deaths from 2011 to 2012.
        For these reasons, Harm Reduction Coalition believes that as
    efforts continue to mount a comprehensive response to prescription
    painkiller overdoses, it is necessary to incorporate the intertwined
    rise in heroin misuse and adopt a broader strategic framework to
    address all opioids. An opioid epidemic framework would maintain and
    intensify the array of activities such as those aimed at opioid
    prescribing practices and monitoring programs, safe disposal, patient
    and public education, regulatory and enforcement actions, and expansion
    of effective addiction treatment and recovery services. At the same
    time, the broader opioid epidemic framework recognizes the vital need
    for additional public health interventions and opportunities, including
    the role of expanded access to naloxone, alongside heightened attention
    to the risks of hepatitis C and other blood-borne viruses transmissible
    through injection drug use.
        Naloxone is a generic medication which acts as an opioid
    antagonist, blocking the effects of opioids such as painkillers or
    heroin and capable of reviving individuals from opioid overdoses. A
    substantial body of research and practice has demonstrated that
    naloxone is safe and effective in the hands of laypersons; in the words
    of Dr. Nora Volkow, Director of the National Institute on Drug Abuse,
    ``several experimental overdose education and naloxone distribution
    (OEND) programs have issued naloxone directly to opioid users and their
    friends or loved ones, or other potential bystanders, along with brief
    training in how to use these emergency kits. Such programs have been
    shown to be an effective, as well as cost-effective, way of saving
    lives.''
        Dr. Volkow cites data published by CDC showing that through 2010,
    overdose education and naloxone distribution programs reported
    preventing over 10,000 opioid overdose deaths across the country. As of
    this month, eighteen States have passed legislation to facilitate
    broader access and utilization of naloxone, ranging from Kentucky to
    Connecticut, Ohio to California; Georgia passed naloxone legislation on
    March 18th , which now awaits the governor's signature. These overdose
    education and naloxone distribution programs vary in setting and scope.
    In North Carolina, Project Lazarus trains physicians to co-prescribe
    naloxone to pain patients receiving opioids. In Massachusetts, support
    groups for parents with children struggling with opioid dependence are
    trained and provided with naloxone. In Rhode Island, naloxone is
    provided through pharmacies. In Kentucky, some of the strongest
    advocates for naloxone have been the addiction recovery community. In
    New York, my organization has provided naloxone training to dozens of
    drug treatment programs, syringe exchange programs, shelters, and law
    enforcement agencies. In other parts of the country, overdose education
    and naloxone distribution programs are launching in emergency
    departments, jails, and Veterans Administration Medical Centers.
        These programs are gaining increased Federal attention; in the last
    month, the Attorney General echoed the Office of National Drug Control
    Policy in calling upon first responders and law enforcement officers to
    be trained and equipped with naloxone. The Agency for Healthcare
    Research and Quality highlighted the Massachusetts overdose education
    and naloxone distribution program and featured accompanying quality
    tools, including an overdose and naloxone program manual from the Harm
    Reduction Coalition. Last year, the Substance Abuse and Mental Health
    Services Administration (SAMHSA) released an opioid overdose toolkit
    featuring naloxone. NIDA and FDA have worked to support and facilitate
    the development of new, consumer-friendly formulations of naloxone. The
    Ohio Department of Health's Violence and Injury Prevention Program has
    used a portion of its CDC injury prevention funding to expand Project
    DAWN, an overdose education and naloxone distribution program, to
    additional counties.
        The President's fiscal year 2015 budget requests $26 million to
    prevent prescription drug overdose, of which $16 million would expand
    CDC's Core Violence and Injury Prevention Program grants to States,
    with an expected $10 million directed to prescription drug overdose
    activities, and $10 million to SAMHSA would fund State planning grants
    to develop prevention strategies for prescription drug abuse. The Harm
    Reduction Coalition supports these proposals, and believes that these
    resources would be valuable in establishing a foundation to reverse the
    prescription drug overdose epidemic. We also believe that additional
    emergency funding is necessary to stem the tide of opioid overdose from
    both prescription opioids and, increasingly, heroin. Within the context
    of a comprehensive approach to the opioid epidemic, including expanding
    access to addiction treatment and recovery, the Harm Reduction
    Coalition views the rapid expansion and scale up of overdose education
    and naloxone distribution programs as an urgent and underfunded
    priority to save lives.
        To that end, we request that $5 million be provided to CDC Injury
    Prevention and Control to support opioid overdose fatality prevention
    efforts within State and local health departments and community-based
    organizations to strengthen their ability to deliver overdose
    recognition and intervention training and education, and expand access
    to rescue medications and other evidence-based strategies. We also
    request that $5 million be provided to SAMHSA's Center for Substance
    Abuse Treatment to support community-based opioid overdose fatality
    prevention efforts, with a focus on those initiatives that provide
    overdose recognition and intervention training and education, access to
    rescue medications, and facilitate linkage to treatment and recovery
    services.
        Across the country, emerging overdose education and naloxone
    distribution programs rely on limited funding to meet a growing need.
    The availability of targeted Federal funds through both the public
    health and addiction treatment and recovery communities would hasten
    the expansion of these programs to meet growing need and demand.
        In the battle against opioid overdose, there is much to be done,
    and no time to lose. We need a twofold approach of long-range efforts
    to address the underlying causes and factors which led to the initial
    rise in prescription opioid misuse, coupled with immediate actions to
    avert additional deaths and tragedies in the short-term. As a person
    who has lost friends and loved ones to opioid overdose, and listened to
    the stories of grieving parents who only wish someone had told them
    about naloxone before it was too late for their children, I
    respectfully ask for your consideration of our requests.
        If you have any questions, or would like more information or data
    on naloxone, please feel free to contact: Daniel Raymond, Harm
    Reduction Coalition. Thank you for your attention and consideration.
                                     ______

      Prepared Statement of the Health Professions and Nursing Education
                                   Coalition
        The members of the Health Professions and Nursing Education
    Coalition (HPNEC) are pleased to submit this statement for the record
    recommending $520 million in fiscal year 2015 for the health
    professions education programs authorized under Titles VII and VIII of
    the Public Health Service Act and administered through the Health
    Resources and Services Administration (HRSA).
        HPNEC is an alliance of national organizations dedicated to
    ensuring the healthcare workforce is trained to meet the needs of the
    country's growing, aging, and diverse population. Titles VII and VIII
    are the only federally-funded programs that seek to improve the supply,
    distribution, and diversity of the health professions workforce, with a
    focus on primary care and interdisciplinary training. By providing
    educational and training opportunities to aspiring and practicing
    health professionals, the programs also play a critical role in helping
    the workforce adapt to meet the Nation's changing healthcare needs.
        Titles VII and VIII are structured to allow grantees to test
    educational innovations, respond to changing delivery systems and
    models of care, and address timely topics in their communities. By
    assessing the needs of the communities they serve, Titles VII and VIII
    are well positioned to fill gaps in the workforce and increase access
    to care for all populations. Further, the programs emphasize
    interprofessional education and training, bringing together knowledge
    and skills across disciplines to provide effective, efficient and
    coordinated care.
        While HPNEC recognizes the Subcommittee faces difficult decisions
    in a constrained budget environment, a continued commitment to programs
    supporting healthcare workforce development should remain a high
    priority. The Nation faces a shortage of health professionals, which
    will be exacerbated by the addition of millions of Americans to the
    healthcare system. Failure to fully fund the Title VII and Title VIII
    programs would jeopardize activities to fill these vacancies and to
    prepare the next generation of health professionals.
        The Title VII and Title VIII programs can be considered in seven
    general categories:
      --The Primary Care Medicine and Oral Health Training programs support
            education and training of primary care professionals to improve
            access and quality of healthcare in underserved areas. Two-
            thirds of Americans interact with a primary care provider every
            year. Over one-third of primary care providers trained through
            these programs work in underserved areas, compared to 10
            percent of those trained in other traditional programs. The
            General Pediatrics, General Internal Medicine, and Family
            Medicine programs provide critical funding for primary care
            physician training in community-based settings and support a
            range of initiatives, including medical student and residency
            training, faculty development, and the development of academic
            administrative units. The Rural Physician Training Grants focus
            on increasing the number of medical school graduates practicing
            in rural communities. The primary care cluster also provides
            grants for Physician Assistant programs to encourage and
            prepare students for primary care practice in rural and urban
            Health Professional Shortage Areas. The General Dentistry,
            Pediatric Dentistry, Dental Public Health, and Dental Hygiene
            programs provide grants to dental schools, dental hygiene
            schools, and hospitals to create or expand primary care dental
            training.
      --Because much of the Nation's healthcare is delivered in remote
            areas, the Interdisciplinary, Community-Based Linkages cluster
            supports community-based training of health professionals.
            These programs are designed to encourage health professionals
            to return to such settings after completing their training and
            to encourage collaboration between two or more disciplines. The
            Clinical Training in Interprofessional Practice program
            supports interdisciplinary training opportunities that prepare
            providers to deliver coordinated, efficient, and high-quality
            care. The Area Health Education Centers (AHECs) offer clinical
            training opportunities to health professions and nursing
            students in rural and other underserved communities by
            extending the resources of academic health centers to these
            areas. AHECs improve health by leading the Nation in the
            recruitment, training, and retention of a diverse health
            workforce for underserved communities. By leveraging State and
            local matching funds to form networks of health-related
            institutions, AHECs also provide education services to
            students, faculty, and practitioners. The Geriatric Health
            Professions programs, including the Geriatric Academic Career
            Award program and Geriatric Education Centers, are all designed
            to bolster the number and quality of healthcare providers
            caring for the rapidly growing number of older adults and to
            expand geriatrics training to all healthcare professionals. For
            example, the programs provide interprofessional education and
            training on Alzheimer's disease and related dementias. The
            Graduate Psychology Education (GPE) program is the Nation's
            only Federal program dedicated solely to the education and
            training of doctoral-level psychologists. GPE supports the
            interprofessional training of doctoral-level psychology
            students in providing supervised mental and behavioral health
            services to underserved populations (i.e. older adults,
            children, chronically ill, and victims of abuse and trauma,
            including returning military personnel and their families) in
            rural and urban communities. The Mental and Behavioral Health
            Education and Training Grant Program supports the training of
            psychologists, social workers, and child and adolescent
            professionals. These programs together work to close the gap in
            access to quality mental and behavioral healthcare services by
            increasing the number of qualified mental health clinicians.
      --The Minority and Disadvantaged Health Professionals Training
            cluster helps improve healthcare access in underserved areas
            and the representation of minority and disadvantaged
            individuals in the health professions. Diversifying the
            healthcare workforce is a central focus of the programs, making
            them a key player in mitigating racial, ethnic, and socio-
            economic health disparities. Further, the programs emphasize
            cultural competency for all health professionals, an important
            role as the Nation's population is growing and becoming
            increasingly diverse. Minority Centers of Excellence support
            increased research on minority health, establish educational
            pipelines, and provide clinical experiences in community-based
            health facilities. The Health Careers Opportunity Program helps
            to improve the development of a competitive applicant pool
            through partnerships with local educational and community
            organizations and extends the healthcareers pipeline to the K-
            12 level. The Faculty Loan Repayment and Faculty Fellowship
            programs provide incentives for schools to recruit
            underrepresented minority faculty. The Scholarships for
            Disadvantaged Students supports students from disadvantaged
            backgrounds who are eligible and enrolled as full-time health
            professions students.
      --The Health Professions Workforce Information and Analysis program
            provides grants to institutions to collect and analyze data to
            advise future decisionmaking on the health professions and
            nursing programs. The Health Professions Research and Health
            Professions Data programs have developed valuable, policy-
            relevant studies on the distribution and training of health
            professionals. The National Center for Workforce Analysis
            performs research and analysis on health workforce issues,
            including supply and demand, to help inform both public and
            private decisionmaking.
      --The Public Health Workforce Development programs help increase the
            number of individuals trained in public health, identify the
            causes of health problems, and respond to such issues as
            managed care, new disease strains, food supply, and
            bioterrorism. The Public Health Traineeships and Public Health
            Training Centers seek to alleviate the critical shortage of
            public health professionals by providing up-to-date training
            for current and future public health workers, particularly in
            underserved areas. Preventive Medicine Residencies, which do
            not receive funding through Medicare GME, provide training in
            the only medical specialty that teaches both clinical and
            population medicine to improve community health. This cluster
            also includes a focus on loan repayment as an incentive for
            health professionals to practice in disciplines and settings
            experiencing shortages. The Pediatric Subspecialty Loan
            Repayment Program offers loan repayment for pediatric medical
            subspecialists, pediatric surgical specialists, and child and
            adolescent mental and behavioral health specialists, in
            exchange for service in underserved areas.
      --The Nursing Workforce Development programs under Title VIII provide
            support for nursing students across the entire education
            spectrum improve the access to, and quality of, healthcare in
            underserved areas. These programs provide the largest source of
            Federal funding for nursing education, providing loans,
            scholarships, traineeships, and programmatic support that,
            between fiscal year 2006 and 2012, supported over 450,000
            nurses and nursing students as well as numerous academic
            nursing institutions and healthcare facilities. Each year,
            nursing schools turn away tens of thousands of qualified
            applications at all degree levels due to an insufficient number
            of faculty, clinical sites, classroom space, clinical
            preceptors, and budget constraints. At the same time, the need
            for nursing services and licensed, registered nurses is
            expected to increase significantly over the next 20 years. The
            Advanced Education Nursing program awards grants to train a
            variety of nurses with advanced education, including clinical
            nurse specialists, nurse practitioners, certified nurse-
            midwives, nurse anesthetists, public health nurses, nurse
            educators, and nurse administrators. Workforce Diversity grants
            support opportunities for nursing education for students from
            disadvantaged backgrounds through scholarships, stipends, and
            retention activities. Nurse Education, Practice, and Retention
            grants help schools of nursing, academic health centers, nurse-
            managed health centers, State and local governments, and other
            healthcare facilities to develop programs that provide nursing
            education, promote best practices, and enhance nurse retention.
            The Loan Repayment and Scholarship Program repays up to 85
            percent of nursing student loans and offers full-time and part-
            time nursing students the opportunity to apply for scholarship
            funds in exchange for 2 years of practice in a designated
            nursing shortage area. The Comprehensive Geriatric Education
            grants are used to train nursing professionals who will provide
            direct care to older Americans, develop and disseminate
            geriatric curricula, train faculty members, and provide
            continuing education. The Nurse Faculty Loan program provides a
            student loan fund administered by schools of nursing to
            increase the number of qualified nurse faculty.
      --The loan programs under Student Financial Assistance support
            financially disadvantaged health professions students. The
            NURSE Corps supports undergraduate and graduate nursing
            students with a preference for those with the greatest
            financial need. The Primary Care Loan (PCL) program provides
            loans in return for dedicated service in primary care. The
            Health Professional Student Loan (HPSL) program provides loans
            for financially needy health professions students based on
            institutional determination. These programs are funded out of
            each institution's revolving fund and do not receive Federal
            appropriations. The Loans for Disadvantaged Students program
            provides grants to institutions to make loans to disadvantaged
            students.
        Title VII and Title VIII programs guide individuals to high-demand
    health professions jobs, helping individuals reach their goals and
    communities fill their health needs. Further, numerous studies
    demonstrate that the Title VII and Title VIII programs graduate more
    minority and disadvantaged students and prepare providers that are more
    likely to serve in Community Health Centers (CHC) and the National
    Health Service Corps (NHSC).
        The multi-year nature of health professions education and training,
    coupled with provider shortages across many disciplines and in many
    communities, necessitate a strong, continued, and reliable commitment
    to the Title VII and Title VIII programs.
        While HPNEC members understand the budget limitations facing the
    Subcommittee, we respectfully urge support for $520 million for the
    Title VII and VIII programs. We look forward to working with the
    Subcommittee to prioritize the health professions programs in fiscal
    year 2015 and into the future.
                                     ______

               Prepared Statement of the HIV Medicine Association
        The HIV Medicine Association (HIVMA) of the Infectious Diseases
    Society of America (IDSA) represents more than 5,000 physicians,
    scientists and other healthcare professionals who practice on the
    frontline of the HIV/AIDS pandemic. Our members provide medical care
    and treatment to people with HIV/AIDS in the U.S. and globally, lead
    HIV prevention programs and conduct research that has led to the
    development of effective HIV prevention and treatment options. We urge
    you to invest in the medical research supported by the National
    Institutes of Health and sustain and grow funding for the Ryan White
    Program at the Health Resources and Services and Administration and the
    Centers for Disease Control and Prevention's (CDC) HIV and STD
    prevention programs.
        Early access to effective HIV treatment helps patients with HIV
    live healthy and productive lives and is cost effective.\1\ Treatment
    not only saves the lives of individuals with HIV but has critical
    benefits to public health in that it reduces risk of transmitting HIV
    to near zero.\2\ However, despite our remarkable progress in HIV
    prevention, diagnosis and treatment, HIV/AIDS remains a serious
    epidemic in the United States with a record 1.1 million people living
    with HIV and an estimated 50,000 new infections occurring annually. In
    our country, HIV infection disproportionately impacts racial and ethnic
    minority communities and low income people who depend on public
    services for their life-saving healthcare and treatment. The rate of
    new HIV infection in African Americans is 8 times that of whites based
    on population size.\3\ Globally there are more than 35.3 million people
    living with HIV, the great majority of them in Sub-Saharan Africa. We
    are beginning to see improvements thanks in large part to U.S.
    investments in programs like PEPFAR: HIV prevalence has leveled to
    about 0.8 percent, the number of deaths have declined by 30 percent
    since 2005 and new infections have declined by 33 percent since 2001.
    Still there are 2.3 million new infections each year--more than 6,300
    each day.
    ---------------------------------------------------------------------------
        \1\ Kitahata, Gange, Abraham, et al. Effect of early versus
    deferred antiretroviral therapy for HIV on survival. New Engl J Med
    2009;360:1815-26.
        \2\ Cohen, Myron S., et al. Prevention of HIV-1 Infection with
    Early Antiretroviral Therapy. 2011 New England Journal of Medicine 493-
    505: V365, no 6, http://www.nejm.org/doi/full/10.1056/NEJMoa11052.
        \3\ CDC Fact Sheet, February, 2014, accessed online at: http://
    www.cdc.gov/hiv/risk/racialethnic/aa/facts/index.html.
    ---------------------------------------------------------------------------
        The funding requests in our testimony largely reflect the consensus
    of the Federal AIDS Policy Partnership (FAPP), a coalition of HIV
    organizations from across the country, and are estimated to be the
    amounts necessary to mount an effective response to the domestic HIV
    epidemic and meet the need in communities across the country.
        National Institutes of Health (NIH)--Office of AIDS Research (OAR):
    HIVMA strongly supports an fiscal year 2015 funding level of at least
    $32 billion for the NIH, including at least $3.2 billion for the NIH
    Office of AIDS Research. This level of funding is vital to sustain the
    pace of research that will improve the health and quality of life for
    millions of men, women and children in the U.S. and in the developing
    world. Years of flat funding for biomedical research has eroded our
    capacity to sustain our Nation's historic worldwide leadership in HIV/
    AIDS research and innovation, and is discouraging cultivation of the
    next generation of scientists.
        Our past investment in comprehensive HIV/AIDS research paid off
    enormously in dramatic gains that resulted in reductions in mortality
    from AIDS of nearly 80 percent in the U.S. and in other countries where
    treatment is available. This research also helped reduce the mother to
    child HIV transmission rate from 25 percent to less than 1 percent in
    the U.S. and to very low levels in other countries where treatment is
    available.
        Strong, sustained NIH funding is a critical national priority that
    will foster better health, economic revitalization and help realize the
    goals of the National HIV/AIDS Strategy. Sustained increases in funding
    are also essential to train the next generation of scientists and
    prepare them to make tomorrow's HIV discoveries. Congress should ensure
    the Nation does not delay vital HIV/AIDS research progress.
        HIV/AIDS Bureau of the Health Resources and Services
    Administration: We strongly urge you to increase funding for the Ryan
    White Program by $123.2 million in fiscal year 2015. For Ryan White
    Part C programs in fiscal year 2015, we urge an allocation of at least
    $225.1 million, or a $24 million increase over the fiscal year 2014
    level for Part C. The comprehensive HIV care model or ``medical home''
    that is supported by the Ryan White Program has been highly successful
    at achieving positive clinical outcomes with a complex patient
    population. The annual healthcare costs for HIV patients who are not
    able to achieve viral suppression (often due to delayed diagnosis and
    care) are nearly 2.5 times that of healthier HIV patients.\4\
    ---------------------------------------------------------------------------
        \4\ Based on data from Gilman BH, Green, JC. Understanding the
    variation in costs among HIV primary care providers. AIDS
    Care.2008:20;1050-6.
    ---------------------------------------------------------------------------
        The HIV medical clinics funded through Part C have been struggling
    to meet the increased demand for patients making an increase in funding
    critical to prevent additional staffing, laboratory and service cuts.
    At a bare minimum, we strongly urge you to support an increase of $24
    million over fiscal year 2014 appropriated funding for Ryan White Part
    C.
        While HIVMA welcomes the $4 million increase for Part C programs
    proposed in the President's fiscal year 2015 budget, we are concerned
    about the proposal to consolidate Ryan White Part D funding into Part
    C. Our specific concerns include:
      --Part D funding supports effective HIV care and treatment services
            for vulnerable populations, including women and adolescents.
            With adolescents accounting for 39 percent of new HIV
            infections in the U.S., it is critical to target resources
            effectively.
      --A loss of a Part D program could reduce the community's access to
            HIV care and treatment as programs are forced to compete or
            consolidate with Part C clinics.
      --Since most Ryan White medical clinics receive funding from multiple
            parts of the Ryan White Program, reduction of funding to one
            part can have damaging and unintended consequences to the
            overall services provided.
        While the ACA provides important new healthcare coverage options
    for many patients, most health insurers fail to support the
    comprehensive care and treatment necessary for many patients to manage
    HIV infection. High cost sharing, benefit gaps and limited state uptake
    of the Medicaid expansion necessitate a vital and ongoing role for the
    Ryan White Program.
        Center for Disease Control and Prevention's (CDC) National Center
    for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP): HIVMA
    strongly urges total fiscal year 2015 funding of $1.319 billion for the
    CDC's NCHHSTP, an increase of $198.2 million over the fiscal year 2014
    level, including increases of: $55.1 million for HIV prevention and
    surveillance, $16.4 million for viral hepatitis and $57.4 million for
    tuberculosis prevention. We also support a funding level of at least
    $464.3 million for CDC's global health programs, which includes
    resources for the agency's essential role in implementing PEPFAR
    programs in developing Nations. We are especially concerned about flat
    funding of CDC's global HIV programs, and request an increase of at
    least $3.3 million to that line item for a total of $132 million.
        Policy Riders--Remove the Harmful Ban on Federal Funding for
    Syringe Exchange Programs: HIVMA strongly urges re-instatement in
    fiscal year 2015 report language of policy previously enacted into law
    in fiscal year 2010 and fiscal year 2011 allowing Federal funding to be
    used for syringe exchange programs. Such action will support local
    control by letting local communities make their own decisions about how
    best to prevent new HIV and viral hepatitis infections. We cannot
    afford to forego any of the scientifically proven tools in the HIV
    prevention tool box if we are going to end AIDS in the U.S. and around
    the globe.
        Conclusion: Historically, our Nation has made significant strides
    in responding to the HIV pandemic here at home and around the world,
    but years of flat funding is now causing us to lose ground, as funding
    priorities have shifted away from public health and research programs.
    We must seize the opportunity to limit the toll of this deadly
    infectious disease on our planet, to save the lives of millions who are
    infected or at risk of infection here in the U.S. and around the globe,
    and to realize the vision of an AIDS-free generation.

        [This statement was submitted by Jeanne Keruly, MS, CRNP, Johns
    Hopkins University, HIV Medicine Association.]
                                     ______

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

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

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

        We respectfully request the subcommittee to consider the following
    language for inclusion in the appropriations bill:
    Of the funds appropriated to NIH, $5,000,000 shall be for grants or
            contracts for construction, renovation, or repair of the
            sanctuary system established by Section 404K of the Public
            Health Service Act.
        We appreciate the opportunity to share our views for the Labor,
    Health and Human Services, Education and Related Agencies
    Appropriations Act for fiscal year 2015. We hope the Committee will be
    able to accommodate this request. Thank you for your consideration.
     high throughput screening, toxicity pathway profiling, and biological
                           interpretation of findings
             national institutes of health--office of the director
        In 2008, NIH, NIEHS and EPA signed a memorandum of understanding to
    collaborate with each other to identify and/or develop high throughput
    screening assays that investigate ``toxicity pathways'' that contribute
    to a variety of adverse health outcomes (e.g., from acute oral toxicity
    to long-term effects like cancer). In addition, the MOU recognized the
    necessity for these Federal research organizations to work with
    ``acknowledged experts in different disciplines in the international
    scientific community.'' Much progress has been made, including FDA
    joining the MOU, but there is still a significant amount of research,
    development and translational science needed to bring this vision
    forward to where it can be used with confidence for safety
    determinations by regulatory programs in the government and product
    stewardship programs in the private sector. In particular, there is a
    growing need to support research to develop the key science-based
    interpretation tools which will accelerate using 21st century
    approaches for predictive risk analysis. We believe the Office of the
    Director at NIH can play a leadership role for the entire US government
    by funding both extramural and intramural research.
        We respectfully request the following committee report language as
    a placeholder, which is supported by The HSUS, HSLF, and the American
    Chemistry Council.
    NIH Director
        The Committee supports NIH's leadership role in modernizing the
    approach for evaluating the safety of pharmaceuticals and chemicals
    based on the incorporation of advanced molecular biological and
    computational methods that envisions a move away from animal tests. NIH
    has indicated that development of this science is critical to several
    of its priorities, from personalized medicine to tackling specific
    diseases such as cancer and diabetes and including critical initiatives
    such as BRAIN and the National Center for Advancing Translational
    Science. The Committee encourages NIH to continue to expand both its
    intramural and extramural support for the use of human biology-based
    experimental and computational approaches in health research to further
    define human biology, disease pathways, and toxicity and to develop
    tools for their integration into clinical strategies and safety
    determination paradigms. Extramural and intramural funding should be
    made available for the development and evaluation of the relevance and
    reliability of human biology-based and pathway approaches and
    prediction tools to assure readiness and utility for regulatory and
    clinical applications, including pilot studies of pathway-based risk
    assessments. The Committee requests an update on current activities, a
    plan for future activities, and the fiscal year 2015 funding level for
    this area of research in the fiscal year 2016 congressional budget
    justification.
                                     ______

       Prepared Statement of the Infectious Diseases Society of America's
        On behalf of the Infectious Diseases Society of America (IDSA), I
    am pleased to provide testimony in support of the U.S. Department of
    Health and Human Services (HHS) components that work to prevent, detect
    and treat infectious diseases (ID). IDSA represents more than 10,000 ID
    physicians and scientists devoted to patient care, prevention, public
    health, education, and research. As communicated to the full Senate
    Appropriations Committee through testimony for the record in advance of
    its April 29th hearing ``Driving Innovation through Federal
    Investments,'' IDSA recommends increased fiscal year 2015 Federal
    investments in public health and biomedical research to save lives,
    contain healthcare costs, and promote economic growth. More
    specifically, IDSA encourages the Subcommittee to provide a program
    level of $7.8 billion for the Centers for Disease Control and
    Prevention (CDC) as well as $32 billion for the National Institutes of
    Health (NIH). IDSA is particularly supportive of the proposed CDC
    Detect and Protect Against Antibiotic Resistance Initiative and
    requests that it be fully funded at $30 million. We ask that the
    Subcommittee also advance fiscal year 2015 appropriations that reflect
    the national security and public health significance of the Biomedical
    Advanced Research and Development Authority (BARDA). All of these
    investments are a necessary part of a Federal strategy to decrease the
    incidence and fatality of infectious diseases in our population.
                   centers for disease control and prevention
        The ID community's partnership with the CDC has never been more
    necessary, as we work to address the public health crisis of rising
    antibiotic resistance while continuing efforts in other important areas
    such as increasing immunization rates and slowing the spread of HIV.
        Last fall, CDC issued a report, Antibiotic Resistance Threats in
    the United States, 2013 that for the first time ranked and detailed the
    threats posed by antibiotic resistant microbes. Conservative estimates
    reveal that more than two million Americans suffer antibiotic resistant
    infections each year, which result in approximately 23,000 deaths. The
    actual numbers are likely far higher, as our surveillance and data
    collection capabilities cannot yet capture the full disease burden.
    These infections due to antibiotic resistant microbes cost tens of
    billions of dollars to the U.S. healthcare system annually, and the
    problem is worsening. The CDC recommended actions in four core areas to
    address the problem, including prevention, tracking, antibiotic
    stewardship, and development of new antibiotics and rapid diagnostics.
    The CDC has proposed fiscal year 2015 activities in each of these
    areas.
    National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
        The NCEZID plays a leading role in CDC efforts to address
    antibiotic resistance. As such, we ask that it be provided at least the
    $445 million requested by the Administration, including at least $30
    million for the Detect and Protect Against Antibiotic Resistance
    Initiative. This initiative, which is supported by many stakeholders in
    the health community, would establish regional prevention
    collaboratives to implement best practices for antibiotic use and
    infection prevention, create a detection network of five regional labs
    to speed up identification of the most concerning threats, improve
    antibiotic stewardship, and develop an isolate library that will help
    facilitate the development of desperately needed new antibiotics and
    diagnostics. The initiative directly addresses the recommended actions
    from the CDC 2013 report. The CDC projects that over 5 years the
    initiative will lead to a 50 percent reduction in health-care
    associated Clostridium difficile (C. diff), 50 percent decline in
    health-care associated carbapenem-resistant Enterobacteriaceae (CRE),
    30 percent decline in invasive methicillin-resistant Staphylococcus
    aureus (MRSA), 30 percent decline in health-care associated drug-
    resistant Pseudomonas sp., and 25 percent reduction in drug-resistant
    Salmonella infections. These bacteria claim thousands of lives
    annually. CRE, for one, have become resistant to all or nearly all
    currently available antibiotics. Further, nearly 50 percent of those
    who develop bloodstream infections from CRE die.
        IDSA and numerous other stakeholders support the proposed $14
    million increase for the National Healthcare Safety Network (NHSN),
    which would increase the number of healthcare facilities reporting
    antibiotic use and antibiotic resistance data and would develop and
    evaluate new infection prevention strategies.
        IDSA thanks Congress for funding the Advanced Molecular Detection
    (AMD) initiative in fiscal year 2014 and recommends that at least $30
    million be allocated for it in fiscal year 2015. AMD strengthens CDC's
    molecular sequencing tools and bioinformatics capacity to more rapidly
    and accurately detect infectious diseases and resistance.
        A recent World Health Organization report on antimicrobial
    resistance reiterates that we are in the midst of a public health
    crisis that is impacting all regions of the world and requires
    immediate action on the part of governments and society. IDSA applauds
    the Administration for launching a Global Health Security Agenda, which
    would strengthen the capacity of nations to prevent, detect and slow
    the spread of infectious diseases across borders, simultaneously
    reducing threats to the United States. We ask that you provide the
    initiative with funding allocated in the fiscal year 2015 PBR.
    National Center for Immunization and Respiratory Diseases (NCIRD)
        We know that vaccines are among the most cost-effective clinical
    preventative services. However, according to the February 2014 CDC
    Morbidity and Mortality Weekly Report (MMWR), adult immunization rates
    remain low for most routinely recommended vaccines and considerably
    short of Healthy People 2020 targets. Each year in the United States,
    more than 40,000 adults die from illnesses that are preventable through
    vaccination.
        IDSA opposes the $51 million program level reduction to the CDC
    Immunization Grant Program (Section 317) contained in the PBR. Although
    the Affordable Care Act requires insurers to cover immunizations, this
    alone will not guarantee access or utilization. The Section 317 funds
    are critical to help providers obtain and store vaccines; establish and
    maintain vaccine registries; as well as to educate providers and the
    public about vaccine recommendations, effectiveness and safety; and
    promote universal vaccination of healthcare workers.
        CDC plays a critical role in seasonal and pandemic influenza
    preparedness and response, including conducting important surveillance
    activities that better inform response efforts and providing public
    communications regarding influenza prevention and treatment. Lack of
    sufficient funding for these efforts could lead to an increased
    incidence and severity of influenza, as well as increased
    hospitalization costs and mortality. In the long term, continuously
    funded efforts will be more cost-effective than the periodic emergency
    supplemental funding approach that historically has been used to fund
    such efforts. IDSA supports the proposed fiscal year 2015 increase of
    $15 million for these efforts.
                         national institutes of health
    National Institute of Allergy and Infectious Diseases (NIAID)
        Within NIH, we believe that the National Institute of Allergy and
    Infectious Diseases (NIAID) should be funded at least at the $4.58
    billion requested by the Administration in the fiscal year 2014 PBR.
    Nearly flat-funding NIAID limits investment in new research and serves
    as a disincentive for young people to pursue ID research careers so
    critical to the discovery of new therapies, new diagnostic approaches,
    and new preventive strategies.
        The NIAID recently began funding a new clinical trials network
    focused on antibiotic-resistant bacterial infections. With sufficient
    funding, the new research network/infrastructure will conduct critical
    studies to address antibiotic resistance as well as begin to answer
    questions that will help fill the nearly empty antibiotic R&D pipeline.
    Severe economic disincentives have caused a mass exodus of private
    companies from the antibiotics market, making federally funded research
    in this area more critical than ever. An IDSA report issued in April
    2013 identified only seven new drugs in development for the treatment
    of infections caused by multidrug-resistant Gram-negative bacilli
    (GNB). The Transatlantic Task Force on Antimicrobial Resistance
    (TATFAR) also recently issued a report, which identified the broken
    pipeline of new antibacterial drugs as a key obstacle in dealing with
    resistance. The TATFAR report highlighted NIAID support of clinical
    research aimed at filling gaps in drug R&D and lowering the associated
    economic risk to industry. We applaud NIAID's initiative in launching
    the new network. However, IDSA recommends increased investment in this
    area.
        A recent IDSA report, Better Tests, Better Care: Improved
    Diagnostics for Infectious Diseases, highlighted the need for
    advancements in diagnostic tools to address bacterial, viral and fungal
    infections and recommends strengthened NIAID funding for this priority.
    Faster, more accurate diagnostics lead to better treatments and
    improved patient outcomes. In addition, new diagnostics are needed to
    identify patients with highly contagious illnesses so that containment
    and prevention measures can be undertaken. Diagnostics can improve
    physicians' ability to discern which infections need antibiotics, and
    thereby help reduce the unnecessary use of antibiotics that drives the
    development of antibiotic resistance.
            assistant secretary for preparedness and response (aspr)
    Biomedical Advanced Research and Development Authority (BARDA)
        ASPR plays a key leadership role in coordinating Federal efforts to
    sufficiently protect the Nation from biothreats, pandemics and emerging
    infections. IDSA recommends increased funding for BARDA, which has been
    flat-funded for several years. Additional investment in medical
    countermeasure development is critical to prepare for both intentional
    attacks and naturally emerging infections. BARDA is a critical source
    of funding for public-private collaborations for antibiotic, diagnostic
    and vaccine R&D.
        We ask that the Subcommittee move forward with a sense of urgency
    to bolster Federal initiatives aimed at dealing with issues such as
    antimicrobial resistance, antibiotics and rapid diagnostics R&D, adult
    immunizations, and biodefense. The appropriation of sufficient fiscal
    year 2015 resources to address ID issues is a necessary complement to
    efforts that are currently underway within the Senate and House
    authorizing committees.
        Thank you for the opportunity to submit this statement on behalf of
    the Nation's ID physicians and scientists. Please forward any questions
    to Jonathan Nurse.

        [This statement was submitted by Jonathan Nurse, Director,
    Government Relations, Public Policy and Government Relations,
    Infectious Diseases Society of America.]
                                     ______

       Prepared Statement of the International Foundation for Functional
                           Gastrointestinal Disorders
    _______________________________________________________________________

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

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

        [This statement was submitted by Nancy J. Norton, President and Co-
    Founder, International Foundation for Functional Gastrointestinal
    Disorders.]
                                     ______

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

        [This statement was submitted by Gregory E. Conrad, Executive
    Director, Interstate Mining Compact Commission.]
                                     ______

          Prepared Statement of the Interstitial Cystitis Association
                summary of recommendations for fiscal year 2015
    _______________________________________________________________________

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

    _______________________________________________________________________

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

        [This statement was submitted by Lee Claassen, Executive Director,
    Interstitial Cystitis Association.]
                                     ______

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

        [This statement was submitted by Hon. W. Ron Allen, Tribal
    Chairman/CEO, Jamestown S'Klallam Tribe.]
                                     ______

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

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

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

        The below text comes from CMS' website:
    Intermediate Care Facilities for Individuals with Mental Retardation
            (ICF/MR)
        Intermediate Care Facilities for individuals with Mental
    Retardation (ICF/MR) is an optional Medicaid benefit that enables
    States to provide comprehensive and individualized healthcare and
    rehabilitation services to individuals to promote their functional
    status and independence. Although it is an optional benefit, all States
    offer it, if only as an alternative to home and community-based
    services waivers for individuals at the ICF/MR level of care.
        IMPORTANT NOTE: Federal law and regulations use the term
    ``intermediate care facilities for the mentally retarded''. CMS prefers
    to use the accepted term ``individuals with intellectual disability''
    (ID) instead of ``mental retardation.'' However, as ICF/MR is the
    abbreviation currently used in all Federal requirements, that acronym
    will be used here.
    Eligibility for ICF/MR Benefit
        ICF/MR is available only for individuals in need of, and receiving,
    active treatment (AT) services. AT refers to aggressive, consistent
    implementation of a program of specialized and generic training,
    treatment and health services. AT does not include services to maintain
    generally independent clients who are able to function with little
    supervision and who do not require a continuous program of habilitation
    services. States may not limit access to ICF/MR service, or make it
    subject to waiting lists, as they may for HCBS. Therefore in some cases
    ICF/MR services may be more immediately available than other long term
    care options. Many individuals who require this level of service have
    already established disability status and Medicaid eligibility.
    State Variation
        Need for ICF/MR is specifically defined by States, all of whom have
    established ICF/MR level of care criteria. State level of care
    requirements must provide access to individuals who meet the coverage
    criteria defined in Federal law and regulation. In addition to level of
    care for AT, the need for AT must arise from ID or a related condition.
    The definition of related condition is primarily functional, rather
    than diagnostic, but the underlying cause must have been manifested
    before age 22 and be likely to continue indefinitely. States vary in
    practical application of the concept of related condition. In some
    States individuals applying for ICF/MR residence may be eligible for
    Medicaid under higher eligibility limits used for residents of an
    institution.
    Services Included in the ICF/MR Benefit
        ICFs/MR provides active treatment (AT), a continuous, aggressive,
    and consistent implementation of a program of specialized and generic
    training, treatment, and health or related services, directed toward
    helping the enrollee function with as much self-determination and
    independence as possible. ICF/MR is the most comprehensive benefit in
    Medicaid.
        Federal rules provide for a wide scope of required services and
    facility requirements for administering services. All services
    including healthcare services and nutrition are part of the AT, which
    is based on an evaluation and individualized program plan (IPP) by an
    interdisciplinary team. Facility requirements include staffing,
    governing body and management, client protections, client behavior and
    physical environment, which are specified in the survey and
    certification process.
    Day Programs
        Many ICF/MR residents work in the community, with supports, or
    participate in vocational or other activities outside of the residence,
    and engage in community interests of their choice. These activities are
    collectively often referred to as day programs. The ICF/MR is
    responsible for all activities, including day programs, because the
    concept of AT is that all aspects of support and service to the
    individual are coordinated towards specific individualized goals in the
    IPP.
    Where ICF/MR Services are Provided
        Medicaid coverage of ICF/MR services is available only in a
    residential facility licensed and certified by the State survey agency
    as an ICF/MR. Medicaid ICF/MR services are available only when other
    payment options are unavailable and the individual is eligible for
    Medicaid. There are few resources similar to an ICF/MR, under any
    payment source.
                                     ______

              Prepared Statement of the KNI Parent Guardian Group
        Dear Senate Appropriations Sub-committee, thank you for the
    opportunity to provide testimony. It is with a heavy heart that I
    submit outside witness testimony today, respectfully requesting your
    full consideration of the effects of pervasive Intermediate Care
    Facility (institutional--ICF/ID) closure activities.
        Numerous federally funded agencies under the Department of Health
    and Human Services (HHS) are pursuing an idealistic agenda that puts
    the weakest members of our society into harm's way, while ignoring
    significant deficiencies in the home and community based service system
    (HCBS).
        I am calling on this Sub-committee to PROHIBIT the use of Federal
    HHS appropriations supporting deinstitutionalization activities which
    evict without cause, and without regard to individual choice, people
    with the most profound intellectual and developmental disabilities (I/
    DD) from HHS-licensed ICF homes.
                             community deficiencies
      --Stagnant Direct Support Staff wages, high turnover rates, staff
            rationing, and inadequate professional oversight of scattered
            homes are affecting quality of care for those served in HCBS
            waiver systems. The most helpless on the disability spectrum
            are particularly affected by these systemic deficiencies.
      --Diminishing incentive to retain quality staff is reflected in the
            pervasive, stagnant wage crisis, while re-imbursement rates
            have not changed significantly for over a decade. As a result,
            the profoundly disabled often do not get to choose who cares
            for them, even if they somehow could indicate with whom they
            would like to live. This reality flies in the face of
            idealism--pushing ``community for all.''
      --There is no adequate system in place which represents persons
            adjudicated incompetent, who have no or extremely limited self-
            advocacy skills, particularly to express abusive acts committed
            against them in poorly supervised community homes with rationed
            staff and limited professional oversight.
        As the Guardian of a profoundly disabled young man, I have
    navigated and utilized a broad array of community services for over 15
    years. My final recourse after exhausting every option, was to place my
    loved one at the Kansas Neurological Institute (KNI), because no one in
    the HCBS system was able to handle him.
        Since his placement at KNI our grandson has been very well cared
    for, being restored to a place of stability unparalleled in the
    community. We have tried without success, to reintegrate him into
    community as unfortunately, more than a a few community providers have
    refused to serve him.
        Facilities like KNI are the safety net for those whom the community
    is not suitable or has failed to keep safe, yet these havens are under
    attack nation-wide. A number of HHS funded programs are displacing our
    most vulnerable without regard to clarifications in the Supreme Court
    Olmstead ruling, which highlights individual choice, need and safety.
        Groups including the ARC, National Council on Disabilities, State
    DD Councils, Universities for Excellence, and State Protection &
    Advocacy have ignored mounting evidence of abhorrent community outcomes
    for the most helpless within the disability spectrum. These federally
    funded entities appear to collaborate and push the extreme agenda of
    forced closure of all State ``institutions''. This radical agenda fails
    to recognize community capacity issues and an increasing number of
    documented tragedies occurring within the community system.
        Why are these agencies pushing to close facilities where
    compassionate staff care for our weakest, forcing our most vulnerable
    into questionable environments?
        How is ``justice'' served when the most helpless are placed in
    community settings, suffering neglect and death after a few months time
    at the hands of poorly trained staff who have little or no professional
    oversight?
        ``Is it ever right to handcuff and over-medicate someone with
    disabilities, just so you can `handle' them?'' This question was
    presented to the National Council on Disabilities in December by a
    guardian whose brother had been de-institutionalized, and subsequently
    bounced around to unsuccessful community placements.
    HCBS tragedies are happening to such a degree that your colleague,
            Senator Chris Murphy has called for a nation-wide
            investigation.
        Parents and guardians are speaking out for those who cannot speak
    for themselves, many of whom had experienced failed community
    placements, yet these parents are vilified as obstacles to ``systems
    change.''
    Do current HCBS deficiencies and tragic outcomes for the weakest
            reflect sound policy?
        There is a compelling need for both community-based and congregate
    care settings. States need to operate a range of services to meet the
    diverse requirements of persons with disabilities as clarified within
    the Supreme Court Olmstead ruling:
                                    olmstead
        ``We emphasize that nothing in the ADA or its implementing
    regulations condones termination of institutional settings for persons
    unable to handle or benefit from community settings...Nor is there any
    Federal requirement that community-based treatment be imposed on
    patients who do not desire it.'' Id. at 601-602.
        A plurality of Justices noted:
        ``[N]o placement outside the institution may ever be appropriate .
    .  . `Some individuals, whether mentally retarded or mentally ill, are
    not prepared at particular times-perhaps in the short run, perhaps in
    the long run-for the risks and exposure of the less protective
    environment of community settings' for these persons, `institutional
    settings are needed and must remain available''' (quoting Amicus Curiae
    Brief for the American Psychiatric Association, et al).
        Justice Kennedy noted in his concurring opinion, ``It would be
    unreasonable, it would be a tragic event, then, were the Americans with
    Disabilities Act of 1990 (ADA) to be interpreted so that States had
    some incentive, for fear of litigation to drive those in need of
    medical care and treatment out of appropriate care and into settings
    with too little assistance and supervision.'' Id. at 610.
        The real civil rights issue is the disregard for those who have
    been forced from safe environments by pervasive deinstitutionalization,
    without addressing the mounting capacity issues. As a Nation, we have
    neglected to ensure supports necessary for success, including
    adequately paid support staff and solid accountability parameters,
    while pursuing an over-reaching push of ``Community for all.''
        Until the community Direct Support Staff wage issue is honestly
    solved, the deficient abuse reporting system remedied, and systemic
    assurances providing adequate oversight for the most defenseless living
    in scattered homes across our States, we have no true, successful
    inclusion for the profoundly disabled who cannot speak or defend
    themselves.
        On behalf of ``the least of these,'' our most vulnerable, I provide
    comment today, and ask the Committee to take compassionate actions on
    their behalf.

        [This statement was submitted by Joan Kelley, Legal Guardian; Vice-
    president, KNI Parent Guardian Group.]
                                     ______

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

        [This statement was submitted by Judith A. Salerno, MD, MS,
    President and Chief Executive Officer, Susan G. Komen.]
                                     ______

       Prepared Statement of the Lenders Coalition for Community Health
                                    Centers
        The Lenders Coalition for Community Health Centers (LCCHC) is
    pleased to provide the following written testimony related to proposed
    fiscal year 2015 HRSA funding for federally Qualified Health Centers
    (FQHCs) funded under Section 330 of the Public Health Services Act.
    This testimony includes recommendations to assist the Administration
    and Congress in developing policies that will help meet a near
    universal goal--expanding community health centers in an affordable and
    sustainable manner to meet the healthcare needs of millions of families
    in underserved communities throughout the United States.
        LCCHC is a coalition of community development financial
    institutions (CDFIs) and related entities whose main goal is to
    advocate for resources and policies that will strengthen health
    centers' access to capital and CDFIs' ability to finance health center
    growth. The CDFIs that form the LCCHC are all currently undertaking
    health center lending. They have made loans totaling more than $1.4
    billion to develop primary care capacity that gives more than 3 million
    patients access to primary care every year.
        The LCCHC has been on record in support of increased--and
    continued--operational funding support for health centers. Our
    institutions sent a letter to the President advocating the full
    operational increase in mandatory funds from the Health Centers Fund in
    fiscal year 2015, and underscored the need to sustain and grow that
    investment over the next 5 years to ensure the financial stability of
    our client FQHCs moving forward.
        We note that the President's fiscal year 2015 budget proposes
    utilizing $800 million in health center funding for one-time capital
    grants. We believe that to the extent any new funding for capital
    projects is included in this year's final appropriation, HHS should
    encourage awardees to use these scarce dollars to leverage other
    sources of capital--both grants and loans from the public and private
    sector--to maximize their impact on health center growth. Given that
    $800 million represents less than 10 percent of the estimated $10
    billion of capital funding that will be needed in order to meet the
    goal of serving 35 million patients in FQHCs by the end of 2018,
    developing policies that promote the availability of multiple public
    and private sources of capital will be critical to health centers'
    successful growth. By incorporating incentives to encourage leveraging
    into the HHS review process of any potential capital grant funding for
    those FQHCs that can raise other sources of capital and/or afford to
    take on some reasonable amount of debt, HHS will be able to support a
    much larger number of FQHCs around the country.
        We also recognize that capital from the Health Centers Fund--even
    if it is leveraged--is not a complete solution to address the capital
    needs of FQHCs. We strongly encourage the consideration of robust
    Federal credit enhancement programs targeting FQHCs expansion, which
    would leverage much greater levels of private sector financing for
    FQHCs.. Programs such as these are available and have been used to
    considerable success for a number of vital sectors, including small
    businesses (SBA), rural and agricultural enterprises (USDA), charter
    schools (ED) housing and hospitals (HUD).
        We wish to be clear that we reject policies encouraging FQHCs to
    pursue leverage irresponsibly. Over-leverage is a real risk in any
    sector; where it involves the development of critical health
    infrastructure and the use of public funds, it simply must be
    prevented. Indeed, as community lenders, our mission is aligned with
    our borrowers, and we have a stake in their sustainability and success.
        Attached, please find a brief that highlights the benefits of
    leveraging HHS capital dollars. The arguments in this brief assume that
    FQHCs work with responsible lenders, develop financially and
    operationally sustainable expansion projects, and assume a level of
    debt that supports their expansion without negatively impacting their
    current operations or financial stability. Based on our collective
    experience in the FQHC sector itself, as well as across a broad range
    of other capital needs within low income communities (e.g., affordable
    housing, healthy food financing, and school financing), we are
    confident that the Administration and Congress can maintain policies
    that enable these conditions.
      why leveraging of hrsa capital grants is essential to the future of
                   federally qualified health centers (fqhcs)
        HRSA has set, and the health center field has embraced, the goal of
    expanding health centers to meet the stated goal of serving 35 million
    patients by the end of 2018 (from approximately 22 million today).
    Based on an estimate from Capital Link, more than $10 billion in
    additional capital will need to flow into FQHC facility development and
    expansion to meet this target.
        If public funding alone will not suffice to meet the FQHC field's
    collective expansion goal, the only feasible alternative is instead to
    ensure that limited public funds be deployed strategically to bring
    private sector capital to bear. Such an approach can stretch scarce
    Federal resources, attract more lenders into the market, lower
    borrowing costs, and incentivize FQHCs to develop projects with greater
    impact on patients than would be possible otherwise.
    The Lack of a Clear, Unambiguous Signal that Leverage is Integral to
            HRSA's Future Plans for FQHCs Causes Inefficiencies in FQHC
            Financing to Persist
        Capital Grant Funding Rounds that Fail to Incentivize Leverage
    Disrupt the Existing FQHC Pipeline and Distort Project Sizing.--Today,
    FQHCs often work with CDFIs and other lenders across the country to
    generate a pipeline with hundreds of viable FQHC expansion projects in
    varying stages of development. When HRSA announces a capital grant
    round (or even the possibility of a capital grant round) that holds out
    the promise of a one-stop, debt-free financing strategy, that pipeline
    largely freezes, as FQHCs understandably put development plans on hold
    in the hope of avoiding the need to borrow money at all.
        Unfortunately, that hope is often in vain, given the reality that
    demand far outstrips the funding available, leading to lengthy grant
    application and review processes and many unfunded projects.
    Additionally, FQHCs size their projects to the HRSA grant maximum
    rather than to the size that best serves the healthcare needs of the
    community and that CDFIs or other responsible lenders will underwrite.
    The result is delays or cancellation of FQHC expansion projects that
    could have served hundreds of thousands of patients.
    Thoughtful Incentives to Promote Leverage would Enable HRSA to Magnify
            the Impact of its Capital Grants and Supplement its Own
            Oversight of FQHCs with Private Sector Underwriting
        Leverage is a `Force Multiplier' for Limited HRSA Capital Grants.--
    Simply put, a given level of Federal operating and capital funding can
    yield dramatically increased FQHC expansion if it unlocks access to
    private sector capital. When FQHCs are required to supplement Federal
    grant funding with outside capital, they are more likely to develop
    projects that are scaled to the needs of the community rather than to
    the size of the grant award, offering the opportunity for greater
    impact on the community's health.
        To offer an instructive experience in another sector, in fiscal
    year 2014, Congress enacted the Administration's Rental Assistance
    Demonstration (RAD), providing public housing authorities new
    flexibilities to leverage their annual public housing operating and
    capital grants from the Department of Housing and Urban Development
    (HUD) to rehab or redevelop up to 60,000 units of public housing.
    Notably, no `new' money was appropriated--i.e., the operating and
    capital fund allocations that the local agencies received remained the
    same (well below their annual operating costs and accumulated capital
    backlog). To date, applications submitted to HUD under this `no cost'
    leveraging strategy have proposed to bring to bear in excess of $6
    billion in private and other public sector capital to the rehab and
    redevelopment of public housing units previously assisted exclusively
    by Federal funds.
        If Congress appropriates capital funding for health centers in
    fiscal year 2015, HRSA should draw from the experience of the
    affordable housing field, and other sectors, in the effort to deploy
    leverage strategically in service of health center capital expansion
    goals. Health centers have, for the moment, the further good fortune of
    being `ahead of the curve,' relative to the field's funding levels and
    capital needs (the public housing field, for example, embraced policy
    reforms like RAD only after years of underfunding and a capital backlog
    in excess of $27 billion).
        Leverage Leads to Superior `Front End' Underwriting and Faster
    Project Development.--When an FQHC uses debt financing for a project,
    the project goes through a rigorous review by the lender (or lenders)
    as part of the underwriting process, creating a higher likelihood for
    successful development of the project. Scrutiny of the experience and
    capacity of the project's development team ensures that the right
    pieces are in place for construction that is on time and within budget.
    Furthermore, the lenders' scrutiny of underlying financials and
    staffing plans and testing of revenue projections can lead to an FQHC
    making constructive modifications to its plans. To be clear, this is
    not a substitute for the conscientious and diligent oversight conducted
    by HRSA staff on behalf of the taxpayer, but rather a useful supplement
    to their efforts by project development experts whose livelihood
    depends on having their loans paid back.
        Leverage Builds in `Early Warning' Systems that Prevent FQHC
    Project Failure.--Experience across capital financing sectors,
    including affordable housing (e.g., three decades of experience with
    the Low Income Housing Tax Credit), has demonstrated that private
    sector oversight of project operations is a useful supplement to the
    scrutiny of dedicated, competent but often overextended public
    servants, Lenders, as part of their loan servicing and monitoring, keep
    a monthly watch on every borrower, enabling them to see financial
    problems early on, before they have grown more expensive and difficult
    to fix. When lenders provide financing to FQHCs, they are responsible
    for ensuring regular loan repayments. Borrowers are required to submit
    regular financial statements showing cash flow, accounts payables and
    receivables, and other indicators of financial health. If the borrower
    misses loan payments or shows other signs of financial distress, a CDFI
    can work with borrowers to develop solutions that will bring a health
    center back to financial stability. When necessary, this assistance may
    involve working with other stakeholders, including foundations, State
    Medicaid agencies, or HRSA to make sure a community is not deprived of
    vital primary care capacity.
        Leverage Creates Financial, Community and Political Partners in
    Ensuring Health Center Sustainability.--Critically, the involvement of
    other stakeholders in FQHC health--from philanthropy to CDFIs to banks
    and private sector investors--is not limited to the all-hands-on-deck
    project workouts described above. When FQHCs are required to assemble
    matching or contributing funds for a project, they seek funding
    assistance from a range of other public and private sources, including
    grants and loans. The act of assembling these funds generates community
    ``buy-in'' and support for a proposed project, which ultimately
    contributes to its success by aligning community priorities and
    resources toward a common end.
        Indeed, the broadening of the constituency of stakeholders with
    `skin in the game' when it comes to both individual FQHCs and the field
    more broadly, is essential to FQHCs' long-term sustainability: it
    creates a bulwark against appropriations risk while simultaneously
    helping to ensure that FQHCs remain viable and competitive in the
    rapidly evolving field of primary care provision to low income
    neighborhoods and populations.
                                     ______

        Prepared Statement of the Local Initiatives Support Corporation
        Chairman Harkin, Ranking Member Moran, and Distinguished Members of
    the Senate Appropriations Subcommittee on Labor, Health and Human
    Services, Education and Related Agencies: Thank you for the opportunity
    to offer written testimony on the Administration's fiscal year 2015
    Budget Request for the Department of Health and Human Services,
    Administration for Children and Families. The Local Initiatives Support
    Corporation (LISC) views this hearing as a positive step toward
    understanding the importance of early childhood development and
    securing critically needed investments to ensure that all children,
    especially low-income children, are given a strong start and enter
    kindergarten ready to learn. As you consider ways that Congress can
    help children get an early start on the pathway to success, we
    encourage you to recognize the critical role that early childhood
    facilities play in preparing young children for achievement in school
    and in life, and urge you to ensure that Federal policies adequately
    finance the acquisition, construction, and improvement of these spaces.
                                   about lisc
        Established in 1979, the Local Initiatives Support Corporation
    (LISC) is a national nonprofit with Community Development Financial
    Institution (CDFI) designation, dedicated to helping community
    residents transform distressed neighborhoods into healthy places of
    choice and opportunity--good places to work, do business and raise
    children. LISC mobilizes corporate, government and philanthropic
    support to provide local community development organizations with
    loans, grants and equity investments; local, statewide and national
    policy support; and technical and management assistance.
        LISC has local offices in 30 cities and partners with more than 50
    organizations serving rural communities throughout the country. We
    focus our activities across five strategic community revitalization
    goals:
      --Expanding Investment in Housing and Other Real Estate
      --Increasing Family Income and Wealth
      --Stimulating Economic Development
      --Improving Access to Quality Education, and
      --Supporting Healthy Environments and Lifestyles.
        For more than three decades, LISC has developed programs and raised
    investment capital to help local groups revive their neighborhoods.
    Because we recognize the link between human opportunity and social and
    economic vitality, we have spent the last 17 years working to bring
    high quality early care and education settings to low-income
    neighborhoods where children enter the world at high risk for negative
    outcomes. Through our signature early childhood program, the Community
    Investment Collaborative for Kids (CICK), LISC has invested $48 million
    in planning and developing 184 new facilities serving 20,000 children
    in more than 65 low-income urban and rural neighborhoods across the
    country.
                                    overview
        Early childhood is a critical development period. Research shows
    that a complex interplay between genetics and environment profoundly
    influences how children grow physically, socially, and emotionally.
    Investments in high quality early childhood programs can help promote
    healthy development and strong communities. Those active in community
    revitalization believe without question, that early care and education
    programs are essential parts of every neighborhood--they prepare young
    children for success in school and life, support working parents, and
    improve family well-being.
        Regrettably, many families--particularly those who are low-income
    or in rural areas--lack access to the stable, high-quality early
    childhood centers that parents need to maintain gainful employment and
    children need to grow and thrive. Additionally, while there is
    appropriate focus on the need for high quality curriculum and qualified
    teachers, the physical environment is an essential feature that is
    often forgotten.
        In this testimony, we highlight the important role that physical
    environments play in supporting the quality of early learning programs
    and healthy early childhood development and encourage Congress to
    address the need for comprehensive early childhood facility policies.
                                   background
    Early Childhood is a Critical Development Period
        Decades of research has shown that early life experiences are
    extremely important to the social, emotional, and academic development
    of children.\1\ Positive experiences promote healthy brain development
    and behavior, while negative experiences undermine development--and, in
    severe circumstances, permanently impair a child's nervous and immune
    system, stunting healthy growth.\2\ High quality early care and
    education is widely regarded as the single most effective intervention
    to promote healthy development and close the academic achievement gap
    for low-income children at-risk for poor social and economic
    outcomes.\3\ The data are clear: the quality of one's early childhood
    experiences profoundly influence that person's future life trajectory.
    ---------------------------------------------------------------------------
        \1\ Jack P. Shonkoff and Deborah A. Phillips, Editors, From Neurons
    to Neighborhoods: The Science of Early Childhood Development, National
    Research Council Institute of Medicine, National Academy Press,
    Washington, DC 20000
        \2\ National Scientific Council on the Developing Child.
    ``Excessive Stress Disrupts the Architecture of the Developing Brain.
    Working Paper No. 3'' (2005) http://www.developingchild.net/pubs/wp/
    Stress_Disrupts_Architecture_Developing_Brain.pdf. (Accessed June 17,
    2009).
        \3\ http://www.readynation.org/uploads//
    20130919_ReadyNationVitalLinksLowResEndnotes.pdf, Schweinhart, L. J.,
    Montie, J., Xiang, Z., Barnett, W. S., Belfield, C. R., & Nores, M.
    (2005). Lifetime Effects: The High/Scope Perry Preschool Study Through
    Age 40. Ypsilanti, MI: High/Scope Press. And Reynolds, A. J., Temple,
    J. A., Robertson, D. L., & Mann, E. A. (2002). Age 21 Cost-Benefit
    Analysis of the Title I Chicago Child-Parent Centers. Madison, WI:
    Institute for Research on Poverty. And FPG Child Development Center.
    (1999). Early Learning, Later Success: The Abecedarian Study. Chapel
    Hill, NC: University of North Carolina.
    ---------------------------------------------------------------------------
    The Quality of Early Childhood Facilities Matters
        While many factors contribute to program quality, the physical
    environment is an essential feature that is often overlooked. The link
    between the quality of buildings and the quality of programs tends to
    be only vaguely understood and largely undocumented among child care
    providers. Despite this inclination, evidence about the connection
    between space and effectiveness has been found even when physical space
    is not the focal point of the research undertaken. A study conducted at
    the School for Young Children (SYC), a distinguished preschool program
    housed at St. Joseph College in West Hartford, Connecticut, provides a
    compelling example.\4\
    ---------------------------------------------------------------------------
        \4\ Tony Proscio, Carl Sussman & Amy Gillman, Authors, Child Care
    Facilities: Quality by Design, (2004). http://www.lisc.org/content/
    publications/detail/815 .
    ---------------------------------------------------------------------------
        Every State has a minimum adult-child ratio for licensed centers,
    in large part because attention from nurturing adults is a prime
    indicator of quality in child care programs. SYC is a highly regarded
    preschool program with a more than ample staffing ratio; the program is
    largely viewed as meeting if not exceeding minimum quality standards.
    Yet, when a research team set out to monitor enrolled children's
    contact with adults during free play time they found shocking results:
    Only 3 percent of the children's time was spent engaged in meaningful
    interactions with a teacher.
        While the SYC executive director was digesting the researchers'
    negative findings in order to develop a workable solution, her
    organization moved to new accommodations. A routine follow-up test in
    the new space immediately showed a strikingly higher result. Teacher-
    child interactions increased to 22 percent. There had been no change in
    the management, staff, or program, only the physical space. The new
    space, which Bye had taken pains to design, was considerably roomier
    and there were bathrooms, telephones, storage space, and other
    logistical necessities in each classroom. Adults no longer had to leave
    the room to escort children to the bathroom, retrieve or store
    supplies, or take a phone call. Fewer distractions and interruptions
    for adults naturally meant more time for children.
        Both children and staff benefited from the new space configuration.
    The more generous square footage allowed staff to configure each
    classroom into well-defined areas for different activities. Children
    were no longer crowded together into inadequate space and distracted by
    one another, so they ran into conflicts less often, and had better play
    experiences--making their interactions with adults and other children
    more constructive. Teachers were able to use their time in a more
    effective and rewarding way, resulting in higher morale and lower staff
    turnover for. Overall, the effect of the new space on the content of
    the program was considerable and measurable--even when not a single
    change had been made in the program itself.
        Space matters: a facility's layout, size, materials and design
    features can improve program quality and contribute positively to child
    development while a poorly adapted and overcrowded environment
    undermines it.\5\ Bathrooms adjacent to classrooms, accessible cubbies,
    and child-sized sinks, counters, furnishings and fixtures increase
    children's autonomy and competence while decreasing the demands on
    teachers. Early learning centers with ample classrooms divided into
    well-configured activity areas support uninterrupted self-directed pay
    and exploration. The physical configuration of early care and education
    spaces directly affect adult/child interaction and influence how
    children grow and learn.
    ---------------------------------------------------------------------------
        \5\ http://www.lisc.org/docs/publications/2007
    _nieer_cick_facilities_brief.pdf
    ---------------------------------------------------------------------------
        The National Association for the Education of Young Children
    (NAEYC) acknowledges the importance of a quality environment in the
    following statement: ``The physical environment sets the stage and
    creates the context for everything that happens in any setting--a
    classroom, a play yard, a multipurpose room. A high-quality environment
    welcomes children; engages children in a variety of activities;
    provides space for individual, small-group, and large-group activities;
    and generally supports the program's philosophy and goals. Ultimately,
    the physical environment must convey values and messages about who is
    welcomed, what is important, and what the beliefs are about how
    children learn.'' \6\
    ---------------------------------------------------------------------------
        \6\ http://www.naeyc.org/store/node/402
    ---------------------------------------------------------------------------
    What Facilities Experts Know
        Although physical spaces play an important role in promoting
    program quality and healthy development, it is rare to find high
    quality facilities designed to meet the unique needs of very young
    children, especially in low-income communities. Early childhood
    specialists have long maintained that the physical environments where
    learning takes place--and where young children spend the majority of
    their waking hours--significantly influence the quality of early care
    and education programs.
        Facilities experts and those proficient in financing the design,
    acquisition, construction, and improvement of early care and education
    spaces concur and largely agree that:
      --Well-designed facilities enhance child development and program
            quality;
      --An adequate supply of facilities is needed to support rapidly
            increasing preschool education programs;
      --The quality and location of the facilities can encourage enrollment
            and parent involvement;
      --Facilities can help promote a positive workplace in an industry
            challenged to retain experienced teachers;
      --Child care program income, especially in low-income communities, is
            typically not sufficient to cover the full cost of delivering
            quality early education services and doesn't allow for the
            added cost of constructing or improving appropriate facilities;
            and
      --Few centers have the experience or personnel to handle the
            complexities of real estate development tasks and require
            specialized technical assistance to address their facilities
            needs.
        Early Childhood Facilities Financing Challenges
        Despite what is known about the importance of the spaces where
    learning takes place, there is no dedicated source of capital to help
    early care and education programs develop well-designed facilities
    suitable for our youngest learners. Programs serving low-income
    communities are highly dependent on public operating revenues that
    don't cover the cost of purchasing or renovating an appropriate
    facility. Without a consistent and effective financing system or
    capital subsidies, providers are left to pursue piecemeal approaches,
    cobbling together small donations and grants from a variety of sources.
    This prevents the early childhood field from addressing its physical
    facility needs and creating the kind of environments that support high
    quality programs.
        Historically, private financial institutions have not made
    significant infrastructure investments in early care and education--
    particularly in economically distressed areas. Few mainstream banks,
    credit unions, and lending institutions are willing to finance early
    childhood facility projects, which tend to require relatively small,
    complex loans often characterized by uncertain future funding for
    repayment through government operating subsidies. The projects
    generally have little to no equity, and limited collateral value. In
    addition, private banks typically don't employ staff with specialized
    knowledge of the child care sector, consequently they are unable to
    understand the needs of child care or preschool centers and assist
    program directors lacking experience with real estate development and
    financing.
        Certified Community Development Financial Institutions (CDFI)
    working in market niches that are underserved by traditional financial
    entities are among the small number of organizations who have made
    investments in early childhood physical spaces. They have a proven
    track record in economically challenged regions and are experienced
    with providing a unique range of financial products and services that
    spur private investment in their target markets. Unfortunately, given
    the limited funding available to CDFIs to carry out their comprehensive
    mission, demand for early childhood facilities capital far outstrips
    supply.
                                recommendations
        As Congress considers ways to help children get an early start on
    the pathway to success, we urge you to:
          1. Recognize the critical role that early childhood facilities
            play in preparing young children for achievement in school and
            in life.
          Congress has the power to influence and support State and local
            early childhood priorities. We believe that conversations about
            early care and education should always acknowledge the
            significant impact of early childhood physical settings on
            early learning.
          2. Ensure that Federal policies adequately finance the
            acquisition, construction, and improvement of early care and
            education spaces.
          Currently, there is no dedicated source of funding for the
            acquisition, construction, and improvement of early care and
            education spaces. Additionally, the economic instability of the
            past 5 years has resulted in very little investment in early
            childhood physical infrastructure. Capital must be available in
            order for early care and education providers to create high
            quality physical spaces that promote early learning. We are
            encouraged by the national dialogue on the importance of
            investments in early childhood development, and request that
            you create the supportive policy, regulatory, and funding
            environment that is needed to enable the early care and
            education field to meet its physical capital needs.
                                   conclusion
        As investments are made to increase access to preschool and child
    care, attention must be paid to the physical environment where many
    young children spend the majority of their waking hours. Without
    support for facilities, programs will locate in the least expensive and
    most readily available spaces--makeshift, donated, or surplus space
    such as basements and storefronts or outdated classrooms for older
    students that have not been adapted for our youngest children and fall
    far short of standards to support high quality programs.
        We look forward to continuing conversations with you and your
    staff. Our organization serves on the Executive Committee of the
    National Children's Facilities Network (NCFN), a coalition of like-
    minded nonprofit financial and technical assistance intermediaries
    involved in planning, developing, and financing facilities for low-
    income child care and early education programs. Both LISC and NCFN
    would welcome an opportunity to serve as a resource.
        Thank you again for your leadership.

        [This statement was submitted by Matthew Josephs, Senior Vice
    President, Policy, and Amy Gillman, Senior Program Director, Community
    Investment Collaborative For Kids.]
                                     ______

              Prepared Statement of the March of Dimes Foundation

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

        The three million volunteers and 1,200 staff members of the March
    of Dimes Foundation appreciate the opportunity to submit Federal
    funding recommendations for fiscal year 2015. The March of Dimes is a
    unique partnership of scientists, clinicians, parents, members of the
    business community and other volunteers affiliated with chapters in
    every State, the District of Columbia and Puerto Rico. The March of
    Dimes recommends the following funding levels for programs and
    initiatives that are essential investments in maternal and child
    health.
                                 preterm birth
        Preterm birth is a serious health problem that costs the United
    States more than $26 billion annually. Employers, private insurers and
    individuals bear approximately half of the cost of healthcare for these
    infants, and another 40 percent is paid by Medicaid. One in nine
    infants in the U.S. is born preterm. Prematurity is the leading cause
    of newborn mortality and the second leading cause of infant mortality.
    Among those who survive, one in five faces health problems that persist
    for life such as cerebral palsy, intellectual disabilities, chronic
    lung disease, and deafness. For the past 6 years preterm birth rates
    have declined, resulting in 176,000 fewer babies being born preterm and
    saving more than $9 billion. The March of Dimes believes a key factor
    behind this continued decline was Congress' passage of the 2006 PREEMIE
    Act (Public Law 109-450), which brought the first-ever national focus
    to prematurity prevention and generated a public-private agenda to spur
    innovative research at the National Institutes of Health (NIH) and
    Centers for Disease Control and Prevention (CDC) and advanced evidence-
    based interventions to prevent preterm birth. In 2013 Congress passed
    the PREEMIE Reauthorization Act (Public Law 113-55), which renews our
    Nation's commitment to giving every baby a healthy start. The March of
    Dimes' fiscal year 2015 funding requests regarding preterm birth are
    based on continuing to enhance public and private investment into
    understanding the causes of preterm birth and promoting known
    interventions.
    Eunice Kennedy Shriver National Institute of Child Health and Human
            Development (NICHD)
        The March of Dimes recommends at least $32 billion for the National
    Institutes of Health and $1,370 billion for the NICHD in fiscal year
    2015. This funding will allow NICHD to sustain its preterm birth-
    related research through extramural grants, Maternal-Fetal Medicine
    Units, the Neonatal Research Network and the intramural research
    program. This funding would also allow for NICHD to continue
    investments in transdisciplinary research to identify the causes of
    preterm birth, as recommended in the Director's 2012 Scientific Vision
    for the next decade, the Institute of Medicine 2006 report on preterm
    birth, and the 2008 Surgeon General's Conference on the Prevention of
    Preterm Birth. The March of Dimes fully supports NICHD's pursuit of
    transdisiplinary science, which facilitates the exchange of scientific
    ideas and leads to novel approaches to understanding complex health
    issues and their prevention.
    Centers for Disease Control and Prevention--Preterm Birth
        The mission of the CDC's National Center for Chronic Disease
    Prevention and Health Promotion's Safe Motherhood Initiative is to
    promote optimal reproductive and infant health. The March of Dimes
    recommends funding of $46 million for the Safe Motherhood program and
    re-instatement of the preterm birth sub-line at $2 million, as
    reauthorized in the PREEMIE Reauthorization Act, to reflect current
    preterm birth research within the CDC.
        The CDC funds state-based Perinatal Quality Collaboratives,
    networks of hospitals, healthcare providers, State health departments,
    consumer groups, and others that advance evidence-based clinical
    practices and processes. These networks collect data in real time on
    healthcare practices and outcomes and provide immediate feedback for
    quality improvement. For example, the New York State Obstetrical and
    Neonatal Quality Collaborative reduced deliveries without indication
    from 25 percent in 2010 to 7-8 percent in 2012. Reducing elective
    deliveries before 39 weeks gestation is a proven way to lower preterm
    birth and improve infant outcomes.
    Health Resources and Services Administration (HRSA)--Preterm Birth
        The March of Dimes recommends the Subcommittee specify $3 million
    within the Title V Special Projects of Regional and National
    Significance account be used to support current preterm birth and
    infant mortality initiatives, as authorized in the PREEMIE Act, and to
    support the expansion of its initiatives nationwide. The PREEMIE
    Reauthorization Act renewed preterm birth-related demonstration
    projects, which are aimed at improving education, treatment and
    outcomes for babies born preterm. This funding will support HRSA's
    Collaborative Improvement & Innovation Network (COIIN) to Reduce Infant
    Mortality, which assists State agencies focusing on a range of
    interventions proven to reduce preterm birth and improve maternal and
    child health.
                                 birth defects
        According to the CDC, an estimated 120,000 infants in the U.S. are
    born with major structural birth defects each year. Birth defects are
    the leading cause of infant mortality and the causes of more than 70
    percent are unknown. Federal investments are sorely needed to support
    research to discover the causes of all birth defects and for the
    development of effective interventions to prevent them or reduce their
    prevalence.
    CDC--National Center on Birth Defects and Developmental Disabilities
            (NCBDDD)
        For fiscal year 2015, the March of Dimes recommends funding of $139
    million for NCBDDD. We also request the Subcommittee provide at least
    $22.3 million to support birth defects research and surveillance and
    $2.8 million to support folic acid education. Birth defects research
    and surveillance activities have been severely curtailed due to funding
    reductions which means a slowed pace to research identifying causes of
    birth defects and decreased ability to track birth defects and connect
    families to services. Specifically, two Centers for Birth Defects
    Research and Prevention have been eliminated. Specific expertise from
    the previously funded Centers in Texas and Utah (medications used
    during pregnancy, environmental exposures of concern, maternal
    infections, and birth defects risk among Hispanics) is no longer
    contributing to the study and 25 percent fewer families are
    participating in CDC birth defects research. Birth defects surveillance
    programs funded by NCBDDD have gone from 28 in 2004 to 14 in 2013, with
    a 40 percent (800,000) reduction in the number of live births monitored
    by States.
                               newborn screening
        Newborn screening is a vital public health activity designed to
    identify genetic, metabolic, hormonal and functional disorders in
    newborns. Screening detects conditions in newborns that, if left
    untreated, can cause disability, developmental delays, intellectual
    disabilities, serious illnesses or even death. If diagnosed early, many
    of these disorders can be managed successfully. The March of Dimes
    urges the Subcommittee to provide $18 million for HRSA's heritable
    disorders program, which plays a critical role in assisting States in
    the adoption of additional screenings, enhancing provider and consumer
    education, and ensuring coordinated follow-up care. Also funded by this
    program is the work of the Advisory Committee on Heritable Disorders in
    Newborns and Children, which provides States with a Recommended Uniform
    Screening Panel (RUSP) to ensure that every infant is screened for
    conditions having a known treatment. The RUSP has helped bring about
    comprehensive newborn screening in every State. In 2007, only 10 States
    and DC required infants to be screened for the recommended disorders;
    today, 42 States and DC require screening of at least 29 of the 31
    treatable conditions.
                                    closing
        The Foundation's volunteers and staff in every State, the District
    of Columbia and Puerto Rico look forward to working with Members of
    this Subcommittee to secure the resources needed to improve the health
    of the Nation's mothers, infants and children.
                                     ______

                  Prepared Statement of The Marfan Foundation
        Chairman Harkin and distinguished members of the Subcommittee,
    thank you for your time and your consideration of the priorities of the
    heritable connective tissue disorders community as you work to craft
    the fiscal year 2015 Labor, Health and Human Services Appropriations
    Bill.
        about marfan syndrome and heritable connective tissue disorders
    Marfan Syndrome
        Marfan syndrome is a genetic disorder that affects the body's
    connective tissue. Connective tissue holds all the body's cells, organs
    and tissue together. It also plays an important role in helping the
    body grow and develop properly.
        Connective tissue is made up of proteins. The protein that plays a
    role in Marfan syndrome is called fibrillin-1. Marfan syndrome is
    caused by a defect (or mutation) in the gene that tells the body how to
    make fibrillin-1. This mutation results in an increase in a protein
    called transforming growth factor beta, or TGF-b. The increase in TGF-b
    causes problems in connective tissues throughout the body, which in
    turn creates the features and medical problems associated with Marfan
    syndrome and some related disorders.
        Because connective tissue is found throughout the body, Marfan
    syndrome can affect many different parts of the body, as well. Features
    of the disorder are most often found in the heart, blood vessels,
    bones, joints, and eyes. Some Marfan features--for example, aortic
    enlargement (expansion of the main blood vessel that carries blood away
    from the heart to the rest of the body)--can be life-threatening. The
    lungs, skin and nervous system may also be affected. Marfan syndrome
    does not affect intelligence.
    Related Conditions
        There are disorders related to Marfan syndrome that can cause
    people to struggle with some of the same or similar physical problems.
    Some examples are Loeys-Dietz syndrome, Ehlers-Danlos syndrome, and
    Familial Thoracic Aortic Aneurysm and Dissection.
        Disorders related to Marfan syndrome can also cut lives short,
    particularly when they go unchecked, and they can deeply affect the
    quality of life of the individuals and families who must cope with
    them. Just like people with Marfan syndrome, those affected by related
    disorders need early and accurate diagnosis to ensure they receive
    proper care and treatment.
        Many of these disorders are genetic conditions that, like Marfan
    syndrome, cause the aorta (the main blood vessel that carries blood
    from the heart to the rest of the body) to enlarge, a problem that
    requires medicine and regular monitoring to determine appropriate
    treatment. Other features that may overlap with Marfan syndrome include
    those involving the heart, bones, joints and eyes. Related connective
    tissue disorders include:
      --Loeys-Dietz Syndrome
      --Ehlers-Danlos Syndrome
      --Familial Thoracic Aortic Aneurysm and Dissection
      --Mass Phenotype
      --Ectopia Lentis Syndrome
      --Beals Syndrome
      --Bicuspid Aortic Valve
      --Stickler Syndrome
      --Shprintzen-Goldberg Syndrome
                              about the foundation
        The Marfan Foundation creates a brighter future for everyone
    affected by Marfan syndrome and related disorders.
      --We pursue the most innovative research and make sure that it
            receives proper funding.
      --We create an informed public and educated patient community to
            increase early diagnosis and ensure life-saving treatment.
      --We provide relentless support to families, caregivers, and
            healthcare providers.
        We will not rest until we've achieved victory--a world in which
    everyone with Marfan syndrome or a related disorder receives a proper
    diagnosis, gets the necessary treatment, and lives a long and full
    life.
                               one family's story
        Hector Roman was 36 years old when he died on June 25, 2012, of an
    aortic dissection caused by Marfan syndrome. He was never diagnosed
    with Marfan syndrome--despite being treated by several medical
    specialists for myriad health issues--and he did not know he was a risk
    of a sudden early death. He was in pain for days and didn't rush to the
    hospital because he was frustrated with the lack of help he was getting
    with his health concerns. He had no idea this delay would be deadly.
    After a few days in pain, he went into shock and a friend call 911. He
    died 3 days later during his third surgery.
        Now, his partner, Teresita Mompeller, of Phoenix, AZ, is raising
    their three boys--Jovan,5, Joel, 3, and Justus, 2--alone. After Hector
    died, Teresita learned about Marfan syndrome. Most alarming to her was
    that affected people have a 50 percent chance of passing it to their
    offspring. She had her sons checked immediately. Joel and Justus have
    been diagnosed with Marfan syndrome and already have aortic
    enlargement. While their condition is the same as their dad; their
    prognosis is better. The boys can live a normal life span because they
    have the diagnosis and are being monitored. They can avoid a fatal
    situation because they know.
        Teresita, who has a Facebook page called ``Do You Know Marfan?''
    (and a parallel page in Spanish) recently wrote: ``Thanks to the work
    of The Marfan Foundation, I know that my boys have a greater chance of
    living a long life. I know first-hand what it is to be a mother with
    many questions and concerns about a rare disorder that nobody seemed to
    know anything about. The Marfan Foundation has guided me through all of
    my concerns. They have given me all the support and information needed
    to advocate for my children [so they receive] proper treatment. The
    Foundation has given me and thousands of other people, the peace of
    mind that they are working hard to better the lives of those
    affected.''
                                 sequestration
        We have heard from the medical research community that
    sequestration and deficit reduction activities have created serious
    issues for Federal funding opportunities and the career development
    pipeline. In order to ensure that research into heritable connective
    tissue disorders can continue to move forward, and, more importantly,
    to ensure that our country is adequately preparing the next generation
    of young investigators, we urge you to avert, mitigate, or otherwise
    eliminate the specter of sequestration. While the Foundation has
    anecdotal accounts of the harms of sequestration, the Federated
    American Societies for Experimental Biology has reported:
      --In constant dollars (adjusted for inflation), the NIH budget in
            fiscal year 2013 was $6 billion (22.4 percent) less than it was
            in fiscal year 2003.
      --The number of competing research project grants (RPGs) awarded by
            NIH has also fallen sharply since fiscal year 2003. In fiscal
            year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3
            percent) fewer than in fiscal year 2003.
      --Awards for R01-equivalent grants, the primary mechanism for
            supporting investigator-initiated research, suffered even
            greater losses. The number awarded fell by 2,528 (34 percent)
            between fiscal year 2003 and fiscal year 2013.
        The pay line for some NIH funding mechanisms has fallen from 18
    percent to 10 percent while the average age for a researcher to receive
    their first NIH-funded grant has climbed to 42. These are strong
    disincentives to choosing a career as a medical researcher. Our
    scaling-back is occurring at a time when many foreign countries are
    investing heavily in their biotechnology sectors. China alone plans to
    dedicate $300 million to medical research over the next 5 years; this
    amount is double the current NIH budget over the same period of time.
    Scientific breakthroughs will continue, but America may not benefit
    from the return-on-investment of a robust biotechnology sector. For the
    purposes of economic and national security, as well as public health,
    the Foundation asks that you work with your colleagues to eliminate
    sequestration and recommit to supporting this Nation's biomedical
    research enterprise.
                   centers for disease control and prevention
        People with Marfan syndrome are born with it, but features of the
    disorder are not always present right away. Some people have a lot of
    Marfan features at birth or as young children--including serious
    conditions like aortic enlargement. Others have fewer features when
    they are young and don't develop aortic enlargement or other signs of
    Marfan syndrome until they are adults. Some features of Marfan
    syndrome, like those affecting the heart and blood vessels, bones or
    joints, can get worse over time.
        This makes it very important for people with Marfan syndrome and
    related disorders to receive accurate, early diagnosis and treatment.
    Without it, they can be at risk for potentially life-threatening
    complications. The earlier some treatments are started, the better the
    outcomes are likely to be.
        Knowing the signs of Marfan syndrome can save lives. Our community
    of experts estimates that nearly half the people who have Marfan
    syndrome don't know it. CDC and NCBDDD have critical programs that can
    help improve awareness and recognition of warning signs, which can save
    lives. Some of these programs including CDC's Million Hearts Campaign
    and NCBDDD's newborn screening activities. Meaningful funding increases
    will allow CDC and NCBDDD to expand their successful awareness efforts
    to include additional conditions.
                         national institutes of health
        NIH has worked closely with the Foundation to investigate the
    mechanisms of these conditions. In recent decades, this research has
    yielded significant scientific breakthroughs that have the potential to
    improve the lives of affected individuals. In order to ensure that the
    heritable connective tissue disorders research portfolios can continue
    to expand and advance, NIH requires meaningful funding increases to
    invest in emerging and promising activities.
    NHLBI
        The Marfan Foundation anxiously await the results of this first-
    ever multicenter clinical trial for our patient population conducted by
    the National Heart, Lung and Blood Institute's Pediatric Heart Network
    (PHN). After 4 years of recruitment and 3 years of follow-up
    evaluations, the results are expected to be released in November 2014
    at the American Heart Association Meeting. 604 Marfan syndrome patients
    (age 6 months to 25 years) are enrolled in the study. Patients are
    randomized onto either losartan or atenolol (a beta blocker that is the
    current standard of care for Marfan patients with an enlarged aortic
    root). The Marfan Foundation thanks both NHLBI and NIAMS for their
    dedicated support and careful execution of this trial.
    NEI
        Ectopia lentis, dislocation of the lens, occurs in up to 60 percent
    of patients with Marfan syndrome. The central positioning of the lens
    depends on the zonule of Zinn, a fibrous structure which has fibrillin-
    1 as a major component. NEI-supported investigators are studying the
    protein interactions of fibrillin-1 in health and disease in the zonule
    of Zinn to understand the disease mechanisms that cause ectopia lentis.
    It is hoped that this research will provide therapeutic insights to
    better treat this complication of Marfan syndrome.
    NIAMS
        NIAMS continues to support the Consortium for Translational
    Research in Marfan Syndrome, which is investigating the disease process
    in MFS. These studies, building on previous advances, are aimed at
    identifying new biological targets for therapy, as well as predictive
    biomarkers of vascular and skeletal manifestations, which are the major
    causes of mortality and morbidity in MFS.
    ORDR
        The National Center for Advancing Translational Sciences houses
    ORDR and leads other important activities. In addition to the Rare
    Disease Clinical Research Consortia, translational treatment
    development programs hold promise for the heritable connective tissue
    disorders community.
                                     ______

        Prepared Statement of Mary A. Vitale, Guardian/Sibling/Advocate
        Dear Committee Members: The opportunity to submit personal
    testimony to this committee is much appreciated. As 2015 appropriation
    requests are being considered, this submission of testimony is a
    request for a review of the misuse of Federal funds by the Health and
    Human Services (HHS) agencies that promote forced
    deinstitutionalization of persons with severe and profound intellectual
    disabilities.
        I have been an active guardian for 35 years for my 61 year old
    brother who has severe intellectual disabilities, behavior challenges,
    and ongoing medical concerns. He has never been able to walk or talk.
    He has only partial use of one of his arms. He needs maximum assistance
    for all his needs. Despite his many disabilities, he is a happy man.
    His care at his intermediate care facility for individuals with
    intellectual disabilities (ICF/IID) home is successful, stable,
    sustainable, consistent, comprehensive, and cost-effective.
        HHS agencies, such as State Planning Councils and State Protection
    and Advocacy Services, are misusing Federal funds to promote the
    closing of ICF/IID homes like where my brother lives, despite the
    objections of legal guardians.
        The Supreme Court 1999 Olmstead ruling states: ``It would be
    unreasonable, it would be a tragic event, then, were the Americans with
    Disabilities Act of 1990 (ADA) to be interpreted so that States had
    some incentive, for fear of litigation to drive those in need of
    medical care and treatment out of appropriate care and into settings
    with too little assistance and supervision.''
        To the great dismay of families, this ``tragic event'' is exactly
    what is happening across the United States by the misuse of HHS
    funding.
        Appropriate, cost-effective care for those with the severest
    disabilities is available in ICF/IID homes, and yet they are
    aggressively targeted for closure, flagrantly ignoring the educated
    choice of guardians.
        Many community settings have too little assistance and too little
    supervision to be appropriate for those with severe multiple
    intellectual and physical impairments. Tragically, the result is an
    increase in neglect and abuse.
        I ask each member of this committee to seriously question HHS about
    misusing Federal funds to promote forced total deinstitutionalization
    for persons with intellectual disabilities. Help us keep our beloved
    family members safe and healthy.
                                     ______

        Prepared Statement of the Meals On Wheels Association of America
        Chairman Harkin and Ranking Member Moran: Thank you for the
    opportunity to present testimony to your Subcommittee concerning fiscal
    year 2015 funding for Older Americans Act (OAA) Nutrition Programs
    administered by the Administration for Community Living/Administration
    on Aging within the U.S. Department of Health and Human Services. We
    are sincerely grateful for your longstanding support, as well as your
    leadership in ensuring that these programs received a restoration of
    funding in fiscal year 2014 over the devastating fiscal year 2013
    sequestration cuts.
        Last month, we sent a joint letter with the National Association of
    Nutrition and Aging Services Program (NANASP) to you, Chairman Mikulski
    and Ranking Member Shelby urging increased investments in OAA Nutrition
    Programs, including the Congregate Nutrition Program, Home-Delivered
    Nutrition Program (commonly referred to as Meals on Wheels), and the
    Nutrition Services Incentive Program. Specifically, we requested
    funding these programs at their fiscal year 2010 levels--totaling $819
    million. During the fiscal year 2015 appropriations process, we implore
    you to give this modest request your utmost consideration due to the
    significant moral and economic benefits these programs offer.
        This week, a new report released by the National Foundation to End
    Senior Hunger shows that nearly 9.3 million Americans over the age of
    60 struggled with hunger in 2012, up from 8.8 million in 2011--and a
    28% increase since the start of the recession in 2007. Because OAA
    funding has not kept pace with needs, the chasm continues to widen.
    Through OAA Nutrition Programs, we are only able to provide nutritious
    meals to 2.5 million of them,\1\ leaving a staggering gap of nearly 7
    million seniors still in need. The infrastructure and network exists to
    serve more of our seniors in need, but the financial resources fall
    substantially short. That is why we are asking for a critical boost in
    funding levels.
    ---------------------------------------------------------------------------
        \1\ 2011 Older Americans Act State Program Reports. U.S. Department
    of Health and Human Services, Administration on Aging. March 2013.
    http://www.agid.acl.gov/.
    ---------------------------------------------------------------------------
        Senior hunger is a growing epidemic that has serious implications
    for our current and future Mandatory spending. Without proper nutrition
    and the critical social connection that comes along with it, one's
    health deteriorates and inevitably fails. It is extremely costly not
    only in personal terms for the individuals who struggle with hunger,
    but also for our Nation in terms of increased healthcare costs. As
    such, we hope that you recognize the need to invest in Discretionary
    programs, like OAA Nutrition Programs, that help prevent and mitigate
    the effects of chronic diseases, improve quality of life, expedite
    recovery after an illness or injury, and reduce unnecessary Medicare
    and Medicaid expenses both today and in the future. These programs are
    part of the solution to our Nation's fiscal challenges.
        For over 40 years, OAA Nutrition Programs in communities large and
    small, urban and rural have been effectively serving our country's most
    vulnerable, frail and isolated seniors. What started as a demonstration
    project has grown into a highly effective community-based, nationwide
    network of more than 5,000 local programs. While not all programs
    receive OAA funds, the majority rely, in part, on the Federal dollars
    authorized under Title III of the Act as a foundation on which to
    leverage other funding. This enables a very successful public-private
    partnership to help raise the remaining resources needed to provide
    daily nutritious meals and social contact to seniors 60 years of age
    and older who are at significant risk of hunger and losing their
    ability to remain independent and able to live in their homes.
        The evidence demonstrates that these programs are not only saving
    lives and taxpayer dollars every day, but they are doing precisely what
    they were designed to do by effectively reaching our Nation's most at-
    risk seniors.
        Data from the 2012 National Survey of OAA Participants shows that
    the seniors receiving Meals on Wheels and congregate meals are
    primarily over age 75, impoverished, live alone, are in poor health and
    functionally impaired. For the majority of the individuals served, the
    meal that they receive provides one half or more of their total food
    for the day.
        Of the seniors receiving Meals on Wheels:
      --60 percent have six to 14 chronic health conditions
      --51 percent take from six to at least 23 medications daily
      --29 percent have three or more limitations in everyday activities,
            such as bathing, getting dressed and toileting
        Of the seniors receiving congregate meals:
      --40 percent have six to 14 chronic health conditions
      --29 percent take from six to at least 23 medications daily
      --50 percent have at least one limitation in everyday activities,
            such as preparing meals or grocery shopping
        Each day, Meals on Wheels programs in Iowa, Kansas and in every
    State across the Nation are serving far more than just meals to seniors
    in need. They are delivering a caring and efficient service--nutritious
    meals, friendly visits, and safety checks--enabling more than 2.5
    million seniors to continue to live independently in their own homes
    and without the worry of hunger and isolation. In short, these programs
    are a lifeline.
        The following comments from individuals served illustrate the
    degree to which these OAA Nutrition Programs are delivering far more
    than just a meal.
      --``The companionship and fellowship as well as the nutritious meals
            keep me getting up in the morning, getting dressed and to the
            site to eat.''
      --``My husband needs lots and lots of help . . .  If it wasn't for
            meals, I wouldn't be able to continue taking care of him in our
            home.''
      --``If it wasn't for Meals on Wheels, I would starve.''
      --``Once a day a knock at my door means I eat for that day.''
      --``I am so grateful for the volunteer drivers . . . sometimes it is
            the only human contact I have for days.''
      --``I had major surgery. I feel these meals are big step toward
            keeping me from going to a nursing home.''
      --``I do not get much social security so at least I have food to eat;
            this is my only meal; I am 89 and need Meals on Wheels or I
            can't stay in my home; the friendly volunteers are the only
            people I see most days.'' \2,3\
    ---------------------------------------------------------------------------
        \2\ Lloyd, Jean & Greuling, Holly. The Older Americans Act
    Nutrition Program Sets a New Table. Aging Today Online. American
    Society on Aging. March 2014. http://bit.ly/ONK7eK.
        \3\ Don't Empty My Plate Campaign: http://bit.ly/1oUgRQ9 and http:/
    /bit.ly/1jvLSGO.
    ---------------------------------------------------------------------------
        Beyond the real people and lives these programs impact on a daily
    basis, there is increasing and irrefutable evidence that improving and
    bolstering funding for OAA Nutrition Programs will substantially reduce
    healthcare costs--both in the short- and long-term. A recent report
    from the Center for Effective Government found that for every $1
    invested in Meals on Wheels, up to $50 could be saved in Medicaid
    alone.\4\ Brown University conducted a recent study which found that by
    investing more in Meals on Wheels, more seniors can be kept out of
    nursing homes. Specifically, the research found that for every
    additional $25 a State spends on home-delivered meals each year, per
    person over 65, the low-care nursing home population--seniors who are
    nursing home eligible but could remain in their homes with only a
    little outside support--decreases by a percentage point.\5\ One
    percentage point can translate to billions of dollars in savings
    annually.
    ---------------------------------------------------------------------------
        \4\ Schieder, Jessica & Lester, Patrick. Sequestering Meals on
    Wheels Could Cost the Nation $489 Million per year. The Center for
    Effective Government. April 2013. http://bit.ly/16jmmRU.
        \5\ Thomas, Kali & Mor, Vincent. The Relationship between Older
    Americans Act Title III State Expenditures and Prevalence of Low-Care
    Nursing Home Residents. Brown University. December 2012. http://bit.ly/
    16wl0B2.
    ---------------------------------------------------------------------------
        On top of the social and economic cases for investing in OAA
    Nutrition Programs, the public overwhelmingly supports them. In fact,
    an October 2013 survey found that 7 in 10 Americans agree that the
    government should pay for Meals on Wheels.\6\ The growing problem of
    senior hunger in America requires the continued public-private
    partnerships that have been a pivotal foundation; however, the Federal
    Government must serve as the strongest and most reliable fiscal partner
    by elevating its support to higher levels that keep pace with a rapidly
    aging population, increased need and ever-rising costs.
    ---------------------------------------------------------------------------
        \6\ SSRS, independent research company. Survey among a nationally
    representative sample of respondents age 18+. October 2013.
    ---------------------------------------------------------------------------
        We understand the difficult decisions you and your colleagues are
    tasked with in fiscal year 2015 and beyond. However, the evidence
    demonstrates that these programs are not only saving lives and taxpayer
    dollars every day, but they are effectively reaching our Nation's most
    vulnerable seniors and have the capacity to serve more if properly
    resourced. In short, these proven and effective programs are a part of
    the solution to our Nation's fiscal challenges and should be looked to
    as such.
        As your Subcommittee crafts and considers the fiscal year 2015
    Labor-HHS-Education appropriations bill, we ask that you provide fiscal
    year 2010 appropriations levels for all three nutrition programs
    authorized under the OAA--Congregate Nutrition Program, Home-Delivered
    Nutrition Program, and the Nutrition Services Incentive Program. You
    have the ability to shorten waiting lists and increase the number of
    nutritious meals we can serve to seniors today. At the same time you
    will be investing in a stronger fiscal path for our country by reducing
    future healthcare costs.
        Again, we thank you for the opportunity to present this testimony
    to you, and for your continued support.
                                     ______

     Prepared Statement of the Medical Library Association and Association
                     of Academic Health Sciences Libraries
                  summary of fiscal year 2015 recommendations
      --Continue the commitment to the National Library of Medicine (NLM)
            by supporting the President's budget proposal which requests
            $372.85 million, and an additional $8.2 million from amounts
            under Section 241 of the Public Health Service Act, for the
            National Information Center on Health Services Research and
            Health Care Technology.
      --Continue to support the medical library community's role in NLM's
            outreach, telemedicine, disaster preparedness, health
            information technology initiatives, and healthcare reform
            implementation.
                                  introduction
        The Medical Library Association (MLA) and Association of Academic
    Health Sciences Libraries (AAHSL) thank the Subcommittee for the
    opportunity to submit testimony regarding fiscal year 2015
    appropriations for the National Library of Medicine (NLM), an agency of
    the National Institutes of Health (NIH). Working in partnership with
    the NIH and other Federal agencies, NLM is the key link in the chain
    that translates biomedical research into practice, making the results
    of research readily available to all who need it.
    NLM Leverages NIH Investments in Biomedical Research
        In today's challenging budget environment, we recognize the
    difficult decisions Congress faces as it seeks to improve our Nation's
    fiscal stability. We thank the Subcommittee for its long-standing
    commitment to strengthening NLM's budget. While extramural funding
    comprises the largest portion of funding for institutes within the NIH,
    some eighty percent of NLM's budget supports intramural services and
    programs that sustain the Nation's biomedical research enterprise and
    more--it builds, sustains, and augments NLM's suite of more than 200
    databases which provide information access to health professionals,
    researchers, educators, and the public. Intramural funding also
    supports all aspects of library operations and programs, including the
    acquisition, organization, preservation, and dissemination of the
    world's biomedical literature, no matter the medium.
        In fiscal year 2015 and beyond, it is critical to continue
    augmenting NLM's baseline budget to support expansion of its
    information resources, services, and programs which collect, organize,
    and make readily accessible rapidly expanding biomedical knowledge
    resources and data. NLM maximizes the return on the investment in
    research conducted by the NIH and other organizations. The Library
    makes the results of biomedical information more accessible to
    researchers, clinicians, business innovators, and the public, enabling
    such data and information to be used more efficiently and effectively
    to drive innovation and improve health. NLM is a leader in Big Data and
    plays a critical role in accelerating nationwide deployment of health
    information technology, including electronic health records (EHRs), by
    leading the development, maintenance and dissemination of key standards
    for health data interchange that are now required of certified EHRs.
    NLM also contributes to Congressional priorities related to drug safety
    through its efforts to expand its clinical trial registry and results
    database (ClinicalTrials.gov) in response to legislative requirements,
    and to the Nation's ability to prepare for and respond to disasters.
    Growing Demand for NLM's Basic Services
        NLM delivers more than a trillion bytes of data to millions of
    users daily that helps researchers advance scientific discovery and
    accelerate its translation into new therapies; provides health
    practitioners with information that improves medical care and lowers
    its costs; and gives the public access to resources and tools that
    promote wellness and disease prevention. Every day, medical librarians
    across the Nation use NLM services to assist clinicians, students,
    researchers, and the public in accessing information they need to save
    lives and improve health. Without NLM, our Nation's medical libraries
    would be unable to provide the quality information services that our
    Nation's health professionals, educators, researchers and patients
    increasingly need.
        NLM's data repositories and online integrated services such as
    GenBank, PubMed, and PubMed Central are revolutionizing medicine and
    ushering in an era of personalized medicine in which care is based on
    an individual's unique genetic profile. GenBank is the definitive
    source of gene sequence information. PubMed, with more than 23 million
    citations to the biomedical literature, is the world's most heavily
    used source of bibliographic information. Approximately 760,000 new
    citations were added in fiscal year 2013, and the database provided
    high quality medical information to about 2.3 million users each day.
    PubMed Central is NLM's digital archive which provides public access to
    the full-text versions of more than 3 million biomedical journal
    articles, including those produced by NIH-funded researchers. On a
    typical weekday more than one million users download 1.65 million full-
    text articles, including those submitted in compliance with the NIH
    Public Access Policy.
        As the world's largest and most comprehensive medical library,
    NLM's traditional print and electronic collections continue to steadily
    increase each year, standing at more than 21 million items--books,
    journals, technical reports, manuscripts, microfilms, photographs and
    images. By selecting, organizing and ensuring permanent access to
    health sciences information in all formats, NLM ensures the
    availability of this information for future generations, making it
    accessible to all Americans, irrespective of geography or ability to
    pay, and guaranteeing that citizens can make the best, most informed
    decisions about their healthcare.
    Encourage NLM Partnerships
        NLM's outreach programs are essential to MLA and AAHSL membership
    and to the profession. Through the National Network of Libraries of
    Medicine (NN/LM), with over 6,000 members in communities nationwide,
    these activities educate medical librarians, health professionals and
    the general public about NLM's services and train them in the most
    effective use of these services. The NN/LM promotes educational
    outreach for public libraries, secondary schools, senior centers and
    other consumer-based settings, and its emphasis on outreach to
    underserved populations helps reduce health disparities among large
    sections of the American public. NLM's ``Partners in Information
    Access'' program improves access by local public health officials to
    information which prevents, identifies and responds to public health
    threats and ensures every public worker has electronic health
    information services that protect the public's health.
        NLM's MedlinePlus provides consumers with trusted, reliable health
    information on more than 900 topics in English and Spanish. It has
    become a top destination for those seeking information on the Internet,
    attracting more than 1.2 million visitors daily. NLM has continued to
    make enhancements to MedlinePlus, with selected materials now available
    in forty other languages. Other products and services that benefit
    public health and wellness include the NIH MedlinePlus Magazine and NIH
    MedlinePlus Salud, available in doctors' offices nationwide, and NLM's
    MedlinePlus Connect--a utility which enables clinical care
    organizations to implement links from their electronic health records
    systems to relevant patient education materials in MedlinePlus.
        MLA and AAHSL applaud the success of NLM's outreach initiatives,
    and we look forward to continuing to work with NLM on these programs.
    Emergency Preparedness and Response
        Through its Disaster Information Management Research Center, NLM
    collects and organizes disaster-related health information, ensures
    effective use of libraries and librarians in disaster planning and
    response, and develops information services to assist responders. NLM
    responds to specific disasters worldwide with specialized information
    resources appropriate to the need, including information on
    bioterrorism, chemical emergencies, fires and wildfires, earthquakes,
    tornadoes, and pandemic disease outbreaks. MLA and NLM continue to
    develop the Disaster Information Specialization (DIS) program to build
    the capacity of librarians and other interested professionals to
    provide disaster-related health information outreach. Working with
    libraries and publishers, NLM's Emergency Access Initiative makes
    available free full-text articles from hundreds of biomedical journals
    and reference books for use by medical teams responding to disasters.
    MLA and AAHSL ask the Subcommittee to support NLM's role in this
    crucial area which ensures continuous access to health information and
    use of libraries and librarians when disasters occur.
    Health Information Technology and Bioinformatics
        For more than 40 years, NLM has supported informatics research,
    training and the application of advanced computing and informatics to
    biomedical research and healthcare delivery including telemedicine
    projects. Many of today's biomedical informatics leaders are graduates
    of NLM-funded informatics research programs at universities nationwide.
    A number of the country's exemplary electronic and personal health
    record systems benefit from findings developed with NLM grant support.
        The importance of NLM's work in health information technology
    continues to grow as the Nation moves toward more interoperable health
    information technology systems. A leader in supporting the development,
    maintenance, and dissemination of standard clinical terminologies for
    free nationwide use (e.g., SNOMED), NLM works closely with the Office
    of the National Coordinator for Health Information Technology to
    promote the adoption of interoperable electronic records, and has
    developed tools to make it easier for EHR developers and users to
    implement accepted health data standards in their systems.
    Organizational Bios
        The Medical Library Association (MLA) is a nonprofit, educational
    organization with 4,000 health sciences information individual and
    institutional members. Founded in 1898, MLA provides lifelong
    educational opportunities, supports a knowledge base of health
    information research, and works with a network of partners to promote
    the importance of quality information for improved health to the
    healthcare community and the public.
        The Association of Academic Health Sciences Libraries (AAHSL)
    supports academic health sciences libraries and directors in advancing
    the patient care, research, education and community service missions of
    academic health centers through visionary executive leadership and
    expertise in health information, scholarly communication, and knowledge
    management.
        Thank you again for the opportunity to present our views. We look
    forward to continuing this dialogue and supporting the Subcommittee's
    efforts to secure the highest possible funding level for NLM in fiscal
    year 2015 and the years beyond to support the Library's mission and
    growing responsibilities. Information about NLM and its programs can be
    found at http://www.nlm.nih.gov.
                                     ______

       Prepared Statement of the Mesothelioma Applied Research Foundation
        Chairman Harkin, Ranking Member Moran and Members of the
    Subcommittee, thank you for the opportunity to provide written
    testimony on behalf of the mesothelioma community. My name is Mary
    Hesdorffer and I am the Executive Director of the Mesothelioma Applied
    Research Foundation. I am testifying on behalf of the mesothelioma
    community composed of patients, physicians, caregivers and family
    members. I am a Nurse Practitioner with over sixteen years' experience
    working with mesothelioma patients in the clinical setting. I would
    like to use this opportunity to emphasize the great need for increased
    funding for the National Institutes of Health (NIH), including the
    National Cancer Institute (NCI), both of which play a critical role in
    improving treatment for mesothelioma.
        Mesothelioma is an aggressive cancer known to be caused by exposure
    to asbestos. Doctors say it is among the most painful of cancers, and
    the prognosis is poor even with the best available treatment.
        The harsh reality for patients with malignant mesothelioma is that
    it is a terminal illness; the five-year survival rate is five to ten
    percent, making it one of the most deadly cancers. Left untreated,
    survival ranges from six to 9 months, and if treated with the sole Food
    and Drug Administration (FDA) approved therapy, median survival is only
    12.3 months.
        With only one FDA approved treatment available, mesothelioma
    patients must take a trial and error approach to treatment, making
    agonizing decisions each step of the way. Most patients must make the
    tough decision to go into a clinical trial, use off label treatments,
    or undergo drastic surgeries knowing they may see no benefit
    whatsoever. They choose to do this with a powerful hope they can help
    doctors learn how to treat mesothelioma, possibly live a while longer
    and prevent future mesothelioma patients from enduring the same
    difficult experience.
        Fortunately, there are brilliant researchers dedicated to
    mesothelioma. The Mesothelioma Applied Research Foundation has made a
    significant investment, funding a total of $8.7 million to support
    research in hopes of giving researchers the first seed grant they need
    to get started. We need the continued partnership with the Federal
    Government to develop the promising findings into effective treatments.
        In research, innovative and personalized therapies from the mapping
    of the human genome or those that utilize the body's own immune system
    are becoming a reality for mesothelioma. These developments have the
    potential to reduce the human toll of mesothelioma, but need continued
    research funding to bring the advances from the bench to the bedside.
        Recent research findings have linked mesothelioma to a germline
    mutation in the BAP1 gene and a somatic mutation in the NF2 gene.
    Currently, the research goal of the BAP1 and NF2 genes is for
    prevention and early detection of mesothelioma. For example,
    individuals known to be exposed to asbestos who carry this gene can be
    studied to determine if a cancer signal can be picked up before the
    development of mesothelioma. The idea is that if you have a germ line
    mutation, you and your immediate family will be screened for cancers
    associated with this gene in the hope of picking up an early
    malignancy. Also, researchers will study ways to turn off this gene, if
    defective. There is great potential in these findings.
        Immunotherapy is another exciting area of research. An
    immunotherapy is a treatment that uses certain parts of a person's
    immune system to target cancer, and is one of the most exciting areas
    in cancer research. Dr. Raffit Hassan at the NCI and his collaborators
    have shown that mesothelin, a tumor antigen which was discovered at the
    NCI, is a useful target for tumor-specific therapy of malignant
    mesothelioma. His group is presently conducting clinical trials of
    three different agents targeting mesothelin. Namely, SS1P which is an
    anti-mesothelin immunotoxin, MORAb-009 which is a chimeric anti-
    mesothelin monoclonal antibody and CRS-207 which is a mesothelin tumor
    vaccine. They have seen some success, and it has given patients a
    reason to be optimistic.
        It is efforts like these that give mesothelioma patients hope. I am
    grateful for the Federal Government's investment in mesothelioma
    research and I want to see it continued and increased. Unless
    researchers have the funds to continue, these discoveries will not
    yield improved treatments, patients will run out of options and
    continue to die from this disease.
        Cancer research funding as a share of the NIH budget has declined
    while the scientific and public health need has gone up. In the late
    1990s, NCI's budget made up 18.7 percent of the NIH budget. Today, it
    is 16.4 percent of the NIH budget . That decline has reduced NCI's
    funding by $680 million below what it would have received in fiscal
    year 2014 if its share of NIH's total budget had been maintained.
        The mesothelioma community asks that the Subcommittee recognize the
    National Institutes of Health (NIH) as a critical national priority by
    providing at least $32 billion, including $5.26 Billion for the
    National Cancer Institute in funding in the fiscal year 2015 Labor-HHS-
    Education Appropriations bill. This funding recommendation represents
    the minimum investment necessary to avoid further loss of promising
    research and at the same time allows the NIH's budget to keep pace with
    biomedical inflation.
        I look to the Labor, Health and Human Services, Education and
    Related Agencies Appropriations Subcommittee to provide continued
    leadership and hope to the people who develop this fatal cancer. Thank
    you for the opportunity to submit testimony and for funding the
    National Institutes of Health and the National Cancer Institute at the
    highest possible level.
        About the Mesothelioma Applied Research Foundation:
        The Mesothelioma Applied Research Foundation is the nonprofit
    collaboration of patients and families, physicians, advocates, and
    researchers dedicated to eradicating the life-ending and vicious
    effects of mesothelioma. We believe in a cure for mesothelioma. Given
    the human toll of suffering the disease causes, the compassion and
    energy of the mesothelioma community, the moral, legal and economic
    aspects of asbestos, and the benefits of mesothelioma research to
    cancer research generally, we believe that the resources to accomplish
    this cure are available and must be mobilized. We seek to marshal and
    utilize these resources responsibly, as effectively as possible, with
    financial transparency and by adhering to health policy guidelines that
    foster ethical clinical and administrative practices, and ethical
    decisionmaking to:
      --Offer hope and support to patients and families by educating them
            on the disease, helping them to obtain the most up-to-date
            information on treatment options and to connect with
            mesothelioma treatment specialists, and providing them
            assistance, emotional support and community with others;
      --Fund the highest quality and most promising mesothelioma research
            projects from around the world through rigorous peer-review;
            and
      --Raise awareness of mesothelioma, and advocate that the public and
            private sectors partner in the effort to cure it by directing
            the resources needed to stop this global tragedy
                                     ______

              Prepared Statement of the National AHEC Organization
        The members of the National AHEC Organization (NAO) are pleased to
    submit this statement for the record recommending $75 million in fiscal
    year 2015 for the Area Health Education Center (AHEC) Program
    authorized under Title VII of the Public Health Service Act and
    administered through the Health Resources and Services Administration
    (HRSA) at the Department of Health and Human Services.
        The NAO is the professional organization representing AHECs. The
    AHEC Program is an established and effective national primary care
    training network built on committed partnerships of 53 medical schools
    and academic centers. Additionally, 253 AHEC centers within 48 States
    and tens of thousands of community practitioners are affiliated with
    the AHEC's national clinical training network.
        AHEC is one of the Title VII Health Professions Training programs,
    originally authorized at the same time as the National Health Service
    Corps (NHSC) to create a complete mechanism to provide primary care
    providers for Community Health Centers (CHCs) and other direct
    providers of healthcare services for underserved areas and populations.
    The plan envisioned by creators of the legislation was that the CHCs
    would provide direct service. The NHSC would be the mechanism to fund
    the education of providers and supply providers for underserved areas
    through scholarship and loan repayment commitments.
        The AHEC program would be the mechanism to recruit providers into
    primary healthcareers, diversify the workforce, and develop a passion
    for service to the underserved in these future providers, i.e. Area
    Health Education Centers are the workforce development, training and
    education machine for the Nation's healthcare safety-net programs. The
    AHEC program is focused on improving the quality, geographic
    distribution and diversity of the primary care healthcare workforce and
    eliminating the disparities in our Nation's healthcare system.
        AHECs develop and support the community based training of health
    professions students, particularly in rural and underserved areas. They
    recruit a diverse and broad range of students into healthcareers, and
    provide continuing education, library and other learning resources that
    improve the quality of community-based healthcare for underserved
    populations and areas.
        The Area Health Education Center program is effective and provides
    vital services and national infrastructure. Nationwide, over 379,000
    students have been introduced to healthcareer opportunities, and over
    33,000 mostly minority and disadvantaged high school students received
    more than 20 hours each of healthcareer exposure. Over 44,000 health
    professions students received training at 17,530 community-based sites,
    and furthermore; over 482,000 health professionals received continuing
    education through AHECs. AHECs perform these education and training
    services through collaborative partnerships with Community Health
    Centers (CHCs) and the National Health Service Corps (NHSC), in
    addition to Rural Health Clinics (RHCs), Critical Access Hospitals,
    (CAHs), Tribal clinics and Public Health Departments.
    Justification for Recommendations
        The AHEC network is an economic engine that fuels the recruitment,
    training, distribution, and retention of a national health workforce.
    AHEC stands for JOBS.
      --AHECs are critical in the recruitment, training, and retention of
            the primary care workforce.
      --Research has demonstrated that the community-training network is
            the most effective recruitment tool for the health professions
            and those who teach remain longer in underserved areas and
            communities.
      --AHECs are in almost every county in the United States.
      --With the aging and growing population, the demand for primary care
            workforce is far outpacing the supply.
      --AHECs continue to educate and train current workforce, as well as
            recruiting and preparing future workforce
      --In 2012, AHEC's trained 476,585 Health Professionals in 48 States
            in 13,842 Health Professions Shortage Areas (HPSAs)--26.4
            percent of those trained were physicians (125,818).
      --In 2012, the AHEC's introduced nearly 403,000 students to the
            healthcareers professions and workforce from grades K-College.
      --The AHEC network's outcomes are the backbone of the Nation's
            community-based health professions training, with a focus on
            training primary care workforce.
      --Continued funding for the AHEC program is necessary as demonstrated
            by 1) a growing unmet need for primary care doctors in rural
            areas, and 2) the use of the national network of AHEC programs
            to carry out administrative priorities.
        1.   The National Health Service Corps (NHSC), has been mentioned
                as a program that addresses the priority of increasing
                diversity in the health professions workforce in
                underserved and rural areas and addresses the end of the
                pipeline. The AHEC program engages in pre-pipeline,
                pipeline, and post-pipeline activities that works to move
                individuals through a healthcareers pathway and beyond,
                with a special focus on primary care doctors.
        2.   The national network of the AHEC program has been tasked with:

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

        [This statement was submitted by Rob Trachtenberg, Executive
    Director, National AHEC Organization.]
                                     ______

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

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

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

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

        As NEI works to achieve this goal, it will build upon its
    breakthrough research funded through past Federal investment. For
    example, NEI has been a leader in determining the genetic basis of
    disease-the research it has funded has identified more than 500 genes
    associated with both common and rare eye diseases, which is 7.5 percent
    of all disease-causing genes discovered to-date. Understanding the
    genetic basis of the disease and underlying mechanisms will lead to
    better diagnostics and therapies. Since last year's testimony, NEI has
    announced that:
      --The AMD Gene Consortium, a network of international investigators
            representing 18 research groups, has discovered seven new
            regions of the human genome-called loci-that are associated
            with increased risk of AMD. They also confirmed 12 loci already
            identified in previous studies. These loci implicate a variety
            of biological functions, including regulation of the immune
            system, maintenance of cellular structure, growth and
            permeability of blood vessels, lipid metabolism, and
            atherosclerosis. AMD is the leading cause of vision loss
            overall, as well as the leading cause in individuals are 60-
            plus.
      --The NEI Glaucoma Human Genetics Collaboration (NEIGHBOR)
            Consortium, which involves clinicians and geneticists at
            multiple institutions throughout the U.S. who are studying
            genetic variants associated with Primary Open Angle Glaucoma-
            the most common form of the disease-has identified the first
            common genetic risk factors for normal pressure glaucoma.
            NEIGHBOR, unique because it is the largest Genome-Wide
            Association Study to-date, will generate new insights into the
            molecular pathogenesis, effective screening and prevention
            strategies, and more rational treatment approaches for this
            disease. Glaucoma is three-to-four times more prevalent in
            African Americans than non-Hispanic Whites and is the leading
            cause of blindness in the Latino population.
        These are ambitious goals that require increased-not decreased-
    funding. Our Nation's investment in vision health is an investment in
    its overall health. NEI's breakthrough research is a cost-effective
    investment, since it is leading to treatments and therapies that can
    ultimately delay, save, and prevent health expenditures, especially
    those associated with the Medicare and Medicaid programs. It can also
    increase productivity, help individuals to maintain their independence,
    and generally improve the quality of life, especially since vision loss
    is associated with increased depression and accelerated mortality.
        The very health of the vision research community is also at stake
    with the decrease in NEI funding. Not only will funding for new
    investigators be at risk, but also that of seasoned investigators,
    which threatens the continuity of research and the retention of trained
    staff, while making institutions more reliant on bridge and
    philanthropic funding. .
                                  about naevr
        NAEVR, which serves as the ``Friends of the NEI,'' is a 501(c)4
    non-profit advocacy coalition comprised of 55 professional
    (ophthalmology and optometry), patient and consumer, and industry
    organizations involved in eye and vision research. Visit NAEVR's Web
    site at www.eyeresearch.org.
                                     ______

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

        [This statement was submitted by Mary Giliberti, Executive
    Director, National Alliance on Mental Illness.]
                                     ______

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

        [This statement was submitted by Monika Johnson-Hostler, Board
    President, National Alliance to End Sexual Violence.]
                                     ______

         Prepared Statement of the National Alopecia Areata Foundation
        Chairman Harkin and distinguished members of the Subcommittee,
    thank you for your time and your consideration of the priorities of the
    community of individuals affected by alopecia areata as you work to
    craft the fiscal year 2015 Labor, Health and Human Services
    Appropriations Bill.
                             about alopecia areata
        Alopecia areata is a prevalent autoimmune skin disease resulting in
    the loss of hair on the scalp and elsewhere on the body. It usually
    starts with one or more small, round, smooth patches on the scalp and
    can progress to total scalp hair loss (alopecia totalis) or complete
    body hair loss (alopecia universalis).
        Alopecia areata affects approximately 2.1 percent of the
    population, including more than 6.5 million people in the United States
    alone. The disease disproportionately strikes children and onset often
    occurs at an early age. This common skin disease is highly
    unpredictable and cyclical. Hair can grow back in or fall out again at
    any time, and the disease course is different for each person. In
    recent years, scientific advancements have been made, but there remains
    no cure or indicated treatment options.
        The true impact of alopecia areata is more easily understood
    anecdotally than empirically. Affected individuals often experience
    significant psychological and social challenges in addition to the
    biological impact of the disease. Depression, anxiety, and suicidal
    ideation are health issues that can accompany alopecia areata. The
    knowledge that medical interventions are extremely limited and of minor
    effectiveness in this area further exacerbates the emotional stresses
    patients typically experience.
                              about the foundation
        NAAF, headquartered in San Rafael, California, supports research to
    find a cure or acceptable treatment for alopecia areata, supports those
    with the disease, and educates the public about alopecia areata. NAAF
    is governed by a volunteer Board of Directors and a prestigious
    Scientific Advisory Council. Founded in 1981, NAAF is widely regarded
    as the largest, most influential, and most representative foundation
    associated with alopecia areata. NAAF is connected to patients through
    local support groups and also holds an important, well-attended annual
    conference that reaches many children and families.
        Recently, NAAF initiated the Alopecia Areata Treatment Development
    Program (TDP) dedicated to advancing research and identifying
    innovative treatment options. TDP builds on advances in immunological
    and genetic research and is making use of the Alopecia Areata Clinical
    Trials Registry which was established in 2000 with funding support from
    the National Institute of Arthritis and Musculoskeletal and Skin
    Diseases; NAAF took over responsibility financial and administrative
    responsibility for the Registry in 2012 and continues to add patients
    to it. NAAF is engaging scientists in active review of both basic and
    applied science in a variety of ways, including the November 2012
    Alopecia Areata Research Summit featuring presentations from the Food
    and Drug Administration (FDA) and NIAMS.
                                 deidre's story
        It has been 15 years since I first found the bald patch on my head
    that would completely change the course of my life. As a student at
    Florida State University during my junior year I found a perfectly
    round bald patch while blow-drying my very thick long hair--my pride
    and joy! Little did I know then the significant effect alopecia areata
    would have on my life.
        I followed the typical patient profile for this disease. I started
    with one patch the size of a 50 cent piece, which later evolved into
    patches of varying sizes all over my head, and then to total loss of
    all scalp hair, which progressed to the most severe form of the
    disease: total loss of all body hair including my scalp, eyebrows,
    eyelashes, etc. Recently, my hair has inexplicably started to grow back
    in a very patchy and strange fashion on my head, while most of my body
    still remains hairless; a perfect example of the completely
    unpredictable course of this disease, which can cause significant
    emotional turmoil and distress for the sufferer.
        As a professional woman, this disease has had a severe impact on my
    life. I have to present a confident image to the outside world. Living
    in constant fear of being discovered as a bald woman, being thought to
    be sick, bizarre, or worse has always been on the forefront of my mind.
        The exorbitant cost for treatments such as cortisone injections,
    extremely painful with questionable efficacy, has been an issue for me
    along with the expensive cranial prosthetics. Over the course of the
    years these have cost me thousands of dollars. If a lawyer like myself
    has financial difficulty when it comes to paying for treatments and
    prosthetics (which are not covered by insurance due to lack of CMS
    coverage benefits for those with Alopecia Areata), can you imagine the
    plight facing those patients that live on limited or fixed income?
        The fact that there is so little known about the causes or possible
    treatments/cure for this disease only adds to the pain and suffering.
    This is a disease that alters the way you see yourself and the way the
    outside world treats you, and also causes significant and often
    debilitating emotional distress. The fact that there is little that can
    currently be done adds to that pain and suffering. Patients face a
    bleak outlook. For me, it has been a constant battle. I have not lived
    a single moment in the 5,475 days since that I have not looked in the
    mirror and wanted to scream or cry, not a single day that I haven't
    thought that I am damaged, abnormal, or ugly because of my hair loss,
    not a single day that I haven't worried about how a client, colleague,
    friend, or love-interest might see and judge me. Many will say to me
    that ``it is only hair'' or ``at least it's not cancer.'' These
    comments only frustrate and upset me more. The feelings of being
    ostracized as an outcast can become deafening, even for a confident,
    intelligent professional. I shudder to think how others who don't
    possess my strength of character handle the stresses of this disease.
        It is only with additional funding for research that we might hope
    to improve the lives of the millions in the U.S. living with alopecia
    areata. Few have even heard of the disease. That fact alone creates
    additional stresses and difficulties for those of us with the disease,
    constantly having to explain what is ``wrong'' with us. Increased
    research into viable treatment options and a potential cure could
    significantly impact millions of lives, from small children to adults,
    facing the constant battle that comes from a total loss of self image
    and confidence.
        I thank you on behalf of myself and of the entire alopecia areata
    community for consideration of NAAF's requests.
                                 sequestration
        We have heard from the medical research community that
    sequestration and deficit reduction activities have created serious
    issues for Federal funding opportunities and the career development
    pipeline. In order to ensure that research into alopecia areata, skin,
    and autoimmune disorders can continue to move forward, and, more
    importantly, to ensure that our country is adequately preparing the
    next generation of young investigators, we urge you to avert, mitigate,
    or otherwise eliminate the specter of sequestration. While the
    Foundation has anecdotal accounts of the harms of sequestration, the
    Federated American Societies for Experimental Biology has reported:
      --In constant dollars (adjusted for inflation), the NIH budget in
            fiscal year 2013 was $6 billion (22.4 percent) less than it was
            in fiscal year 2003.
      --The number of competing research project grants (RPGs) awarded by
            NIH has also fallen sharply since fiscal year 2003. In fiscal
            year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3
            percent) fewer than in fiscal year 2003.
      --Awards for R01-equivalent grants, the primary mechanism for
            supporting investigator-initiated research, suffered even
            greater losses. The number awarded fell by 2,528 (34 percent)
            between fiscal year 2003 and fiscal year 2013.
        The pay line for some NIH funding mechanisms has fallen from 18
    percent to 10 percent while the average age for a researcher to receive
    their first NIH-funded grant has climbed to 42. These are strong
    disincentives to choosing a career as a medical researcher. Our
    scaling-back is occurring at a time when many foreign countries are
    investing heavily in their biotechnology sectors. China alone plans to
    dedicate $300 million to medical research over the next 5 years; this
    amount is double the current NIH budget over the same period of time.
    Scientific breakthroughs will continue, but America may not benefit
    from the return-on-investment of a robust biotechnology sector. For the
    purposes of economic and national security, as well as public health,
    the Foundation asks that you work with your colleagues to eliminate
    sequestration and recommit to supporting this Nation's biomedical
    research enterprise.
                   centers for disease control and prevention
        CDC and NCCDPHP are well-positioned to improve our understanding of
    alopecia areata through surveillance and surveys. There are many
    opportunities in this area due to the fact that alopecia areata is the
    most easily observable autoimmune disease. Robust epidemiology could
    yield important information for all autoimmune diseases, not just
    alopecia areata. CDC requires a meaningful investment in fiscal year
    2015 so that it can expand its crucial public health activities beyond
    winnable battles.
                         national institutes of health
        NIH hosts a modest alopecia areata research portfolio, and the
    Foundation works closely with NIH to advance critical activities. NIH
    projects, in coordination with the Foundation's TDP, have the potential
    to identify biomarkers and develop therapeutic targets. In fact,
    alopecia areata research has a strong value proposition as scientific
    advancements may have applications for other autoimmune and skin
    diseases. Please provide NIH with meaningful funding increases to
    facilitate growth in the alopecia areata research portfolio.
        One exciting emerging opportunity is the new Accelerating Medicines
    Partnership (AMP) that was recently announced by NIH. This effort is
    outcomes-oriented and based on a public private-partnership model.
    Industry, patient organizations, and researchers work together to
    conduct research with the goals of improving treatments and diagnostic
    tools. Rheumatoid arthritis is one of the diseases being examined in
    the first round of study, which should generate opportunities for
    alopecia areata due to the similarities between the conditions. Please
    support AMP and encourage NIH to expand activities in this area,
    particularly when there is research overlap between conditions
                             additional activities
        FDA nominated alopecia areata as a potential condition for specific
    review through the Patient-Focused Drug Development Initiative (PFDDI).
    This is because many of the impacts of alopecia areata have to be
    reported by patients and cannot be measured biologically. While we
    appreciate that FDA falls under the guise of the Agriculture
    Appropriations Subcommittee, we ask that you work with your colleagues
    on the Appropriations Committee to support this important program.
    Further, FDA should be encouraged to review all originally-nominated
    conditions in a timely manner so the PFDDI can continue to move
    forward.
        Thank you for your time and your consideration of the community's
    requests.
                                     ______

     Prepared Statement of the National Association for Geriatric Education
        The National Association for Geriatric Education (NAGE) is pleased
    to submit this statement for the record recommending $41.997 million in
    fiscal year 2015 to support geriatrics programs under the Health
    Resources and Services Administration (HRSA), Title VII, Section 753 of
    the Public Health Service Act. NAGE respectfully requests that the
    Subcommittee return to its approved level for fiscal year 2010, which
    was also included that year in the Administration's request, but was
    not included in the final bill. Unfortunately, only $34 million was
    funded in the final bill, and that has been cut to under $34 million in
    subsequent years.
        NAGE is a non-profit membership organization representing Geriatric
    Education Centers (GECs) and other programs that provide education and
    training to health professionals in the areas of geriatrics and
    gerontology. Our mission is to help America's health workforce be
    better prepared to render age-appropriate care to today's older
    Americans and those of tomorrow.
        NAGE recognizes the Subcommittee faces difficult decisions in a
    constrained budget environment, a continued commitment to programs
    supporting the growing need for geriatric education programs that help
    the Nation's health professions better serve the older and disabled
    population should remain a top priority. The Nation faces a shortage of
    geriatric health professionals. Every day in America 10,000 more
    persons reach the age of 65 years. There simply are not enough
    geriatricians, gerontological nurse practitioners and the myriad other
    health professions needed to provide interprofessional care to this
    burgeoning older population.
        Three geriatric health professions programs are financed under
    Title VII, Section 753 of the Public Health Service Act and are
    included in the Health Resources and Services Administration (HRSA).
    Geriatric Education Centers (GECs) and their related programs, the
    Geriatric Academic Career Awards and the Geriatric Faculty Fellowships,
    provide much needed interdisciplinary geriatric and gerontology
    training to a broad range of health professionals who serve our rapidly
    growing aging population.
        GECs train healthcare professional faculty, students, and
    practitioners in the interprofessional diagnosis, management and
    prevention of disease, disability, and other health problems of the
    elderly. This program also provides interprofessional continuing
    education for healthcare practitioners related to prominent issues in
    the field of geriatrics, such as Alzheimer's disease, dementia, and
    advances in palliative care, among others. The GEC program currently
    funds 45 GECs in 34 States, including statewide and multi-state
    programs. About half of GECs provide education for areas that are more
    than 50 percent rural and one-fourth of GECs focuses on training in
    areas that are 25-49 percent rural. In the 2012-2013 Academic Year, GEC
    programs provided over 1,650 different continuing education courses to
    over 94,000 trainees. GEC grantees exceeded the program's performance
    goal by 58.5 percent.
        Geriatrics Training for Physicians, Dentists, and Behavioral/Mental
    Health Professionals (GTPD) support faculty fellowships that help
    physicians, dentists, and behavioral and mental health professionals
    who plan to teach geriatrics in their selected fields. The aim of the
    program is increase the number of quality, culturally competent
    geriatric faculty and to retain mid-career faculty in geriatrics. GTPD
    provided funding for 64 fellows in the academia field of geriatric
    medicine, dentistry, and psychiatry. The GTPD fellows received clinical
    training in over 200 different healthcare locations across the Nation.
    The majority were trained in Veteran's Affairs hospitals, private
    hospitals and academic centers with nearly half of the sites located in
    medically underserved communities. Notably, each fellow dedicated at
    least 25 percent of their time for teaching health students about
    geriatric-related topics. In Academic Year 2012-2013, it is estimated
    that over 275 courses, workshops and other activities were delivered by
    GTPD fellows.
        Geriatrics Academic Career Awards (GACAs) provide a financial
    incentive for junior faculty to pursue an academic career in
    geriatrics. GACA currently supports 62 newly trained geriatric
    physicians. Award recipients delivered over 1,110 different health
    courses, workshops and other types of training activities to over
    53,000 trainees across the health profession spectrum. The most common
    health professions include medical school students, residents in
    internal medicine and residents in geriatrics.
        These successful programs improve the education, supply,
    distribution, diversity, and quality of healthcare professionals who
    care for our Nation's growing older adult population, including the
    underserved and minorities. Thus, we need your continued support for
    geriatric programs to adequately prepare the next generation of health
    professionals for the rapidly changing and emerging needs of the
    growing and aging population.
        On behalf of NAGE, thank you for this opportunity to share our
    requests for support for these important programs. We ask that you
    thoughtfully consider our request for funding in fiscal year 2015.

        [This statement was submitted by Thomas Caprio, MD, MPH, CMD, FACP,
    University of Rochester, Division of Geriatrics & Aging; Co-Director,
    Finger Lakes Geriatric Education Center, President, National
    Association for Geriatric Education.]
                                     ______

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

        [This statement was submitted by Jenae Conti Bjelland, Executive
    Director, National Association for State Community Services Programs.]
                                     ______

      Prepared Statement of the National Association of Chain Drug Stores
        The National Association of Chain Drug Stores (NACDS) thanks the
    Members of the Subcommittee on Labor, Health and Human Services,
    Education and Related Agencies for the opportunity to submit the
    following statement for the record regarding pharmacy-related
    provisions contained within the fiscal year 2015 Department of Health
    and Human Services (HHS) Budget. NACDS and the chain pharmacy industry
    are committed to partnering with Congress, HHS, patients, and other
    healthcare providers to improve the quality and affordability of
    healthcare services.
        NACDS represents traditional drug stores and supermarkets and mass
    merchants with pharmacies. Chains operate more than 40,000 pharmacies,
    and NACDS' 125 chain member companies include regional chains, with a
    minimum of four stores, and national companies. Chains employ more than
    3.8 million individuals, including 175,000 pharmacists. They fill over
    2.7 billion prescriptions yearly, and help patients use medicines
    correctly and safely, while offering innovative services that improve
    patient health and healthcare affordability. NACDS members also include
    more than 800 supplier partners and nearly 40 international members
    representing 13 countries. For more information, visit www.NACDS.org.
        As the face of neighborhood healthcare, community pharmacies and
    pharmacists provide access to prescription medications and over-the-
    counter products, as well as cost-effective health services such as
    immunizations and disease screenings. Through personal interactions
    with patients, face-to-face consultations and convenient access to
    preventive care services, local pharmacists are helping to shape the
    healthcare delivery system of tomorrow--in partnership with doctors,
    nurses and others.
        In recent years, retail community pharmacies have played an
    increasingly important role in providing patient care, including
    medication therapy management (MTM) and expanded immunization services.
    Moreover, policymakers have begun to recognize the vital role that
    local pharmacists can play in improving medication adherence. The role
    of appropriate medication use in lowering healthcare costs has been
    acknowledged by the Congressional Budget Office (CBO). The CBO revised
    its methodology for scoring proposals related to Medicare Part D and
    found that for each 1 percent increase in the number of prescriptions
    filled by beneficiaries there is a corresponding decrease in overall
    Medicare spending. When projected to the entire population, this
    translates into a savings of $1.7 billion in overall healthcare costs,
    or a savings of $5.76 for every person in the U.S. for every 1 percent
    increase in the number of prescriptions filled.
        Congress has recognized the importance of pharmacist-provided
    services such as MTM by including it as a required offering in the
    Medicare Part D program. The experiences of Part D beneficiaries, as
    well as public and private studies, have confirmed the effectiveness of
    pharmacist-provided MTM. A 2013 Centers for Medicare and Medicaid
    Services (CMS) report found that Part D MTM programs consistently and
    substantially improved medication adherence and quality of prescribing
    for evidence-based medications for beneficiaries with congestive heart
    failure, COPD, and diabetes. The study also found significant
    reductions in hospital costs, particularly when a comprehensive
    medication review (CMR) was utilized. This included savings of nearly
    $400 to $525 in overall hospitalization costs for beneficiaries with
    diabetes and congestive heart failure. The report also found that MTM
    can lead to reduced costs in the Part D program as well; showing that
    the best performing plan reduced Part D costs for diabetes patients by
    an average of $45 per patient.
        How and where MTM services are provided also impact its
    effectiveness. A study published in the January 2012 edition of Health
    Affairs identified the key role of retail pharmacies in providing MTM
    services. The study found that a pharmacy-based intervention program
    increased adherence for patients with diabetes and that the benefits
    were greater for those who received counseling in a retail, face-to-
    face setting as opposed to a phone call from a mail-order pharmacist.
    The study suggested that interventions such as in-person, face-to-face
    interaction between the retail pharmacist and the patient contributed
    to improved adherence behavior with a return on investment of 3 to 1.
        Since pharmacists have the proven ability to provide services that
    lead to better clinical outcomes and lower healthcare costs, we urge
    the implementation of budget proposals that allow all healthcare
    providers, including retail pharmacists, to practice to their maximum
    capabilities, working in partnership to provide accessible, high
    quality care to patients.
        NACDS appreciates HHS's proposed goals to reduce healthcare costs
    and produce a more efficient healthcare system; however, we have
    concerns with some proposals contained in the fiscal year 2015 HHS
    Budget. HHS has proposed excluding brand and authorized generic drugs
    from the calculation of average manufacture price (AMP), thereby
    calculating Medicaid Federal Upper Limits (FULs) based only on generic
    drug prices. While the goal of this provision may be to decrease
    Medicaid costs, we believe it may in fact reduce access to prescription
    drugs and pharmacy services for Medicaid patients, resulting in
    increased overall healthcare expenditures.
        Given that AMP has never been used as a basis for pharmacy
    reimbursement, and that AMP-based FULs remain in draft form, we believe
    the fiscal year 2015 budget provisions changing the calculation of FULs
    are premature. In fact, based on NACDS' most recent analysis,
    approximately 35 percent of the draft FULs are below National Average
    Drug Acquisition Cost (NADAC). This analysis confirms that additional
    efforts by CMS are necessary to ensure that pharmacies are not
    reimbursed below their costs using the reimbursement formula created by
    the Affordable Care Act. We urge CMS to utilize the rulemaking process
    to implement the Medicaid pharmacy provisions in a manner consistent
    with Congressional intent, rather than pursuing policies that would
    further cut pharmacy reimbursement.
        The fiscal year 2015 HHS Budget includes a proposal to limit
    Medicaid reimbursement of durable medical equipment (DME) to the rates
    paid by Medicare. Implementing a blanket proposal to reduce payment for
    Medicaid DME has the potential to disrupt access to DME and produce
    poorer health outcomes. This is particularly true in the case of
    diabetes testing supplies (DTS). Last year, CMS established a new
    Medicare single payment of $10.41 for DTS. This amount drastically
    decreased Medicare reimbursement by an average of 72 percent for retail
    pharmacies. The current reimbursement amount barely covers a pharmacy's
    costs-of-goods plus dispensing and counseling for these products and
    services. Reducing Medicaid reimbursement for DTS to match the Medicare
    rate could similarly produce hardships for Medicaid beneficiaries in
    terms of reducing access to needed supplies and threatening the health
    of an already fragile population. NACDS urges CMS to refrain from
    making any changes to Medicaid reimbursement for DTS.
        The fiscal year 2015 budget also includes several provisions to
    increase the utilization of generic drugs. NACDS applauds the inclusion
    of these important provisions, which would encourage the use of generic
    medications by Medicare Low Income Subsidy (LIS) beneficiaries, and
    promote generic competition for biologics. Increasing generic
    utilization is one of the most effective ways of controlling
    prescription drug costs, and the generic dispensing rate of retail
    pharmacies--80 percent--is higher than any other practice setting.
        Finally, the fiscal year 2015 HHS Budget includes a number of
    proposals to cut waste, fraud and abuse in the Medicare and Medicaid
    programs, including the ability to suspend coverage and payment for
    questionable Part D prescriptions. NACDS applauds HHS for working to
    ensure that such activity does not exist in these Federal programs.
    However, NACDS urges HHS to move forward in a cautious manner which
    does not disrupt beneficiary access or jeopardize beneficiary health.
    This can be done by ensuring that overly-burdensome requirements are
    not placed on providers to the point that it interferes with the
    ability to treat and care for patients.
        NACDS thanks the Subcommittee for consideration of our comments. We
    look forward to working with policymakers and stakeholders on these
    important issues.
                                     ______

      Prepared Statement of the National Association of Community Health
                                    Centers
    Introduction
        Chairman Harkin, Ranking Member Moran, and Distinguished Members of
    the Subcommittee: on behalf of health centers across the Nation, we
    wish to thank you for the opportunity to submit testimony for the
    committee to review as you craft the fiscal year 2015 Labor-Health and
    Human Services-Education and Related Agencies Appropriations bill.
    Health Centers- General Background
        Health Centers are community-owned and operated non-profit entities
    providing primary medical, dental, and behavioral healthcare as well as
    pharmacy and a variety of enabling and support services. Today, there
    are over 1,200 health centers operating at more than 9,000 urban and
    rural communities nationwide. We are the ``healthcare home'' for more
    than 22 million patients in all 50 States and nearly every
    Congressional district.
        By statute and mission, health centers are located in medically
    underserved areas or serve a medically underserved population. Health
    centers are directed by patient-majority boards, a model which helps to
    ensure they are responsive to the needs of each individual community
    they serve. Health centers offer comprehensive care to all residents of
    the community who seek their care, regardless of ability to pay or
    insurance status and offer services on a sliding fee scale. Our unique
    model of care has enabled us to save the entire health system
    approximately $24 billion annually. Health Centers reduce preventable
    hospitalizations and Emergency Department use, as well as the need for
    more expensive specialty care. The services provided at health centers
    save $1,263 per patient per year compared to expenditures for non-
    health center users.
        In addition to reducing costs, health centers also serve as small
    businesses and economic drivers in their communities. In 2012, health
    centers employed 153,000 individuals and in 2009 generated $20 billion
    in total economic benefits in poor urban and rural communities.
    Fiscal year 2014 Funding Background
        In fiscal year 2014, health centers received a total of $3.7
    billion in total Federal funding. This includes $1.49 billion in
    discretionary funding provided by the Health Resources and Services
    Administration (HRSA) and $2.2 billion in mandatory funding for health
    centers through the Health Center Fund. We want to thank the members of
    this Subcommittee for their support of health centers within the
    Consolidated Appropriations Act of 2014 to ensure health center funding
    continues to reach communities in need.
    Access to a Health Center Reduces Barriers to Primary Care
        NACHC's recently released a report entitled: Access is the Answer
    finds 62 million Americans lack regular access to primary care and the
    vast majority of these medically disenfranchised Americans actually
    have insurance coverage. Many individuals still face barriers such as
    availability, affordability, and accessibility to primary and
    preventive care. Even among people who have an insurance card, access
    may be out of reach because of who they are and where they live. As
    health reform changes the healthcare landscape, we know that demand for
    health centers will continue to climb among the uninsured, underinsured
    and underserved due to the lack of other healthcare providers willing
    to see our patients.
        True ``access'' means having a regular, reliable source of quality
    preventive and primary healthcare and simply having an insurance card
    does not guarantee ready access to primary care. With our unique model
    of care, Health Centers can help address these primary care demands in
    a cost effective manner. However, Health Centers cannot continue to
    deliver results without a sound financial base.
    Fiscal year 2015 Funding Request and Health Center Funding Cliff
        In fiscal year 2015, Health Centers are respectfully requesting
    level discretionary funding of $1.49 billion for the Health Center
    program. Together with the $3.6 billion in funding available in fiscal
    year 2015 through the mandatory Health Center Fund, health centers are
    requesting a total of $5.1 billion in total program funding. This
    funding for the Health Center program, which requires no new
    appropriation from this Subcommittee, should be fully utilized during
    fiscal year 2015 to increase access to primary care in medically
    underserved communities. With access to all available funding for the
    program in fiscal year 2015, Health Centers could build the capacity to
    serve up to 11 million new patients, both in new communities and
    through expanded services and capacity at existing health centers. In
    addition, existing Health Centers could ensure they are keeping up with
    current patient demand.
        The President's proposed fiscal year 2015 Health Resources and
    Services Administration (HRSA) budget provides $1 billion in
    discretionary funding for the Health Centers program. Together with the
    $3.6 billion in fiscal year 2015 mandatory funding available for health
    centers, under the President's proposal, health centers would receive a
    net increase of $960 million in total programmatic funding for fiscal
    year 2015 equaling total funding of $4.6 billion. Within this proposal,
    the President will allocate $860 million for one-time quality
    improvement and capital development awards and $100 million to fund new
    health center sites.
        We strongly oppose the President's proposed $500 million
    discretionary funding reduction for health centers as it further
    reduces the discretionary allocation for the program beyond the levels
    in place prior to the inception of the Health Center Fund. Health
    centers simply cannot survive further decreases to their base
    discretionary funding which undermines the long-term sustainability of
    the program, and may well threaten access for existing patients.
        We do appreciate the President's acknowledgement and recognition of
    the looming funding crisis for health centers upon the expiration of
    the Health Center Fund after fiscal year 2015. Under current law the
    Health Center Fund will end after fiscal year 2015, resulting in as
    much as a 70 percent reduction in health center grant funding in fiscal
    year 2016. Averting the health center cliff is critical to ensuring
    that health centers remain financially viable and able to serve the
    diverse needs of their communities. However, the President only
    proposes a temporary (3 year) solution reducing program funding down to
    fiscal year 2014 levels after a one-time increase in fiscal year 2015.
    Given the number of communities and individuals in need of access to
    healthcare, longer-term solutions must encompass both stability and
    expansion of access to care.
    Conclusion
        We understand this Subcommittee must make difficult budgetary
    decisions as you work within the funding limits set for the
    subcommittee's bill. As the fiscal year 2015 appropriations process
    moves forward, we urge you to keep in mind that without their local
    health center, many individuals located in medically underserved
    communities will seek care in emergency departments and hospitals,
    often waiting until they are sicker get treatment. This will mean
    poorer health for these patients and much higher costs to the system.
    Health centers have continually proven to be a worthwhile investment by
    delivering high quality, affordable healthcare while generating savings
    to the entire health system in these communities. We are extremely
    grateful for your past support and ask for the Subcommittee's continued
    support for the Health Center program. We look forward to working with
    you and thank you for your consideration.

        [This statement was submitted by Daniel R. Hawkins, Jr., Senior
    Vice President, Public Policy and Research.]
                                     ______

       Prepared Statement of the National Association of County and City
                                Health Officials
        The National Association of County and City Health Officials
    (NACCHO) is the voice of the 2,800 local health departments across the
    country that work every day to ensure the safety of the water we drink,
    the food we eat, and the air we breathe. On behalf of local health
    departments, NACCHO submits the following requests:
    Prevention and Public Health Fund
        In fiscal year 2015, NACCHO requests $1 billion for the Prevention
    and Public Health Fund (PPHF), a dedicated Federal investment in
    programs that prevent disease at the community level. NACCHO wishes to
    thank Congress for allocating the PPHF in fiscal year 2014 and setting
    specific funding levels to support the prevention of disease and
    promotion of health in communities across the Nation.
    CDC Public Health Emergency Preparedness
        NACCHO urges the Subcommittee to provide $675 million for the
    Public Health Emergency Preparedness (PHEP) grant program in fiscal
    year 2015. PHEP protects communities by strengthening local and State
    public health department capacity to effectively respond to public
    health emergencies including terrorist threats, infectious disease
    outbreaks, natural disasters, and biological, chemical, nuclear, and
    radiological emergencies. These grants have been cut more than 30
    percent since fiscal year 2007 with more than 55 percent of local
    health departments relying solely on Federal funds for emergency
    preparedness activities. NACCHO urges inclusion of language asking CDC
    to provide information on how much of the State PHEP grants are being
    allocated to local health departments and on what basis or formula each
    State is determining such allocations, including the method through
    which States reach statutorily-required concurrence with local health
    departments.
    Assistant Secretary for Preparedness and Response
        NACCHO urges the Subcommittee to fund the Hospital Preparedness
    Program (HPP) at $300 million in fiscal year 2015 and restore some of
    the $104 million (35 percent) cut from the program in fiscal year
    2014.. HPP supports health department preparedness coordinators to
    organize coalitions of public health and healthcare providers to plan
    and prepare for public health emergencies, including medical surge
    following terrorist attacks, mass casualty incidents, an influenza
    pandemic or other infectious disease outbreak. NACCHO is concerned that
    the 35 percent cut to HPP in fiscal year 2014 will erode medical system
    preparedness, making communities across the country more vulnerable.
    NACCHO urges Congress to request information from Assistant Secretary
    for Preparedness and Response (ASPR) on how State HPP funding is
    distributed at the local level, including how much is being allocated
    to local health departments and on what basis or formula each State
    making such allocations. This information should be publicly available.
    CDC Section 317 Immunization Program
        NACCHO urges the Subcommittee to provide $650 million for the
    Section 317 Immunization Program in fiscal year 2015. The Section 317
    Immunization Program funds 50 States, six large cities and eight
    territories for vaccine purchase for at-need populations and
    immunization program operations, including support for implementing
    immunization billing systems at public health clinics to sustain high
    levels of vaccine coverage. NACCHO supports directing $8 million of the
    funding, as proposed in the President's Budget, to continue projects to
    facilitate billing by health departments of public and private
    insurance for covered immunization services.
    CDC Chronic Disease Prevention
        Partnerships to Improve Community Health (Community Prevention
    Grants).--NACCHO urges the Subcommittee to provide $100 million to
    support continuation of the Partnerships to Improve Community Health
    program in fiscal year 2015, which supports implementation of evidence-
    based strategies to address heart attacks, strokes, cancer, diabetes,
    and other chronic diseases which contribute to the soaring cost of
    healthcare. Local health departments lead efforts to reduce tobacco
    use, increase physical activity and expand access to nutrition in order
    to reduce costly chronic diseases like heart disease and diabetes.
    NACCHO urges Congress to encourage CDC to conduct a comprehensive
    national evaluation of the program including recommendations for
    national qualitative and quantitative standards for quality preventive
    services and a report of how much of the funding was granted to the
    local level and to which eligible entities.
        Heart Disease and Stroke.--NACCHO urges the Subcommittee to
    continue to support Heart Disease and Stroke Prevention at $130 million
    in fiscal year 2015. In fiscal year 2014, Congress provided a $76
    million increase for heart disease and stroke prevention and urged CDC
    to ensure that some portion of the increase in funding is sub-granted
    to the local level. The risk factors of obesity and smoking must be
    addressed at the community level to combat disease. Local health
    departments who are experts on community needs and prevention
    interventions in the area of heart disease and stroke.
        Diabetes Prevention and Control.--NACCHO urges the Subcommittee to
    continue to support Diabetes Prevention at $150 million in fiscal year
    2015. In fiscal year 2014, Congress provided a $76 million increase for
    diabetes prevention and urged CDC to ensure that some portion of the
    increase in funding is sub-granted to the local level. Because
    evidence-based disease self-management programs are effective at
    improving health, greater emphasis must be placed on enhancing the
    reach of these community level interventions.
    CDC Preventive Health and Health Services Block Grant
        In fiscal year 2015, NACCHO urges the Subcommittee to continue to
    support the Preventive Health and Health Services (PHHS) Block Grant at
    $160 million. This unique funding gives States the flexibility to
    address State problems and provide similar support to local
    communities, while demonstrating the local, State, and national impact
    of this investment. NACCHO urges Congress to encourage CDC to enhance
    reporting and accountability for the PHHS Block Grant including
    providing capacity building to States for core public health capacities
    that may not be supported through other CDC categorical funding
    streams. In order to make sure that funding supports the needs of local
    communities, local health departments should be full partners in
    developing State plans. CDC should also require States to report the
    funding allocation used to subgrant funds to local health departments
    and to encourage they include locals in their statewide planning
    efforts.
    CDC Food Safety
        NACCHO urges the Subcommittee to support CDC's Food Safety Program
    at $54 million in fiscal year 2015. Local and State health departments
    are an essential part of the process that ensures that food is safe to
    eat at home, at community events, in restaurants, and in schools.
        As the Subcommittee drafts the fiscal year 2015 Labor-HHS-Education
    Appropriations bill, NACCHO urges consideration of these
    recommendations for programs that protect the public's health and
    safety.
                                     ______

     Prepared Statement of the National Association of State Directors of
                   Career and Technical Education Consortium
        Dear Chairman Mikulski, Ranking Member Shelby, Chairman Harkin and
    Ranking Member Moran: On behalf of the National Association of State
    Directors of Career and Technical Education Consortium (NASDCTEc), I am
    writing to urge the committee to support Career Technical Education
    (CTE) through a strong Federal investment in the Carl D. Perkins Career
    and Technical Education Act (Perkins). The passage of the Consolidated
    Appropriations Act of 2014 has helped to alleviate most of the harmful
    sequester cuts which have negatively impacted important Federal
    investments in CTE programs through this legislation. However, our
    organization recognizes that there are still difficult decisions to be
    made regarding individual program funding levels in fiscal year 2015.
    To that end, NASDCTEc is requesting that the committee restore funding
    for the Perkins Basic State Grant to at least $1.264 billion,
    equivalent to the pre-sequestration level of 2010, and make investing
    in Perkins a top priority in the fiscal year 2015 Labor, Health and
    Human Services, and Education appropriations bill.
        Perkins is the principal source of Federal support for CTE programs
    at secondary and postsecondary institutions across the county. This
    Federal investment is crucial to ensuring that students have the
    academic, technical and employability skills that are needed for
    expanding fields like engineering, information technology, advanced
    manufacturing and healthcare. Perkins-funded CTE programs are working
    with business and industry partners to help fill positions that are
    available today, while preparing a qualified workforce for the careers
    of tomorrow. In a rapidly changing job market, CTE provides students
    with transferable skills that ensure they are college-and career-ready,
    while offering retraining opportunities to many adult or dislocated
    workers.
        CTE produces a strong return on the Federal investment and has an
    unmistakably positive societal and economic impact. Students enrolled
    in CTE programs are more engaged, perform better academically and
    graduate at higher rates. CTE supports the development of an educated
    and highly skilled workforce that provides a direct benefit to
    employers, while strengthening the economy through increased
    productivity and innovation.
        However, funding for CTE has not been immune to significant budget
    cuts over the past several years. The Perkins Act basic State grant
    program still remains approximately $5 million below pre-sequestration
    levels. In addition to sequestration, funding for Perkins was reduced
    by over $140 million between fiscal year 2010 and fiscal year 2012,
    dramatically reducing the capacity of CTE programs to offer
    academically rigorous instruction and career training that is aligned
    to the needs of business and industry. Dozens of States are currently
    receiving funding allocations close to the levels they received in
    1998. When taking into account inflation over this period, the relative
    investment in CTE through the Perkins Act has declined considerably
    more. This erosion has hurt high schools, CTE centers, community and
    technical colleges, employers and millions of CTE students nationwide.
    This pathway of disinvestment in our Nation's CTE system is
    unsustainable-- we cannot cut our way to a 21st century workforce!
    Instead, Perkins funding must be restored to meet the needs of CTE
    programs around the country and ensure students are fully prepared for
    their future academic and career goals.
        Thank you for your continued leadership in this difficult fiscal
    environment and for your thoughtful consideration during the
    appropriations process. NASDCTEc looks forward to working with the
    committee in a bipartisan fashion to restore funding for CTE and
    support the millions of CTE students across the Nation.

        [This statement was submitted by Kimberly Green, Executive
    Director, National Association of State Directors of Career and
    Technical Education Consortium.]
                                     ______

      Prepared Statement of the National Association of State Head Injury
                                 Administrators
        Dear Chairman Tom Harkin and Ranking Member Jerry Moran: On behalf
    of the National Association of State Head Injury Administrators
    (NASHIA), thank you for the opportunity to submit testimony regarding
    the fiscal year 2015 appropriations for programs authorized by the
    Traumatic Brain Injury (TBI) Act within the Department of Health and
    Human Services (HHS). The TBI Act programs are the only programs
    providing Federal assistance to help States with developing an array of
    rehabilitation, home and community-based services and other short-term
    and long-term supports specific to the cognitive and behavioral needs
    of individuals with TBI and their families. These programs are designed
    to restore and improve functioning and assist individuals to return to
    school, engage in employment and to live as independently as possible.
    To assist States in improving and expanding service delivery, NASHIA
    recommends the following:
    Centers for Disease Control and Prevention (CDC), National Injury
            Center
        The CDC National Injury Center supports State TBI registries,
    surveillance, data collection and analysis; State and local prevention
    interventions to address falls related, motor vehicle related, and
    sports-related injuries, including concussions (mild TBI); as well as
    educates primary clinicians and other professionals to be able to
    identify, diagnose and manage TBIs appropriately and effectively.
    NASHIA recommends an increase in funding for the CDC TBI Program in the
            amount of $10 million to address the expanding population of
            TBI.
        CDC's National Injury Center is the primary Federal agency
    responsible for translating science into effective programs and
    policies to prevent and minimize the consequences of TBI when they
    occur. Through its funded programs and activities, the Injury Center
    works with national organizations, Federal agencies, State health
    agencies, and other key groups to develop, implement, and promote
    effective injury and violence prevention and control practices.
    Health Resources and Services Administration (HRSA), Federal TBI
            Program
        NASHIA recommends $12 million total for the HRSA TBI Federal
    Program, which is split by HRSA between two programs: HRSA Federal TBI
    State Grant Program and the HRSA Federal TBI Protection & Advocacy
    (P&A) Systems Grant Program.
    HRSA Federal TBI State Grant Program
        Since 1997, HRSA has awarded grants to 48 States, District of
    Columbia and one Territory, although not concurrently, to develop and
    improve services and systems to address the short-term and long-term
    needs. These grants have been time limited and are relatively small.
    Five years ago, HRSA increased the amount of the award from
    approximately $100,000 to $250,000 to make it more feasible for States
    to carry out their grant goals and the legislative intent. While this
    increased amount is more attractive to States, this change reduced the
    number of grantees to 21--less than half of the States and Territories
    receive funding. As a result, States that do not have Federal grant
    funding are finding it increasingly difficult to sustain their previous
    efforts, let alone expand and improve service delivery, due to other
    budget constraints within their States. Therefore, NASHIA recommends:
    $8 million in total for the HRSA Federal TBI State Grant Program to
            increase the number of State grant awards.
        Over the course of the grant program, States have developed State
    plans and implemented initiatives for improving service delivery;
    information & referral systems; service coordination systems; outreach
    and screening among unidentified populations such as children, victims
    of domestic violence, and veterans; and training programs for direct
    care workers and other staff. States have conducted public awareness
    and educational activities that have helped States to leverage and
    coordinate funding in order to maximize resources within States to the
    benefit of individuals with TBI.
        While NASHIA is well aware that Federal funds are becoming
    increasingly difficult to obtain, NASHIA is recommending increased
    funding for the Federal TBI Act programs because:
      --The number of Americans who sustain a TBI is increasing, especially
            among older adults and young children, and among our men and
            women in uniform as a result of the wars in Iraq and
            Afghanistan.
      --All States have enacted legislation to develop return to play
            guidelines with regard to sports-related concussions among our
            youth. Two States have recently expanded their laws to include
            ``return to learn'' guidelines to help with the identification
            of TBI and appropriate accommodations and related educational
            assistance that may be needed after a mild TBI (concussion) in
            order to be successful academically. Through these efforts,
            children and youth are now being identified and screened for
            potential assistance.
      --State budgets have not been able to keep up with the demand for
            services.
    HRSA Federal TBI Protection & Advocacy (P&A) Systems Grant Program
        HRSA also administers the Federal TBI P&A Systems Grant Program
    which is a formula-based program that allows 57 States, Territories,
    and the Native American Protection and Advocacy Project to assess their
    State P&A Systems' responsiveness to TBI issues and provide advocacy
    support to individuals with TBI and their families. Together, P&As
    comprise the Nation's largest provider of legally based advocacy
    services for people with disabilities. To further the work of the P&As,
    NASHIA recommends:
    $4 million in total be appropriated to increase the amount of grant
            awards administered by HRSA Federal TBI P&A Systems Grant
            Program.
        The TBI Act, which was last reauthorized in 2008, is due for
    reauthorization. TBI stakeholders are working with key Congressional
    leaders to extend authorization of appropriations for these critical
    programs. In addition:
    NASHIA recommends transferring the HRSA TBI State Grant and P&A
            programs to the Administration for Community Living to maximize
            resources to support the array of services and supports needed
            following a brain injury.
        Transferring the TBI State Grant and P&A Grant programs within ACL
    would:
      --Integrate TBI into the HHS long-term services initiatives, which
            also rely on Aging and Disability Resource Centers (ADRCs) as
            the entry point into these systems;
      --Promote collaboration with the Administration on Aging (AoA) on
            falls related TBIs among older adults;
      --Include TBI in the veterans initiatives between HHS and Department
            of Veterans Affairs to support Home and Community-Based
            Services (HCBS) for veterans and returning servicemembers
            coordinated by the ACL's Office of Disability and Aging
            Policy's Office of Integrated Programs;
      --Coordinate and enhance services for individuals with TBI who could
            benefit from the ACL's Administration on Intellectual/
            Developmental Disabilities (AIDD) initiatives to improve
            education, transition services, employment outcomes and self-
            advocacy for children and youth; and
      --Include TBI in the Office of Disability and Aging Policy's Office
            of Integrated Policy initiatives (i.e. Lifespan Respite Care
            Program, Participant Direction Program, Evidenced-Based Care
            Transitions, and Transportation Research and Demonstration
            Program).
        In keeping with the Olmstead decision, States are taking advantage
    of Federal initiatives and opportunities to expand community long-term
    services options. Unfortunately, most States focus on the traditional
    populations of I/DD, physical disabilities, aging and mental health and
    are omitting TBI in their long-term care initiatives. This leaves
    individuals with TBI with little options, other than nursing facilities
    or other segregated living programs, for assistance with activities of
    daily living and residential or housing needs. We believe that aligning
    the Federal TBI State Grant Program with these other programs will help
    address these concerns.
    About the National Association of State Head Injury Administrators
            (NASHIA)
        NASHIA is a non-profit organization representing and assisting
    State governmental officials who administer an array of short-term and
    long-term rehabilitation and community services and supports for
    individuals with TBI and their families. Since 1990, NASHIA has held an
    annual State-of-the-States conference, and has served as a resource to
    State TBI program managers and others seeking public programs and
    services. Membership also includes associate members who are
    professionals, provider agencies, State affiliates of the Brain Injury
    Association of America (BIAA) or U.S. Brain Injury Alliance, family
    members and individuals with TBI.
        Over the past 30 years, States have initiated efforts to develop
    capacity for offering information and referral services, service
    coordination, rehabilitation, in-home support, personal care,
    counseling, transportation, housing, vocational and other support
    services for persons with TBI and their families. These services vary
    in size and scope across the country and even within a State. Twenty-
    four States have enacted legislation to assess fines or surcharges to
    traffic related offenses or other criminal offenses and/or assessed
    additional fees to motor vehicle registration or drivers license to
    generate funding for TBI programs and services, generally referred to
    as trust fund programs. About the same number of States have
    implemented TBI Home and Community-Based Medicaid Waiver Programs with
    twelve States having the advantage of administering both a trust fund
    and waiver program. These programs are administered by State public
    health, Vocational Rehabilitation, mental health, Medicaid,
    intellectual disabilities, education or social services agencies within
    the States.
        Thank you.
                                     ______

    Prepared Statement of the National Association of State Long-Term Care
                               Ombudsman Programs
        I am pleased to present this testimony on behalf of residents and
    tenants residing in Iowa's long-term care facilities in collaboration
    with the National Association of State Long-Term Care Ombudsman
    Programs (NASOP). This statement and the following funding
    recommendations for fiscal year 2015 for the Long-Term Care Ombudsman
    Programs administered through the Administration for Community Living
    (ACL) is submitted for the record.
      --$5 million authorized under the Elder Justice Act for Long-Term
            Care Ombudsman Program (LTCOP) services and training to fight
            elder abuse, neglect, and exploitation;
      --$16.83 million authorized under Title VII of the Older Americans
            Act for LTCOPs to restore funding back to the fiscal year 2011
            level;
      --$20 million for LTCOP services in assisted living facilities; and
      --$1 million authorized under Title II of the Older Americans Act for
            the National Long-Term Care Ombudsman Resource Center (NORC).
        NASOP, formed in 1985 as a non-profit organization, is composed of
    state long-term care ombudsmen representing their State programs
    created by the Older Americans Act (OAA). The primary function of the
    LTCOP in the Federal OAA is to identify, investigate, and resolve
    complaints that relate to action, inaction or decisions that may
    adversely affect the health, safety, welfare, and rights of residents
    of long-term care facilities. Ombudsman representatives work with the
    consent and at the direction of residents in the resolution of their
    problems. They visit residents living in nursing homes and residential
    care homes. Ombudsman representatives ask them about problems or
    concerns they have and if they need or want our help to resolve these
    issues. Ombudsman representatives act as their advocates. We strongly
    believe that our work not only improves the quality of life for
    millions of long-term care facility residents, but also saves Medicare
    and Medicaid resources by avoiding unnecessary costs associated with
    poor quality care.
        Nationally, n Federal fiscal year 2012, over 11,000 volunteers,
    including 8,712 individuals certified to investigate complaints, and
    1,180 staff served in 573 local LTCOPs. Ombudsmen investigated and
    worked to resolve 193,650 complaints made by 126,398 individuals.
    Ombudsmen were able to resolve or partially resolve 73 percent, or
    almost three out of every four complaints investigated. In addition,
    ombudsmen provided information on rights, care and related services
    405,589 times.
        Iowa's LTCOP is responsible for advocating for 53,287 residents and
    tenants residing within 844 long-term care facilities. The Iowa Office
    of State Long-Term Care Ombudsman consists of the State Long-Term Care
    Ombudsman; 8 Local Long-Term Care Ombudsman; 2 Volunteer Coordinators;
    numerous volunteers, and an Administrative Assistant. Currently, the
    Federal funding for our program only fully funds two (2) of the twelve
    (12) paid positions.
        In Federal fiscal year 2013, Iowa's LTCOP received 1,174 complaints
    by or on behalf of residents and tenants; directly served 3,226
    residents and tenants; provided 4,445 hours of advocacy services beyond
    complaint handling; and provided 5,360 consultations, education
    sessions, visits, and other activities. Our office advocates for 53,
    287 residents/tenants in 844 facilities and we do this with just a few
    staff. We are grateful for the staffing that we do have, but feel that
    our efforts are just a drop in the bucket. According to two national
    studies from the Institute of Medicine and the Bader Report, the
    national recommendation for States to follow is 1 long-term care
    ombudsman for 2,000 beds or people. With the current number of long-
    term care ombudsman staff in Iowa, our ombudsmen are serving 6,661 beds
    or people. Iowa would need a total of 27 local long-term care ombudsmen
    to fully meet this Federal recommendation. This would ensure that all
    individuals residing in long-term care would have immediate access to
    an advocate who can represent their interests.
        We understand that this Subcommittee faces a strained financial
    situation, but a continued commitment to Ombudsman programs advocating
    for the healthcare needs and safety of millions of older adults living
    in nursing homes and assisted living facilities across the Nation
    should remain a high priority. Since 1978, the LTCOP has been a core
    program of the OAA. It is the only program in the OAA that specifically
    serves residents of nursing homes and assisted living facilities. We
    all appreciate and value the importance of living in one's own home.
    The OAA provides critically needed home and community based services
    that often delay institutionalization. However, some elders can no
    longer live safely in their own homes and must move at some point in
    their lives to either an assisted living facility or a nursing home.
    These residents are usually frail and extremely vulnerable and rely on
    the advocacy services of the LTCOP.
        Demand for our services and advocacy is growing. The number of
    complex and very troubling cases that long-term care ombudsmen
    investigate has been steadily increasing. In addition, there continues
    to be a disturbing increase in the frequency and severity of citations
    for egregious regulatory violations by long-term care providers. These
    violations put facility residents in immediate jeopardy of harm. This
    trend suggests a frightening decline in the quality of long-term care
    services. Ombudsmen are needed now more than ever in nursing homes,
    board and care facilities, and in assisted living communities. As well,
    the demand placed on the program by the need to assist residents who
    are relocating from long-term care facilities that are downsizing or
    closing their doors continues to complicate ombudsman programs' daily
    operations.
        Administrators in many long-term care facilities have recognized
    the value and benefit of having ombudsmen assist with staff training
    and consultation and this form of outreach has also placed an
    increasing strain on available advocacy resources. In order to improve
    advocacy and services available to residents of long-term care
    facilities, NASOP recommends, and the Iowa Office of the State Long-
    Term Care Ombudsman supports, several augmentations to appropriations
    that support the work of LTCOP.
        NASOP requests $5 million to support the work of the LTCOP under
    the Elder Justice Act. This appropriation would allow States to hire
    additional staff and leverage that staff to recruit additional
    volunteers to help support the investigation of complaints of abuse,
    neglect, and exploitation of residents of nursing home and assisted
    living facilities.
        NASOP request $16.83 million authorized under Title VII of the
    Older Americans Act for LTCOPs to restore funding back to the fiscal
    year 2011 level. Programs in every district and State are suffering
    from recent cuts. These funds would help in a partial way to restore
    our reduced ability to visit residents in nursing homes.
        NASOP requests $20 million to support 333 additional Ombudsman
    salaried staff at an estimated $60,000 average annual salary/fringe
    benefits and necessary staff training. The requests adds new ombudsman
    positions specifically dedicated to providing Ombudsman services to
    residents of assisted living facilities and other community-based long-
    term care delivery systems, which currently suffer from a significant
    lack of personnel resources around the country.
        Finally, NASOP wants to acknowledge the importance and value of the
    National Long-Term Care Ombudsman Resource Center (NORC). The NORC
    provides valuable and reliable technical assistance, training, and
    support to State and local LTCOPs.
        NASOP requests an appropriation of $1 million to support the work
    of the NORC in providing training and technical assistance to State and
    local LTCOPs. Congress funds the NORC at $550,000 per year; the very
    same level of funding it has received since 1993. This request adds
    $450,000 to the line item for the NORC, which is such a critical
    component of the ombudsman program. The NORC plays an integral role in
    assuring the overall effectiveness of LTCOPs across the country through
    its training, educational materials, data analysis, and best practices
    efforts.
        Overall, Ombudsmen offer valuable consumer protections to residents
    and provide a voice for those unable to speak for themselves. Every day
    in America, 10,000 more persons reach the age of 65 years. With a
    rapidly growing older population, LTCOPs can continue to enhance the
    quality of life, improve the level of care, protect the individual's
    rights and promote the dignity of Americans across the Nation.
        On behalf of residents, tenants and State Long-Term Care Ombudsmen
    across this Nation, thank you for this opportunity to share these
    requests for support of this important program that protects the
    health, safety, welfare, and rights of vulnerable older adults and
    persons with disabilities. We ask that you thoughtfully consider our
    detailed request for funding in fiscal year 2015.

        [This statement was submitted by Deanna Clingan-Fischer, JD, Iowa
    State Long-Term Care Ombudsman.]
                                     ______

      Prepared Statement of the National Association of States United for
                             Aging and Disabilities
        Chairman Harkin, Ranking Member Moran: Thank you to for the
    opportunity to submit this testimony. As you work to develop fiscal
    year 2015 funding priorities, the National Association of States United
    for Aging and Disabilities (NASUAD) urges you to consider the
    Administration for Community Living's (ACL) fiscal year 2015 request
    for $25 million to address the all-too prevalent problem of elder
    abuse. This investment would support initial implementation of the
    Elder Justice Act's (EJA) Adult Protective Services (APS), research,
    and evaluation activities.
        NASUAD represents the 56 officially designated State and
    territorial agencies on aging and disabilities. Each of our members
    oversees the implementation of the Older Americans Act (OAA), and many
    also serve as the operating agency in their State for Medicaid waivers
    that serve older adults and individuals with disabilities. Together
    with our members, we work to design, improve, and sustain State systems
    delivering home and community based services and supports for people
    who are older or have a disability, and their caregivers.
        According to ACL, an estimated 2.1 million older Americans are
    victims of elder abuse, neglect, or exploitation each year. As the
    Nation's older population increases, so too does the incidence of elder
    abuse. While there is no single set of national elder abuse prevalence
    data, the number of reported cases is on the rise. A 2004 national
    survey of State APS programs showed a 16 percent increase in the number
    of elder abuse cases from an identical study conducted in 2000.
    Additionally, an overwhelming number of cases of abuse, neglect, and
    exploitation go undetected and untreated each year. Experts estimate
    that for every case of elder abuse or neglect reported, as many as five
    cases go unreported.
        Despite the clear and growing need, there is no dedicated Federal
    funding for, or corresponding Federal oversight of, elder abuse
    prevention services. Absent a national framework, States have been left
    to address this issue independently from one another, and must rely on
    multiple funding streams to support their work, ultimately resulting in
    a fragmented system. Though each State has developed an APS program
    that responds to reports of elder abuse, neglect, and exploitation,
    these programs vary greatly from State to State--from the populations
    they serve, to the reporting mechanisms they use, and the budget
    structures under which they operate. These discrepancies, which
    continue to be exacerbated by the absence of Federal APS funding,
    necessarily impede efforts to compare, evaluate, and improve State
    approaches to reducing and preventing elder abuse.
        To address the systemic inadequacies in our Nation's approach to
    eradicating elder abuse, neglect, and exploitation, we urge you to
    support ACL's request of $25 million in discretionary funding to
    implement the EJA in fiscal year 2015. This critical funding would be
    used to develop much-needed program standards and data collection
    efforts, as well as to support the implementation of a nationwide APS
    data system; these dollars would also fund research activities,
    including efforts to translate promising interventions from other
    violence prevention areas to elder abuse, and evaluations of the
    effectiveness of these interventions.
        NASUAD believes that efforts to improve the response to, awareness
    of, and intervention in elder abuse, neglect, and exploitation could be
    more effectively coordinated through the establishment of a national
    APS program. Accordingly, we urge you to fully fund the Elder Justice
    Initiative in fiscal year 2015.
        Thank you for the opportunity to provide input on this critical
    issue, and for your leadership. NASUAD looks forward to working with
    all of you to preserve the dignity, independence, and health of older
    adults, and to protect those who may no longer be able to protect
    themselves.
                                     ______

             Prepared Statement of the National Blood Clot Alliance
        The National Blood Clot Alliance (NBCA) is pleased to submit this
    statement in support of increased appropriations for fiscal year 2015
    for the Centers for Disease Control and Prevention's (CDC) Division of
    Blood Disorders, a component of CDC's National Center on Birth Defects
    and Developmental Disabilities. NBCA's statement addresses the programs
    specific to blood clots, known scientifically as Deep Vein Thrombosis
    (DVT) and Pulmonary Embolism (PE), a major public health problem facing
    this Nation. Combined, these disorders are known as venous
    thromboembolism (VTE). Preventing death and disability from VTE is an
    important public health priority, and the Division is responsible for
    all CDC activities related to blood clots and other bleeding disorders.
        NBCA asks the Subcommittee to restore funding for the Division to
    its fiscal year 2010 level, $19.9 million. The fiscal year 2014 funding
    has dropped precipitously to $13 million. Of this, support for blood
    clot prevention has been cut in half, to a mere $560,000, hardly enough
    to make a dent in a major public health problem that annually kills
    more Americans than AIDS, breast cancer and motor vehicle accidents
    combined. NBCA further requests that the Subcommittee establish a
    budget line item specific to blood clots and clotting disorders and
    that $4 million be appropriated for this line each year for the next 5
    years.
        Funding this program at the requested level will be a major step in
    advancing the Surgeon General's 2008 ``Call to Action to Prevent Deep
    Vein Thrombosis (DVT) and Pulmonary Embolism (PE)'' and the Nation's
    ``Healthy People 2020 Objectives.'' The urgency of this request is
    underscored by the fact that the great majority of blood clots could be
    prevented. We have the tools to do that, but the resources to deploy
    them are woefully inadequate.
        Blood clots are the leading cause of unnecessary hospital
    readmissions in the U.S., costing our Nation an estimated $10 billion
    dollars in avoidable healthcare expenses annually. According to the
    American Public Health Association, DVT deaths are the most common
    preventable cause of hospital death. Researchers at Johns Hopkins
    University School of Medicine recently reported that as many as 70
    percent of healthcare associated VTE could be eliminated with the
    application of improved prevention protocols. Other targeted
    population-based prevention tools can be applied to avert disability
    and death from blood clots due to aging, lengthy travel, immobility,
    obesity and other risk factors.
    The National Blood Clot Alliance
        Founded in 2003, NBCA is a patient led non-profit, voluntary health
    organization dedicated to advancing the prevention, early diagnosis and
    successful treatment of life-threatening blood clots such as deep vein
    thrombosis, pulmonary embolism and clot-provoked stroke. We work on
    behalf of people who have or could be susceptible to blood clots,
    including, but not limited to, people with clotting disorders, atrial
    fibrillation, cancer, traumatic injury, and risks related to surgery,
    lengthy immobility, child birth and birth control. NBCA accomplishes
    its mission through programs that build public awareness, educate
    patients and healthcare professionals and promote supportive public and
    private sector policy. Our content is reviewed by an internationally
    recognized Medical and Scientific Advisory Board. We invite the Members
    of the Subcommittee to visit our website at www.stoptheclot.org to
    learn more about blood clots and the programs of NBCA.
    Who Has Blood Clots and What Are They?
        No American is immune from life-threatening blood clots, regardless
    of age, gender, race, ethnicity or health status. Normal blood clots
    play an important role in protecting our health because they stop
    bleeding from a cut or wound. However, blood clots can also form
    abnormally, causing a heart attack, stroke, or other serious medical
    problems. Experts estimate that two million Americans suffer such
    venous and arterial blood clots every year. More than 200,000 Americans
    die from them annually. An often silent killer, death can be sudden
    with no forewarning. But in most instances, the damage can be averted
    or contained. Age, smoking, obesity can all contribute to clotting
    risk, but so can birth control or pregnancy or cancer. Even prominent
    athletes in peak physical condition have suffered career- ending, life
    -threatening clots. It can happen to any of us. In fact, the memories
    of former U.S. Reps. Walter Capps (D-CA) and Jennifer Dunn (R-WA), who
    died due to blood clots while serving in Congress, motivated the
    creation of National Blood Clot Awareness Month in March of 2009.
        Physicians estimate that as little as 20 percent of blood clots are
    actually recognized for what they are. Misdiagnosis and delayed
    diagnosis are all too common and all too often fatal. The general
    public is even farther behind, with surveys showing that nearly three
    quarters of the population has little or no knowledge about blood
    clots, their risks, their signs and symptoms and their prevention. The
    Government must play a greater role in educating the general public,
    people who are at special risk and health professionals. This is the
    ``low hanging fruit'' of public health prevention that has yet to be
    adequately picked and the return on invest can be tens of thousands of
    lives saved and billions of dollars in unnecessary healthcare expenses
    avoided!
    The Federal Government Has a Vital Role in Meeting this Acknowledged
            Public Health Priority
        Many Federal agencies play important roles in the effort to reduce
    death and disability from blood clots and clotting disorders. The
    National Institutes of Health and the National Science Foundation
    support the work of basic scientists in their efforts to understand the
    causes and effects of blood clots and identify improved treatments. The
    VA also supports research in this field and strives to prevent blood
    clots in the special population of Americans it serves. The Agency for
    Healthcare Research and Quality in 2001 was among the first to
    recognize that blood clot prevention in hospitals was our best
    opportunity for patient safety improvement. The Partnership for
    Patients makes made blood clot prevention a key component of improved
    hospital care. CMS includes surgery-related blood clot prevention as a
    key measure of hospital quality. DOD has examined how blood clots can
    be prevented in the military, affecting soldiers who must often live in
    cramped conditions, suffer dehydration and experience bone fractures
    and more severe injuries that require surgery.
        Each of these agencies plays a special role in the effort to reduce
    clotting death and injury. However, the CDC, the Nation's leading
    prevention agency, is the one best suited to guide and coordinate
    Federal efforts targeted at populations more broadly. No other agency
    possesses its unique capabilities in public health outreach, education
    and promotion. Regrettably the agency best suited for leadership is the
    one with the fewest resources. NBCA believes it is imperative that
    Congress act now to provide adequate, sustained funding for this
    specific activity at CDC--the reduction of death and disability due to
    blood clots.
        The funding request presented at the beginning of this statement
    will provide CDC with the resources it needs to begin seriously to meet
    this public health challenge. fiscal year 2014 funding for blood clot
    programs is only $560,000, half of what was available in the last
    fiscal year. The Administration's proposed fiscal year 2015 budget
    would make no change to this level. The current funding situation for
    the Blood Disorders Division has already forced CDC to cut or curtail
    the few programs it has been able to support. These include two pilot
    programs to improve community-based VTE surveillance and evaluation;
    one focused on healthcare provider education; one targeted at women's
    health (e.g., blood clots are the leading cause of maternal mortality);
    and a collaboration with the VA and academia to develop new VTE
    surveillance tools. Staffing of the Division has also been cut nearly
    in half, decreasing by 18 FTEs, including essential personnel with
    specialized laboratory, IT and analytic skills. At a time when this
    public health problem is growing, we have allowed even the small
    investment in CDC to address it become further negligible. This is
    neither thoughtful public policy nor wise economically.
        NBCA believes that our citizens deserve better and that Federal
    support for this acknowledged public health priority should be equal to
    the task. Tragically, it is not at present. NBCA urges the Subcommittee
    to take the lead in making the changes needed to provide CDC with the
    funds it needs to combat this major public health issue--blood clots,
    clotting disorders and the ensuing disability that consumes far too
    many lives and dollars in the U.S. unnecessarily.

        [This statement was submitted by Joseph C. Isaacs, Chief Executive
    Officer, National Blood Clot Alliance.]
                                     ______

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

        [This statement was submitted by Lindsay E. Jones, Esq., Director,
    Public Policy & Advocacy, National Center for Learning Disabilities.]
                                     ______

        Prepared Statement of the National Children's Facilities Network
        Chairman Harkin, Ranking Member Moran, and distinguished Members of
    the Appropriations Subcommittee on Labor, Health and Human Services,
    Education, and Related Agencies: Thank you for the opportunity to offer
    written testimony on the Administration's fiscal year 2015 Budget
    Request for the Department of Health and Human Services, Administration
    for Children and Families. I write on behalf of the National Children's
    Facilities Network (NCFN) to express support for the funding of Head
    Start, Early Head Start-Child Care Partnerships and other programs that
    provide access to high quality early care and education. These
    initiatives are critical to ensuring that all children, especially low-
    income children, are given a strong start and the tools necessary to
    succeed in life. As you make important funding decisions about programs
    that provide children with the opportunity to obtain an early start on
    the pathway to success, we encourage you to recognize the critical role
    that early childhood facilities play in preparing young children for
    achievement in school and in life, and support Federal policies that
    adequately finance the acquisition, construction, and improvement of
    these spaces.
        NCFN is a national coalition of nonprofit organizations that
    provide financing, technical assistance and training on the design,
    development and financing of early care and education facilities in
    low-income communities throughout the country. We see the positive
    impact of high quality early learning on children's lives and on the
    future economic health and development of neighborhoods. Our coalition
    also recognizes the importance of the spaces where these programs take
    place. A growing body of research shows that a well-designed, well-
    equipped physical environment supports learning and good outcomes for
    children, while a poorly adapted and overcrowded space undermines it.
    For example, bathrooms adjacent to classrooms, accessible cubbies, and
    child-sized sinks, counters, furnishings and fixtures increase
    children's autonomy and competence while decreasing the demands on
    teachers.
        Infants, toddlers, and young children should be educated and cared
    for in high quality physical spaces that meet their needs and
    complement high quality programs. Federal programs focused on improving
    families' access to high quality early care and education options
    should include adequate funding for the acquisition, construction, and
    improvement of facilities.
        Thank you for your leadership on these issues. Please consider us
    as a resource as you advance early childhood policies. If you would
    like additional information about our work, please contact Karen
    O'Mansky, Center for Community Self-Help, Chair, National Children's
    Facilities Network.
                                     ______

        Prepared Statement of the National Congress of American Indians
        On behalf of the National Congress of American Indians (NCAI), this
    testimony addresses programs in the Departments of Education and Labor
    and the Corporation for Public Broadcasting. NCAI also supports the
    testimony of the National Indian Child Welfare Association, the
    American Indian Higher Education Consortium, and the National Indian
    Education Association. NCAI is the oldest and largest American Indian
    organization in the United States. Tribal leaders created NCAI in 1944
    as a response to termination and assimilation policies that threatened
    the existence of American Indian and Alaska Native tribes. Since then,
    NCAI has fought to preserve the treaty rights and sovereign status of
    tribal governments, while also ensuring that Native people may fully
    participate in the political system. As the most representative
    organization of American Indian tribes, NCAI serves the broad interests
    of tribal governments across the Nation.
    Department of Education
        Investing in the education of American Indian and Alaska Native
    students is not only one most of the most important cornerstones of the
    Federal trust responsibility to tribes, but is also critical strategy
    for creating jobs and securing the Nation's future prosperity in
    today's challenging economic climate. Education provides tribal
    economies with a more highly-skilled workforce while also directly
    spurring economic development and job creation. The profound value of
    education for Native Nations extends beyond just economics, however.
    Education drives personal advancement and wellness, which in turn
    improves social welfare and empowers communities--elements that are
    essential to maintaining tribes' cultural vitality and to protecting
    and advancing tribal sovereignty.
        Despite the enormous potential of education for transforming tribal
    communities, Native education is in a state of emergency. American
    Indian and Alaska Native students lag far behind their peers on every
    educational indicator, from academic achievement to high school and
    college graduation rates. For example, in 2011, only 18 percent of
    Native fourth graders and 22 percent of Native eighth graders scored
    proficient or advanced in reading, and only 22 percent of Native fourth
    graders and 17 percent of Native eighth graders scored proficient or
    advanced in math.\1\ The crisis of Indian education is perhaps most
    apparent in the Native high school dropout rate, which is not only one
    of the highest in the country, but is also above 50 percent in many of
    the States with high Native populations.\2\
    ---------------------------------------------------------------------------
        \1\ National Indian Education Study 2011, NCES 2012-466. National
    Center for Education Statistics, Institute of Education Sciences,
    United States Department of Education.
        \2\ School Year 2010-2011 4-Year Regulatory Adjusted Cohort
    Graduation Rates, Department of Education.
    ---------------------------------------------------------------------------
        Title I, Part A Local Education Agency Grants--Provide $25 billion
    for Title I, Part A.--Title I of the Elementary and Secondary Education
    Act provides critical financial assistance to local educational
    agencies and schools with high percentages of children from low-income
    families that ensure all children meet challenging State academic
    standards. Currently, there are over 600,000 Native students across the
    country with nearly 93 percent of those students attending non-Federal
    institutions, such as traditional public schools in rural and urban
    locations. A drastic increase in funding to counter annual inflation
    and sequestration is necessary to meet the needs of Native students and
    students from low-income families.
        Impact Aid--Provide $2 billion for Impact Aid, Title VIII of the
    Elementary and Secondary Education Act (ESEA).--Impact Aid provides
    direct payments to public school districts as reimbursements for the
    loss of traditional property taxes due to a Federal presence or
    activity, including the existence of an Indian reservation. With nearly
    93 percent of Native students enrolled in public schools, Impact Aid
    provides essential funding for schools serving Native students. In
    fiscal year 2014, Impact Aid saw an increase of $64 million over fiscal
    year 2013 that restored most of the destructive sequestration cuts
    tribal communities faced in Indian Country. In order to ensure Native
    students have access to education, however, Impact Aid must be fully
    funded at $2 billion. Furthermore, Impact Aid should be converted to a
    forward-funded program to eliminate the need for cost transfers and
    other funding issues at a later date.
        Title VII (Indian Education Formula Grants)--Provide $198 million
    for Title VII of the ESEA.--This grant funding is designed to
    supplement the regular school program and assist Native students so
    they have the opportunity to achieve the same educational standards and
    attain equity with their non-Native peers. Title VII provides funds to
    school divisions to support American Indian, Alaska Native, and Native
    Hawaiian students in meeting State standards. Furthermore, Title VII
    funds support early-childhood and family programs, academic enrichment
    programs, curriculum development, professional development, and
    culturally-related activities. Currently, funding for Title VII only
    reaches 500,000 Native students leaving over 100,000 without
    supplementary academic and cultural programs in their schools.
        State-Tribal Education Partnership (STEP) Program--Provide $5
    million for the State-Tribal Education Partnership Program..--Congress
    appropriated roughly $2 million dollars for the STEP program to five
    participating tribes in fiscal year 2012 and fiscal year 2013 under the
    Tribal Education Department appropriations' line that is administered
    by the Department of Education. In order for this program to continue
    to succeed and thrive, it must receive its own line of appropriations
    in fiscal year 2015. Collaboration between tribal education agencies
    and State educational agencies is crucial to developing the tribal
    capacity to assume the roles, responsibilities, and accountability of
    Native education departments and increasing self-governance over Native
    education.
        Alaska Native Education Equity Assistance Program--Provide $35
    million for Title VII, Part C of the ESEA.--This assistance program
    funds the development of curricula and education programs that address
    the unique educational needs of Alaska Native students, as well as the
    development and operation of student enrichment programs in science and
    mathematics. This funding is crucial to closing the gap between Alaska
    Native students and their non-Native peers. Other eligible activities
    include professional development for educators, activities carried out
    through Even Start programs and Head Start programs, family literacy
    services, and dropout prevention programs.
        Native Hawaiian Education Program--Provide $35 million for Title
    VII, Part B of the ESEA.--This program funds the development of
    curricula and education programs that address the education needs of
    Native Hawaiian students to help bring equity to this Native
    population. Where Native Hawaiians once had a very high rate of
    literacy, today Native Hawaiian educational attainment lags behind the
    general population.
    Department of Labor
        Fund the Department of Labor's Indian and Native American Program
    (INAP) at a minimum of $60.5 million. Fund the Native American
    Employment and Training Council at $125,000 from non-INAP resources.--
    In order to reduce the education and employment disparity between
    Native people and other groups, a concentrated effort is required that
    provides tailored and sufficient assistance to enhance education and
    employment opportunities, to create pathways to careers and skilled
    employment, and to secure a place for Native people within the Nation's
    middle class. The Workforce Investment Act (WIA) Section 166 program
    (INAP) serves the training and employment needs of over 38,000 American
    Indians and Alaska Natives via a network of 175 grantees through the
    Comprehensive Service Program (Adult) and Supplemental Youth Service
    Program (Youth), and the Indian Employment and Training and Related
    Services Demonstration Act of 1992, Public Law 102-477. Furthermore,
    the number of American Indians and Alaska Natives served through WIA
    does not fully capture its impact in Indian Country, as many more are
    served by grantees that leverage WIA funding, along with other similar
    federally funded employment and training programs, through PL 102-477.
        There has been a trend of decreasing funds for INAP, and a failure
    to appropriate at the statutory minimum level of $55 million. These
    decreases in funding are detrimental and hamper progress in Indian
    Country's labor situation. According to the Census, the average
    unemployment rate on reservations dropped more than 3 percentage points
    since 2000,\3\ but more still needs to be done as American Indians and
    Alaska Natives still lag significantly behind. With the average
    unemployment rate in Indian Country cited up to 17 percent \4\ and an
    average rate of joblessness of approximately 50 percent,\5\ INAP is
    vital to helping reverse these trends.
    ---------------------------------------------------------------------------
        \3\ U.S. Census Bureau. Census 2000 Summary File 4, 2006-2010,
    2009-2011 American Community Survey.
        \4\ U.S. Census. 2011 American Community Survey.
        \5\ U.S. Department of Interior. Bureau of Indian Affairs. 2005
    American Indian Labor Force Report.
    ---------------------------------------------------------------------------
        Further, because INAP is the only Federal employment and job
    training program that serves American Indians and Alaska Natives who
    reside both on and off reservations, it is imperative that its funding
    is preserved. For Native citizens living on remote reservations or in
    Alaska Native villages, it can be difficult to access the State and
    local workforce systems. In these areas, INAP can be the lone
    employment and training provider. Since 2003, WIA has been up for
    reauthorization; and over this 11-year period, WIA has not accounted
    for the population growth of tribal communities, nor the economic
    environment that has drastically changed. WIA authorizes the INAP to be
    funded at ``not less than $55 million,'' but Section 166 is currently
    being funded at approximately $46 million. WIA also authorizes the
    Native American Employment and Training Council to advise the Secretary
    on the operation and administration of INAP, but it uses funds that are
    intended for INAP grantees. Since the current INAP funding is already
    below $55 million, the Secretary should use other streams of funding to
    support its advisory council. Without an increase in funding, not
    enough tribes are able to benefit from the support and training
    activities for employment opportunities in Indian Country.
        Restore the YouthBuild Program funding to a minimum of $102.5
    million, restore the rural and tribal set-aside in the YouthBuild
    program, and reinstate a dedicated 10 percent rural and tribal set-
    aside of at least $10.25 million.--The YouthBuild program is a
    workforce development program that provides significant academic and
    occupational skills training and leadership development to youth ages
    16-24, and engages approximately 10,000 youth annually. According to
    YouthBuild, in 2010, 4,252 youth participated in the program and had a
    completion rate of 78 percent, and 60 percent of those who completed
    the program were placed in jobs or further education.\6\ There are a
    number of tribal YouthBuild programs in several States, and Native
    Americans make up roughly 4 percent of YouthBuild participants. With
    the recent reduction in tribal YouthBuild programs, high unemployment
    rates, serious housing challenges in Indian Country, and the growing
    Native youth population (42 percent of American Indian/Alaska Native
    population is under 25 years old),\7\ it is critical that the 10
    percent rural and tribal set- aside be restored.
    ---------------------------------------------------------------------------
        \6\ See youthbuild.org/research.
        \7\ U.S. Census Bureau, 2010 Census, Summary File 1.
    ---------------------------------------------------------------------------
    Corporation for Public Broadcasting
        In the CPB, NCAI supports an advanced fiscal year 2016
    appropriation of $5 million for American Indian and Alaska Native radio
    stations. This $5 million appropriation would come out of the fiscal
    year 2015 advanced appropriation of $445 million for the overall CPB
    budget. This is the same budget amount enacted for fiscal year 2014 and
    requested for fiscal year 2015.
        For more than 30 years, decisions on the amount of Federal support
    for public broadcasting have been made 2 years ahead of the fiscal year
    in which the funding is allocated. Since 1976, CPB's 2-year advance
    appropriation has served as a Congressional strategy to protect public
    media from any immediate political pressure. Community Service Grants
    (CSGs) account for approximately 70 percent of CPB's appropriation,
    which directly funds 1,300 local public television and radio stations
    including 35 Native radio stations.
        In Indian Country, Native radio stations are essential to the
    tribal communities they serve since they are often the first source of
    emergency reporting and information. Public broadcasters use datacast
    technology for homeland security, public alert and warning systems, and
    public safety purposes. In Oklahoma, KCNP Chickasaw radio provided real
    time weather reports that saved lives during the 2013 tornado season.
    In Arizona, KUYI Hopi radio provides ``House Calls,'' a health call-in
    show that connects listeners with a local doctor on questions about
    hanta virus, diabetes, HIV, and other local health issues. In Alaska,
    KNBA covers news from Alaska Native villages about climate change
    refugees, language revitalization, and other hyper local stories
    important and relevant to Alaska Native communities. Often, the only
    place where Native stories and issues are heard is on Native radio
    stations.
        Local public media stations and their employees have experienced
    significant reductions through cuts to other Federal programs that
    benefit public media. The elimination of CPB's Digital appropriation
    and the Public Telecommunications Facilities Program coupled with cuts
    to programs at the Departments of Education and Agriculture represent a
    $57.5 million, or 7.3 percent, funding cut between fiscal year 2010 and
    fiscal year 2012. These cuts come at a time when stations are
    struggling to maintain service to their communities in the face of
    shrinking nonFederal revenues--a $239 million, or 10.8 percent, drop
    between fiscal year 2008 and fiscal year 2011.
        CPB also funds the essential system-wide station support services
    provided by Native Public Media, Inc., and content production and
    satellite programming distribution by Koahnic Broadcast Corporation.
    Access to these funds allows Native Public Media, Inc., to ensure that
    Native radio stations stay on the air by maintaining compliance with
    FCC and other Federal rules and regulations, and by providing the
    training and support Native broadcasters need. Native public radio
    stations still exist as one of the primary sources of public
    information on tribal lands, and represent cornerstones of tribal
    efforts for information dissemination. Much of Indian Country remains
    disconnected from vital telecommunications services, radio should not
    be counted among them. Radio has always existed as a key component of
    public information and 55 tribal radio stations among this country's
    566 federally recognized tribes illustrates the need for these services
    in Indian Country.
                                     ______

     Prepared Statement of National Council of Social Security Management
                                  Associations
        On behalf of the National Council of Social Security Management
    Associations (NCSSMA), thank you for the opportunity to submit this
    testimony regarding the Social Security Administration's (SSA's) fiscal
    year 2015 Appropriation.
        NCSSMA is a membership organization of nearly 3,300 SSA managers
    and supervisors who provide leadership in over 1,200 community-based
    field offices and teleservice centers throughout the country. We are
    the front-line service providers for SSA in communities all over the
    Nation. Since the founding of our organization over 44 years ago,
    NCSSMA has considered a stable SSA, which delivers quality and timely
    community-based service to the American public, our top priority. We
    also consider it a top priority to be good stewards of the taxpayers'
    monies and the Social Security programs we administer.
        We would like to express our appreciation for the fiscal year 2014
    Limitation on Administrative Expenses (LAE) account funding of $11.697
    billion provided to SSA. Increased resources, especially in SSA's field
    offices and teleservice centers, will have a positive impact on
    delivering vital services to the American public and in fulfilling the
    agency's stewardship responsibilities. Since October 2010, SSA field
    offices had lost almost 4,100 permanent employees prior to the first
    wave of fiscal year 2014 hiring. The teleservice centers (TSCs) lost
    1,159 employees during the same timeframe. For the first time in over 3
    years, we are replacing some of these losses. Because of the fiscal
    year 2014 funding, authority was granted to field offices and
    teleservice centers to hire 2,350 and 850 permanent employees,
    respectively. In addition, 550 permanent hires were approved for
    Workload Support Units (WSUs) that are expected to ease the burden
    placed on field offices.
        The dramatic growth in SSA workloads, along with the attrition in
    our offices over the last several years, has highlighted the need to
    receive necessary resources to maintain service levels vital to the
    nearly 65 million Social Security beneficiaries and Supplemental
    Security Income (SSI) recipients. Despite agency strategic planning,
    expansion of online services, significant productivity gains, and the
    best efforts of management and employees, SSA still faces many
    challenges providing the service the American public has earned and
    deserves.
        Over the last several years, SSA has experienced a significant
    increase in Social Security claims. The additional claims receipts are
    driven in large part by the initial wave of the nearly 80 million baby
    boomers who will be filing for Social Security benefits by 2030, an
    average of 10,000 per day.
      --In fiscal year 2013, SSA field offices assisted 43.3 million
            visitors, received 4.9 million retirement, survivor and
            Medicare applications, and 2.9 million initial disability
            claims.
      --In fiscal year 2013, SSA completed 2,987,883 initial disability
            claims. Since fiscal year 2007, initial disability claims
            receipts have increased by over 25 percent.
      --In fiscal year 2013, SSA completed 5,006,855 retirement, survivor,
            and Medicare claims (5,001,092 in fiscal year 2012)--a record
            number and over a million more than completed in fiscal year
            2007.
      --In fiscal year 2013, retirement, survivor, and Medicare claims were
            30 percent higher as compared to fiscal year 2007.
      --Each day over 155,000 people visit SSA field offices and more than
            436,000 call SSA for a variety of services.
        We fully support the President's budget request of $12.024 billion
    for SSA's LAE account in fiscal year 2015. While this would be a much-
    appreciated increase of $327 million over the fiscal year 2014 level of
    funding, it would only address fixed cost increases. The fiscal year
    2015 Budget Request submitted by Acting Commissioner Carolyn Colvin to
    President Obama for SSA's administrative funding was $12.6 billion.
    This level of funding will allow SSA to continue improving and
    modernizing customer service, enhance program integrity efforts, detect
    and deter fraud and errors, and continue to address high volumes of
    work. In November of 2013, NCSSMA co-authored a letter with 29 other
    organizations, which was submitted to the Office of Management and
    Budget (OMB) and recommended a funding level consistent with the Acting
    Commissioner's request for SSA's administrative funding. Specifically
    the letter stated:
         SSA teleservice centers, hearing offices, program service centers,
            disability determination services (DDS), and field offices are
            in critical need of adequate resources to address their growing
            workloads. The recommended fiscal year 2015 budget of no less
            than $12.6 billion would allow SSA to cover inflationary
            increases, resume efforts to reduce hearings and disability
            backlogs, complete deficit-reducing program integrity work, and
            replace critical staffing losses in SSA's components, including
            field offices, teleservice centers, and DDSs.

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

        [This statement was submitted by Scott Hale, President, National
    Council of Social Security Management Associations.]
                                     ______

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

        [This statement was submitted by Mark Wolfe, Executive Director,
    National Energy Assistance Directors' Association.]
                                     ______

       Prepared Statement of the National Family Planning & Reproductive
                               Health Association
        Summary: Requesting $337 million in funding for fiscal year 2015
    for the national family planning program (Title X of the Public Health
    Service Act).
        My name is Clare Coleman; I'm the President & CEO of the National
    Family Planning & Reproductive Health Association (NFPRHA), a
    membership organization representing the Nation's safety-net family
    planning providers--nurse practitioners, nurses, physicians,
    administrators and other key healthcare professionals. Many of NFPRHA's
    members receive Federal funding from Medicaid and through Title X of
    the Federal Public Health Service Act, the only federally funded,
    dedicated, family planning program for the low income and uninsured.
    These critical components of the Nation's public health safety net are
    essential resources for those providing access to high-quality services
    in communities across the country. As the Committees work on the fiscal
    year 2015 appropriations bill, NFPRHA respectfully requests that you
    make a significant investment in Title X by including $337 million to
    restore the capacity of the program to serve those in need.
        NFPRHA was disappointed to see the president's fiscal year 2015
    proposal only included $286.5 million for Title X. As more individuals
    gain access to healthcare coverage through the Affordable Care Act, the
    publicly funded family planning network will continue to play an
    essential role in our Nation's service delivery framework, setting the
    standard for and providing high-quality care to all patients--the
    insured, uninsured, under-insured as well as patients seeking
    confidential services. If the Massachusetts health reform experience
    were to prove representative of what could be expected by nationwide
    health reform, there will be a strong increase in demand for services
    within the already-strained safety net. At present, six in ten women
    describe family planning centers as their usual source of medical care.
    According to a report by the Centers for Disease Control and Prevention
    (CDC), as health reform in Massachusetts expanded coverage for most
    people living in the State, Title X family planning health centers
    continued to have high volumes of patients, both insured and uninsured,
    and remained providers of choice for many.
        The failure of States to expand Medicaid eligibility for all adults
    up to 138 percent of the Federal poverty level (an income of $16,105 a
    year for an individual in 2014)--along with new barriers to coverage
    being sought by some expansion States, such as premiums and other cost-
    sharing requirements--compounds the demand being placed on the Title X
    safety net. Currently, 25 States have not expanded their Medicaid
    eligibility under the ACA. Twenty-one of these States have Medicaid
    eligibility equal to or less than 75 percent of FPL (an income of
    $8,753 a year); 14 have eligibility at or below 50 percent (an income
    of $5,835 a year). Five States have eligibility set at less than 25
    percent of FPL--that means individuals making more than $2,918 are too
    ``rich'' for Medicaid.
        Similar to other publicly funded health programs, Title X has
    unfortunately suffered budget cuts despite rising patient need. Between
    fiscal year 2010-fiscal year 2013, the Title X family planning program
    was cut $39.2 million (-12.3 percent). As a result, the total number of
    Title X users shrunk from 5.22 million users to 4.76 million during
    this time period, with no indication that patients went elsewhere for
    care. Congress made incremental progress in fiscal year 2014, funding
    Title X at $286.5 million, a restoration of $8.2 million over the
    fiscal year 2013 post-sequester level. As appropriators grapple with
    how best to distribute limited Federal resources, NFPRHA encourages the
    Committees continue to prioritize investments in programs, including
    Title X, that are proven to save critical taxpayer dollars. Every $1
    invested in publicly funded family planning services saves $5.68 in
    Medicaid costs associated with unplanned births. Additionally, services
    provided in Title X-supported centers alone yielded $5.3 billion of the
    $10.5 billion in total savings for publicly funded family planning in
    2010.
        Lastly, Title X supports critical infrastructure and technology
    necessary for modern service delivery that are not reimbursable under
    Medicaid and commercial insurance. Resources for electronic health
    record implementation for safety-net providers--just as for others in
    the safety net--are necessary to help achieve the ACA goal of having a
    nationwide health information technology infrastructure and more
    coordinated models of care. Increased Title X funding is essential to
    help address the gap caused by the oversight in Federal planning that
    led to most family planning health providers' ineligibility for the
    electronic health records (EHR) incentives available under the HITECH
    Act.
        For these reasons, NFPRHA urges the Committees to make a
    significant investment in the Nation's safety-net family planning
    health services and requests funding for Title X at $337 million in
    fiscal year 2015.
        [This statement was submitted by Clare Coleman, President & CEO,
    National Family Planning & Reproductive Health Association.]
                                     ______

           Prepared Statement of the National Head Start Association
        Chairman Harkin, Ranking Member Moran, and Members of the
    Subcommittee, thank you for allowing the National Head Start
    Association (NHSA) to submit testimony on behalf of funding for Head
    Start and Early Head Start in fiscal year 2015 . For almost 50 years,
    Head Start centers have been creating opportunities for at-risk
    children and families to achieve success in life by providing critical
    early education, health, nutrition, parent engagement and family
    support services. NHSA respectfully urges the Subcommittee to continue
    its enduring bipartisan support by allocating $8,868,389,000 for Head
    Start and Early Head Start in fiscal year 2015, in line with the
    President's Budget.
        Head Start and Early Head Start directors remain appreciative of
    your leadership in ensuring that the fiscal year 2014 Omnibus
    Appropriations legislation not only restored the damaging cuts from
    sequestration, but also prioritized high quality by including
    additional funds to retain qualified staff and cope with the increased
    costs of program operation. We also sincerely appreciate the new
    investment in one of our most underserved populations--low-income
    infants and toddlers.
        Within the total amount of funding for fiscal year 2015, we urge
    the Subcommittee to continue and build on these investments. In
    particular, we propose a $150 million increase to support workforce
    quality improvements and to help offset the continued rise in energy,
    transportation, and other fixed costs related to operating a Head Start
    program. It is well known that one of the hallmarks of excellence in
    any early learning program is the caliber of its teachers. Head Start
    teachers are required to possess Bachelor's degrees in early learning
    or related fields, which enables the program to have one of the best-
    trained workforces in the country. However, the average salary for
    these degreed teachers is $30,086--lower than what many schools pay
    teachers, and much lower than salaries for many other jobs with
    comparable education requirements.
        Examples of programs losing their best staff to higher paying
    schools or other providers are plentiful across the country. In New
    York, one Head Start social/emotional education mentor-coach reported
    seeing several ``gifted teachers, assistants and aides leave our
    classrooms after short stays due to the pressure to provide for their
    own families.'' Many of the staff who choose to stay with Head Start
    struggle to make ends meet--such as the Oregon teachers who have
    depended on a local food bank to help feed their own children. Others
    depend on other income supports. Focusing increased investment toward
    workforce quality improvements will help enable programs to hold on to
    dedicated teachers, and provide a solid foundation for the good of our
    students and families.
    Supporting a High-Quality Birth-to-Five Pipeline:
        NHSA also urges the Subcommittee to support the continued
    development of a birth-to-five pipeline of services through expanded
    access to Early Head Start, which today is only able to serve a scant 4
    percent of eligible infants and toddlers. Continued early brain
    research tells us that with the achievement gap present as early as 18
    months, these first 2 years of life represent a critical window in
    development. Early Head Start centers are among the highest quality
    environments for children of this age. We propose that the Subcommittee
    continue to fund the new Early Head Start-Child Care Partnerships at
    $500 million. These funds should, as in fiscal year 2014, support the
    straight expansion of Early Head Start as well as partnerships with
    Child Care providers, ensuring programs designed by and solely based on
    the needs of individual communities.
        We are aware of many underserved areas with few options for
    partnerships--these communities should be given as much flexibility as
    possible to increase access to high-quality care. For example, Audubon
    Area Community Services, Inc. in Kentucky serves a 16 county area.
    However, even though there are an estimated 17,911 children in their
    service area that are eligible for Early Head Start, they are only
    funded to serve 301 Early Head Start slots. In two of those 16
    counties, there are 600 eligible children but no licensed child care
    facilities with which possibly to partner. In yet a third county, there
    is licensed child care but none of it for infants and toddlers. With
    flexibility to invest in expansion, they could find a way to serve
    those areas.
        Further, NHSA also urges the Subcommittee to allocate $100 million
    to fund the expansion of the Birth-to-Five pilot programs that the
    Office of Head Start (OHS) began last year in Detroit, Baltimore,
    Jersey City, Washington, DC, and Mississippi's Sunflower County as part
    of the first Designation Renewal System (DRS) recompetition. The grants
    are meant to encourage applicants to develop comprehensive, flexible,
    seamless Birth-to-Five programs which incorporate both Head Start and
    Early Head Start funding. We hope the Subcommittee will recognize the
    value of this approach and support expansion of these models outside of
    DRS. In particular, we suggest that the Administration utilize a
    portion of the funds to create a process that enables current grantees
    that hold both types of grants to streamline the administrative burden
    and combine these two grants into one.
        These Birth-to-Five expansion funds should also be used to assist
    Head Start grantees to add Early Head Start slots and convert existing
    Head Start slots for 3-4 year olds to Early Head Start slots; both
    actions support the goal of providing an Early Head Start slot to
    complement each Head Start slot. Across the country, as States and
    localities both expand and contract services for infants, toddlers, and
    preschoolers, Head Start programs have the necessary skills to adapt
    their services to fit the changing needs of their community. But as
    resources shift, additional funding to help transition to new or
    different types of slots would be a welcome support.
        For instance, many States have increased their investment in
    serving 4-year-olds in a variety of settings through their mixed
    delivery system, including through organizations who receive Head Start
    grants. Head Start grantees are able to tap into this funding stream to
    support and expand their current services to 4-year-olds--however many
    of those communities are now under-investing in low-income infants and
    toddlers. If that same Head Start grantee were able to apply for funds
    to help transition some of its Head Start slots to Early Head Start
    slots, the community would then be served by a more comprehensive
    birth-to-five pipeline--meeting a significant need for the working
    parents of very young children.
    Ongoing Quality Improvements:
        Robust funding for Head Start and Early Head Start will ensure that
    key quality improvement initiatives are able to continue at the Office
    of Head Start. In particular, we are keen for the Office of Head Start
    to finalize an update to our rigorous performance standards as mandated
    in the 2007 Head Start Reauthorization Act. Serious and meaningful
    efforts are underway to ensure that the standards are modernized to
    reflect the needs of today's children, families, teachers, staff, and
    communities--while allowing for innovation and local adaptability.
    These standards are the heart of Head Start's model, and critical to
    future success.
        Further, we are hopeful that the Office of Head Start is able to
    continue its improvements to the Head Start Monitoring System--the
    oversight mechanism that ensures Head Start and Early Head Start
    grantees are meeting all of their high standards. We are pleased that
    the Office has instituted new initiatives that aim to work with
    programs to prevent issues before they occur. We are also appreciative
    that they are enabling iterative feedback and data collection to better
    target assistance and intervention where programs require it most.
    These are welcome changes, and we are hopeful that the Office of Head
    Start is afforded the resources to continue these improvements.
        One of the best-known provisions of the 2007 Head Start Act
    requires Head Start grantees designated as low-performing to compete
    for the continuation of their grant. Different from the Head Start
    grant termination process, this additional accountability measure, the
    Designation Renewal System (DRS) which is now in its third cycle, has
    been an enormous undertaking for the Office of Head Start and requires
    adequate resources to fully staff and execute.
        We support the Administration's request for $25 million to assist
    with grantee transition costs in the event that a grant turns over,
    though NHSA remains concerned that the Office of Head Start's timetable
    for executing these competitions is unintentionally poorly timed.
    Currently, Head Start grantees are notified in January of their
    recompetition status, but the results of those competitions are not
    determined until late in the summer. With a school year beginning
    shortly thereafter, any new grantee taking over for a low-quality
    incumbent faces a steep climb to recruit teachers, enroll children, and
    find any necessary facilities and other resources to start up their
    program. This is an avoidable strain on communities.
        Considering the opportunity that DRS provides to improve program
    quality, we must ensure that the process is done right. We hope the
    Subcommittee considers additional assistance to the Office of Head
    Start to ensure that these competitions are run effectively and
    efficiently, and that the process is accurately capturing programs that
    are of low quality.
    Head Start is a High Yield Investment:
        To take a step back, NHSA believes that the budget caps now in
    place limit the opportunities to make effective investments in our
    future. President Obama proposed an additional $800 million to support
    Head Start and Early Head Start expansion. We support the President's
    focus on the need to reach the large population of underserved, at-risk
    infants, toddlers, and preschoolers, but understand that appropriations
    that exceed the fiscal year 15 budget caps are unlikely.
        Certainly, we respect the idea that our debt cannot be left for the
    very children we serve. We do hope that deficit reduction can still be
    achieved in a way that does not squander our highest-yield investments.
    Studies show that for every one dollar invested in a Head Start child,
    society earns at least $7 back through increased earnings, employment,
    and family stability; \1\ as well as decreased welfare dependency,\2\
    healthcare costs,\3\ crime costs,\4\ grade retention,\5\ and special
    education.\6\ These are the very results taxpayers demand.
    ---------------------------------------------------------------------------
        \1\ Ludwig, J. and Phillips, D. (2007). The Benefits and Costs of
    Head Start. Social Policy Report. 21 (3: 4); Deming, D. (2009). Early
    childhood intervention and life-cycle skill development: Evidence from
    Head Start. American Economic Journal: Applied Economics, 1(3): 111-
    134; Meier, J. (2003, June 20). Interim Report. Kindergarten Readiness
    Study: Head Start Success. Preschool Service Department, San Bernardino
    County, California; Deming, D. (2009, July). Early childhood
    intervention and life-cycle skill development: Evidence from Head
    Start, p. 112.
        \2\ Meier, J. (2003, June 20). Kindergarten Readiness Study: Head
    Start Success. Interim Report. Preschool Services Department of San
    Bernardino County.
        \3\ Frisvold, D. (2006, February). Head Start participation and
    childhood obesity. Vanderbilt University Working Paper No. 06-WG01;
    Currie, J. and Thomas, D. (1995, June). Does Head Start Make a
    Difference? The American Economic Review, 85 (3): 360; Anderson, K.H.,
    Foster, J.E., & Frisvold, D.E. (2009). Investing in health: The long-
    term impact of Head Start on smoking. Economic Inquiry, 48 (3), 587-
    602.
        \4\ Reuters. (2009, March). Cost of locking up Americans too high:
    Pew study; Garces, E., Thomas, D. and Currie, J. (2002, September).
    Longer-term effects of Head Start. American Economic Review, 92 (4):
    999-1012.
        \5\ Barnett, W. (2002, September 13). The Battle Over Head Start:
    What the Research Shows.; Garces, E., Thomas, D. and Currie, J. (2002,
    September). Longer-Term Effects of Head Start. American Economic
    Review, 92 (4): 999-1012.
        \6\ NHSA Public Policy and Research Department analysis of data
    from a Montgomery County Public Schools evaluation. See Zhao, H. &
    Modarresi, S. (2010, April). Evaluating lasting effects of full-day
    prekindergarten program on school readiness, academic performance, and
    special education services. Office of Shared Accountability, Montgomery
    County Public Schools.
    ---------------------------------------------------------------------------
        Again, the Head Start community understands the pressure the
    Subcommittee faces and is grateful for the commitment shown by Congress
    and the President to keep early learning, and Head Start in particular,
    as a priority. We urge the Subcommittee to build on the investments
    made in Head Start and Early Head Start, to increase access, to improve
    accountability, and ensure the prosperity of our next generation. Thank
    you for your time and consideration.

        [This statement was submitted by Yasmina Vinci, Executive Director,
    National Head Start Association.]
                                     ______

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

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

        This program is designed to provide funds to operate a coordinated
    program of family preservation, family support, reunification, and
    adoption services. Promoting Safe and Stable Families is authorized
    with both a mandatory capped entitlement ($345 million) as well as a
    discretionary appropriation ($200 million). Tribes are eligible for
    funds based on a 3 percent set-aside of the total appropriation. All
    tribes whose plan receives approval are eligible for a portion equal to
    that tribe's relative share of children compared with all tribal
    entities with approved plans. Tribes who would qualify for less than 10
    thousand dollars under the formula are not eligible to receive funding.
        Tribal child welfare programs work tirelessly to strengthen
    families and provide services that keep children safely in their homes.
    This program is an integral part of these efforts. It supports
    parenting classes, home-visiting services, respite care for caregivers
    of children, and other services that safely preserve families.
        One hundred and thirty tribes and tribal consortia depend on this
    funding. Yet because of the funding levels, many tribes are ineligible
    for these formula grant dollars as their portion of the tribal set-
    aside is less than $10,000. Increasing this program's discretionary
    funding to $75 million and fully funding the $345 million in mandatory
    funding would help dozens of new tribes access this funding and
    hundreds of families obtain tribal child welfare services.
                      child welfare other recommendations
        Child Abuse Discretionary Activities, including Innovative
    Evidence-Based Community Prevention Programs recommendation: Increase
    appropriations to $35 million to account for tribes' recent eligibility
    for these funds while holding state and other grantees harmless.
        The Community Based Child Abuse Prevention Program recommendation:
    Increase funding to $60 million, so that more tribes can have access to
    these scarce child abuse prevention dollars.
        Demonstration to Address Over-Utilization of Psychotropic
    Medications for Children in Foster Care (Presidents fiscal year 2015
    Initiative) recommendation: Fund this initiative at the proposed $250
    million and ensure a tribal set-aside of 3 percent so that tribal
    communities can also participate in this important initiative to ensure
    children receive holistic mental healthcare.
    department of health and human services recommendations substance abuse
                   and mental health services administration
               children's mental health priority recommendations
        Programs of Regional and National Significance: Children and Family
    Programs (Circles of Care) recommendation: Fund Circles of Care Program
    at $6.5 million as recommended by the President to ensure current
    communities can continue their important work and new tribal
    communities can have access to this program.
        The Children and Family Programs line item represents funds
    allocated to the Circles of Care Program. The Circles of Care program
    is the cornerstone of children's mental health programming in tribal
    communities. The Circles of Care program is the only SAMHSA grant
    program that is focused specifically on AI/AN children's mental health
    needs. It is also the only SAHMSA program that allows tribes and tribal
    organizations to apply without competing for funding with other
    governmental entities such as States, counties, or cities. There are
    currently seven communities receiving Circles of Care funding.
        The American Psychiatric Association has found that AI/AN children
    and youth face a "disproportionate burden" of mental health issues
    while simultaneously facing more barriers to quality mental healthcare
    (2010). Circles of Care provides communities with funding to plan and
    build culturally competent services and design integrated supports that
    meet the specific needs of their youth with behavioral health
    challenges. It is essential to the well-being of AI/AN children. It is
    imperative that funding that matches the President's Budget request of
    $6.5 million be reserved in this line item for the Circles of Care
    program. This will ensure that more tribal communities can access this
    grant and improve their children's mental healthcare systems.
        Children's Mental Health Services Program: Children's Mental Health
    Initiative (Systems of Care) recommendation: Maintain funding at $117
    million to continue support of Tribal children's mental health systems
    change efforts.
        The various Systems of Care grants funded under this line item
    support a community's efforts to plan and implement strategic
    approaches to mental health services and supports that are family
    driven; youth guided; strength based; culturally and linguistically
    competent; and meet the intellectual, emotional, cultural, and social
    needs of children and youth.
        The American Psychiatric Association (APA; 2010) has recognized
    family, culture, and traditional health practices as important
    protective factors for AI/ANs struggling with mental health challenges.
    The Systems of Care program, which foster those protective factors
    described by the APA, has been both well-received and particularly
    effective in tribal communities. Currently, 17 tribal communities are
    funded under the Children's Mental Health Initiative line item.
        The well-being of AI/AN children is dependent on the ability of
    more tribes to access these funds and create real systems change. Thus,
    funding must be maintained at $117 million as recommended by the
    President's Budget. This will ensure the current Systems of Care
    grantees can continue, and a new robust cohort of grantees can begin
    this important work.
                    children's mental health recommendations
        Tribal Behavioral Health Grants recommendation: Implement
    President's Budget fiscal year 2013 recommendation to fund this new
    initiative at $40 million so that additional tribal communities can
    receive resources for children's mental health and substance abuse.
        The GLS State/Tribal Youth Suicide Prevention and Early
    Intervention Program recommendation: Keep funding at the fiscal year
    2014 appropriated level of $35.5 million to ensure that current
    grantees can complete their projects, and a similar sized cohort of
    annual grantees will have access to this program.
        AI/AN Suicide Prevention program recommendation: Fund at the
    President's Budget recommended amount of $2.94 million, to ensure that
    the epidemic of AI/AN suicide receives the attention it warrants.
        If you have any questions about this testimony please contact NICWA
    Government Affairs Associate Addie Smith at addie@nicwa.org.
                                     ______

        Prepared Statement of the National Indian Education Association
        The National Indian Education Association (NIEA) was incorporated
    in 1970 and is the most representative Native education organization in
    the United States. NIEA's mission is to advance comprehensive and equal
    educational opportunities for American Indian, Alaska Native, and
    Native Hawaiian students. NIEA supports tribal sovereignty over
    education as well as strengthening traditional Native cultures and
    values that enable Native learners to become contributing members of
    their communities. As the most inclusive Native education organization,
    NIEA membership consists of tribal leaders, educators, students,
    researchers, and education stakeholders from all 50 States. From
    communities in Hawaii, to tribal reservations across the continental
    U.S., to villages in Alaska and urban communities in major cities, NIEA
    has the most reach of any Native education organization in the country.
        Tribes and Native communities have a tremendous stake in an
    improved education system, because an improved system equates to better
    services for Native people and students. As tribes work to increase
    their footprint in education, there must be support for that increased
    participation. The Federal Government must uphold its trust
    relationship with tribes. Established through treaties, Federal law,
    and U.S. Supreme Court decisions, this relationship includes a
    fiduciary obligation to provide parity in access and equal resources to
    all American Indian and Alaska Native students, regardless of where
    they attend school. National fiscal and policy concerns should not be
    addressed by decreasing funds and investment to Native students or the
    programs that serve them. Rather, Native education, including those
    programs and services under the Departments of Education (ED) and
    Health and Human Services (HHS), is one of the most effective and
    efficient investments the Federal Government can make.
        As tribes and Native communities work with Congress for parity in
    access to increase their role and responsibility in administering
    education, Federal support for tribal governments and Native education
    institutions has continued to shrink as a percentage of the Federal
    budget. Historical funding trends illustrate that the Federal
    Government is abandoning its trust responsibility by decreasing Federal
    funds to Native-serving programs by more than half in the last 30
    years. Sequestration only exacerbated those shortfalls.
        While fiscal year 2014 funding increases over sequestration levels
    were welcome, several Native-serving programs remained flat with 2013
    sequestration levels, such as Elementary and Secondary Education Act
    Title VII funding. These levels continue to be insufficient for
    effectively and equally serving Native students. Partly as a result of
    this insufficient funding, Native students continue to lag behind their
    non-Native peers. Graduation rates often hover around 50 percent in
    many States, which can lead to increased substance abuse, criminal
    acts, and extended periods of unemployment. If the 25,000 Native
    students who dropped out of the Class of 2010 had graduated, an
    additional $295 million would likely have been added to total annual
    earnings, supplementing local and regional economies.
        To provide tribes and Native communities the educational
    institutions that supplement economic growth, the Federal Government
    should fund Native education programs at the levels requested below as
    they detail the minimum appropriations needed to maintain a system that
    is already struggling and underfunded. The following funding requests
    illustrate continuing need for Native programs but do not comprise the
    full list of budget requests, which can be found in the fiscal year
    2015 NIEA Budget Document. Further, NIEA supports the budget requests
    of the National Congress of American Indians and American Indian Higher
    Education Consortium.
    State-Tribal Education Partnership (STEP) Program (ED)
      --Provide $5 million. An increase of $3 million.
        Congress appropriated roughly $2 million dollars for the STEP
    program to five participating tribes under the Tribal Education
    Department appropriations. In order for this program to successfully
    achieve the original intent of the appropriation, it must receive its
    own line and authorization of appropriations in fiscal year 2015.
    Collaboration between tribal education agencies and State education
    agencies is crucial to developing the tribal capacity to assume the
    roles, responsibilities, and accountability of tribal education
    departments that increase self-governance in Native education.
    Impact Aid (ED)
      --Provide $2 billion for Impact Aid, under ESEA Title VIII. An
            increase of $711 million.
        Impact Aid provides direct payments to public school districts as
    reimbursement for the loss of traditional property taxes due to a
    Federal presence or activity, including the existence of an Indian
    reservation. With nearly 93 percent of Native students enrolled in
    public schools, Native students were disproportionately affected by the
    devastating reductions implemented under sequestration. Additional
    funds are required to cover previous Impact Aid shortfalls.
    Title VII (Indian Education Formula Grants in ED)
      --Provide $198 million under ESEA Title VII, Part A. An increase of
            $74 million.
        This grant funding is designed to supplement the regular school
    program and assist Native students so they have the opportunity to
    achieve the same educational standards as their non-Native peers. Title
    VII funding, which was maintained at 2013 sequestration levels in
    fiscal year 2014, only reaches 500,000 Native students leaving over
    100,000 without supplementary academic and cultural programs in their
    schools. As Native students continually lag behind their non-Native
    peers in educational achievement, increased funding is necessary to
    address this substantial gap.
    Native Hawaiian Education Program (ED)
      --Provide $35 million under ESEA Title VII, Part B. An increase of $3
            million.
        The Native Hawaiian Education program empowers innovative
    culturally-appropriate programs to enhance the quality of education for
    Native Hawaiians. When establishing the Native Hawaiian Education
    Program, Congress acknowledged the trust relationship between the
    Native Hawaiian people and the United States. These programs strengthen
    Native Hawaiian culture and improve educational attainment, both of
    which are correlated with positive economic outcomes.
    Alaska Native Education Equity Assistance Program (ED)
      --Provide $35 million under ESEA Title VII, Part C. An increase of $5
            million.
        This assistance program funds the development of curricula and
    education programs that address the unique educational needs of Alaska
    Native students as well as the development and operation of student
    enrichment programs in science and mathematics. Other eligible
    activities include professional development for educators, activities
    carried out through Even Start and Head Start programs, family literacy
    services, and dropout prevention programs.
    Vocational Rehabilitation Services Projects for American Indians with
            Disabilities (ED)
      --Provide $67 million to Vocational Rehabilitation Services Projects.
            Create a line item of $5 million for providing outreach to
            tribal recipients.
        According to the Centers for Disease Control and Prevention,
    approximately 30 percent of Native adults have a disability--the
    highest rate of any other population in the Nation. Of those, 51
    percent reported having fair or poor health. A number of issues
    contribute to this troubling reality, including high incidences of
    diabetes, heart disease, and preventable accidents. As a result, tribes
    have an extraordinary need to support their disabled citizens in
    improving their health, attaining experiential learning courses, and
    becoming self-sufficient. Tribes have limited access to funding for
    vocational rehabilitation and job training as compared to States and
    $67 million would begin to put tribes on par to support their disabled
    citizens.
    Native Languages Preservation (Esther Martinez Program Grants in HHS)
      --Provide $12 million for Native language preservation with $5
            million designated to fund the Esther Martinez Native Language
            Programs. An increase of $3 million.
        Native language grant programs are essential to revitalizing Native
    languages and cultures, many of which are at risk of disappearing in
    the upcoming decades. In addition to protecting Native languages, these
    immersion programs promote higher academic success for participating
    students in comparison to their Native peers who do not participate.
    The Federal budget should include $12 million for Native language
    preservation activities which would include $5 million designated to
    support Esther Martinez Native Language Programs' immersion
    initiatives.
        Thank you for your consideration of this testimony. For more
    information or to attain NIEA's complete budget document with all
    fiscal year 2015 requests for the Departments of Education and Health
    and Human Services, please contact Ahniwake Rose, NIEA Executive
    Director, at arose@niea.org.
                                     ______

              Prepared Statement of the National Kidney Foundation
        The National Kidney Foundation (NKF) is pleased to submit testimony
    for the written record in support of the Centers for Disease Control
    and Prevention Chronic Kidney Disease Program, the National Institute
    of Diabetes and Digestive and Kidney Disease, and the Health Resources
    and Services Administration Division of Transplantation. NKF is
    America's largest and oldest health organization dedicated to the
    awareness, prevention and treatment of kidney disease for hundreds of
    thousands of healthcare professionals, millions of patients and their
    families, and tens of millions of people at risk. In addition, we have
    provided universally recognized evidence-based clinical practice
    guidelines for all stages of chronic kidney disease (CKD) since 1997
    through the NKF Kidney Disease Outcomes Quality Initiative (NKF KDOQI).
        We respectfully request fiscal year 2015 funding of $2.1 million
    for the CDC Chronic Kidney Disease Program, $2.066 billion for NIDDK,
    and $24 million for the HRSA Division of Transplantation.
        In 2011, almost 616,000 Americans had End Stage Renal Disease
    (ESRD), including more than 430,000 dialysis patients and nearly
    186,000 kidney transplant recipients, with members of many minority
    populations disproportionately affected. Complicating the cost and
    human toll is the fact that it is a disease multiplier, with patients
    very likely to be diagnosed with diabetes, cardiovascular disease, or
    hypertension (40 percent of ESRD patients had a diagnosis of diabetes
    and two-thirds have diabetes or hypertension). ESRD is the only
    disease-specific coverage under Medicare regardless of age or other
    disability. In 2011, ESRD was present in 1.4 percent of Medicare
    beneficiaries but responsible for more than 7 percent of Medicare
    expenditures. (1)
        NKF recently announced an initiative to help address awareness of
    CKD by increasing communication between practitioners and patients.
    There is a misconception that once someone is diagnosed with CKD, there
    must be a referral to a nephrologist. However, there are not enough
    nephrologists to care for the 15 percent of the U.S. population with
    chronic kidney disease. NKF's CKD Primary Care Initiative will
    disseminate CKD guidelines to primary care physicians through education
    programs, symposia and practical implementation tools so they can
    provide this care to the growing numbers of Americans with CKD. Our
    initiative will help build on CDC's program, outlined below.
    CDC Chronic Kidney Disease Program
        To address the social and economic impact of kidney disease, NKF
    worked with Congress to initiate a Chronic Kidney Disease Program at
    CDC in fiscal year 2006. Prior to this, no national public health
    program focusing on early detection and treatment existed. Cost-
    effective treatments exist to potentially slow progression of kidney
    disease and prevent its complications, but only if individuals are
    diagnosed before the latter stages of CKD.
        The CDC program is designed to identify members of populations at
    high risk for CKD, develop community-based approaches for improving
    detection and control, and educate health professionals about best
    practices for early detection and treatment. The National Kidney
    Foundation respectfully urges the Committee to maintain $2.1 million in
    line-item funding for the Chronic Kidney Disease Program for fiscal
    year 2015. Continued support will benefit kidney patients and Americans
    who are at risk for kidney disease, advance the objectives of Healthy
    People 2020 and the National Strategy for Quality Improvement in Health
    Care, and fulfill the mandate created by Sec. 152 of the Medicare
    Improvement for Patients and Providers Act.
        It is estimated that CKD affects 26 million adult Americans (2) and
    73 million more are at risk. Furthermore, a task force of the American
    Heart Association noted that decreased kidney function has consistently
    been found to be an independent risk factor for cardiovascular disease
    (CVD) outcomes and all-cause mortality and that the increased risk is
    present with even mild reduction in kidney function. (3) Therefore
    addressing CKD is a way to achieve one of the priorities in the
    National Strategy for Quality Improvement in Health Care: Promoting the
    Most Effective Prevention and Treatment of the Leading Causes of
    Mortality, Starting with Cardiovascular Disease.
        CKD is often asymptomatic, especially in the early stages and
    therefore goes undetected without laboratory testing. Some people
    remain undiagnosed until they have reached CKD Stage 5 and must begin
    dialysis immediately. However, early identification and treatment can
    slow the progression of kidney disease, delay complications, and
    prevent or delay kidney failure. Accordingly, Healthy People 2020
    Objective CKD--2 is to ``increase the proportion of persons with
    chronic kidney disease (CKD) who know they have impaired renal
    function.''
        Screening and early detection provides the opportunity for
    interventions to foster awareness, foster adherence to medications and
    control risk factors. Additional data collection is required to
    precisely define the incremental benefits of early detection on kidney
    failure, cardiovascular events, hospitalization and mortality.
    Increasing the proportion of persons with CKD who know they are
    affected requires expanded public and professional education programs
    and screening initiatives targeted at populations who are at high risk.
    As a result of consistent congressional support, the National Center
    for Chronic Disease Prevention and Health Promotion at CDC has
    instituted a series of projects that could assist in attaining the
    Healthy People 2020 objective. However, this forward momentum will be
    stifled and CDC's investment in CKD to date jeopardized if line-item
    funding is not continued.
        As noted in CDC's Preventing Chronic Disease: April 2006, Chronic
    Kidney Disease meets the criteria to be considered a public health
    issue: (1) the condition places a large burden on society; (2) the
    burden is distributed unfairly among the overall population; (3)
    evidence exists that preventive strategies that target economic,
    political, and environmental factors could reduce the burden; and (4)
    evidence shows such preventive strategies are not yet in place.
        The Chronic Kidney Disease program has consisted of three projects
    to promote kidney health by identifying and controlling risk factors,
    raising awareness, and promoting early diagnosis and improved outcomes
    and quality of life for those living with CKD. These projects include
    (1) demonstrating approaches for identifying individuals at high risk
    for CKD through State-based screening; (2) conducting an economic
    analysis on the economic burden of CKD and the cost-effectiveness of
    interventions; and (3) establishing a surveillance system for CKD by
    analyzing and interpreting information to assist in prevention and
    health promotion efforts for kidney disease. The surveillance project
    includes a CDC website program containing information on risk factors,
    early diagnosis, and strategies to improve outcomes.
        Undetected Chronic Kidney Disease can lead to costly and
    debilitating irreversible kidney failure. However, cost-effective
    interventions are available if patients are identified in the early
    stages of CKD. With the continued support of Congress, NKF is confident
    a feasible detection, surveillance and treatment program can be
    established to slow, and possibly prevent, the progression of kidney
    disease.
    NIDDK
        NKF joins multiple other kidney patient and professional
    organizations to request $2.066 billion for NIDDK in fiscal year 2015.
    Medicare spends $77 billion annually to care for patients with kidney
    disease, including nearly $35 billion for individuals with ESRD, yet
    NIH funding for kidney disease research is only about $600 million
    annually or less than $25 per patient for the 26 million adults with
    CKD. In March 2014, NKF hosted a Kidney Patient Summit that included
    participation from our advocates and those of five other kidney patient
    organizations. Increased Federal support for kidney disease research
    was one of the requests the advocates presented in meetings with their
    congressional delegations.
        We were honored to have NIDDK Director Dr. Griffin Rodgers address
    the Kidney Summit where we learned of exciting opportunities in CKD
    research. America's scientists are at the cusp of many potential
    breakthroughs in improving our understanding of CKD and providing new
    therapies to delay and treat various kidney diseases. With the unique
    status of ESRD in the Medicare program, it can be argued that
    breakthroughs in CKD have the potential to provide cost savings to the
    Federal Government like that of no other chronic disease. We urge
    Congress to continue its strong bipartisan support for NIH in fiscal
    year 2015 and to fund NIDDK at this requested level that is widely
    supported by the kidney community.
    HRSA Organ Transplantation
        NKF also urges the Committee to support the President's Budget
    Request of $24 million for organ donation and transplantation programs
    run by the Health Resources and Services Administration's (HRSA)
    Division of Transplantation (DoT). This represents an increase of less
    than $500,000 over the fiscal year 2014 level and would restore funding
    to the fiscal year 2012 level.
        The national organ transplant wait list contains more than 122,000
    listings, including 100,000 people waiting for a kidney.
    Transplantation remains the treatment of choice for most patients with
    kidney failure yet few of them will be given an opportunity to receive
    a new kidney, especially if they do not have a potential living kidney
    donor. Kidney recipients often have an improved quality of life (and
    are more likely to stay in or return to the work force) and
    transplantation is tremendously cost effective. Medicare spends about
    $25,000 per year on a kidney recipient after the year of transplant,
    compared to more than $80,000 annually on a dialysis patient (these
    figures reflect all Medicare expenses and are not limited to kidney
    related care).
        The HRSA program supports the Organ Procurement and Transplantation
    Network (OPTN) which allocates donor organs to individuals on wait
    lists. Additional activities supported by DoT include initiatives to
    increase the number of donor organs; a grant program to assist living
    donors with out-of-pocket expenses that are not reimbursed by
    insurance, a health benefit program, or any other State or Federal
    program; State donor registry initiatives to enroll potential donors;
    and, activities to build upon achievements of HRSA's Breakthrough
    Collaboratives of a decade ago.
        Thank you for your consideration of our requests for fiscal year
    2015.
        (1) 2013 U.S. Renal Data System Annual Report.
        (2) Josef Coresh, et al. ``Prevalence of Chronic Kidney Disease in
    the United States,''JAMA, November 7, 2007.
        (3) Mark J. Sarnak, et al. Kidney Disease as a Risk Factor for the
    Development of Cardiovascular Disease: A Statement from the American
    Heart Association Councils on Kidney in Cardiovascular Disease, High
    Blood Pressure Research, Clinical Cardiology, and Epidemiology and
    Prevention. Circulation 2003: 108: 2154-69.
                                     ______

             Prepared Statement of the National League for Nursing
        The National League for Nursing (NLN) is the premiere organization
    dedicated to promoting excellence in nursing education to build a
    strong and diverse nursing workforce to advance the Nation's health.
    With leaders in nursing education and nurse faculty across all types of
    nursing programs in the United States--doctorate, master's,
    baccalaureate, associate degree, diploma, and licensed practical--the
    NLN has more than 1,200 nursing school and healthcare agency members,
    40,000 individual members, and 24 regional constituent leagues.
        The NLN urges the subcommittee to fund the following HRSA nursing
    programs:
      --The Title VIII Nursing Workforce Development Programs at $251
            million in fiscal year 2015; and
      --The Title III Nurse-Managed Health Clinics at $20 million in fiscal
            year 2015.
    Nursing Education Is a Jobs Program
        According to the Bureau of Labor Statistics (BLS), the registered
    nurse (RN) workforce will grow by 19.4 percent from 2012 to 2022,
    outpacing the 11 percent average for most occupations. BLS projects
    that this growth will result in 1,052,600 job openings in the economy,
    representing one of the largest numeric job increases for all
    occupations. BLS calculates the openings from an increase of 526,800
    new RN jobs due to technological advancements fueling growth in
    treatments, preventive care being emphasized more, expanding demand
    from new health reform enrollments, and accelerating demand from the
    two million Baby Boomers aging into Medicare every year. A particularly
    disconcerting element of the probable RN job openings is a loss of
    nursing expertise owing to the replacement need of some 525,700 jobs
    vacated by RNs expected to leave the profession and/or retire from the
    labor force by 2022.
        The March 7, 2014, BLS Employment Situation Summary--February 2014
    likewise reinforces the strength of the nursing workforce in creating
    job growth. While the Nation's overall unemployment rate was little
    changed at 6.7 percent for February 2014, the employment in healthcare
    increased with the addition of 10,000 jobs at ambulatory healthcare
    services, hospitals, and nursing and residential care facilities,
    amounting to an unemployment rate of only 4.0 percent in the industry.
        BLS notes that the healthcare sector is a critically important
    industrial complex for the Nation. It is at the center of the economic
    recovery with the number of jobs climbing steadily. Growing even when
    the recession began in December 2007, healthcare jobs are up
    nationwide. Almost five million workers are in hospital settings, which
    often are the largest employer in a State. Healthcare has been a
    stimulus program generating employment and income, and nursing is the
    predominant occupation in the healthcare industry with more than 4.031
    million active, licensed RNs in the United States in 2014.
        The Nursing Workforce Development Programs provide training for
    entry-level and advanced degree nurses to improve the access to, and
    quality of, healthcare in underserved areas. The Title VIII nursing
    education programs are fundamental to the infrastructure delivering
    quality, cost-effective healthcare. The NLN applauds the subcommittee's
    bipartisan efforts to recognize that a strong nursing workforce is
    essential to a health policy that provides high-value care for every
    dollar invested in capacity building for a 21st century nurse
    workforce.
        The current Federal funding falls short of the healthcare
    inequities facing our Nation. Absent consistent support, slight boosts
    to Title VIII will not fulfill the expectation of generating quality
    health outcomes, nor will episodic increases in funding fill the gap
    generated by a 15-year nurse and nurse faculty shortage felt throughout
    the U.S. health system.
    The Nurse Pipeline and Education Capacity
        Although the recession resulted in some stability in the short-term
    for the nurse workforce, policy makers must not lose sight of the long-
    term growing demand for nurses in their districts and States. The NLN's
    findings from its Annual Survey of Schools of Nursing--Academic Year
    2011-2012 cast a wide net on all types of nursing programs, from
    diploma through doctoral, to determine rates of application,
    enrollment, and graduation. This data can be found at http://
    www.nln.org/researchgrants/slides/index.htm. Key findings include:
      --Demand for spots in nursing education programs historically
            outstripped supply. In 2012, 43 and 37 percent of master's and
            doctoral nursing programs, respectively, rejected qualified
            applicants. More dramatically, 72 percent of programs offering
            practical nursing (PN) degrees and 84 percent offering
            associate's degrees in [registered] nursing programs (ADN) were
            forced to turn away qualified candidates, as did almost two-
            thirds (64 percent) of baccalaureate in science of [registered]
            nursing (BSN) programs. The aggregate rate across all basic RN
            programs was 28 percent of qualified applications not accepted
            in the Fall 2012.
      --Expansion of nursing education programs impeded by shortage of
            faculty. Deans and directors of schools providing programs that
            did not accept all eligible applicants were asked to identify
            the primary obstacle to expanding their program's capacity.
            Since 2010, the percentage of those directing ADN and PN
            programs that cited a shortage of clinical sites as the primary
            impediment to expansion has steadily increased. For PN programs
            in particular, the percentage jumped to 51 percent in 2012. By
            contrast, graduate programs consistently cite a lack of faculty
            as the primary obstacle to expansion. A strong correlation
            exists between the shortage of nurse faculty and the inability
            of nursing programs to keep pace with the demand for new nurse
            faculty and new RNs. Increasing the productivity of education
            programs is a high priority in most States, but faculty
            recruitment is a glaring problem. Without faculty to educate
            our future nurses, the shortage cannot be resolved.
      --Age of associate degree students rises. A substantial increase in
            the percentage of ADN students who were over 30 years old
            occurred, rising in 2012 to 50 percent of the student nursing
            enrollments. Because ADN students comprise two-thirds of all
            pre-licensure RN enrollees, this uptick in enrollments among
            older students could reignite concerns over an aging nursing
            workforce and the potential for future labor shortages.
    Equally Pressing Is Lack of Diversity
        Our Nation is enriched by cultural diversity--37 percent of our
    population identify as racial and ethnic minorities. Yet ethnic,
    cultural, and gender diversity eludes the nursing student and nurse
    educator populations. A survey of nurse educators conducted by the NLN
    and the Carnegie Foundation's Preparation for the Professions Program
    found that only 7 percent of nurse educators were minorities compared
    with 16 percent of all U.S. faculty. The lack of faculty diversity
    limits nursing schools' ability to deliver culturally appropriate
    health professions education. In addition, the NLN survey for the 2011-
    2012 academic year reported that:
      --African-American enrollment drops. The percentage of racial-ethnic
            minority students enrolled in pre-licensure RN programs has
            declined steadily over the past 2 years--ultimately dropping
            from a high of 29 percent in 2009 to 24 percent in 2011 and up
            to 26 percent in 2012. The majority of that decline stems from
            a steep reduction in the percentage of African-American
            students enrolled in associate degree nursing programs, which
            dropped by almost 5 percent to 9 percent. BSN programs saw a
            small, but not significant drop, in African-American
            enrollment, down from 13 to 12 percent. Inversely, diploma
            programs saw a sharp rise in African-American enrollments to 30
            percent, but because they represent just 4 percent of all basic
            RN programs, the impact is not great.
      --Hispanic representation, while still lagging, inches upward.
            Hispanics remain dramatically underrepresented among nursing
            students. Representing a mere 6 percent of associate degree and
            baccalaureate nursing students, Hispanics were enrolled in
            basic nursing programs at less than half the rate at which they
            were enrolled in undergraduate programs overall. However, the
            percentage of Hispanics enrolled in post-licensure programs has
            nearly doubled at every level.
      --Men's enrollment at historic high. While significantly less than
            the proportion in the U.S. population, at 15 percent, men
            enrolled in basic RN programs (i.e., 13 percent BSN, 16 percent
            diploma, and 16 percent ADN) remained at the historic high
            reached at the start of the recession. Approximately 11 percent
            of PN students, RN-to BSN students, master's, and doctoral
            students were male in 2012.
        Besides representing an untapped talent pool to remedy the nursing
    shortage, ethnic, cultural, and gender-diverse minorities in nursing
    are essential to developing a healthcare system that understands and
    addresses the needs of our rapidly diversifying population. Workforce
    diversity is needed where research indicates that factors such as
    societal biases and stereotyping, communication barriers, limited
    cultural sensitivity and competence, and system and organizational
    determinants contribute to healthcare inequities.
    Title VIII Federal Funding Reality
        Today's undersupply of appropriately prepared nurses and nurse
    faculty, as well as the projected loss of experienced nurses over the
    next decade, does not bode well for our Nation. The Title VIII Nursing
    Workforce Development Programs are a comprehensive system of capacity-
    building strategies that provide students and schools of nursing with
    grants to strengthen education programs, including faculty recruitment
    and retention efforts, facility and equipment acquisition, clinical lab
    enhancements, and loans, scholarships, and services that enable
    students to overcome obstacles to completing their nursing education
    programs. A few examples of HRSA's Title VIII data below provide
    perspective on current Federal investments.
        Nurse Faculty Loan Program (NFLP)--BLS projects a need of 35
    percent more faculty members to meet the expected increase in demand.
    In addition, with 10,200 current faculty members expected to retire,
    34,200 new nursing instructors will be needed by 2022. NFLP supports
    the establishment and operation of a loan fund at participating schools
    of nursing to assist nurses in completing their graduate education to
    become qualified nurse faculty. Ongoing NFLP support for faculty
    production is critical to building the pipeline that assures the full
    capacity of the Nation's future nursing workforce. Targeting a portion
    of those funds for minority faculty preparation is fundamental to
    achieving that goal. In fiscal year 2012, NFLP grantees exceeded the
    program's performance target by 49.6 percent in providing loans to
    2,259 students pursuing faculty preparation. About one out of every
    four students receiving the NFLP loans were considered underrepresented
    minorities.
        Comprehensive Geriatric Education Program (CGEP)--CGEP provides
    support to educate individuals in providing geriatric care for the
    elderly. This goal is accomplished through curriculum development and
    dissemination, continuing education, and traineeships for individuals
    preparing for advanced nursing education degrees. In fiscal year 2012,
    CGEP grantees awarded traineeships to 74 students--the majority of whom
    (81 percent) were pursuing a Master's Degree in Nursing.
        Nurse Education, Practice, Quality, and Retention Grants (NEPQR)--
    NEPQR addresses the critical nursing shortage via projects to expand
    the nursing pipeline, promote career mobility, provide continuing
    education, and support retention. Grants to support recruiting and
    retaining nursing assistants and personal and home care aides in
    occupational shortage and/or high demand areas trained 4,624 students
    during fiscal year 2012. NEPQR also supported expanding the size of BSN
    programs and supported nurse-managed health clinics.
    Nurse-Managed Health Clinics (NMHC)
        NMHCs are a nurse-practice arrangement, managed by advanced
    practice registered nurses, that provides primary care or wellness
    services. NMHCs are associated with a school, college, university, or
    department of nursing, federally qualified health center, or
    independent nonprofit health or social services agency.
        NMHCs deliver comprehensive primary healthcare services, disease
    prevention, and health promotion in medically underserved areas for
    vulnerable and specialized populations (e.g., veterans and/or families
    of active military). The complexity of care for these patients presents
    significant financial barriers, heavily affecting the sustainability of
    these clinics. While providing access points in areas where primary
    care providers are in short supply, expansion of NMHCs also increases
    the number of structured clinical teaching sites available to train
    nurses and other primary care providers. In fiscal year 2012, more than
    1,600 health professions students were trained in NMHCs, where the
    majority of NMHCs and associated training sites were primarily located
    in medically underserved communities (97 percent) and served as a
    primary care setting for their local community (65 percent).
    Appropriating $20 million in fiscal year 2015 to NMHCs would increase
    access to primary care for thousands of underserved people.
        The NLN can state with authority that the deepening health
    inequities, inflated costs, and poor quality of healthcare outcomes in
    this country will not be reversed until the concurrent shortages of
    nurses and qualified nurse educators are addressed. Your support will
    help ensure that nurses exist in the future who are prepared and
    qualified to take care of you, your family, and all those who will need
    our care. Without national efforts of some magnitude to match the
    healthcare reality facing our Nation today, an under resourced nurse
    education and its adverse effect in healthcare generally will be
    difficult to avoid.
        The NLN urges the subcommittee to maintain the Title VIII Nursing
    Workforce Development Programs by funding them at a level of $251
    million in fiscal year 2015. We also recommend that the Title III
    Nurse-Managed Health Clinics be funded at $20 million in fiscal year
    2015.

        [This statement was submitted by Beverly Malone, PhD, RN, FAAN,
    Chief Executive Officer, National League for Nursing.]
                                     ______

                 Prepared Statement of the National MPS Society
        The National MPS Society supports research to find cures for
    Mucopolysaccharidoses (MPS) and related diseases, and provides hope and
    support for affected individuals and their families through research,
    advocacy, and awareness of these devastating disorders. The Society
    submits this testimony to request insertion of language in the fiscal
    year 2015 Appropriations to direct the National Institutes of Health
    (NIH) to fund MPS research.
        MPS diseases are rare genetic diseases that affect both children
    and adults. They cause progressive damage to cells in the body,
    resulting in severe disability and early death. There are currently few
    treatments and no cures. There are 11 types of MPS but only 4 FDA
    approved enzyme replacement therapy treatments to slow disease
    progression. The damage from MPS results in severe problems, including
    profound intellectual disabilities, heart disease, vision loss, speech
    and hearing impairment, short stature, stiff joints, and pain, among
    others. MPS diseases are devastating for children and families, largely
    due to the progressive nature of the diseases. Babies are often born
    looking perfectly healthy. It is only later, as cell damage becomes
    worse, that parents receive the heartbreaking diagnosis. All MPS
    diseases are terminal with most affected individuals not surviving
    beyond teenage years.
        The National MPS Society is requesting the insertion of language
    specific to MPS and related diseases into the fiscal year 2015
    Appropriations Bill. This language will help focus NIH research efforts
    related to MPS and related diseases. After several years of decreased
    funding, the NIH budget for MPS research increased between 2010 through
    2013 but saw a significant decline in 2014 due to sequestration.
        Researchers focused on MPS diseases get almost all of their funding
    from the NIH. There is very little private funding for MPS and related
    diseases research. Although there are very few therapies for MPS
    diseases, the ones that are available are the result of NIH-funded
    research. Prominent researchers in the field believe that continued
    research holds the promise of effective treatments and cures for MPS
    diseases, including stem cell therapies, gene therapies, and small
    molecule therapies. Researchers are beginning to build momentum in
    their work on MPS diseases. Increased funding for MPS and related
    diseases research will ensure that this momentum translates into
    progress toward new treatments and a cure. Reduced funding stalls
    progress and prevents these critical gains.
        On behalf of the children and families impacted by MPS diseases,
    the National MPS Society respectfully requests the insertion of the
    following language into the fiscal year 2015 Appropriations Bill.
        Mucopolysaccharidoses: The Committee encourages the NINDS and NIDDK
    to expand research efforts in the development of effective treatments
    for MPS diseases. The Committee commends the National Institute of
    Neurological Disorders and Stroke (NINDS) and the Office of Rare
    Diseases Research (ORDR) and National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) for sponsoring scientific
    conferences like the Gordon Research Conference (April 2013) focusing
    on basic science of lysosomal biology and function but with strong
    emphasis on pathogenic mechanisms of lysosomal disease. The Committee
    further acknowledges and applauds the National Institutes of Health
    ORDR, NINDS and NIDDK for their work related to the Rare Diseases
    Clinical Research Network (RDCRN) over the next 5 years to fund
    research consortia including lysosomal diseases: mucopolysaccharidosis
    (MPS), and MPS bone disease, helping to create additional opportunities
    for small research communities, such as the Lysosomal Disease Network,
    to address some of these clinical research needs.
        Mucopolysaccharidoses (MPS) are a group of genetic, progressive
    diseases that are caused by the absence or malfunctioning of certain
    enzymes needed to break down molecules called glycosaminoglycans--long
    chains of sugar carbohydrates in each of our cells. When mutations
    occur in the genes for the enzymes involved in the normal turnover of
    Mucopolysaccharidoses, excess amounts of them are stored in the body,
    causing progressive damage to a number of different organs and tissues,
    and, in most cases, early death. There are no current cures for MPS,
    although stem cell transplants and enzyme replacement therapy show
    potential for reducing symptom severity. Treatment for the skeletal
    abnormalities remains a challenge due to the difficulty of introducing
    replacement enzymes or transplanted cells into skeletal tissues.
    Although the greatest benefit is likely to be discovered through MPS
    research supported by other NIH components, ongoing research at the
    NIAMS in other areas of skeletal research may help to inform the
    science base and potentially improve the quality of life of patients
    with the disease.
        Action taken or to be taken: The Committee encourages NINDS, ORDR
    and NIDDK to continue supporting scientific conferences in the
    Mucopolysaccharidoses and other Lysosomal Disease research community,
    such as the Lysosomal Disease Network's Annual WORLD Symposium. This
    international conference gives researchers an opportunity to share
    findings in basic, translational and clinical research and to establish
    collaborations that could enable multicenter studies in natural history
    and other areas of clinical research. In addition, this Symposium
    promotes interaction among interested lay participants and medical and
    scientific experts, in addition to representatives from pharmaceutical
    industry, involved in lysosomal diseases.
        The intent of the report language is to focus and encourage the
    National Institutes of Health's efforts with respect to the direction
    of Mucopolysaccharidoses and other Lysosomal Disease related research.
    The language included annually in the LHHS report has consistently
    addressed some of the most pressing, scientific needs in this complex
    area of biomedical research. The outcome has been, and one would hope
    continue to be, the Institutes examination of the issues raised by the
    Committee so that it can make meaningful efforts to enhance NIH
    activity on these important Mucopolysaccharidoses and Lysosomal Disease
    research issues.
                                     ______

         Prepared Statement of the National Multiple Sclerosis Society
        Mr. Chairman and Members of the Subcommittee, thank you for this
    opportunity to provide testimony regarding funding of critically
    important Federal programs that impact those affected by multiple
    sclerosis. We urge the Subcommittee to provide the following in fiscal
    year 2015: $2.5 million for the Lifespan Respite Care Program; at least
    $32 billion for the National Institutes of Health (NIH); robust support
    for Medicare and Medicaid; and $12.6 billion for the Social Security
    Administration (SSA).
        Multiple sclerosis (MS) is an unpredictable, often disabling
    disease of the central nervous system that interrupts the flow of
    information within the brain, and between the brain and body. Symptoms
    range from numbness and tingling to blindness and paralysis. The
    progress, severity, and specific symptoms of MS in any one person
    cannot yet be predicted. Most people with MS are diagnosed between the
    ages of 20 and 50, with at least two to three times more women than men
    being diagnosed with the disease.
        The National MS Society sees itself as a partner to the Government
    in many critical areas. As we advocate for NIH research, we do so as an
    organization that in 2013, funded approximately $48 million in MS
    research through funds generated through the Society's fundraising
    efforts. And as we advocate for Lifespan Respite funding, we do so as
    an organization that works to provide some level of respite relief for
    caregivers. So while we're here to advocate for Federal funding, we do
    it as an organization that commits tens of millions of dollars each
    year to similar or complementary efforts as those being funded by the
    Federal Government.
    Lifespan Respite Care Program
        Up to one quarter of individuals living with MS require long-term
    care services at some point during the course of the disease. Often, a
    family member steps into the role of primary caregiver. According to a
    2011 AARP report, 61.6 million family caregivers provided care at some
    point during 2009 and the value of their uncompensated services was
    approximately $450 billion per year. Family caregivers allow the person
    living with MS to remain home for as long as possible and avoid
    premature admission to costlier institutional facilities.
        Family caregiving, while essential, can be draining and stressful.
    A 2012 National Alliance for Caregiving (NAC) survey of individuals
    providing care to people living with MS shows that on average,
    caregivers spend 24 hours a week providing care. Sixty 4 percent of
    caregivers were emotionally drained, 32 percent suffered from
    depression and 22 percent have lost a job due to caregiving
    responsibilities.
        The Lifespan Respite Care Program, enacted in 2006 under President
    Bush, provides competitive grants to States to establish or enhance
    statewide lifespan respite programs that better coordinate and increase
    access to quality respite care. Respite offers professional short-term
    help to give caregivers a break from the stress of providing care and
    has been shown to provide family caregivers with the relief necessary
    to maintain their own health and bolster family stability. Perhaps the
    most critical aspect of the program for people living with MS is that
    Lifespan Respite serves families regardless of special need or age--
    literally across the lifespan. Much existing respite care has age
    eligibility requirements and since MS is typically diagnosed between
    the ages of 20 and 50, Lifespan Respite programs are often the only
    open door to needed respite services.
        For these reasons, the National MS Society asks that Congress
    provide $2.5 million for the Lifespan Respite Care Program in fiscal
    year 2015.
    National Institutes of Health
        As mentioned previously, the National MS Society invested $48
    million to MS research in 2013 and sees the NIH as an invaluable
    partner to stop MS in its tracks, restore function and end MS forever.
    Approximately $115 million of fiscal year 2013 was directed to MS-
    related research and over the years, NIH research projects have helped
    make significant progress in understanding MS. NIH scientists were
    among the first to report the value of MRI in detecting early signs of
    MS and have enhanced knowledge about how the immune system works and
    its role in the development of MS lesions.
        Twenty years ago, there were no MS therapies or medications--now
    there are ten. The NIH provided the basic research necessary so that
    these therapies could be developed. Despite this progress, there are
    still no treatments approved for people living with progressive MS.
    Only with continued investment will the innovation momentum continue,
    allowing us to find successful treatments for those with progressive MS
    and a cure for all.
        The NIH also directly supports jobs in all 50 States and 17 of the
    30 fastest growing occupations in the U.S. are related to medical
    research or healthcare. More than 83 percent of the NIH's funding is
    awarded through almost 50,000 competitive grants to more than 325,000
    researchers at over 3,000 universities, medical schools, and other
    research institutions in every State.
        For these reasons, the Society urges Congress to provide at least
    $32 billion for the NIH in fiscal year 2015.
    Centers for Medicare & Medicaid Services
        Medicare: It is estimated that over 20 percent of the MS population
    relies on Medicare as its primary insurer. The majority of these
    individuals are under the age of 65 and receive the Medicare benefit as
    a result of their disability. Of particular importance to the MS
    community are: having appropriate reimbursement levels for Medicare
    physicians, maintaining access to diagnostics and durable medical
    equipment, protecting access to needed speech, physical and
    occupational therapy services, and discouraging overly burdensome cost-
    sharing for prescription drugs.
        Medicaid: Medicaid provides comprehensive health coverage to over
    eight million persons living with disabilities, plus six million
    persons with disabilities who rely on Medicaid to fill Medicare's gaps.
    The latest statistics (which are pre-recession) show that about 5-10
    percent of people with MS have Medicaid coverage. The most recently
    available data (2007) reveals that the average annual direct and
    indirect (e.g. lost wages) cost for someone with MS in the U.S. is
    approximately $69,000. After years of paying to manage their disease,
    some people with MS have spent the vast majority of their earnings and
    savings, making their financial situation so dire that Medicaid becomes
    their only option for health coverage.
        The National MS Society urges Congress to maintain funding for
    Medicaid and reject proposals to cap or block grant the program. Any of
    these proposals would merely shift costs to States, forcing States to
    shoulder a seemingly insurmountable financial burden or cut services on
    which our most vulnerable rely. The Society also urges Congress to
    protect and promote access to home- and community-based care in line
    with the 1999 U.S. Supreme Court decision Olmstead.
    Social Security Administration
        Because of the unpredictable nature and sometimes serious
    impairment caused by the disease, SSA recognizes MS as a chronic
    illness or ``impairment'' that can cause disability severe enough to
    prevent an individual from working. During such periods, people living
    with MS are entitled to and rely on Social Security Disability
    Insurance (SSDI) or Supplemental Security Income (SSI) benefits to
    survive. The National MS Society urges Congress to provide $12.3
    billion for the SSA's administrative budget so that it can continue
    efforts to reduce hearings and disability backlogs, pay monthly
    benefits in a timely manner, and determine post-entitlement issues in a
    timely manner.
    Conclusion
        The National MS Society thanks the Committee for the opportunity to
    provide written testimony and our recommendations for fiscal year 2015
    appropriations. The agencies and programs we have discussed are of
    vital importance to people living with MS and we look forward to
    continuing to working with the Committee to help move us closer to a
    world free of MS. Please don't hesitate to contact me with any
    questions.

        [This statement was submitted by Ted Thompson, Vice President,
    Federal Government Relations.]
                                     ______

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

        [This statement was submitted by Tine Hansen-Turton, CEO, National
    Nursing Centers Consortium.]
                                     ______

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

        [This statement was submitted by Jill Kagan, Chair, National
    Respite Coalition.]
                                     ______

          Prepared Statement of the National Rural Health Association
        The National Rural Health Association (NRHA) is pleased to provide
    the Labor, Health and Human Services, Education and Related Agencies
    Appropriations Subcommittee with a statement for the record on fiscal
    year 2015 funding levels for programs with a significant impact on the
    health of rural Americans.
        NRHA is a national nonprofit membership organization with a diverse
    collection of 21,000 individuals and organizations who share a common
    interest in rural health. The Association's mission is to improve the
    health of rural Americans and to provide leadership on rural health
    issues through advocacy, communications, education and research.
        NRHA is advocating support for a group of rural health program that
    assist rural communities in maintaining and building a strong
    healthcare delivery system into the future. Most importantly, these
    programs help increase the capacity of the rural healthcare delivery
    system and true safety net providers. Rural Americans, on average, are
    poorer, sicker and older than their urban counterparts. Programs in the
    rural health safety net increase access to healthcare, help communities
    create new health programs for those in need and train the future
    health professionals that will care for the 62 million rural Americans.
    With modest investments, these programs evaluate, study and implement
    quality improvement programs and health information technology systems.
        Important rural health programs supported by NRHA are outlined
    below.
        Rural Health Outreach and Network Grants provide capital investment
    for planning and launching innovative projects in rural communities
    that later become self-sufficient. These grants are unique in the
    Federal system as they allow the community to build a program around
    their needs. These grants award funding to develop needed formal,
    integrated networks of providers that deliver primary and acute
    services. The grants have led to projects including information
    technology networks, oral screenings, and preventative care. Due to the
    community nature of the grants and a focus on self-sustainability after
    the terms of the grant have run out--85 percent of the Outreach
    Grantees continue to deliver services 5 full years after Federal
    funding ended. Request: $62.7 million.
        Rural Health Research and Policy Grants form the Federal
    infrastructure for rural health policy. Without these funds, rural
    America has no coordinated voice in the Department of Health and Human
    Services (HHS). In addition to the expertise provided to agencies such
    as the Centers for Medicare and Medicaid Services, this line item also
    funds rural health research centers across the country. Additionally,
    we urge the Subcommittee to include in report language instructions to
    the Office of Rural Health Policy to direct additional funding to the
    State rural health associations. Request: $10.3 million.
        State Offices of Rural Health are the State counterparts to the
    Federal rural health research and policy efforts, and form the State
    infrastructure for rural health policy. They assist States in
    strengthening rural healthcare delivery systems by maintaining a focal
    point for rural health within each State and by linking small rural
    communities with State and Federal resources to develop long term
    solutions to rural health problems. Without these funds, States would
    have diminished capacity to administer many of the critical rural
    health programs. The State offices play a key role in assisting rural
    health clinics, community health centers, and small, rural hospitals
    assess community healthcare needs. This program creates a State focus
    for rural health interests, brings technical assistance to rural areas,
    and helps frontier communities tap State and national resources
    available for healthcare and economic development. In partnership with
    other State agencies, the State rural health offices have been
    essential in addressing the unique needs of rural communities. Request:
    $11.1 million.
        Rural Hospital Flexibility Grants fund quality improvement and
    emergency medical service projects for Critical Access Hospitals (CAHs)
    across the country. The BBA created this essential program to improve
    access to essential healthcare services by CAHs, rural hospital
    networks and rural emergency medical services. These grants allow
    statewide coordination and provide expertise to CAHs for quality
    improvement or information technology activities. Also funded in this
    line is the Small Hospital Improvement Program (SHIP), which provides
    grants to more than 1,500 small rural hospitals (50 beds or less)
    across the country to help improve their business operations, focus on
    quality improvement and to ensure compliance provisions related to
    health information privacy. Request: $47.7 million.
        Rural and Community Access to Emergency Devices assist communities
    in purchasing emergency devices and training potential first responders
    in their use. Defibrillators double a victim's chance of survival after
    sudden cardiac arrest, which an estimated 163,221 Americans experience
    every year. This program trains lay rescuers and first responders in
    their use and places them in public areas where sudden cardiac arrest
    is likely to occur. Request: $3.7 million.
        The Office for the Advancement of Telehealth supports distance-
    provided clinical services and is designed to reduce the isolation of
    rural providers, foster integrated delivery systems through network
    development and test a range of telehealth applications. Long-term,
    telehealth promises to improve the health of millions of Americans,
    provide constant education to isolated rural providers and save money
    through reduced office visits and hospital care. The OAT leads,
    coordinates and promotes the use of telehealth technologies by
    fostering partnerships between Federal agencies, States and private
    sector groups to create telehealth projects. These approaches are still
    new and unfolding and continued investment in the infrastructure and
    development is needed. Request: $15.3 million.
        National Health Service Corps (NHSC) plays a critical role in
    providing primary healthcare services to rural underserved populations
    by placing healthcare providers in our Nation's most underserved
    communities. Investment in our healthcare workforce is absolutely vital
    to support the newly insured population resulting from health reform
    and the long-term underserved in isolated rural communities. Programs
    like the NHSC help maximize the capacity of our health system to care
    for patients. The demand for primary care providers far exceeds the
    supply, and the needs of our rural communities continue to grow. The
    NRHA supports the President's request to ensure that the NHSC has
    access to the dedicated funding through the CHC Fund.
        Frontier Community Health Integration Demonstration Program (F-
    CHIP) funds development and testing of new models for the delivery of
    healthcare services in frontier areas through improving access and
    integration of the delivery of healthcare to Medicare beneficiaries.
        Frontier Extended Stay Clinic (FESC) a geographically isolated
    medical clinic designed to provide primary, emergency, and extended-
    stay care 24 hours per day when hospital services are not readily
    available. The Federal Office of Rural Health Policy (ORHP) has
    provided funding for infrastructure development to four clinics in
    Alaska.
    Title VII Health Professions Training Programs (with a significant
            rural focus):
      --Area Health Education and Centers (AHECs) financially support and
            encourage those training to become healthcare professionals to
            practice in rural areas. Without this experience and support
            while in medical school, far fewer professionals would make the
            commitment to rural areas and facilities including Community
            Health Centers, Rural Health Clinics and rural hospitals. The
            AHEC Programs and Centers play a critical national role in
            addressing healthcare workforce shortages, particularly those
            in primary care through an established infrastructure. The
            program grantees support the recruitment and retention of
            physicians, students, faculty and other primary care providers
            in rural and medically underserved areas by providing local,
            community-based, interdisciplinary primary care training.
            Educating and training rural healthcare providers ensures a
            sound future in the delivery of rural healthcare. It has been
            estimated that nearly half of AHECs would shut down without
            Federal funding. Request: $75 million.
      --Rural Physician Pipeline Grants will help medical colleges develop
            special rural training programs and recruit students from rural
            communities, who are more likely to return to their home
            regions to practice. This ``grow-your-own'' approach is one of
            the best and most cost-effective ways to ensure a robust rural
            workforce into the future. Request: $4.4 million.
      --Geriatric Programs train health professionals in geriatrics,
            including funding for Geriatric Education Centers (GEC). There
            are currently 47 GECs nationwide that ensure access to
            appropriate and quality healthcare for seniors. Rural America
            has a disproportionate share of the elderly and could see a
            shortage of health providers without this program. Request:
            $36.7 million.
        The National Rural Health Association appreciates the opportunity
    to provide our recommendations to the Subcommittee. These programs are
    critical to the rural health delivery system and help maintain access
    to high quality care in rural communities. We greatly appreciate the
    support of the Subcommittee and look forward to working with Members of
    the Subcommittee to continue making these important investments in
    rural health.
                                     ______

               Prepared Statement of the National Safety Council
        Chairman Harkin, Ranking Member Moran, and Members of the
    subcommittee, thank you for the opportunity to submit testimony
    regarding the National Safety Council's workplace safety appropriations
    priorities. My name is Jim Johnson, and I am Vice President of
    Workplace Safety Initiatives at the National Safety Council. We are a
    100 year-old Congressionally chartered nonprofit safety organization
    dedicated to saving lives by preventing injuries and deaths at work, in
    homes and communities, and on the roads through leadership, research,
    education, and advocacy. Our more than 14,000 member companies
    represent over 8 million employees at more than 51,000 worksites. Today
    I am seeking support for $565.01 million for the Occupational Safety
    and Health Administration (OSHA) and $332.86 million for the National
    Institute for Occupational Safety and Health (NIOSH), two organizations
    whose work is vitally important to the mission of safety.
    Occupational Safety and Health Administration
        The National Safety Council believes that an effective and
    efficient OSHA is important for the safety of American workers and
    workplaces. NSC supports stable funding for OSHA that adequately funds
    all the agency's key functions, including compliance assistance and
    support to companies striving for safety excellence, the timely
    promulgation of regulations to protect America's workers, enforcement
    actions against companies that fail to comply with OSHA standards, and
    whistle blower protection for workers.
        The Council supports the top line funding level of $565.01 million
    for the agency included in the President's fiscal year 2015 budget
    request, and we strongly encourage the committee to fund the agency at
    a minimum of this funding level. While the Council is pleased that OSHA
    rulemaking and enforcement efforts in fiscal year 2014 have been
    restored to pre-sequester funding levels, we continue to have strong
    concerns about funding constraints placed on the agency's Federal
    compliance assistance efforts, which are presently funded at $69.4
    million, more than 9 percent less than fiscal year 2012 enacted levels.
        Of special concern to the Council is the impact that reduced
    compliance assistance funding has had on the agency's Voluntary
    Protection Programs (VPP). We encourage the committee to include report
    language recommending that VPP receive no less than $3 million in
    fiscal year 2015.
        VPP were created by OSHA in 1982 as a way of recognizing those
    employers who successfully implement effective safety and health
    management systems and maintain injury and illness rates below the
    national average for their industries. Under VPP, company stakeholders
    establish a relationship with OSHA based on a cooperative partnership.
    Because of this, approval into VPP is as much a proactive effort as it
    is recognition of hard work and effort put in by employers and
    employees to achieve exceptional records in occupational safety and
    health.
        The pursuit of VPP status has helped many safety professionals
    encourage their employers' leadership to improve safety management
    systems by complying with the program's criteria. Organizations with
    VPP status represent business leaders who have implemented strong
    safety management systems and demonstrated a commitment to continuous
    improvement. VPP sites have a Days Away Restricted or Transferred
    (DART) case rate of 52 percent below the industry average. The majority
    of VPP sites have less than 100 employees.
        However, despite the success of this program, recent budget
    constraints have required the agency to slow the growth in the number
    of new cooperative program participants. Following sequestration in
    fiscal year 2013, OSHA only reapproved sites that could be visited
    through local travel. As it stands, OSHA is not scheduling new VPP site
    approvals until a region's backlog of re-approvals of existing VPP
    facilities is eliminated. Minimum funding at a level of at least $3
    million will ensure that OSHA has the resources necessary to address
    the backlog of re-approvals of existing VPP facilities and to begin to
    approve new VPP sites.
    National Institute for Occupational Safety and Health
        Funding NIOSH at the fiscal year 2014 program level of $332.86
    million at a minimum, and preserving the fiscal year 2014 level of $24
    million for the Institute's Agriculture, Forestry and Fishing (AgFF)
    Sector Program and $27.5 million for the Education and Research Centers
    (ERCs), is essential to ensuring that NIOSH can fulfill its mission of
    saving lives and preventing injuries.
        Finally, I would like to focus on the important role that NIOSH
    programs play in reducing workplace injuries and fatalities. NIOSH's
    primary responsibility is to conduct research and make recommendations
    for the prevention of work-related injuries and illnesses. NIOSH works
    to ensure the health and safety of the American workforce through
    research, education and training. It is not a regulatory agency, and
    can only issue recommendations for health and safety standards. The
    Council is disheartened to see the President's budget request again
    target the Institute's Agriculture, Forestry and Fishing (AgFF) Sector
    Program and Education and Research Centers (ERCs) by eliminating their
    budget.
        NIOSH established the AgFF program in 1990 in response to evidence
    that agricultural workers were suffering higher rates of injury and
    illness than other U.S. workers. The agriculture, forestry, and
    fishing, industry fatality rate is more than 8 times that of the all-
    industry average. Yearly, almost 18,000 workers in this sector are
    injured seriously enough to require time away from work.\1\ Daily, an
    average of over 330 workers in this sector sustain injuries serious
    enough to require medical consultation, and nearly 2 workers die from
    an injury suffered at work.\2\ Today, the initiative includes nine
    regional centers and one national center to address children's farm
    safety. These centers conduct vital research leading to evidence-based
    standards that save lives. The AgFF Program is the only substantive
    Federal effort to meet the obligation to ensure safe conditions for
    workers in this sector, and it is effective.
    ---------------------------------------------------------------------------
        \1\ U.S. Bureau of Labor Statistics, U.S. Department of Labor.
    (2013). Table 2. numbers of nonfatal occupational injuries and
    illnesses by case type and ownership, selected industries, 2012.
    Retrieved February 12, 2014, from http://www.bls.gov/news.release/
    osh.t02.htm.
        \2\ National Safety Council. (2013). Injury Facts, 2013 Edition.
    ---------------------------------------------------------------------------
        NIOSH supports education and research in occupational health
    through academic degree programs and research opportunities, primarily
    through 18 university-based ERCs located at leading universities around
    the country serving all 50 States. The mission of the ERCs is to reduce
    work-related injuries and illnesses in the U.S. by performing
    prevention research and by educating, through degree programs and
    continuing education, high-quality professionals who implement programs
    to improve occupational health and safety and minimize the dangers
    faced by workers across the country. The ERCs provide programs in a
    unique group of disciplines that benefit employers of all sizes and
    industries in every part of the country. Currently, the ERCs are
    responsible for supplying a good portion of the country's OSH graduates
    who will go on to fill professional roles. With an aging occupational
    safety and health workforce, and a shortage of qualified OSH
    professionals, ERCs are essential to educating the next generation of
    professionals.
        Thank you again for the opportunity to submit testimony for the
    record.
                                     ______

    Prepared Statement of the National Technical Institute for the Deaf and
                       Rochester Institute of Technology
        Mr. Chairman and Members of the Committee: I am pleased to present
    the fiscal year 2015 budget request for the National Technical
    Institute for the Deaf (NTID), one of nine colleges of the Rochester
    Institute of Technology (RIT), in Rochester, N.Y. Created by Congress
    by Public Law 89-36 in 1965, we provide university technical and
    professional education for students who are deaf and hard of hearing,
    leading to successful careers in high-demand fields for a sub-
    population of individuals historically facing high rates of
    unemployment and under-employment. We also provide baccalaureate and
    graduate-level education for hearing students in professions serving
    deaf and hard-of-hearing individuals. NTID students live, study and
    socialize with more than 17,000 hearing students on the RIT campus.
    Budget Request
        On behalf of NTID, for fiscal year 2015 I would like to request
    $66,291,000 in Operations. NTID has worked hard to manage its resources
    carefully and responsibly and as such is not requesting an increase in
    support in 2015. Over the past 2 years we have reduced our workforce by
    12 percent (70 positions) and limited our equipment expenditures. We
    also reduced our non-personnel expenditures by over 30 percent in such
    areas as building and equipment maintenance, instructional supplies,
    freelance interpreting, professional travel and student employment.
    NTID has also postponed requests for construction funding for critical
    and long overdue renovations to a 33-year old building currently
    housing three times the number of staff for which it was intended. In
    terms of non-Federal revenues, from fiscal year 2006 to fiscal year
    2014, student tuition and fees increased by 63 percent to offset the
    rising costs of providing a state-of-the-art college education.
    Likewise, from fiscal year 2006 to fiscal year 2013, NTID raised almost
    $20 million in support from individuals and organizations.
        Our fiscal year 2015 request to continue fiscal year 2014 funding
    of $66,291,000 in Operations would allow us to maintain a balanced
    budget and avoid harmful reductions. Without this funding, we would
    have to impose additional limitations in the areas of equipment
    purchasing, interpreting and captioning, scholarship support, building
    maintenance, and, most importantly, in personnel and enrollment. These
    are not the consequences a successful Federal investment should face.
    Enrollment
        Truly a national program, NTID has enrolled students from all 50
    States. In Fall 2013 (fiscal year 2014), we attracted 1,432, the sixth
    straight year of more than 1,400 students. For fiscal year 2015, NTID
    hopes to maintain this high enrollment, if our operational resources
    allow us to do so. Our enrollment history over the last 8 years is
    shown below:

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

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

        [This statement was submitted by Dr. Gerard J. Buckley, President,
    National Technical Institute for the Deaf, and Vice President and Dean,
    Rochester Institute of Technology. ]
                                     ______

         Prepared Statement of the National Violence Prevention Network
        Thank you for this opportunity to submit testimony in support of
    increased funding for the National Violent Death Reporting System
    (NVDRS), which is administered by the National Center for Injury
    Prevention and Control at the Centers for Disease Control and
    Prevention (CDC). The National Violence Prevention Network, a broad and
    diverse alliance of health and welfare, suicide and violence
    prevention, and law enforcement advocates supports increasing the
    fiscal year 2015 funding level to $25 million to allow for nationwide
    expansion of the NVDRS program. fiscal year 2014 NVDRS funding is $11.2
    million.
                                   background
        Each year, about 55,000 Americans die violent deaths. In addition,
    an average of 105 people (22 of which are military veterans) take their
    own lives each day.
        The NVDRS program makes better use of data that are already being
    collected by health, law enforcement, and social service agencies. The
    NVDRS program, in fact, does not require the collection of any new
    data. Instead it links together information that, when kept in separate
    compartments, is much less valuable as a tool to characterize and
    monitor violent deaths. With a clearer picture of why violent deaths
    occurs, law enforcement, public health officials and others can work
    together more effectively to identify those at risk and target
    effective preventive services.
        Currently, NVDRS funding levels only allow the program to operate
    in 18 States, including Alaska, Colorado, Georgia, Kentucky, Maryland,
    Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio,
    Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and
    Wisconsin. Several other States have expressed an interest in joining
    once new funding becomes available. While NVDRS is beginning to
    strengthen violence and suicide prevention efforts in the 18
    participating States, non-participating States continue to miss out on
    the benefits of this important public health surveillance program.
                                nvdrs in action
        Child abuse and other violence involving children and adolescents
    remains a problem in America, and it is only through a comprehensive
    understanding of its root causes that these needless deaths can be
    prevented. Studies suggest that between 3.3 and 10 million children
    witness some form of domestic violence annually. Additionally, 1,560
    children died as a result of abuse or neglect in 2010.
        Children are most vulnerable and most dependent on their caregivers
    during infancy and early childhood. Sadly, NVDRS data has shown that
    young children are at the greatest risk of homicide in their own homes.
    Combined NVDRS data from Alaska, Maryland, Massachusetts, New Jersey,
    Oregon, South Carolina, and Virginia determined that African American
    children aged 4 years old and under are more than four times as likely
    to be victims of homicide than Caucasian children, and that homicides
    of children aged four and under are most often committed by a parent or
    caregiver in the home. The data also shows that household items, or
    ``weapons of opportunity,'' were most commonly used, suggesting that
    poor stress responses may be factors in these deaths. Knowing the
    demographics and methods of child abusers can lead to more effective,
    targeted prevention programs.
        Intimate partner violence (IPV) is another issue where NVDRS is
    proving its value. While IPV has declined along with other trends in
    crime over the past decade, thousands of Americans still fall victim to
    it every year. Intimate partner homicides accounted for 30 percent of
    the murders of women and 5 percent of the murders of men in 2006,
    according to the Bureau of Justice Statistics.
        Despite being in its early stages in several States, NVDRS is
    already providing critical information that is helping law enforcement
    and health and human service officials allocate resources and develop
    programs in ways that target those most at risk for intimate partner
    violence. For example, NVDRS data shows that while occurrences are
    rare, most murder-suicide victims are current or former intimate
    partners of the suspect, and a substantial number of victims were the
    suspect's offspring. In addition, NVDRS data indicate that women are
    about seven times more likely than men to be killed by a spouse, ex-
    spouse, lover, or former lover, and most of these incidents occurred in
    the women's homes.
                              nvdrs & va suicides
        Although it is preventable, every year more than 38,000 Americans
    die by suicide and another one million Americans attempt it, costing
    more than $36 billion in lost wages and work productivity. In the
    United States today, there is no comprehensive national system to track
    suicides. However, because NVDRS includes information on all violent
    deaths--including deaths by suicide--information from the system can be
    used to develop effective suicide prevention plans at the community,
    State, and national levels.
        The central collection of this data can be of tremendous value for
    organizations such as the Department of Veterans Affairs that are
    working to improve their surveillance of suicides. For instance, CDC
    determined from national NVDRS data that veterans comprised 20 percent
    of all suicide victims. The types of data collected by NVDRS including
    gender, blood alcohol content, mental health issues and physical health
    issues can help prevention programs better identify and treat at-risk
    individuals.
                              federal role needed
        At an estimated annual cost of $25 million for full implementation,
    NVDRS is a relatively low-cost program that yields high-quality
    results. While State-specific information provides enormous value to
    local public health and law enforcement officials, data from all 50
    States, the U.S. territories and the District of Columbia must be
    obtained to complete the national picture. Aggregating this additional
    data will allow us to analyze national trends and also more quickly and
    accurately determine what factors can lead to violent death so that we
    can devise and disseminate strategies to address those factors.
             strengthening and expanding nvdrs in fiscal year 2014
        The 2014 Consolidated Appropriations Act recognized the public
    health utility of NVDRS in preventing violent deaths and increased
    NVDRS funding by roughly $8 million to facilitate continued expansion
    of the NVDRS program. With this new funding, NVDRS will expand to
    roughly two-thirds of the country. The time is now to complete the
    nation-wide expansion of NVDRS by providing an appropriation of $25
    million in fiscal year 2015.
        We thank you for the opportunity to submit this statement for the
    record. The investment in NVDRS has already begun to pay off, as the 18
    participating States are adopting effective violence prevention
    programs. We believe that national implementation of NVDRS is a wise
    public health investment that will assist State and national efforts to
    prevent deaths from domestic violence, veteran suicide, teen suicide,
    gang violence and other violence that affects communities around the
    country. We look forward to working with you secure an fiscal year 2015
    NVDRS appropriation of $25 million.
                                     ______

          Prepared Statement of the Native Hawaiian Education Council
        Aloha Chairman Harkin and members of the Senate Committee on
    Appropriations, Labor, HHS, and Education Subcommittee: Mahalo, thank
    you, for allowing us an opportunity to submit this request for
    appropriations.
        We are seeking continued funding at pre-sequestration levels for
    the Native Hawaiian Education Program (NHEP) that targets the Native
    Hawaiian student population. The NHEP is an important part of
    fulfilling the trust relationship between the U.S. and Native
    Hawaiians, and it helps to improve the educational status of Native
    Hawaiians. It is an important element in the Native community's effort
    to control its education programs and policies and to achieve
    educational parity. NHEP aims to close the education achievement gap
    between Native Hawaiians and the general population, and also functions
    to fulfill the trust relationship between the United States and Native
    Hawaiians, the indigenous people of a once sovereign nation. During the
    time of their own sovereignty in the kingdom of Hawai`i, Native
    Hawaiians had a higher rate of literacy than citizens of the United
    States. The educational achievement gap has occurred during the
    intervening years since the loss of Native Hawaiian sovereignty, so
    that today Native Hawaiians are among the most disadvantaged groups in
    the State.
    The NHEP Works
        NHEP has been effective over the years in meeting the goals of the
    program. For example, NHEA has been instrumental in preserving and
    protecting the Native Hawaiian language through funding projects that
    are designed to address the use of the Native Hawaiian language in
    instruction, one of the priorities named in the NHEA. The number of
    speakers nearly doubled in 18 years from 8,872 speakers in 1990 to
    16,864 in 2008 (Source: OHA Data Book 2011 Tables 4.19 and 4.44)
        The NHEP has funded programs that incorporate culture and
    indigenous teaching practices in the classroom that leads to better
    outcomes for Native Hawaiian students. An example is the improvement in
    the graduation rates for Native Hawaiians and math and reading scores.
    Graduation rates for Native Hawaiians between 2002 and 2010 rose from
    70 percent to 72.2 percent (Sources: Kamehameha Schools' Native
    Hawaiian Education Assessment Update 2009, Fig. 9 and HI DOE 2005-06 to
    2009-10).
        Similarly, math and reading scores have risen for Native Hawaiians.
    The percent of Native Hawaiians scoring ``Proficient or Above `` from
    2007 to 2012 rose from 27 percent to 49 percent in math and from 41
    percent to 62 percent in reading (Source: Hawaii DOE Longitudinal Data
    System ).
        School attendance rates in schools with student populations that
    are over 50 percent Native Hawaiian have increased from 90.1 percent in
    the 2000-01 school year to 91.3 percent in the 2011-12 school year
    (Source: Kamehameha Schools' draft Ka Huaka`i update, p. 58)
    The Need Still Exists
        In spite of the gains that Native Hawaiians have made
    educationally, the need for innovative programs to assist Native
    Hawaiians to improve their academic performance still exists, since
    Native Hawaiians have not yet attained parity with the rest of the
    students in the State.
        Timely high school graduation rates for students in the State rose
    from 77 percent to 79.6 percent in the same time period that it rose
    from 70 percent to 72.2 percent for Native Hawaiians (Sources:
    Kamehameha Schools' Native Hawaiian Education Assessment Update 2009,
    Fig. 9 and HI DOE 2005-06 to 2009-10).
        Native Hawaiians still lag behind the rest of the State in academic
    performance; however the gap between the Native Hawaiians and others is
    decreasing. From 2007 to 2012 the increase in the percentage of Native
    Hawaiians scoring ``Proficient or Above `` in math rose 22 percentage
    points, while the increase for the State during the same time period
    was 21 percentage points. The increase for Native Hawaiians in reading
    was even more dramatic during that time period, increasing 21
    percentage points compared to the State increase of only 11 percentage
    points. Unfortunately those gains were not enough to bring Native
    Hawaiians to parity. In 2012 Native Hawaiians were still 10 points
    behind the State in the percentage scoring ``Proficient or Above'' in
    math and nine points behind in the percentage scoring ``Proficient or
    Above'' in reading.

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

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

                 Prepared Statement of the Nephcure Foundation
                summary of recommendations for fiscal year 2015
    _______________________________________________________________________

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

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

        [This statement was submitted by Irving Smokler, PH.D., President
    and Founder, Nephcure Foundation.]
                                     ______

              Prepared Statement of the Neurofibromatosis Network
        Thank you for the opportunity to submit testimony to the
    Subcommittee on the importance of continued funding at the National
    Institutes of Health (NIH) for research on Neurofibromatosis (NF), a
    genetic disorder closely linked to many common diseases widespread
    among the American population. We respectfully request that you include
    the following report language on NF research at the National Institutes
    of Health within your fiscal year 2015 Labor, Health and Human
    Services, Education Appropriations bill.
        Neurofibromatosis [NF]--The Committee supports efforts to increase
    funding and resources for NF research and treatment at multiple NIH
    Institutes, including NCI, NINDS, NIDCD, NHLBI, NICHD and NEI. Children
    and adults with NF are at significant risk for the development of many
    forms of cancer; the Committee encourages NCI to increase its NF
    research portfolio in fundamental basic science, translational research
    and clinical trials focused on NF. The Committee also encourages the
    NCI to support NF centers, NF clinical trials consortia, NF preclinical
    mouse models consortia and NF-associated tumor sequencing efforts.
    Because NF causes brain and nerve tumors and is associated with
    cognitive and behavioral problems, the Committee urges NINDS to
    continue to aggressively fund fundamental basic science research on NF
    relevant to nerve damage and repair, learning disabilities and
    attention deficit disorders. Since NF2 accounts for approximately 5
    percent of genetic forms of deafness, the Committee encourages NIDCD to
    expand its investment in NF2 basic and clinical research.
        On behalf of the Neurofibromatosis (NF) Network, a national
    organization of NF advocacy groups, I speak on behalf of the 100,000
    Americans who suffer from NF as well as approximately 175 million
    Americans who suffer from diseases and conditions linked to NF such as
    cancer, brain tumors, heart disease, memory loss, and learning
    disabilities. Thanks in large measure to this Subcommittee's strong
    support, scientists have made enormous progress since the discovery of
    the NF1 gene in 1990 resulting in clinical trials now being undertaken
    at NIH with broad implications for the general population.
        NF is a genetic disorder involving the uncontrolled growth of
    tumors along the nervous system which can result in terrible
    disfigurement, deformity, deafness, pain, blindness, brain tumors,
    cancer, and even death. In addition, approximately one-half of children
    with NF suffer from learning disabilities. NF is the most common
    neurological disorder caused by a single gene and is more common than
    Muscular Dystrophy and Cystic Fibrosis combined. There are three types
    of NF: NF1, which is more common, NF2, which initially involves tumors
    causing deafness and balance problems, and Schwannomatosis, the
    hallmark of which is severe pain. While not all NF patients suffer from
    the most severe symptoms, all NF patients and their families live with
    the uncertainty of not knowing whether they will be seriously affected
    because NF is a highly variable and progressive disease.
        Researchers have determined that NF is closely linked to heart
    disease, learning disabilities, memory loss, cancer, brain tumors, and
    other disorders including deafness, blindness and orthopedic disorders,
    primarily because NF regulates important pathways common to these
    disorders such as the RAS, cAMP and PAK pathways. Research on NF
    therefore stands to benefit millions of Americans:
    Learning Disabilities/Behavioral and Brain Function
        Learning disabilities affect one-half of people with NF1. They
    range from mild to severe, and can impact the quality of life for those
    with NF1. In recent years, research has revealed common threads between
    NF1 learning disabilities, autism and other related disabilities. New
    drug interventions for learning disabilities are being developed and
    will be beneficial to military dependants, as well as the general
    population. Research being done in this area includes a clinical trial
    of the statin drug Lovastatin, as well as other categories of drugs.
    Bone Repair
        At least a quarter of children with NF1 have abnormal bone growth
    in any part of the skeleton. In the legs, the long bones are weak,
    prone to fracture and unable to heal properly; this can require
    amputation at a young age. Adults with NF1 also have low bone mineral
    density, placing them at risk of skeletal weakness and injury. Research
    currently being done to understand bone biology and repair will pave
    the way for new strategies to enhancing bone health and facilitating
    repair.
    Pain Management
        Severe pain is a central feature of Schwannomatosis, and
    significantly impacts quality of life. Understanding what causes pain,
    and how it could be treated, has been a fast-moving area of NF research
    over the past few years. Pain management is a challenging area of
    research and new approaches are highly sought after.
    Nerve Regeneration
        NF often requires surgical removal of nerve tumors, which can lead
    to nerve paralysis and loss of function. Understanding the changes that
    occur in a nerve after surgery, and how it might be regenerated and
    functionally restored, will have significant quality of life value for
    affected individuals. Light-based therapy is being tested to dissect
    nerves in surgery of tumor removal. If successful it could have
    applications for treating nerve damage and scarring after injury,
    thereby aiding repair and functional restoration.
    Wound Healing, Inflammation and Blood Vessel Growth
        Wound healing requires new blood vessel growth and tissue
    inflammation. Mast cells, important players in NF1 tumor growth, are
    critical mediators of inflammation, and they must be quelled and
    regulated in order to facilitate healing. Researchers have gained deep
    knowledge on how mast cells promote tumor growth, and this research has
    led to ongoing clinical trials to block this signaling, resulting in
    slower tumor growth. As researchers learn more about blocking mast cell
    signals in NF, this research can be translated to the management of
    mast cells in wound healing.
    New Cancer Treatments
        NF can cause a variety of tumors to grow, which includes tumors in
    the brain, spinal cord and nerves. NF affects the RAS pathway which is
    implicated in 70 percent of all human cancers. Some of these tumor
    types are benign and some are malignant, hard to treat and often fatal.
    One of these tumor types is malignant peripheral nerve sheath tumor
    (MPNST), a very aggressive, hard to treat and often fatal cancer.
    MPNSTs are fast growing, and because the cells change as the tumor
    grows, they often become resistant to individual drugs. Clinical trials
    are underway to identify a drug treatment that can be widely used in
    MPNSTs and other hard-to-treat tumors.
        The enormous promise of NF research, and its potential to benefit
    over 175 million Americans who suffer from diseases and conditions
    linked to NF, has gained increased recognition from Congress and the
    NIH. This is evidenced by the fact that numerous institutes are
    currently supporting NF research, and NIH's total NF research portfolio
    has increased from $3 million in fiscal year 1990 to an estimated $18
    million in fiscal year 2014. Given the potential offered by NF research
    for progress against a range of diseases, we are hopeful that the NIH
    will continue to build on the successes of this program by funding this
    promising research and thereby continuing the enormous return on the
    taxpayers' investment.
        We appreciate the Subcommittee's strong support for NF research and
    will continue to work with you to ensure that opportunities for major
    advances in NF research are aggressively pursued. Thank you.
                                     ______

         Prepared Statement of the New England Educational Opportunity
                                  Association
        On behalf of the low-income, first-generation students and students
    with disabilities served by the Federal TRIO Programs (``TRIO'') across
    Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and
    Vermont, the New England Educational Opportunity Association (``NEOA'')
    respectfully requests that the Senate Subcommittee on Labor, Health and
    Human Services, and Education boost TRIO funding by $52 million in
    fiscal year 2015.
        A $52 million funding increase would allow for a total funding
    level of $890 million in fiscal year 2015 which, in turn, would allow
    TRIO's Student Support Services program to expand its reach by 10
    percent and grow to serve 20,000 additional low-income, first-
    generation students at colleges and universities across the Nation
    during the 2015-2016 academic year. This funding level would also allow
    current TRIO programs to sustain the high-quality access and success
    services provided to 750,000 students across the Nation as well as
    allow for the expansion of these services to include 23,000 more who
    stand in need. Such growth is critical as TRIO programs have lost more
    than 120,000 students over the last decade. While we are tremendously
    grateful for the work of this Subcommittee to restore 95 percent of the
    funds lost to sequestration in fiscal year 2014, we would be remiss if
    we did not request additional funding so that we may continue to recoup
    from earlier losses. If the success of TRIO in New England serves as
    any indicator, it becomes clear that greater investment in TRIO is
    critical to boosting educational attainment nationally.
        More than 42,000 students ranging from middle school through
    graduate study participate in TRIO programs across New England.
    Throughout the region, stories of student success abound, with strong
    statistics to support them. For instance, both the Talent Search and
    Upward Bound programs in Rhode Island can boast of 99 percent high
    school graduation rates. Moreover, 86 percent of Rhode Island's Talent
    Search students go directly onto college as do 90 percent of the Upward
    Bound students.
        In New Hampshire, a longitudinal study of Student Support Services
    (``SSS'') participants at the University of New Hampshire demonstrated
    that, compared to eligible non-participants, SSS students exhibited
    higher graduation rates, greater improvement in grades, and lower
    academic suspension rates. Meanwhile, during fiscal year 2010, Plymouth
    State University had a 92 percent retention rate among non-graduating
    SSS participants. The SSS program at the University of Bridgeport in
    Connecticut can demonstrate similar success. During the 2013-2014
    Academic Year, 58 percent of SSS participants made the Dean's List and/
    or the President's List as a result of their GPAs.
        In recent years, the Educational Opportunity Center (EOC) in
    Vermont aided 63 percent of its clients--which include out-of-work
    adults and military veterans--in enrolling in postsecondary education
    programs for the first time; a similar percentage (61 percent) of
    postsecondary ``stop-outs'' re-enrolled in postsecondary education
    programs. Similarly, the EOC program in Maine helped more than 900
    adult learners enroll in college and assisted nearly 2,000 adults in
    developing career and educational plans.
        Massachusetts also produces stellar results through its TRIO
    programs. Many notable examples are found at the University of
    Massachusetts-Boston. For instance, the institution's Veterans Upward
    Bound (VUB) program found that 81.5 percent of VUB participants who
    enrolled in postsecondary education programs persisted through to a
    second year of academic study. Meanwhile, 48 percent of students who
    participated in their Ronald E. McNair Postbaccalaureate Achievement
    program earned doctoral degrees within 10 years of receipt of their
    bachelor's degree.
        This is just a sampling of the success sparked by the supportive
    services provided by TRIO. We hope that you will strongly consider
    these examples when determining funding levels for our program in
    fiscal year 2015.
        Thank you for your consideration of this request.

        [This statement was submitted by Karen Keim, President, New England
    Educational Opportunity Association.]
                                     ______

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

        [This statement was submitted by Richard A. Minard, Jr., Vice
    President, New Hampshire Community Loan Fund.]
                                     ______

                  Prepared Statement of the Nursing Community
        The Nursing Community is a forum comprised of 60 national
    professional nursing associations that builds consensus and advocates
    on a wide spectrum of healthcare and nursing issues surrounding
    practice, education, and research. These organizations are committed to
    promoting America's health through the advancement of the nursing
    profession. Collectively, the Nursing Community represents nearly one
    million Registered Nurses (RNs), Advanced Practice Registered Nurses
    (APRNs-including certified nurse-midwives, nurse practitioners,
    clinical nurse specialists, and certified registered nurse
    anesthetists), nurse executives, nursing students, faculty, and
    researchers.
        For fiscal year 2015, our organizations respectfully request $251
    million for the Health Resources and Services Administration's (HRSA)
    Nursing Workforce Development programs (authorized under Title VIII of
    the Public Health Service Act [42 U.S.C. 296 et seq.]), $150 million
    for the National Institute of Nursing Research (NINR) within the
    National Institutes of Health (NIH), and $20 million in authorized
    funding for the Nurse-Managed Health Clinics (Title III of the Public
    Health Service Act). These investments will help ensure that our
    Nation's population receives the highest-quality nursing services
    possible.
    Demand for Nurses Continues to Grow
        According to the Bureau of Labor Statistics' (BLS) Employment
    Projections for 2012-2022, the expected number of practicing nurses
    will grow from 2.71 million in 2012 to 3.24 million in 2022, an
    increase of 526,800, or 19.4 percent. The number of job openings due to
    demand for registered nursing services and replacements in the
    workforce brings the total of RNs needed to 1.053 million by 2022. In
    addition, nurse practitioners are one of the fastest growing
    occupations according to the BLS projections, noting there will be a
    33.7 percent increase in nurse practitioners between 2012-2022.
        Two primary factors contribute to this overwhelming demand. First,
    America's nursing workforce is aging. A 2013 HRSA report, The U.S.
    Nursing Workforce: Trends in Supply and Education, indicates that over
    the next 10 to 15 years, the nearly one million RNs over age 50
    (comprising approximately one-third of the current workforce), will
    reach retirement age. Secondly, America's Baby Boomer population is
    aging. This population will require a vast influx of nursing services,
    particularly in areas of primary care and chronic illness management. A
    significant investment must be made in the education of new nurses to
    provide the Nation with the nursing services it demands.
    Addressing the Demand: Title VIII Nursing Workforce Development
            Programs
        For 50 years, the Nursing Workforce Development programs,
    authorized under Title VIII of the Public Health Service Act, have
    helped to build the supply and distribution of qualified nurses to meet
    our Nation's healthcare needs. The Title VIII programs bolster nursing
    education at all levels, from entry-level preparation through graduate
    study, and provide support for institutions that educate nurses for
    practice in rural and medically underserved communities. Today, the
    Title VIII programs are essential to ensure the demand for nursing care
    is met. Between fiscal year 2005 and 2012 alone, these programs
    supported over 450,000 nurses and nursing students, as well as numerous
    academic nursing institutions and healthcare facilities.
        The American Association of Colleges of Nursing's (AACN) Title VIII
    Student Recipient Survey gathers information about Title VIII dollars
    and their impact on nursing students. The 2013-2014 survey, which
    included responses from over 800 students, indicated that the Title
    VIII programs played a critical role in funding these students' nursing
    education. The survey showed that 78 percent of the students receiving
    Title VIII funding are attending school full-time. By supporting full-
    time students, the Title VIII programs are helping to ensure that
    students enter the workforce without delay.
        The Title VIII programs also address the need for more nurse
    faculty. Data from AACN's 2013-2014 enrollment and graduations survey
    show that nursing schools were forced to turn away 78,089 qualified
    applications from entry-level baccalaureate and graduate nursing
    programs in 2013, and faculty vacancy was a primary reason. The Title
    VIII Nurse Faculty Loan Program aids in increasing nursing school
    enrollment capacity by supporting students pursuing graduate education,
    provided they serve as faculty for 4 years after graduation.
      --The Nursing Community respectfully requests $251 million for the
            Nursing Workforce Development programs in fiscal year 2015.
    National Institute of Nursing Research: Foundation for Evidence-Based
            Care
        As one of the 27 Institutes and Centers at the NIH, the NINR funds
    research that lays the groundwork for evidence-based nursing practice.
    Nurse scientists at NINR examine ways to improve care models to deliver
    safe, high-quality, and cost-effective health services to the Nation.
    Our country must look toward the prevention aspect of healthcare as the
    vehicle for saving our system from further financial burden, and the
    work of NINR embraces this endeavor through research related to care
    management of patients during illness and recovery, reduction of risks
    for disease and disability, promotion of healthy lifestyles,
    enhancement of quality of life for those with chronic illness, and care
    for individuals at the end of life.
        Moreover, NINR helps to provide needed faculty to support the
    education of future generations of nurses. Training programs at NINR
    develop future nurse researchers, many of whom also serve as faculty in
    our Nation's nursing schools.
      --The Nursing Community respectfully requests $150 million for the
            NINR in fiscal year 2015.
    Nurse-Managed Health Clinics: Expanding Access to Care
        NMHCs are healthcare delivery sites managed by APRNs and are
    staffed by an interdisciplinary health provider team which may include
    physicians, social workers, public health nurses, and therapists. These
    clinics are often associated with a school, college, university,
    department of nursing, federally qualified health center, or
    independent nonprofit healthcare agency. NMHCs serve as critical access
    points to keep patients out of the emergency room, saving the
    healthcare system millions of dollars annually.
        NMHCs provide care to patients in medically underserved regions of
    the country, including rural communities, Native American reservations,
    senior citizen centers, elementary schools, and urban housing
    developments. The populations within these communities are the most
    vulnerable to chronic illnesses that create heavy financial burdens on
    patients and the healthcare system. NMHCs aim to reduce the prevalence
    of disease and create healthier communities by providing primary care
    services and educating patients on health promotion practices.
    Furthermore, NMHCs serve as clinical education training sites for
    nursing students and other health professionals. This is crucial given
    that a lack of training sites is commonly identified as a barrier to
    nursing school enrollment.
      --The Nursing Community respectfully requests $20 million for the
            Nurse-Managed Health Clinics authorized under Title III of the
            Public Health Service Act in fiscal year 2015.
        Without a workforce of well-educated nurses providing evidence-
    based care to those who need it most, including our growing aging
    population, the healthcare system is not sustainable. The Nursing
    Community's request of $251 million for the Title VIII Nursing
    Workforce Development programs, $150 million for the National Institute
    of Nursing Research, and $20 million for Nurse-Managed Health Clinics
    in fiscal year 2015 will help ensure continued access to quality care
    provided by America's nursing workforce.
           members of the nursing community submitting this testimony
    Academy of Medical-Surgical Nurses
    American Academy of Ambulatory Care Nursing
    American Academy of Nursing
    American Assembly for Men in Nursing
    American Association of Colleges of Nursing
    American Association of Critical-Care Nurses
    American Association of Heart Failure Nurses
    American Association of Neuroscience Nurses
    American Association of Nurse Anesthetists
    American Association of Nurse Assessment Coordination
    American Association of Nurse Practitioners
    American College of Nurse-Midwives
    American Nurses Association
    American Organization of Nurse Executives
    American Pediatric Surgical Nurses Association
    American Psychiatric Nurses Association
    American Rehabilitation Nurses
    American Society for Pain Management Nursing
    American Society of PeriAnesthesia Nurses
    Association of Community Health Nursing Educators
    Association of Nurses in AIDS Care
    Association of periOperative Registered Nurses
    Association of Public Health Nurses
    Association of Women's Health, Obstetric and Neonatal Nurses
    Commissioned Officers Association of the U.S. Public Health Service
    Dermatology Nurses' Association
    Developmental Disabilities Nurses Association
    Emergency Nurses Association
    Gerontological Advanced Practice Nurses Association
    Hospice and Palliative Nurses Association
    Infusion Nurses Society
    International Society of Psychiatric Nursing
    National American Arab Nurses Association
    National Association of Clinical Nurse Specialists
    National Association of Hispanic Nurses
    National Association of Pediatric Nurse Practitioners
    National Association of School Nurses
    National Black Nurses Association
    National Forum of State Nursing Workforce Centers
    National Nursing Centers Consortium
    National Organization for Associate Degree Nursing
    National Organization of Nurse Practitioner Faculties
    Nurses Organization of Veterans Affairs
    Oncology Nursing Society
    Preventive Cardiovascular Nurses Association
    Society of Urologic Nurses and Associates

                                     ______

                 Prepared Statement of the Older Americans Act
        Mr. Chairman, Ranking Member, and distinguished Members of the
    Subcommittee, Oral Health America (OHA), a leading organization
    dedicated to changing lives by connecting communities with resources to
    increase access to care, education, and advocacy for all Americans,
    especially those most vulnerable; is requesting fiscal year 2015
    funding for all programs administered under the Older Americans Act
    (OAA) be restored to fiscal year 2012 levels. Of particular interest to
    OHA is to ensure Title III-D, Disease Prevention and Health Promotion,
    is restored to at least $21,000,000 because of the cost-effectiveness
    that health education, prevention and promotion programs provide to the
    system.
        The OAA provides Federal programs that serve to meet the needs of
    millions of older Americans. We understand the United States continues
    to operate amid a challenging budgetary environment. However, OHA
    believes that proper Federal investment in the OAA is critical to keep
    pace with the rate of inflation and to meet the needs of this ever-
    growing segment of the population through the multitude of services the
    OAA provides. Simply stated, proper investment in OAA saves taxpayer
    dollars. This is especially evident when it comes to health services.
    Health services the emphasize prevention and promotion will help to
    reduce disease, leading to the improvement of the overall health and
    well-being of America's older adults and resulting in the reduction of
    premature and costly medical interventions. OHA strongly contends that
    one's health and overall well-being begins with proper oral health.
    Background
        The population of the United States is aging at an unprecedented
    rate. Older adults make up one of the fastest growing segments of the
    American population. In 2009, 39.6 million seniors were U.S. residents.
    This aging cohort is expected to reach 72.1 million by 2030--an
    increase of 82 percent.\1\
    ---------------------------------------------------------------------------
        \1\ Administration on Aging. (2013). Aging Statistics. Retrieved
    from http://www.aoa.gov/Aging_Statistics/.
    ---------------------------------------------------------------------------
        The oral health of older Americans is in a state of decay. The
    reasons for this are complex. Limited access to dental insurance,
    affordable dental services, community water fluoridation, and programs
    that support oral health prevention and education for older Americans
    are significant factors that contribute to the unmet dental needs and
    edentulism among older adults, particularly those most vulnerable.
    While improvements in oral health across the lifespan have been
    observed in the last half century, long term concern may be warranted
    for the 10,000 Americans retiring daily, as it is estimated that only
    9.8 percent of this ``silver tsunami''--baby boomers turning age 65--
    will have access to dental insurance benefits.\2\
    ---------------------------------------------------------------------------
        \2\ Consumer Survey, National Association of Dental Plans. 2012.
    ---------------------------------------------------------------------------
        Dental Health and Disparities.--Older adults experience an
    increased risk for oral conditions such as edentulism, oral cancer, and
    periodontal disease. The reasons for this vary but are often related to
    age-associated physiologic changes, underlying chronic diseases, race,
    gender, and the use of various medications. These oral conditions
    disproportionately affect persons with low income, racial and ethnic
    minorities, and those who have limited or no access to dental
    insurance. Older adults with physical and intellectual disabilities and
    those persons who are homebound or institutionalized are also at
    greater risk for poor oral health.\3\
    ---------------------------------------------------------------------------
        \3\ U.S. Department of Health and Human Services. (2000). Oral
    Health in America: A Report of the Surgeon General. Retrieved from
    http://silk.nih.gov/public/hck1ocv.@www.surgeon.
    fullrpt.pdf.
    ---------------------------------------------------------------------------
        As examples of these disparities, older African American adults are
    1.88 times more likely than their white counterparts to have
    periodontitis; \4\ low-income older adults suffer more than twice the
    rate of gum disease than their more affluent peers (17.49 verses 8.62
    respectively); and Americans who live in poverty are 61 percent more
    likely to have lost all of their teeth when compared to those in higher
    socioeconomic groups.
    ---------------------------------------------------------------------------
        \4\ Borrel, L.N., Burt, B.A., & Taylor, G.W. (2005, October).
    Prevalence and Trends in Periodontitis in the USA: from the NHANES III
    to the NHANES, 1988 to 2000. Journal of Dental Research,84(10).
    Retrieved from http://jdr.sagepub.com/content/84/10/924.abstract.
    ---------------------------------------------------------------------------
        Edentulism and Overall Health.--Despite these existing conditions,
    recent dental public health trends demonstrate that as the population
    at large ages, older Americans are increasingly retaining their natural
    teeth.\5\ Today, many older adults benefit from healthy aging
    associated with the retention of their natural teeth, improvements in
    their ability to chew, and the ability to enjoy a variety of food
    choices not previously experienced by earlier generations of their
    peers.
    ---------------------------------------------------------------------------
        \5\ Dolan, T. A., Atchison, K., & Huynh, T. N. (2005). Access to
    Dental Care Among Older Adults in the United States. Journal of Dental
    Education, 69(9), 961-974. Retrieved from http://www.jdentaled.org/
    content/69/9/961.long.
    ---------------------------------------------------------------------------
        Oral health data reveals that many older adults experience adverse
    oral health associated with chronic and systemic health conditions. For
    example, associations between periodontitis and diabetes have emerged
    in recent years, as well as oral conditions such as xerostomia
    associated with the use of prescription drugs.\6,7\ Xerostomia,
    commonly known as dry mouth, contributes to the inception and
    progression of dental caries (cavities). For older Americans, the
    occurrence or recurrence of dental caries coupled with an inability to
    access treatment may lead to significant pain and suffering along with
    other detrimental health effects.
    ---------------------------------------------------------------------------
        \6\ Ira B. Lamster, DDS, MMSc, Evanthia Lalla, DDS, MS, Wenche S.
    Borgnakke, DDS, PhD and George W. Taylor, DMD, DrPH. (2008). Journal of
    the American Dental Association.
        \7\ Fox, Philip C. (2008). Xerostomia: Recognition and Management.
    Retrieved from: http://www.colgateprofessional.com.hk/LeadershipHK/
    ProfessionalEducation/Articles/Resources/profed_art_access-supplement-
    2008-xerostimia.pdf.
    ---------------------------------------------------------------------------
        Oral Care Provider Issues.--Although a growing number of older
    Americans need oral healthcare, the current workforce is challenged to
    meet the needs of older adults. The current dental workforce is aging,
    and many dental professionals will retire within the next decade.\2\ A
    lack of geriatric specialty programs complicates this problem, and few
    practitioners are choosing geriatrics as their field of choice.
        While these trends are favorable, adverse oral health consequences
    are emerging. Due to reasons stated in this report, together with
    increased demand for services, lack of access to dental benefits
    through Medicare, increased morbidity and mobility among older adults,
    and reduced income associated with aging and retirement, many older
    Americans are unable to access oral healthcare services. As a result,
    many older adults who have retained their natural teeth are now
    experiencing dental problems.
    Older Adults' Oral Health in State of Decay
        OHA released State of Decay on October 8, 2013, which is a State-
    by-State analysis of oral healthcare delivery and public health factors
    impacting the oral health of older adults. The report revealed more
    than half of the country received a ``fair'' or ``poor'' assessment
    when it comes to minimal standards affecting dental care access for
    older adults. The top findings of the report were:
      --Persistent lack of oral health coverage across much of the Nation.
            Forty-two percent of States (21 States) provide either no
            dental benefits or provide only emergency coverage through
            adult Medicaid Dental Benefits. Nearly 70 percent of older
            Americans lack dental insurance, and in the context of a
            rapidly aging Nation, this percentage will only likely
            increase.
      --Strained dental health work force. Thirty-one States (62 percent)
            have high rates of Dental Health Provider Shortage Areas
            (HPSAs), meeting only 40 percent or less of dental provider
            needs.
      --Tooth loss remains a signal of suboptimal oral health. Eight States
            had strikingly high rates of edentulism, with West Virginia
            notably having an adult population that is 33.8 percent
            edentate.
      --Deficiencies in preventive programs. Thirteen States (26 percent)
            have upwards of 60 percent of their residents living in
            communities without water fluoridation (CWF), despite
            recognition for 68 years that this public health measure
            markedly reduces dental caries. Hawaii (89.2 percent) and New
            Jersey (86.5 percent) represent the highest rates of citizens
            unprotected by fluoridation, an unnecessary public peril.
        Moreover, poor oral health has substantial financial implications.
    For example, in 2010 alone, between $867 million and $2.1 billion was
    spent on emergency dental procedures. When compared to care delivered
    in a dentist's office, hospital treatments are nearly ten times more
    expensive than the routine care that could have prevented the
    emergency. This places a costly yet avoidable burden on both the
    individual and the health institutions that must then bear the expense.
        In sum, oral health and access to preventive care significantly
    impact overall health and expenditure, yet are difficult to maintain--
    particularly for older adults--in the Nation's present context of
    support systems and healthcare.
    How OHA Empowers Older Adults to Meet their Oral Health Needs
        Oral Health America's Wisdom Tooth Project aims to change the
    lives of older adults especially vulnerable to oral disease. Its goal
    is to educate Americans about the oral health needs of older adults,
    connect older adults to local resources, and to advocate for policies
    that will improve the oral health of older adults. The Wisdom Tooth
    Project achieves these goals through five strategies: publications, our
    web portal, regional symposia, communications, and demonstration
    projects.

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

        [This statement was submitted by Beth Truett, CEO/President, Oral
    Health America.]
                                     ______

           Prepared Statement of the Ovarian Cancer National Alliance
        The Ovarian Cancer National Alliance (the Alliance) greatly
    appreciates the opportunity to submit testimony for the record
    regarding our fiscal year 2015 funding recommendations. The fiscal year
    2015 programmatic funding levels we are advocating for will help
    advance the awareness, detection and treatment of ovarian cancer, the
    deadliest of gynecologic cancers. Specifically, the Alliance
    respectfully requests Congress provide $7.5 million for the Centers for
    Disease Control and Prevention's (CDC) Ovarian Cancer program, which
    funds critical public health research of ovarian cancer. CDC also leads
    a public gynecologic cancer (ovarian, uterine, cervical, vaginal,
    vulvar) awareness initiative, authorized by Johanna's Law, that plays
    an integral role in women's cancer education, detection and prevention.
    As such, the Alliance respectfully requests Congress appropriate $5.5
    million for Johanna's Law implementation. Furthermore, to advance and
    leverage the important ovarian cancer research funded through the
    National Cancer Institute (NCI) at the National Institutes of Health
    (NIH), the Alliance respectfully requests Congress allocate $5.26
    billion to NCI, as a portion of $32 billion appropriated to NIH in
    fiscal year 2015.
        For 17 years, the Alliance has worked to increase awareness of
    ovarian cancer and advocate on behalf of women with ovarian cancer. As
    an umbrella organization of 58 State and regional Partner Member
    organizations, the Alliance unites the efforts of survivors, caretakers
    and healthcare professionals to bring national attention to ovarian
    cancer. The Alliance advocates at a national level for greater
    investment in Federal research to support the development of an early
    detection test, improved healthcare practices and life-saving treatment
    protocols. The Alliance also educates healthcare professionals about--
    and raises public awareness of--risk factors for and symptoms of
    ovarian cancer.
        Ovarian cancer is a highly deadly disease. According to the
    American Cancer Society, in 2013, an estimated 22,240 women were
    diagnosed with ovarian cancer and 14,030 women lost their lives to this
    terrible disease. A quarter of women diagnosed with ovarian cancer will
    die within 1 year of diagnosis and over half of women do not survive 5
    years after diagnosis. Unfortunately, these rates have not changed in
    nearly 40 years. These grim statistics arise from the fact that there
    is no early detection test for ovarian cancer; tragically, most cases
    of ovarian cancer are diagnosed after the disease has already begun to
    spread and are more difficult to effectively treat. However, if ovarian
    cancer is caught in the early stages, nearly ninety percent of women
    survive. As such, it is critical that women and healthcare providers be
    aware of the signs and symptoms of ovarian cancer and that valid and
    reliable early detection tests be developed.
        Few treatments for ovarian cancer have been approved by the Food
    and Drug Administration (FDA). Many FDA approved drugs are platinum-
    based therapies, to which cancers readily become resistant if multiple
    rounds of chemotherapy are needed. Nearly 80 percent of ovarian cancer
    patients will have a recurrence of disease, underscoring the great need
    for new and better treatments for ovarian cancer. For these reasons, we
    respectfully urge you and your colleagues to support ovarian cancer
    research, education and awareness efforts.
         cdc division of cancer prevention and control--ovarian cancer
        The Ovarian Cancer Line (also known as the Ovarian Cancer Control
    Initiative) funds public health research of ovarian cancer to better
    identify women most at risk for developing ovarian cancer, and design
    risk-reduction and prevention-focused interventions. In fiscal year
    2014, CDC's ovarian cancer program received $4.75 million to achieve
    its mission. Some of the projects being supported by those funds
    include: the development of a Continuing Medical Education curriculum
    on hereditary breast and ovarian cancer that educates physicians about
    how to identify, screen and manage high-risk patients; the
    investigation of ways to improve follow-up care for ovarian cancer
    patients given that so many experience disease recurrence; and the
    examination of risk factors, treatment disparities and other factors
    influencing survival rates to identify ways to improve patient outcomes
    with existing tools and treatments.
        With an allocation of $7.5 million in fiscal year 2015, the CDC
    will be able to continue this important work, and expand a pilot
    initiative that promotes educating women and providers about the BRCA
    mutations, identifies women at high risk for developing breast/ovarian
    cancer and ensures appropriate referral of these at risk women for
    genetic counseling or testing. This pilot program is currently
    operational in three States, but with increased funding, similar
    programs can be established in additional States and communication
    among women and their providers about genomic risk and testing can be
    further encouraged.
        Given the shared risk between ovarian and breast cancers for
    individuals with BRCA mutations, it is imperative that we integrate
    ovarian cancer risk assessment, education and genetic testing into
    other CDC cancer-related programs, such as the EARLY Act and the
    National Breast and Cervical Cancer Early Detection Programs. Combining
    breast and ovarian cancer programs in this manner will leverage scarce
    resources, better coordinate efforts between existing Federal programs,
    create economies of scale and efficiencies with respect to CDC
    education and awareness programs and advance complementary efforts to
    reduce ovarian cancer related deaths.
          cdc division of cancer prevention and control--johanna's law
        Johanna's Law funds a CDC-led gynecologic cancer awareness
    campaign, Inside Knowledge, which educates women and healthcare
    providers about the signs and symptoms of gynecologic cancers. In
    fiscal year 2014, CDC received $4.85 million for Johanna's Law
    activities, which include supporting the ongoing creation and
    dissemination of awareness campaign materials in English and Spanish,
    and a series of print, radio and television PSAs featuring survivor
    stories. In 2012, the campaign achieved one billion views of its PSAs
    across media types.
        With $5.5 million in fiscal year 2015, CDC will be able to continue
    to raise awareness of the signs and symptoms of ovarian and other
    gynecologic cancers, undertake a targeted outreach of its messages to
    high risk women and expand its partnerships with external patient
    advocacy, health professional and other stakeholder organizations to
    leverage scarce resources and amplify their messages. Collaboration
    with these organizations, such as the Alliance, would magnify the CDC's
    efforts to raise awareness and help ensure that women, particularly
    those known to be at a higher risk, seek the healthcare they need to
    identify and treat gynecologic cancers early.
                                   nci at nih
        NCI and the NIH fund the majority of ovarian cancer research in the
    United States and the world. On average, each year, NCI and NIH fund
    more than $140 million in peer-reviewed research grants to researchers
    at universities and small businesses across the United States. These
    studies are generating insights into the origins of ovarian cancer and
    disease progression that may lead to the development of early detection
    tests and better treatments for ovarian cancer. For example, NIH and
    NCI investments in basic research led to the understanding of a class
    of enzymes called PARPs implicated in ovarian cancer. Pharmaceutical
    companies have built upon these insights to develop PARP inhibitors, a
    class of drugs holding great promise for ovarian cancer patients.
        In addition to the basic research underlying future cures, NCI
    supports clinical research necessary for translating those ideas into
    treatments. NCI funding provides critical support to the ovarian cancer
    Specialized Programs of Research Excellence (SPORE), which facilitate
    collaborative research studies on the early detection and treatment of
    ovarian cancer. The Roswell Park Cancer Institute and University of
    Pittsburgh Cancer Institute Ovarian Cancer SPORE is working on reducing
    morbidity and mortality of ovarian cancer through groundbreaking
    translational research aimed at risk stratification, treatment, and
    prevention of relapse. Currently, a phase I clinical trial is being
    conducting on vaccines that induce anti-tumor immunity and several
    other clinical trials are in development. NCI's clinical trials
    enterprise plays an essential role in testing the safety and
    effectiveness of potential treatments for ovarian cancer. Robust NCI
    funding is critical to the continued excellence of the SPOREs.
        Furthermore, NCI recently launched the National Clinical Trials
    Network (NCTN), which consolidates and streamlines existing cooperative
    clinical trial groups. One of these new groups, the NRG Oncology
    Clinical Trial network, includes the Gynecologic Oncology Group (GOG),
    whose trials have been responsible for several advances in ovarian
    cancer research. Specifically, a GOG trial found that chemotherapy
    followed by maintenance use of Avastin increased progression free
    survival time of advanced ovarian cancer patients, when compared to
    chemotherapy alone. By funding important trials such as this, GOG (and
    now NRG) fills a clinical research gap left open by pharmaceutical
    companies that do not often research maintenance therapies. Due to the
    NCTN's critical importance in clinical trial design and implementation,
    robust NCI funding is necessary to accomplish these and other important
    tasks.
        Robust investment in NCI of $5.26 billion, out of a total $32
    billion for NIH in fiscal year 2015, is critical to ensuring the next
    generation of discoveries that will improve the health and well-being
    of women with--and at-risk for--ovarian cancer, as well as all
    Americans.
                                     * * *
        The Alliance maintains a long-standing commitment to working with
    Congress and other stakeholders to improve the survival rates for women
    with ovarian cancer through increased research, education and
    awareness. On behalf of our community of patients, caregivers and
    survivors, we thank you for your consideration of our fiscal year 2015
    requests and urge you to support the aforementioned Federal programs so
    vital to conquering this horrible disease.
                                     ______

                 Prepared Statement of Parents of Dead Children
        Can you please address a serious health epidemic that is affecting
    families everywhere? There is a medical epidemic that no one in
    Congress seems to want to address. That is heroin addiction and proper
    ways to treat it. The government is spending way too much money in the
    wrong places and the money should go for helpful and intensive
    treatment, including a significant amount of time addressing mental
    health treatment--again, something no one wants to talk about. Addicts
    do not choose to be addicts, which seems to be the way the vast
    majority of Americans like to think about it. There are mental health
    issues that go untreated and lead to self-medication. Methadone Clinics
    are a huge failure and have little to no oversight and certainly have
    no statistics that provide meaningful data as to their success or
    failure. The money poured into those places could be better utilized.
    Also, more oversight of in patient treatment centers is desperately
    needed--these are money making ventures and they say they treat for co-
    occurring disorders (such as bi-polar), it is a joke. If a patient
    meets one on one with a psychiatrist for half an hour every 2 weeks,
    how does that help?
        Read this article:The Problem with Methadone Clinics: They Are For-
    Profit Businesses
        Sine Nomine, Yahoo Contributor Network
        Mar 30, 2007
        Today, many Americans go to a methadone clinic. Some do it for
    legitimate reasons, others do it just to get a high. The problem with
    these methadone clinics are that they are for-profit organizations.
    Many people do not realize that the methadone clinic is a business.
    Businesses are open to make money. Here in lies the biggest problem
    facing people who do go to these clinics. The nurses, the counselors,
    and the doctors that are there to help patients are actually there to
    keep patients coming back. Why would they want someone to quit coming
    to the clinic? If everyone decided to quit using methadone then they
    would be out of a job. I know many people who get up every morning and
    make it to the methadone clinic. Some of these people have tried to
    quit and they always go back. Most don't even last 2 days without their
    methadone. These people have ended up trading one addiction for
    another. That is what methadone is, a legal addiction. People can go
    there everyday and get a legal high.
        Besides that, regulations for methadone clinics are practically non
    existent. You can fail a drug test there and not have to worry about
    it. All that will happen to you is that they will make you come there
    everyday to get your methadone. You won't be allowed to take any home
    with you. What is even worse is they do not care if you fail a drug
    test just as long as your back there the next day to get your next
    dose. The government needs to step in and make some serious regulations
    on this business.
        As it stands, right now you can go to the methadone clinic for as
    long as you need to. There is no turning you away just as long as you
    can pay for your dose and to make that easier they will even let you
    charge a day if you don't have the money. People go to the methadone
    clinic for years even decades because they are addicted to the
    methadone. Their bodies won't let them quit. They start suffering
    withdraw symptoms within the first 48 hours. So back to the methadone
    clinic they go. No one will help you detox if they know you are on
    methadone. You have to go to a specialized institution to detox off
    methadone.
        The government can step in and ban the sell of prescription drugs,
    ban the use of marijuana, they even tell you where you can and can't
    smoke today. But what are they doing for the growing methadone problem?
    Very little. More and more people are dying every day because of
    methadone. But let me be clear it is not just the methadone that is
    killing them. These people are mixing methadone with other drugs such
    as Xanax, Valium, Percocet, OxyContin, etc. The drug tests done at
    these methadone clinics show up these other drugs. Yet nothing is done
    about the fact that these people are abusing other drugs that interact
    with methadone causing a lethal combination. The government should step
    in and implement a system for checking this so called business. A
    system that would allow them to check the drug screens of each
    individual. Those individuals that cannot pass three drug screens
    should be eliminated from the program. The government should also make
    it mandatory to drug test each individual at least twice a week. I also
    believe that a set time limit for methadone maintenance should be
    implemented. Every two weeks the patient should be made to come down a
    minimum of two milligrams of methadone. This means that a patient
    starting out at 50 mg will be completely off the methadone in a little
    under a year. By implementing this system the government would decrease
    the patients who abuse methadone and would help those who need the
    methadone without making them methadone addicts.
        Gina Haggerty, mother of a dead son who just wanted help and was
    not going to a methadone clinic because he said they were a joke. The
    deadline for submitting this testimony, May 23rd, would have been his
    25th birthday.
                                     ______

              Prepared Statement of the Parkinson's Action Network
        Dear Chairman Harkin and Ranking Member Moran: The Parkinson's
    Action Network (PAN) appreciates the opportunity to comment on the
    fiscal year 2015 appropriations for the U.S. Department of Health and
    Human Services. Our comments will focus on the importance of Federal
    investment in biomedical research at the National Institutes of Health
    (NIH) and the National Institute of Neurological Disorders and Stroke
    (NINDS), which recently adopted a series of priority research
    recommendations for Parkinson's disease. PAN supports at least $32
    billion in funding for the NIH and an increase for NINDS to support the
    research recommendations set forth by the NINDS planning strategy to
    bring us closer to better treatments and a cure for Parkinson's
    disease.
        PAN is the unified voice of the Parkinson's community advocating
    for better treatments and a cure. In partnership with other Parkinson's
    organizations and our powerful grassroots network, we educate the
    public and government leaders on better policies for research and
    improved quality of life for the estimated 500,000 to 1.5 million
    Americans living with Parkinson's, for whom there is no treatment
    available that slows, reverses, or prevents progression.
        As the second most common neurodegenerative condition after
    Alzheimer's disease, Parkinson's disease is projected to grow
    substantially over the next few decades as the size of the elderly
    population grows and will have a direct impact on the healthcare system
    and economy. A study published in Movement Disorders estimated that the
    economic burden of Parkinson's disease is at least $14.4 billion a year
    in the United States, and the prevalence of Parkinson's will more than
    double by the year 2040.\1\ In addition, the study calculated an
    additional $6.3 billion in indirect costs such as missed work or loss
    of a job for the patient or family member who is helping with care,
    long-distance travel to see a neurologist or movement disorder
    specialist, as well as costs for home modifications, adult day care,
    and personal care aides.
    ---------------------------------------------------------------------------
        \1\ ``The Current and Projected Economic Burden of Parkinson's
    Disease in the United States,'' Movement Disorders, Vol. 28, No. 3,
    2013.
    ---------------------------------------------------------------------------
        A second study also published in Movement Disorders projected that
    if Parkinson's progression were slowed by 50 percent, there would be a
    35 percent reduction in excess costs, representing a dramatic reduction
    in cost of care spread over a longer expected survival.\2\ Both studies
    highlight the enormous economic implications of this devastating
    disease, and make it abundantly clear that increased research funding
    is a wise investment on the front end to help significantly lower or
    eliminate costs on the back end.
    ---------------------------------------------------------------------------
        \2\ ``An Economic Model of Parkinson's Disease: Implications for
    Slowing Progression in the United States,'' Movement Disorders, Vol.
    28, No. 3, 2013.
    ---------------------------------------------------------------------------
        NIH has the unique role of being at the forefront of medical
    discovery in the United States. NIH supports research in all fifty
    States, with more than 80 percent of the funding going to universities,
    research institutions, and small businesses, which create thousands of
    jobs and grow local economies. In 2012, this amounted to over 402,000
    jobs nationwide and $57.8 billion in economic activity. Perhaps even
    more important than their economic contributions is the practical
    impact NIH grants have in identifying and developing a better
    understanding of and treatments for countless complex diseases and
    disorders.
        There is currently a concerted effort at NIH to better target areas
    of unmet medical need, including Parkinson's research. In January 2014,
    NINDS approved a list of 31 priority research recommendations specific
    to Parkinson's that highlight areas in which NINDS and the broader
    field should direct its resources to achieve the greatest impact in
    addressing treatments and the underlying causes of the disease. These
    recommendations were the result of an intensive planning process that
    brought together clinicians, researchers, and the patient community to
    determine the areas of greatest need to reframe how we approach the
    disease. We applaud NINDS for their leadership in this effort, which
    represents an unparalleled opportunity to coordinate critical
    initiatives to help unlock the mysteries of Parkinson's--but its
    success is dependent upon strengthening funding at NIH and NINDS to
    ensure that sufficient capacity and resources are available.
        Unfortunately, due to ongoing fiscal constraints, including
    sequestration, the NIH research budget has not kept pace with inflation
    or the growing needs of an aging population and the overall public
    health. Sequestration alone cut over $1.55 billion from NIH in fiscal
    year 2013, which is roughly equivalent to the entire budget for NINDS.
    NIH, the largest funder of Parkinson's research in the world, was also
    forced to reduce its Parkinson's-related research from a high of $154
    million in fiscal year 2012 to $135 million in fiscal year 2013, a 12
    percent decrease. Across the country, many institutions have felt the
    burden of these cuts, receiving smaller grants or no grants at all. As
    NIH continues to find high-priority areas to fund in order to advance
    Parkinson's research, we should be increasing support and not applying
    cuts that could possibly delay years of progress toward a cure for
    Parkinson's and other diseases.
        Despite some greater certainty in the current appropriations cycle
    because of the budget agreement passed in December 2013, there is still
    grave concern over the implications for medical research long-term. Dr.
    Francis Collins, director of NIH, has even noted that ``without
    sustained investment, many high-priority efforts would move at a
    substantially slower pace, and years of effectively flat funding for
    biomedical research have left scientists facing the lowest chances in
    history of having their research funded by NIH.'' \3\ Because of this
    trend, there is also the fear that the next generation of scientists
    will leave the United States or be reluctant to enter the field of
    neurological research at all because of the uncertainty in financial
    support they see and feel here at home. Innovation and new
    possibilities for medical research are at our fingertips, and we must
    be sure that we have the resources in place to fully recognize and
    cultivate their potential.
    ---------------------------------------------------------------------------
        \3\ ``Investing in the Nation's Health,'' Dr. Francis Collins. The
    Washington Post. Opinions. December 24, 2013.
    ---------------------------------------------------------------------------
        We recognize that due to spending caps put into place by the 2013
    budget agreement, the President's fiscal year 2015 budget proposal only
    requests a modest increase for NIH and many other important programs.
    But, we also understand that the final decision on how these funds
    should be allocated within those caps is the responsibility of
    Congress--and we look to you for your leadership and support. PAN urges
    the Subcommittee to prioritize biomedical research funding by
    supporting at least $32 billion for the NIH overall and increasing
    funding for NINDS to advance critical priorities designed to
    fundamentally change our understanding of Parkinson's disease. We look
    forward to working with the Subcommittee as the fiscal year 2015
    appropriations process moves forward.
                                     ______

            Prepared Statement of the Pew Children's Dental Campaign
        On behalf of the Pew Children's Dental Campaign, thank you for the
    opportunity to submit testimony regarding appropriations for fiscal
    year 2015. We appreciate the subcommittee's recognition of oral health
    as a key aspect of overall health and its continued support of programs
    that expand access to preventive and restorative services through the
    Health Resources and Services Administration (HRSA) and the Centers for
    Disease Control and Prevention (CDC).
        The Pew Children's Dental Campaign works at the State and national
    levels to ensure that more children receive dental care and benefit
    from evidence-based policies, such as community water fluoridation,
    dental sealant programs, and expansion of the dental workforce. Since
    it was established in 2008, our initiative has produced numerous
    reports evaluating access to care across the 50 States and the District
    of Columbia, and while we have made significant progress in advancing
    reforms nationally and in the States, there is still much to be done on
    this important issue.
        Tooth decay affects nearly 60 percent of the Nation's children,
    and, unsurprisingly, its consequences are concentrated
    disproportionately among low-income children.\1\ Dental disease is the
    most common chronic disease among children in the U.S.--five times more
    prevalent than asthma, and in a single year, U.S. students may miss as
    many as 51 million hours of school due to dental health problems.\2\ It
    causes pain, hampers school performance, and if left untreated can lead
    to tooth loss and abscesses that spread infection to the blood and
    brain.\3\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Health and Human Services, Oral Health in
    America: A Report of the Surgeon General, DHHS, Rockville, MD, 2000.
        \2\ Ibid.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        Lack of access to preventive services and oral healthcare also
    imposes a huge cost on States. In 2011, preventable dental conditions
    were the primary reason for 857, 712 emergency room (ER) visits in the
    U.S.\4\ In 2010, Florida spent more than $88 million on more than
    115,000 hospital ER visits for dental problems and in 2007, 60,000
    dental visits to ERs cost the State of Georgia more than $23
    million.\5,6\ Dental problems can also impact the workforce, causing an
    estimated 164 million hours of lost work time each year, and can
    inhibit a person's ability to find a job.\7\ Additionally, a 2008 study
    of the armed forces found that 52 percent of new recruits were found to
    be Class 3 in ``dental readiness,'' meaning they had oral health
    problems that needed urgent attention and would delay overseas
    deployment.\8\
    ---------------------------------------------------------------------------
        \4\ HCUPnet, Healthcare Cost and Utilization Project, ``Information
    on ED visits from the HCUP Nationwide Emergency Department Sample
    (NEDS),'' Agency for Healthcare Research and Quality, Rockville, MD.
    http://hcupnet.ahrq.gov/
        \5\ ``315 Patients a Day Seek Dental Treatment in Florida's
    Hospital Emergency Rooms,'' a news release by the Florida Public Health
    Institute, (December 15, 2011).
        \6\ Andy Miller, ``Fight over Georgia dental rules flares again,''
    Georgia Health News, September 7, 2011, http://
    www.georgiahealthnews.com/2011/09/fight-dental-rules-flares/.
        \7\ U.S. Department of Health and Human Services, Oral Health in
    America: A Report of the Surgeon General, DHHS, Rockville, MD, 2000.
        \8\ T. M. Leiendecker, G. C. Martin et al., ``2008 DOD Recruit Oral
    Health Survey: A Report on Clinical Findings and Treatment Need,'' Tri-
    Service Center for Oral Health Studies (2008), 1.
    ---------------------------------------------------------------------------
        Given the enormous impact of oral health on overall health and the
    associated social and economic consequences, we respectfully request
    that the subcommittee consider the following appropriations requests
    for programs that aim to expand access to care and preventive services
    for those most in need.
    Focusing on prevention
        With support from the CDC Division of Oral Health, States can
    better promote oral health and efficiently administer scarce resources,
    monitor oral health status and problems, and conduct and evaluate
    prevention programs through cooperative agreements. This funding is
    critical to a State's ability to prevent problems before they occur,
    rather than treating them when they are painful and expensive. The
    cooperative agreement program also supports State community water
    fluoridation programs and school-based dental sealant programs, and
    while funding for this program has been authorized for all 50 States,
    the Division is currently only able to support 21 States: Colorado,
    Connecticut, Georgia, Hawaii, Idaho, Iowa, Kansas, Louisiana, Maryland,
    Michigan, Minnesota, Mississippi, New Hampshire, New York, North
    Dakota, Rhode Island, South Carolina, Vermont, Virginia, West Virginia,
    and Wisconsin.
        Research shows that community water fluoridation offers one of the
    greatest returns on investment of any preventive healthcare strategy.
    For most cities, every $1 invested in water fluoridation saves $38 in
    dental treatment costs.\9\ CDC estimates that fluoridated water saves
    more than $4.6 billion annually in dental costs in the United
    States,\10\ and even more could be saved by expanding coverage to some
    of the 70 million people who still do not have it.\11\ Dental sealants
    are also cost-effective; school-based programs can efficiently prevent
    60 percent of decay in the permanent teeth most likely to become
    decayed during childhood.\12\ We recommend a funding level sufficient
    to enable all States and the District of Columbia to receive the
    critical CDC prevention funds, starting with an increase for the coming
    fiscal year to begin moving toward full funding.
    ---------------------------------------------------------------------------
        \9\ Centers for Disease Control and Prevention, ``Cost Savings of
    Community Water Fluoridation,'' Fact Sheet, Accessed March 27, 2014:
    http://www.cdc.gov/fluoridation/factsheets/cost.htm
        \10\ Centers for Disease Control and Prevention, ``Preventing
    Dental Caries with Community Programs,'' Fact Sheet, Accessed March 27,
    2014: http://www.cdc.gov/oralhealth/publications/factsheets/
    dental_caries.htm
        \11\ Centers for Disease Control and Prevention, ``2012 Water
    Fluoridation Statistics,'' Data and Statistics, Accessed March 27,
    2014: http://www.cdc.gov/fluoridation/statistics/2012stats.htm
        \12\ Truman, B. I., Gooch, B. F., Sulemana, I., Gift, H. C.,
    Horowitz, A. M., Evans, C. A., et al. (2002). Reviews of evidence on
    interventions to prevent dental caries, oral and pharyngeal cancers,
    and sports-related craniofacial injuries. American Journal of
    Preventive Medicine, 23(1 Suppl.), 21--54.
    ---------------------------------------------------------------------------
    Funding request for fiscal year 2015: $19 million for the CDC Division
            of Oral Health to expand cooperative agreements to additional
            States
    Addressing the dental access crisis
        Pew's 2013 brief, In Search of Dental Care, found that roughly 45
    million Americans live in dental professional shortage areas, regions
    that have a scarcity of dentists relative to the population.\13\
    Additionally, in 2011, more than 14 million children enrolled in
    Medicaid did not receive any dental service, in part due to the low
    numbers of dentist participation in the Medicaid program.\14\ The
    supply of dentists nationally is also likely to shrink in the coming
    years. The American Dental Association projects that despite the
    addition of new dental schools and possible increase in graduates,
    between 2010 and 2030 the ratio of dentists to Americans will continue
    to fall due to high numbers of dentists approaching retirement age.\15\
    ---------------------------------------------------------------------------
        \13\ The Pew Charitable Trusts, ``In Search of Dental Care,'' June
    2013, http://www.pewstates.org/uploadedFiles/PCS_Assets/2013/
    In_search_of_dental_care.pdf
        \14\ This figure counts children ages 1 to 18 eligible for the
    Early and Periodic Screening, Diagnostic and Treatment Benefit. See
    U.S. Department of Health and Human Services, Centers for Medicare and
    Medicaid Services, Annual EPSDT Participation Report, Form CMS-416
    (National) fiscal year: 2011, April 1, 2013. Analysis by The Pew
    Charitable Trusts; U.S. Department of Health and Human Services,
    Centers for Medicare and Medicaid Services, Early and Periodic
    Screening, Detection and Treatment Web page (accessed May 24, 2013),
    http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/
    Benefits/Early-Periodic-Screening-Diagnosis-and- Treatment.html.
        \15\ American Dental Association, Health Policy Resources Center,
    2011 American Dental Association Workforce Model: 2009-2030 (Chicago:
    American Dental Association, 2011), 11.
    ---------------------------------------------------------------------------
        Many States are expanding scope of practice laws to enable a
    variety of dental care providers to expand access to care to the
    underserved, such as dental therapists in Minnesota and Alaska tribal
    lands, public health hygienists in Kentucky, Maryland, and New
    Hampshire, and community dental health coordinators in Arizona,
    California, Montana, New Mexico, Oklahoma, and Wisconsin. A Federal
    demonstration grant program authorized in 2010 but currently unfunded
    would provide training institutions, community health centers, public
    hospitals, and other organizations with funding to train these types of
    providers, all in accordance with State scope of practice laws, and
    evaluate their impact on access to care.\16\ Also eligible for funding
    through this demonstration are programs such as one in California that
    uses telehealth services to bring care to patients in Head Start
    centers and nursing homes \17\ and ER diversion programs that link
    public hospitals to federally qualified health centers.\18\
    ---------------------------------------------------------------------------
        \16\ Patient Protection and Affordable Care Act of 2010, Public Law
    No. 111-148, sec. 5304, 124 Stat. 119, 621-622 (2010).
        \17\ Virtual Dental Home Demonstration Project, Arthur A. Dugoni
    School of Dentistry, University of the Pacific: http://
    www.dental.pacific.edu/Community_Involvement/
    Pacific_Center_for_Special_Care--(PCSC)/Innovations_Center/
    Virtual_Dental_Home_Demonstration_Project. html.
        \18\ Centers for Medicare and Medicaid Services, ``Emergency Room
    Diversion Grant Program,'' 2008- 2011, http://www.medicaid.gov/
    Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Grant-
    Programs/ER-Diversion-Grants.html.
    ---------------------------------------------------------------------------
        Pilot efforts to assess how new dental providers can increase
    access to care are being developed in Oregon, Michigan, Connecticut and
    Hawaii, and Maine, Kansas, New Mexico, Ohio, and Washington are among
    the States considering legislation to authorize dental therapists.
    These providers and programs can increase access at a lower cost to
    States, and numerous studies have reaffirmed the quality of the
    services being provided.\19\ These evaluations would not only benefit
    those States that have authorized alternative providers, but would also
    provide information to inform policies in the many other States that
    are struggling to find answers to the challenge of expanding access to
    the underserved.
    ---------------------------------------------------------------------------
        \19\ David A. Nash et al., A Review of the Global Literature on
    Dental Therapists, April 2012, W.K. Kellogg Foundation, http://
    www.wkkf.org/knowledge-center/resources/2012/04/nash-dental-therapist-
    literaturereview.aspx.
    ---------------------------------------------------------------------------
    HRSA funding request for fiscal year 2015:
      --Removal of the current funding block on existing funding for the
            Alternative Dental Health Care Provider Demonstration Grants,
            Section 340G-1 of the Public Health Service Act, and an
            appropriation of $10 million to initiate the program
      --$32 million for Title VII program grants to expand and educate the
            dental workforce
        By making targeted Federal investments in effective policy
    approaches, the subcommittee can enable States to sustain programs that
    prevent the pain, missed school hours and long-term health and economic
    consequences of untreated dental disease. A handful of States are
    leading the way, but all States can and must do more to ensure access
    to dental care for those who need it most. Thank you for your
    consideration of this testimony.

        [This statement was submitted by Shelly Gehshan, Director, Pew
    Children's Dental Campaign.]
                                     ______

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

        [This statement was submitted by Anthony Miller, M.Ed., PA-C Chief
    Policy and Research Officer.]
                                     ______

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

        [This statement was submitted by Mary Jo Hoeksema, Director,
    Government Affairs Population Association of America/Association of
    Population Centers.]
                                     ______

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

        [This statement was submitted by Hugh Parry, President & CEO,
    Prevent Blindness.]
                                     ______

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

        [This statement was submitted by Mike Hennenfent, President,
    Prostatitis Foundation.]
                                     ______

          Prepared Statement of the Pulmonary Hypertension Association
        Chairman Harkin and distinguished members of the Subcommittee,
    thank you for your time and your consideration of the priorities of the
    pulmonary hypertension community as you work to craft the fiscal year
    2015 Labor, Health and Human Services Appropriations Bill.
                          about pulmonary hypertension
        Pulmonary hypertension (PH) is a disabling and often fatal
    condition simply described as high blood pressure in the lungs. It
    affects people of all ages, races and ethnic backgrounds. Although
    anyone can get PH, there are risk factors that make some people more
    susceptible.
        Treatment and prognosis vary depending on the type of PH. In one
    type, pulmonary arterial hypertension (PAH), the arteries in the lungs
    become too narrow to handle the amount of blood that must be pumped
    through the lungs. This causes several things to happen: a backup of
    blood in the veins returning blood to the heart; an increase in the
    pressure that the right side of your heart has to pump against to push
    blood through your lungs; and a strain on the right side of your heart
    due to the increased work that it has to do. If this increased pressure
    is not treated, the right side of your heart can become overworked,
    become very weak and may possibly fail. Because the blood has
    difficulty getting through the lungs to pick up oxygen, your blood
    oxygen level may be lower than normal. This can put a strain not only
    on your heart, but also decrease the amount of oxygen getting to your
    brain.
        There is currently no cure for PAH. Twelve treatment options are
    available to help patients manage their disease and feel better day to
    day but even with treatment, life expectancy with PAH is limited.
                             about the association
        From simple beginnings--four women who met around a kitchen table
    in Florida in 1990--the Pulmonary Hypertension Association has evolved
    into a community of well over 10,000 pulmonary hypertension patients,
    caregivers, family members and medical professionals.
        As we have grown, we have stayed true to our roots and the vision
    and ingenuity of our founders: We continue to work every day to end the
    isolation that PH patients face, and find a cure for pulmonary
    hypertension.
    Research
        PHA provides grants to promising researchers in the field of
    pulmonary hypertension. The program fosters new leaders in the field by
    supporting their interest in PH research and providing them with
    opportunities to work with mentors and learn new skills. Researchers
    supported by PHA are looking for new methods for early detection, new
    treatments to prevent the onset of PH and ultimately a cure for this
    terrible illness. To date, PHA has leveraged more than $13 million in
    PH research funding through partnerships with the NIH and others.
    Early Diagnosis Campaign
        It takes too long for pulmonary hypertension to be diagnosed. The
    median survival rate without treatment is approximately 2.8 years,
    making the need to obtain a rapid and accurate diagnosis urgent.
    Unfortunately, the median duration from symptom onset to a confirmed
    diagnosis by right heart catheterization is 1.1 years. We are reaching
    patients too late in the process. Almost three-fourths of patients have
    advanced PH by the time they are diagnosed, leading more costly
    treatments and poorer outcomes. For the most advanced cases of PH, a
    lung or heart-lung transplant may be the only treatment option. The
    goal of PHA's Early Diagnosis Campaign is to discover the disease
    sooner in the early stages. This will allow the start of a treatment
    regimen that can slow the progression of PH and secure a better life
    for the patient.
    Center Accreditation
        The Pulmonary Hypertension Association's Scientific Leadership
    Council, 28 global leaders in the field of pulmonary hypertension, have
    spearheaded the PHA-Accredited PH Care Centers (PHCC) initiative. The
    goal of this initiative is to establish a program for accreditation of
    centers with special expertise in pulmonary hypertension (PH),
    particularly pulmonary arterial hypertension (PAH), to raise the
    overall quality of care and outcomes in patients with this life-
    threatening disease.
                              one patient's story
        In 2011, at the age of 29, GS12 Human Terrain Analyst Jessica
    (Puglisi) Armstrong began experiencing shortness of breath and
    dizziness. She was in Afghanistan at the time. Jessica was first
    diagnosed with dehydration. Then, as is the case with many PH patients,
    she was told she had asthma and was given an inhaler. Two months later,
    she fainted for no apparent reason. An echocardiogram revealed blood
    clots in her lungs and Jessica was medically evacuated to Germany and
    then to the U.S. Six months after her fist symptoms, she was finally
    given a complete work up and diagnosed with pulmonary hypertension.
        Jessica, she had a unique form of PH due to blood clots that can be
    mitigated with a pulmonary thromboendarterectomy (PTE)--a complex
    surgery that involves opening the chest cavity and stopping circulation
    for up to twenty minutes. She describes the surgery, which she
    underwent at the University of California San Diego, as ``more painful
    than I could ever imagine.'' She notes that UCSD's PTE program did not
    begin until 1990 and even now, despite being recognized as the global
    leaders on this procedure, has only completed about 3,000 surgeries.
    The procedure that saved Jessica's was developed in her lifetime.
        Jessica was terminated from Army employment and spent $60,000 out
    of pocket on medical expenses which she has not been able to recoup.
    She was forced to begin a civilian job just two weeks after her PTE in
    order to retain health insurance. Despite this, Jessica is, in many
    ways, one of the lucky ones. I am glad to report that she is now doing
    well and serving an integral role at PHA as the coordinator of our
    Early Diagnosis Campaign.
        Over the past decade, treatment options, and the survival rate, for
    pulmonary hypertension patients have improved significantly. However,
    courageous patients of every age lose their battle with PH each day.
    There is still a long way to go on the road to a cure and biomedical
    research holds the promise of a better tomorrow.
                                 sequestration
        We have heard from the medical research community that
    sequestration and deficit reduction activities have created serious
    issues for Federal funding opportunities and the career development
    pipeline. In order to ensure that the pulmonary hypertension research
    portfolio can continue to grow, and, more importantly, to ensure that
    our country is adequately preparing the next generation of young
    investigators, we urge you to avert, mitigate, or otherwise eliminate
    the specter of sequestration. The Association has anecdotal accounts of
    the harms of sequestration and the Federated American Societies for
    Experimental Biology has reported:
      --In constant dollars (adjusted for inflation), the NIH budget in
            fiscal year 2013 was $6 billion (22.4 percent) less than it was
            in fiscal year 2003.
      --The number of competing research project grants (RPGs) awarded by
            NIH has also fallen sharply since fiscal year 2003. In fiscal
            year 2013, NIH made 8,283 RPG awards, which is 2,110 (20.3
            percent) fewer than in fiscal year 2003.
      --Awards for R01-equivalent grants, the primary mechanism for
            supporting investigator-initiated research, suffered even
            greater losses. The number awarded fell by 2,528 (34 percent)
            between fiscal year 2003 and fiscal year 2013.
        The pay line for some NIH funding mechanisms has fallen from 18
    percent to 10 percent while the average age for a researcher to receive
    their first NIH-funded grant has climbed to 42. These are strong
    disincentives to choosing a career as a medical researcher. Our
    scaling-back is occurring at a time when many foreign countries are
    investing heavily in their biotechnology sectors. China alone plans to
    dedicate $300 million to medical research over the next 5 years; this
    amount is double the current NIH budget over the same period of time.
    Scientific breakthroughs will continue, but America may not benefit
    from the return-on-investment of a robust biotechnology sector. For the
    purposes of economic and national security, as well as public health,
    the Association asks that you work with your colleagues to eliminate
    sequestration and recommit to supporting this Nation's biomedical
    research enterprise.
                  health resources and services administration
        Due to the serious and life-threatening nature of PH, it is common
    for patients to face drastic health interventions, including heart-lung
    transplantation. Federal organ transplantation activities are
    coordinated through HRSA. To ensure HRSA can expand its important
    mission and continue to make improvements in donor lists and donor-
    matching please provide HRSA with a meaningful funding increase in
    fiscal year 2015.
                   centers for disease control and prevention
        As a result of Federal investment in medical research, there are
    now twelve FDA-approved treatments for PH. The effectiveness of these
    therapies though is dependent on how early a patient can receive an
    accurate diagnosis and begin treatment. Unfortunately, two-thirds of
    patients are not diagnosed until PH has reached a late stage. In
    addition to mitigating the impact of many treatments, late diagnosis
    puts PH patients in a position to face interventions like heart-lung
    transplantation and even death. CDC and NCCDPHP have the resources to
    compliment PHA's own Sometimes its PH Early Diagnosis Campaign.
    Improving public awareness and recognition of PH will not only save
    lives, it can save the Federal healthcare system money. Please provide
    CDC with meaningful funding increases so the agency can expand its
    focus beyond winnable battles into increasingly important and cost-
    effective areas.
                         national institutes of health
        NIH hosts a sizable PH research portfolio. Further, NIH and PHA
    have a strong track record of working together to advance our
    scientific understanding of PH. The twelve FDA-approved treatments,
    more than nearly every other rare disease, are evidence of the return-
    on-investment from these activities. Please provide NIH with meaningful
    increases to facilitate expansion of the PH research portfolio so we
    can continue to improve diagnosis and treatment.
    NCATS
        The Office of Rare Diseases Research (ORDR), located within NCATS,
    supports and coordinates rare disease research and provides information
    on rare diseases to patients, their families, healthcare providers,
    researchers and the public. In collaboration with other NIH institutes,
    ORDR funds rare diseases research primarily through the Rare Diseases
    Clinical Research Network (RDCRN), which supports clinical studies,
    investigator training, pilot projects, and access to information on
    rare diseases. The most recent funding opportunity announcement, which
    was widely broadcast and open to all rare diseases, including PAH, was
    issued in the fall of 2013 and awards are expected to be made in the
    summer of 2014
    NHLBI
        The NHLBI-funded Centers for Advanced Diagnostics and Experimental
    Therapeutics in Lung Diseases Stage II program, which will begin in
    fiscal year 2014, will provide a mechanism to accelerate the
    development of therapies for lung diseases, including pulmonary
    fibrosis and pulmonary arterial hypertension.
                             additional activities
    S. 1453
        Senator Robert Casey (D-PA) has introduced the Pulmonary
    Hypertension Research and Diagnosis Act (S.1453). This budget neutral
    legislation has a bipartisan companion in the House due to its emphasis
    on lowering healthcare costs by promoting efficiencies within the
    Federal Government. S. 1453 seeks to establish an HHS-wide Committee
    tasked with preparing a report on how to leverage limited resources to
    improve early diagnosis of PH. Please consider cosponsoring S. 1453 and
    working with your colleagues to advance this important legislation.
    S. 2115
        PHA has written to Senators Richard Durbin (D-IL) and Barbara
    Mikulksi (D-MD) to thank them for their leadership on the American
    Cures Act (S. 2115). We hope this legislation is an indication that
    policymakers have committed themselves to supporting innovative
    proposals to bolster and advance our Nation's biomedical research
    enterprise.
                                     ______

                     Prepared Statement of Research!America
        Research!America, the Nation's largest public education and
    advocacy alliance committed to advancing medical research and
    development, appreciates your stewardship over such a critical subset
    of our Nation's discretionary funding priorities. As the subcommittee
    begins the process of prioritizing fiscal year 2015 funding, we urge
    you to consider the following thoughts on Federal agencies entrusted
    with sustaining our Nation's sophisticated public health
    infrastructure, partnering with the private sector to accelerate
    medical progress, and optimizing healthcare outcomes.
        The National Institutes of Health (NIH), the Centers for Disease
    Control and Prevention (CDC), and the Agency for Healthcare Research
    and Quality (AHRQ) play pivotal roles in combating disabling and deadly
    health conditions. Moreover, the funding, or lack of it, allocated to
    these agencies will bear on our Nation's ability to compete in key
    export markets within the global economy, foster business development
    that grows and maintains jobs across the country, meet our solemn
    obligations to wounded warriors and support troops on the ground,
    combat deadly medical errors, and protect our Nation against pandemics
    and emerging health threats. The stakes truly are that high.
    NIH as a driver of innovation
        In fiscal year 2015, we urge you to provide at least $32 billion in
    NIH funding to drive us beyond the stagnation that squanders
    opportunities to advance science and strengthen our Nation. Research
    funded by the NIH at universities, academic medical centers,
    independent research institutions and small businesses across the
    country lays the foundation for new product development by the private
    sector. Since much of the research NIH supports is at the non-
    commercial stages of the research pipeline, NIH funding does not
    compete with, but rather sets the stage for, critical private sector
    investment and development. These two complementary funding streams
    lead to business development, job growth and beneficial medical
    advances. Taxpayer-funded research through the NIH has helped our
    Nation make remarkable progress against such insidious health threats
    as childhood cancer, HIV-AIDS and heart disease.
        The secrets of diabetes, Alzheimer's, Parkinson's, myriad cancers
    and many other diseases can and will be unlocked by science. The
    question is not if, but when . . . unless we dismiss the significance
    of such progress and continue to allow research resources to stagnate.
    And our Nation's best weapon against spiraling healthcare costs is
    research. Ignoring growing healthcare costs is a ticket to disaster.
    Alzheimer's disease alone is projected to cost the Federal Government
    over $1 trillion during the next 20 years. Ultimately, we must prevent
    and cure disease in order to tackle the costs associated with it.
    CDC as a first responder
        In fiscal year 2015, we urge you to provide a funding level that
    continues the growth in CDC budget authority that was initiated in
    fiscal year 2014. The CDC engages in research that stems deadly and
    costly pandemics, bolsters our Nation's defenses against bioterrorism,
    and helps prevent the onset of debilitating and expensive diseases. The
    CDC is the Nation's first responder to lethal viruses and infections,
    including life-threatening and costly drug-resistant infections that
    pose a particular threat to children and young adults, as well as
    investigating tragic phenomena like cancer clusters. Due to cuts in
    recent years, the CDC is functioning with one hand tied behind its
    back, even as health challenges like the obesity epidemic, autism
    epidemic and infectious disease outbreaks capture headlines and ruin
    lives. It is always more efficient and cost effective to be in front of
    an outbreak or biological attack than to take reactionary measures.
    AHRQ translates medical innovation into the right care at the right
            time
        In fiscal year 2015, we urge you to provide at least $375 million
    in funding for AHRQ. Research supported by AHRQ identifies
    inefficiencies in healthcare delivery that inflate the cost of public
    and private insurance. AHRQ-supported research also combats medical
    errors and improves the quality of care to help reduce the length and
    intensity of disability and disease. It helps patients and physicians
    make informed treatment decisions that improve outcomes and reduce
    costly ``false starts'' in the provision of healthcare services.
        Just one of many success stories is AHRQ's issuance of new
    standards of care and practices related to central line-associated
    bloodstream infections. The implementation of the guidelines resulted
    in a reduction of up to two-thirds of cases during early rollout
    studies. With an annual estimated 80,000 cases, up to 28,000 deaths and
    an average cost per patient of $45,000, this has the potential to save
    $2.3 billion annually in healthcare costs. Given the enormity of the
    challenge of inefficiency in healthcare delivery, AHRQ is severely
    underpowered.
    The threat of sequestration's return
        The Ryan-Murray Bipartisan Budget Act provided America with 2 years
    of partial relief from sequestration after across the board budget cuts
    dramatically impacted medical research in March 2013. Unfortunately,
    sequestration will go back into full effect in 2016 unless Congress
    takes action, and it will be in effect for 2 years longer than
    originally established under the 2011 Budget Control Act. The return of
    sequestration's budget cuts to discretionary spending, including that
    for NIH, CDC and AHRQ, poses potentially devastating setbacks to
    medical research. Short-changing medical research is not a solution to
    the Federal deficit or debt. On the contrary, neglecting medical
    research undercuts strategies to fight chronic disease and the
    multipronged Federal costs that arise from it, while squandering
    opportunities to increase private sector and Federal revenues through
    new medical innovations.
        Research!America appreciates the difficult task facing the
    subcommittee as it seeks to simultaneously confront the budget deficit,
    strengthen the U.S. and promote the well-being of Americans. There are
    few Federal investments that confer as many benefits as medical
    research--new cures, new businesses, new jobs, new solutions to
    healthcare cost inflation, and new fuel to drive U.S. leadership in a
    global economy shaped by the ability of countries to continuously
    innovate. We firmly believe that investing in NIH, CDC and AHRQ is a
    means of advancing all three of these fundamental goals. Thank you for
    your leadership and consideration; we know that your task is
    extraordinarily difficult, and that our Nation is fortunate to have
    such pragmatic, committed and gifted leaders at the helm.
                                     ______

                Prepared Statement of the Research Working Group
        Chairman Harkin, Ranking Member Moran, and members of the
    Committee, thank you for the opportunity to provide testimony on the
    National Institutes of Health (NIH) budget overall and for AIDS
    research in fiscal year 2015. Tomorrow's scientific and medical
    breakthroughs depend on your vision, leadership, and commitment to
    robust NIH funding this year. To this end, the Research Working Group
    (RWG) urges this Committee to support a funding target of $36 billion
    in fiscal year 2015 to maintain the United States' position as the
    world leader in medical research and innovation.
        Investments in health research via the NIH have paid enormous
    dividends in the health and wellbeing of people in the U.S. and around
    the world. NIH-funded HIV and AIDS research has supported innovative
    basic science for better drug therapies, evidence-based behavioral and
    biomedical prevention interventions, and vaccines that have saved and
    improved the lives of millions, and holds great promise for
    significantly reducing HIV infection rates and providing more effective
    treatments for those living with HIV/AIDS in the coming decade.
        Despite these advances, the number of new HIV/AIDS cases continues
    to rise in the U.S. and around the world. There are 1.1 million HIV-
    infected people in the U.S., the highest number in the epidemic's more
    than 30 year history; additionally over 50,000 Americans become newly
    infected every year. In 2012, 35.3 million were infected with HIV/AIDS
    worldwide, 1.6 million died from the disease and 2.3 million people
    were newly infected. With proper funding, we can capitalize on the
    ongoing scientific progress in therapeutics and prevention science,
    vaccines, and finding a cure for HIV, as well as addressing the
    comorbidity such as viral hepatitis and tuberculosis that affect
    patients living with HIV.
        Major advances over the last few years in HIV prevention
    technologies--with HIV vaccines, medical male circumcision,
    antiretroviral treatment as prevention, and pre-exposure prophylaxis
    using antiretrovirals (PrEP) --demonstrate that adequately resourced
    NIH programs can transform our lives. Because HIV disease entails many
    common co-morbidities, HIV research funding is spread across the
    Institutes and Centers--and HIV research discoveries have had broad
    benefits for many other conditions including: aging, cancer,
    immunosuppression and auto-immune disorders, heart disease, stroke,
    Alzheimer's disease, osteoporosis, viral hepatitis, and influenza,
    among others. Federal support for AIDS research has led to new
    treatments for other diseases, including cancer, heart disease,
    Alzheimer's, hepatitis, osteoporosis, and a wide range of autoimmune
    disorders.
        Over the years, the NIH has sponsored the evaluation of a host of
    vaccine candidates, some of which are advancing to efficacy trials. The
    successful iPrEx and HPTN 052 trials have shown the potential of
    antiretroviral drugs to prevent HIV infection. Moreover, increased
    funding will support the future testing of new vaccines, microbicides
    and therapeutics in the pipeline via the newly restructured, cross-
    cutting NIAID clinical trials network that translates NIH-funded
    scientific innovation into critical quality-of-life gains.
        It is also essential to note that NIH-funded HIV pathogenesis and
    clinical research has contributed substantially to our understanding of
    potential curative approaches. The NIAID clinical trial networks
    comprise one of the largest groups of clinical research sites in the
    world and have been instrumental to the progress made in response to
    the HIV epidemic domestically and globally. These networks are now
    taking on the challenges of tuberculosis and hepatitis C and have
    dramatically expanded the opportunities to test new drugs and other
    critically needed interventions to advance knowledge in these leading
    infectious disease killers.
        Increased funding for the NIH in fiscal year 2015 makes good
    bipartisan economic sense, especially in shaky fiscal times. Robust
    funding for the NIH overall will enable research universities to pursue
    scientific opportunity, advance public health, and create jobs and
    economic growth. In every State across the country, the NIH supports
    research at hospitals, universities, private enterprises, and medical
    schools. This includes the creation of jobs that will be essential to
    future discovery. Sustained investment is also essential to train the
    next generation of scientists and prepare them to make tomorrow's HIV
    discoveries. NIH funding puts 350,000 scientists to work at research
    institutions across the country. According to the NIH, each of its
    research grants creates or sustains six to eight jobs, and NIH-
    supported research grants and technology transfers have resulted in the
    creation of thousands of new, independent private-sector companies.
    Strong, sustained NIH funding is a critical national priority that will
    foster better health and economic revitalization.
        Since 2003, funding for the NIH has failed to keep up with our
    existing research needs--damaging the success rate of approved grants
    and leaving very little money to fund promising new research. The real
    value of the increases prior to 2003 has precipitously declined because
    of the relatively higher inflation rate for the cost of research and
    development activities undertaken by the NIH. According to the
    Biomedical Research and Development Price Index, which calculates how
    much the NIH budget must change each year to maintain purchasing power,
    between fiscal year 2003 and fiscal year 2014, the cost of NIH
    activities increased by 38.1 percent. By comparison, the overall NIH
    budget increased by 10.8 percent, over fiscal year 2003. So in real
    terms, the NIH has already sustained budget decreases of close to 30
    percent over the past decade due to inflation alone! As such, flat
    funding or cuts to the NIH will have the clear and devastating effects
    of undermining our Nation's leadership in health research and our
    scientists' ability to take advantage of the expanding opportunities to
    advance healthcare. The race to find better treatments and a cure for
    cancer, heart disease, AIDS, and other diseases, and for controlling
    global epidemics like AIDS, tuberculosis, and malaria, all depend on a
    robust long-term investment strategy for health research at NIH.
        In conclusion, the RWG calls on Congress to continue the bipartisan
    Federal commitment towards combating HIV as well as other chronic and
    life-threatening illnesses by increasing funding for the NIH to $36
    billion in fiscal year 2015. A meaningful commitment to stemming the
    epidemic and securing the well being of people with HIV cannot be met
    without prioritizing the research investment at the NIH that will lead
    to tomorrow's lifesaving vaccines, treatments, and cures. Thank you for
    the opportunity to provide these written comments.
                                     ______

                 Prepared Statement of the Rotary International
        Chairman Harkin, members of the Subcommittee, Rotary International
    appreciates this opportunity to submit testimony in support of the
    polio eradication activities of the U. S. Centers for Disease Control
    and Prevention (CDC). The Global Polio Eradication Initiative (GPEI) is
    an unprecedented model of cooperation among national governments, civil
    society and UN agencies working together to reach the most vulnerable
    children through the safe, cost-effective public health intervention of
    polio immunization. We appeal to this Subcommittee for continued
    leadership to ensure we seize the opportunity to conquer polio once and
    for all. Rotary International strongly supports the President's 2015
    request of $161 million for the polio eradication activities of the CDC
    to enable full implementation of the polio eradication strategies and
    innovations outlined in the Polio Eradication and Endgame Strategic
    Plan (2013-2018).
               progress in the global program to eradicate polio
        Significant strides were made in 2013 toward stopping transmission
    of polio. Thanks to this committee's leadership in appropriating funds
    for the polio eradication activities of the CDC:
      --India was certified polio free in February 2014, following 3 years
            with no cases of polio. The entire Southeast Asia region was
            certified polio free on 27 March 2014.
      --Eradication efforts have led to more than a 99 percent decrease in
            cases since the launch of the GPEI in 1988.
      --The number of polio cases in the endemic countries was 40 percent
            lower in 2013 than in 2012 (160 vs. 217). Afghanistan and
            Nigeria each had less than half the number of cases in 2013
            that they had in 2012.
      --Pakistan is now considered to be the only country in the world with
            uncontrolled transmission of wild polio and as of 20 March,
            accounts for more than 75 percent of polio cases in 2014.
      --Outbreaks in the Horn of Africa and Syria accounted for roughly 60
            percent of all cases in 2013. These outbreaks underscore the
            risk to polio-free countries until the wild poliovirus has been
            eradicated in the remaining places where it persists.
      --Incidence of type 3 polio is at historically low levels. There have
            been no cases of type 3 polio since November 2012.
      --Lack of access to children in insecure areas continues to hamper
            progress. In Pakistan alone, more than 50 health workers and
            security personnel assigned to protect them have been killed in
            targeted attacks since November of 2012. Insecurity/inability
            to access large populations is now a key factor in all endemic
            transmission zones and is also a factor in outbreak areas
            (Syria, Horn of Africa).
        The Polio Eradication and Endgame Strategic Plan (2013-2018)
    launched in 2013 lays out the strategies for the certification of the
    eradication of wild poliovirus by 2018 at a total global cost of US$5.5
    billion. This new plans builds on the lessons learned from the
    successful eradication of polio to date and the substantial advances in
    technology in 2012. The timely availability of funds remains essential
    to the achievement of a polio free world. The United States has been
    the leading public sector donor to the Global Polio Eradication
    Initiative. Members of U.S. Rotary clubs appreciate the United States'
    generous support and recognize increased funding provided by Congress
    in fiscal year 2014 to ensure the GPEI can fully implement the plan.
    Rotarians are committed to continuing their own fundraising for the
    program until the world is certified polio free. Rotarians will also
    continue to advocate support from the public and other governments,
    both polio free and polio affected, to support the successful execution
    of the Strategic Plan. The ongoing support of donor countries, like the
    United States, is essential to assure the necessary human and financial
    resources are made available to polio-endemic and at risk countries to
    certify the world polio free by the end of 2018.
                        the role of rotary international
        Rotary International, a global association of more than 34,000
    Rotary clubs in more than 170 countries with a membership of over 1.2
    million business and professional leaders (more than 345,000 of which
    are in the U.S.), has been committed to battling polio since 1985.
    Rotary International has contributed more than US$1.2 billion toward a
    polio free world--representing the largest contribution by an
    international service organization to a public health initiative ever.
    Rotary also leads the United States Coalition for the Eradication of
    Polio, a group of committed child health advocates that includes the
    March of Dimes Foundation, the American Academy of Pediatrics, the Task
    Force for Global Health, the United Nations Foundation, and the U.S.
    Fund for UNICEF. These organizations join us in thanking you for your
    support of the GPEI.
        the role of the u.s. centers for disease control and prevention
        Rotary commends CDC for its leadership in the global polio
    eradication effort, and greatly appreciates the Subcommittee's
    increased support of CDC's polio eradication activities to support full
    implementation of the Strategic Plan. The United States is the leader
    among donor nations in the drive to eradicate this crippling disease.
    CDC is using the increased Congressional support provided in fiscal
    year 2014 to:
      --Build capacity in Nigeria. Increased investment in Nigeria will
            serve to establish and broaden environmental surveillance;
            strengthen traditional AFP surveillance, scale up the National
            Stop Transmission of Polio Program (N-STOP) in Kano and other
            high risk polio States to ensure broad coverage at the Local
            Government Authority Level, trapping poliovirus in its
            remaining reservoirs in Northern Nigeria.
      --Build capacity in Pakistan. Increased investment in Pakistan will
            focus on training and placing local personnel to strengthen the
            program in areas where access is possible.
      --Provide essential technical assistance in Afghanistan. The
            investment in Afghanistan will support two staff members in
            country.
      --Laboratory Surveillance: Investment with CDC's Polio Global
            Reference Lab will allow the recruitment of additional staff,
            training for country and regional labs, essential IPV research,
            and expansion of environmental surveillance capabilities in the
            field. CDC provides technical and programmatic assistance to
            the global polio laboratory network through the Polio
            Laboratory in CDC's Division of Viral Diseases. CDC's labs
            provide critical diagnostic services and genomic sequencing of
            polioviruses to help guide disease control efforts. CDC will
            continue to serve as the global reference laboratory, while
            expanding environmental surveillance in countries to serve as a
            ``safety measure'' to detect any polioviruses circulating in
            areas without cases.
      --Vaccine Purchase: CDC funds are being used to purchase oral polio
            vaccine to immunize children against polio.
      --Vaccine Operations & Social Mobilization. CDC, through its
            cooperative agreement with WHO, provides funding for
            immunization activities in high risk and polio infected
            countries. CDC funding is essential to supporting the
            supplemental immunization activities that both stop existing
            outbreaks and prevent new outbreaks. CDC collaborates closely
            with UNICEF and provides critical support on analysis and use
            of campaign results to identify and address reasons why
            children are missed and address vaccine hesitancy concerns.
      --Immunization Systems Strengthening. Investment in this area will
            allow CDC to provide scientific assistance across a range of
            topics related to the introduction of IPV to focus countries,
            other GAVI-eligible countries, and to non-eligible countries.
        Continued funding will allow CDC to fully capitalize on the
    resources of the Emergency Operation Center to provide direct support
    and build capacity to continue intense supplementary immunization
    activities in the remaining polio-affected countries, continue
    leadership on data management to drive evidence-based decisionmaking,
    and continue to implement strategies to increase effective management
    and accountability. These funds will also help maintain essential
    certification standard surveillance.
                         benefits of polio eradication
        Since 1988, over 10 million people who would otherwise have been
    paralyzed are walking because they have been immunized against polio.
    Tens of thousands of public health workers have been trained to manage
    massive immunization programs and investigate cases of acute flaccid
    paralysis. Cold chain, transport and communications systems for
    immunization have been strengthened. The global network of 145
    laboratories and trained personnel established by the GPEI also tracks
    measles, rubella, yellow fever, meningitis, and other deadly infectious
    diseases and will do so long after polio is eradicated.
        A study published in the November 2010 issue of the journal Vaccine
    estimates that the GPEI could provide net benefits of at least $40-50
    billion. Polio eradication is a cost-effective public health investment
    with permanent benefits. On the other hand, as many as 200,000 children
    could be paralyzed annually in the next 10 years if the world fails to
    capitalize on the more than $10 billion already invested in
    eradication. Success will ensure that the significant investment made
    by the U.S., Rotary International, and many other countries and
    entities, is protected in perpetuity.
                                     ______

        Prepared Statement of the Ryan White Medical Providers Coalition
        My name is Dr. James Raper, and I serve as the Director of the 1917
    HIV/AIDS Outpatient Clinic at the University of Alabama at Birmingham.
    I am writing to submit testimony on behalf of the Ryan White Medical
    Providers Coalition (RWMPC), which I co-chaired from 2010-2013. I
    remain a member of the RWMPC Steering Committee. Thank you for the
    opportunity to describe the lifesaving HIV/AIDS care and treatment
    provided by Ryan White Part C funded programs, including those provided
    at my own clinic.
        RWMPC is a national coalition of medical providers and
    administrators who work in clinics supported by the Ryan White HIV/AIDS
    Program funded by the HIV/AIDS Bureau (HAB) at the Health Services and
    Resources Administration (HRSA). I thank the Subcommittee for its
    support of Ryan White Part C Programs in fiscal year 2014. And while I
    am grateful for this support, and understand that times are tough, I
    request $225.1 million, or a $24 million increase for Ryan White Part C
    programs in fiscal year 2015. While I know that this is a lot of
    funding, it is in fact well below the estimated need, and Ryan White
    providers would spend those dollars identifying, engaging and treating
    persons living with HIV/AIDS--an infectious disease that can be
    effectively prevented and treated in a way that saves both lives and
    money.
        The 1917 Clinic is a dedicated, not-for profit outpatient HIV/AIDS
    medical and dental clinic established in 1988 at the University of
    Alabama at Birmingham. Ryan White Part C funding provides critical
    assistance in helping the clinic meet the needs of our patients. Today,
    35 percent of the 1917 Clinic's patients are uninsured and would be at
    risk for losing access to lifesaving services without Ryan White
    Program funding.
        The 1917 Clinic provides comprehensive outpatient HIV primary care
    services to residents of Jefferson, Walker, Winston, Cullman, Blount,
    St. Clair, and Shelby counties. Although our service area technically
    includes only these seven counties, we serve people with HIV/AIDS
    throughout Alabama and its neighboring States. In February 2013, the
    1917 Clinic absorbed 800+ new patients from the previously Ryan White
    Part C funded Cooper Green Hospital's St. Georges' Clinic, which closed
    on January 31, 2013. The 1917 Clinic is now providing care to 2,950
    adult patients--this represents approximately 24 percent of the 12,404
    known adults living with HIV/AIDS in Alabama.
        The clinic offers a range of primary care and social services
    critical to successful HIV treatment, including primary medical and
    oral healthcare; on-site case management; mental health and substance
    abuse treatment services; onsite access to clinical trials; medication
    adherence; spiritual, risk reduction, and nutrition counseling;
    infusion therapy; coordination of hospital discharge planning; and home
    healthcare/hospice referral. To avoid emergency room visits, the 1917
    Clinic provides `sick call' services five days a week. Subspecialty
    care is available at the University's Kirklin Clinic--which is located
    just two blocks from the 1917 Clinic.
        In addition to critical funding that Ryan White Part C provides
    through direct Federal grants for comprehensive medical care clinics
    like the 1917 Clinic, most Part C clinics, including the 1917 Clinic,
    also receive support from other Parts of the Ryan White Program that
    help support access to medication; additional medical care, such as
    dental services; and key support services, such as case management and
    transportation, which are essential components of the highly effective
    Ryan White HIV care model that result in excellent outcomes for our
    patients.
    Ryan White Part C Programs Support Comprehensive, Expert and Effective
            HIV Care
        Part C of the Ryan White Program funds comprehensive, expert and
    effective HIV care and treatment--services that are directly
    responsible for the dramatic decrease in AIDS-related mortality and
    morbidity over the last decade. The Ryan White Program has supported
    the development of expert HIV care and treatment programs that have
    become patient-centered medical homes for individuals living with this
    serious, chronic condition. In 2011, a ground-breaking clinical trial--
    named the scientific breakthrough of the year by Science magazine--
    found that HIV treatment not only saves the lives of people with HIV,
    but also reduces HIV transmission by more than 96 percent--proving that
    HIV treatment is also HIV prevention.
        The comprehensive, expert HIV care model that is supported by the
    Ryan White Program has been highly successful at achieving positive
    clinical outcomes with a complex patient population.\1\ In a
    convenience sample of eight Ryan White-funded Part C programs ranging
    from the rural South to the Bronx, retention in care rates ranged from
    87 to 97 percent. In estimates from the Centers for Disease Control and
    Prevention (CDC), only 37 percent of all people with HIV are in regular
    care nationally.\2\ Once in care, patients served at Ryan White-funded
    clinics do well-- with 75 to 90 percent having undetectable levels of
    the virus in their blood. This is much higher than the estimate from
    the CDC that just 25 percent of all people living with HIV in the U.S.
    are virally suppressed.
    ---------------------------------------------------------------------------
        \1\ 1 See Improvement in the Health of HIV-Infected Persons in
    Care: Reducing Disparities at http://cid.oxfordjournals.org/content/
    early/2012/08/24/cid.cis654.full.pdf+html.
        \2\ See CDC's HIV in the United States: The Stages of Care http://
    www.cdc.gov/nchhstp/newsroom/docs/2012/Stages-of-CareFactSheet-508.pdf.
    ---------------------------------------------------------------------------
    Investing in Ryan White Part C Programs Saves Both Lives and Money
        Early and reliable access to HIV care and treatment both helps
    patients with HIV live relatively healthy and productive lives and is
    more cost effective. One study from the 1917 Clinic at the University
    of Alabama at Birmingham found that patients treated at the later
    stages of HIV disease required 2.6 times more healthcare dollars than
    those receiving earlier treatment meeting Federal HIV treatment
    guidelines. On average it costs $3,501 per person per year to provide
    the comprehensive outpatient care and treatment available at Part C
    funded programs. The comprehensive services provided often include lab
    work, STD/TB/Hepatitis screening, ob/gyn care, dental care, mental
    health and substance abuse treatment, and case management.
    Current Challenges--Future Promise
        However, this effective and comprehensive HIV care model is not
    completely supported by Medicaid or most private insurance. While many
    Ryan White Program clients have some form of insurance coverage,
    without the Ryan White Program, they would risk falling out of care.
    Barriers include poor reimbursement rates; benefits designed for
    healthier populations that fail to cover critical services, such as
    care coordination; and inadequate coverage for other important
    services, such as extended medical visits, mental health and substance
    use treatment. Full implementation of the Affordable Care Act plus
    continuation of the Ryan White Program will dramatically improve health
    access and outcomes for many more people living with HIV disease.
    Fully Funding and Maintaining Ryan White Part C Programs Is Essential
        Because of both the inadequacy of insurance coverage for people
    with complex conditions like HIV and the fact that some individuals
    will remain uncovered, even with Affordable Care Act implementation
    (particularly in the non-Medicaid expansion States), fully funding and
    maintaining the Ryan White Program is essential to providing
    comprehensive, expert and effective HIV care nationwide.
        And while RMWPC is concerned about the proposal to consolidate Ryan
    White Part D funding into Part C, it welcomes the $4 million increase
    for Part C programs proposed in the President's fiscal year 2015
    budget. RWMPC's specific concerns include:
      --Part D funding supports effective HIV care and treatment services
            for vulnerable populations, including women and adolescents.
            With adolescents accounting for 39 percent of new HIV
            infections in the U.S., it is critical to target resources to
            support comprehensive services that effectively engage and
            retain young people in HIV care and treatment.
      --In some communities, Part D-funded programs are the main providers
            of HIV care and treatment. It is critical to ensure that
            implementation of any budget proposal does not leave any
            community without adequate access to effective and
            comprehensive HIV care and treatment. Also, for Ryan White
            medical clinics that currently receive only Part D funding, it
            could prove difficult to successfully compete for Part C
            funding if there currently exists a Part C program serving that
            community. Loss of the aforementioned Part D program would
            reduce the community's access to HIV care and treatment.
      --It is unclear how the proposed consolidation would be implemented.
            At this time it is unclear what the consolidation process would
            entail and how it would practically impact grantees and access
            to HIV care and treatment in communities. Since most Ryan White
            medical clinics receive funding from multiple parts of the Ryan
            White Program, reduction of funding to one part can have
            damaging and unintended consequences to the overall services
            provided by Ryan White medical clinics, especially now, at a
            time when providers are working to expand access to HIV care
            and treatment.
        At this critical time in the HIV/AIDS epidemic, when research has
    confirmed that early access to HIV care and treatment not only saves
    lives but prevents new infections by reducing the risk of transmission
    to near zero for patients who are virally suppressed, it is essential
    to maintain overall funding levels for the Ryan White Program. While
    the ACA provides important new healthcare coverage options for many
    patients, most health insurers fail to support the comprehensive care
    and treatment necessary for many patients to manage HIV infection.
    Exorbitant cost sharing, benefit gaps and limited State uptake of the
    Medicaid expansion necessitate a vital and ongoing role for the Ryan
    White Program. Increasing access to and successful engagement in
    effective, comprehensive HIV care and treatment is the only way to lead
    the Nation to an AIDS-free generation and reduce the devastating costs
    of--including lives lost to--HIV infection.
    Conclusion
        Thank you very much for your consideration of RWMPC's fiscal year
    2015 request of $225.1 million for Ryan White Part C programs, a $24
    million increase over fiscal year 2014.

        [This statement was submitted by James L. Raper, PhD, CRNP, JD,
    FAANP, FAAN; Director, 1917 HIV/AIDS Outpatient Clinic; Professor of
    Medicine & Nursing.]
                                     ______

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

        [This statement was submitted by Amber Williams, Executive
    Director, Safe States Alliance.]
                                     ______

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

             Prepared Statement of the Senior Service America, Inc.
        This statement concerns the Administration's proposed fiscal year
    2015 appropriations of $380 million for the Department of Health and
    Human Services--Administration for Community Living's Senior Community
    Service Employment Program. We urge that funding for this program be
    increased to $600 million, returning the program to its funding levels
    prior to the Great Recession (adjusted for inflation). This investment
    would provide jobs and training for more than 30,000 additional
    unemployed older Americans than the Administration's proposal. We also
    urge that the Congress refer to the authorizing committee any proposals
    to revise the mission of the program or transfer the program from the
    Department of Labor.
        The Senior Community Service Employment Program (SCSEP) is the only
    Federal program targeted to provide jobs and training to low-income
    older adults 55 and older. According to GAO Report GAO-11-92, SCSEP is
    one of only three Federal workforce development programs that do not
    overlap with any other program. Launched in 1968, SCSEP is authorized
    by Title V of the Older Americans Act and is currently administered by
    the Department of Labor Employment and Training Administration. In the
    year ending June 30, 2013, SCSEP provided jobs and training for 67,551
    economically disadvantaged older adults, who in turn provided over 37.2
    million hours of staffing to 30,000 local private and private nonprofit
    agencies serving the community. The value of these community service
    hours was $825 million, based on hourly-wage estimates from the
    Independent Sector.
        The Administration's fiscal year 2015 budget proposes to cut
    funding for SCSEP to $380 million, $52 million less than $432 million
    in total grants awarded by the USDOL for fiscal year 2014. Senior
    Service America estimates that this cut would result in 8,600 fewer
    jobs and training nationwide for low income older adults and 4.4
    million fewer staff hours in local agencies (whose value exceeds $97
    million).
        The following facts strongly support increasing the appropriations
    for SCSEP in fiscal year 2015:
        Low-income older workers, most of whom are long-term unemployed,
    continue to suffer extremely high rates of joblessness.--As the
    following table shows, since 2000 the jobless rate of low-income older
    workers (55 years and older with annual family incomes less than $20k)
    has been 2.5 to 3 times higher than the rate among all older workers:

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

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

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

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

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

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

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

        [This statement was submitted by Anthony R. Sarmiento, Executive
    Director, Senior Service America, Inc.]
                                     ______

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

        [This statement was submitted by Dr. Janet Mullington, Ph.D.,
    President, Sleep Research Society.]
                                     ______

       Prepared Statement of The Society for Healthcare Epidemiology of
    America and the Association for Professionals in Infection Control and
                                  Epidemiology
        The Society for Healthcare Epidemiology of America (SHEA) and the
    Association for Professionals in Infection Control and Epidemiology
    (APIC) thank you for this opportunity to submit testimony on Federal
    efforts to detect dangerous infectious diseases, protect the American
    public from preventable healthcare-associated infections (HAIs) and
    address the rapidly growing threat of antibiotic resistance (AR). We
    ask that you support the following programs: First, under the Centers
    for Disease Control and Prevention National Center for Emerging and
    Zoonotic Infectious Diseases: $250 million for Core Infectious Diseases
    including $30 million for the new Detect and Protect Against Antibiotic
    Resistance (AR) Initiative, $32 million for the National Healthcare
    Safety Network (NHSN), and $30 million for the Advanced Molecular
    Detection (AMD) Initiative. Additionally, we request $34 million for
    HAI research activity conducted by the Agency for Healthcare Research
    and Quality (AHRQ) and $4.58 billion for the National Institutes of
    Health/National Institute of Allergy and Infectious Diseases (NIAID).
        HAIs are among the leading causes of preventable death in the
    United States. In hospitals alone, CDC estimates that one in 25
    patients has an HAI, totaling approximately 722,000 infections in 2011.
    According to the CDC, every day, more than 200 Americans with HAIs will
    die during their hospital stay. Further, AR is one of the most critical
    public health and patient safety threats facing us today, causing an
    estimated two million illnesses and approximately 23,000 deaths
    annually. It is estimated that as much as half of antibiotic
    prescribing in hospitals is not necessary. Antibiotics, created to save
    lives, are now contributing to patient's deaths by promoting the
    emergence of highly resistant bacteria and leading to deadly adverse
    events.
    Centers for Disease Control and Prevention (CDC)
        We urge you to support the CDC Coalition's request for $7.8 billion
    in fiscal year 2015 for the CDC's ``core programs.'' We are concerned
    that the President's fiscal year 2015 budget proposal would reduce the
    CDC's budget authority by $243 million when compared with fiscal year
    2014. This total is, in fact, lower than 2003 levels. We urge Congress
    to prioritize funding for the activities and programs supported by CDC
    that are essential to protect the health of the American people and
    reduce healthcare costs.
        We especially want to highlight our support for the $30 million in
    the President's budget for the Detect and Protect Against Antibiotic
    Resistance (AR) Initiative. This initiative will establish a robust
    network of five regional labs that will detect the deadliest AR threats
    and protect patients and communities through the rapid identification
    of outbreaks, saving lives and reducing healthcare costs. It will
    prioritize healthcare prevention collaboratives focused on improving
    antibiotic use and preventing deadly infections caused by Clostridium
    difficile (C. diff), carbapenem-resistant Enterobacteriaceae (CRE),
    Pseudomonas, and methicillin-resistant Staphylococcus aureus (MRSA).
    Most importantly, the initiative will invest in direct action by
    implementing proven evidence-based interventions that reduce the
    emergence and spread of AR pathogens and improve antibiotic use. It is
    critical that Congress prioritize this rapidly growing threat to public
    health and patient safety in our Nation and around the world. Moreover,
    we strongly support CDC's focus on the implementation of antimicrobial
    stewardship programs in all healthcare settings.
        We urge you to support the $32 million in the President's budget
    for the CDC's National Healthcare Safety Network (NHSN). The
    President's request represents a $14 million increase over the fiscal
    year 2014 enacted level for the NHSN to extend HAI prevention efforts
    to more than 3,000 ambulatory surgery centers and other non-hospital
    settings. This will enable CDC to conduct applied research on
    interventions for infection prevention and continue to provide data for
    national HAI elimination and targeted HAI prevention intervention. This
    funding level will also allow for the extension and implementation of
    the NHSN Antimicrobial Use and Resistance Components to enable rapid
    detection of highly resistant pathogens and track antibiotic use in
    healthcare settings.
        The NHSN serves as the foundation for the development of
    innovative, evidence-based HAI prevention strategies through high-
    quality monitoring of HAI prevalence as well as antibiotic usage in the
    US. It is a critical tool used by healthcare facilities to monitor and
    prevent HAIs. The NHSN provides medical facilities, states, regions,
    and the Nation with data collection and reporting capabilities needed
    to comply with state and Federal public reporting mandates, including
    the Centers for Medicare & Medicaid Services' Value-Based Purchasing
    Program. Consistent, scientifically sound and validated data are
    necessary to be reported at the state and Federal levels to ensure that
    accurate data are available to evaluate progress related to the HHS
    National Action Plan to Prevent HAIs as well as to support transparency
    to the public, allowing for fair comparisons between facilities.
        By August 2013, over 12,400 healthcare facilities, including nearly
    all U.S. hospitals, participated in NHSN for quality improvement. The
    number of acute care hospitals reporting multi-drug resistant organisms
    (such as C.diff and MRSA) through NHSN more than doubled to 4,000 in
    fiscal year 2013. Since 2008, the cumulative impact of CDC data
    systems, guidelines and programs has contributed to significant
    reductions of HAIs in healthcare settings, including a 44 percent
    reduction in central line-associated bloodstream infections, a 31
    percent reduction in healthcare-associated invasive MRSA infections,
    and a 20 percent reduction in surgical site infections.
        We strongly support the CDC Prevention Epicenters Program. Funded
    through the NHSN, this program is a collaboration between CDC and
    academic medical centers that conduct innovative infection control and
    prevention research to address important scientific questions regarding
    the prevention of HAIs, antibiotic resistance and other adverse
    healthcare events. The Epicenters Program has provided a unique forum
    in which academic leaders in healthcare epidemiology can partner
    directly with each other and with CDC subject matter experts. The
    resultant emphasis on multicenter collaborative research projects,
    through which investigators work together as a group, allows for
    research that in many cases, would not have been possible for a single
    academic center. Going forward, the Prevention Epicenters will continue
    to address gaps and pilot innovative ways to prevent HAIs and
    antimicrobial resistance.
        We urge your continued support of the President's $30 million
    request for the Advanced Molecular Detection (AMD) Initiative in
    bioinformatics and genomics, which allows CDC to more quickly determine
    where emerging diseases come from, whether microbes are resistant, and
    how microbes are moving through a population. This Initiative is
    critical because it strengthens CDC's epidemiologic and laboratory
    expertise to effectively guide public health action.
        We strongly support the critical work conducted through the
    Emerging Infections Program (EIP), which engages a network of state
    health departments and their academic medical center partners to help
    answer important questions about emerging HAI threats, advanced
    infection tracking methods and antibiotic resistance in the U.S.
    Agency for Healthcare Research and Quality
        We request your support of the proposed investment of $34 million
    for AHRQ's HAI research activity, the level of enacted support in
    fiscal year 2014. Building on the successes of fiscal year 2013 and
    2014, these funds will support a portfolio of grant- and contract-
    funded projects seeking to advance our knowledge about effective
    approaches to reducing HAIs while promoting the implementation of
    proven methods for preventing HAIs. These grants ($13.9 million) and
    contracts ($20.1 million) will investigate methods of controlling HAIs
    in diverse healthcare settings and will address the major types of
    HAIs. In addition, contracts funded by the HAI budget will accelerate
    the nationwide implementation of the Comprehensive Unit-based Safety
    Program (CUSP). To date, widespread adoption of this evidence-based
    checklist of safety practices to over 1,000 intensive care units has
    reduced the incidence of central line-associated bloodstream infections
    (CLABSIs) by 41 percent. Our organizations are pleased to participate
    in the On the CUSP: Stop CAUTI initiative, which aims to reduce mean
    rates of CAUTI in U.S. hospitals by 25 percent by working with state
    organizations and hospitals across the country to implement the CUSP
    and catheter-associated urinary tract infection (CAUTI) reduction
    practices in hospital units. In spite of notable progress, there
    remains work to be done toward the goal of HAI elimination.
    National Institutes of Health (NIH)/National Institute of Allergy and
            Infectious Diseases (NIAID)
        Within NIH, we believe that the National Institute of Allergy and
    Infectious Diseases (NIAID) should be funded at least at the $4.58
    billion requested by the Administration in the fiscal year 2014 budget
    request. Nearly flat-funding NIAID limits investment in new research
    and serves as a disincentive for young people to pursue infectious
    disease research careers so critical to the discovery of new therapies,
    new diagnostic approaches, and new preventive strategies.
        In 2013, the NIAID began funding a new clinical trials network
    focused on antibiotic-resistant bacterial infections. With sufficient
    funding, the new research network/infrastructure will conduct studies
    to address antibiotic resistance as well as begin to answer questions
    that will help fill the nearly empty antibiotic research and
    development pipeline. Severe economic disincentives have caused a mass
    exodus of private companies from the antibiotics market, making
    federally funded research in this area more critical than ever. We
    applaud NIAID's initiative in launching the new network. We recommend
    increased investment in this area.
        We thank you for the opportunity to submit testimony and greatly
    appreciate your leadership in the effort to eliminate preventable HAIs
    and combat antibiotic resistance.
        Please forward questions to:
        Melanie Young, Policy & Strategic Initiatives Director, SHEA,
    myoung@shea-online.org and Lisa Tomlinson, Senior Director, Government
    Affairs, APIC, ltomlinson@apic.org.
                                     ______

               Prepared Statement of the Society for Neuroscience
        Mr. Chairman and members of the Subcommittee, my name is Carol Ann
    Mason, Ph.D. I am a professor of pathology and cell biology,
    neuroscience, and ophthalmic science at Columbia University. I study
    the development of visual pathways in mammalian brains, with a focus on
    how neurons in the eye are encoded to project to the correct side of
    the brain, setting up the circuit for binocular vision. This statement
    is in support of increased funding for NIH for fiscal year 2015.
        I am pleased to submit this testimony in my capacity as president
    of the Society for Neuroscience (SfN). On behalf of the nearly 40,000
    members of SfN, thank you for your past support of neuroscience
    research at NIH. SfN's mission is to advance the understanding of the
    brain and nervous system; provide professional development activities,
    information and educational resources; promote public information and
    general education; and inform legislators and other policymakers.
        The Society stands with others in the research community in
    requesting at least $32 billion for NIH for fiscal year 2015.
    Sequestration is taking an enormous toll on biomedical research, coming
    on top of recent years when funding has failed to keep pace with the
    cost of research--let alone the scientific opportunities that are
    available. SfN urges Congress to reverse the current course and find
    ways to invest more in biomedical research. Let's work to put
    biomedical research on a trajectory of sustained growth that recognizes
    its promise and opportunity as a tool for economic growth and, more
    importantly, for advancing the health of Americans.
    Neuroscience: An Investment in Our Future
        Even in the face of the difficult funding situation, the last
    several years have been a tremendously exciting and productive time for
    neuroscience discoveries. Major research advances on brain development,
    imaging, genomics, circuits, computational neuroscience, neural
    engineering, and many other disciplines are leading to new tools, new
    knowledge, and greater understanding that were unimaginable even a few
    years ago. Sustained investment to fuel and speed these discoveries is
    essential to American health and economic well-being for many reasons.
        First, major investment in basic and translational neuroscience is
    not only fueling an enduring and vital scientific endeavor; it is the
    essential foundation for understanding and treating diseases that
    strike nearly 1 billion people worldwide. All told, there are more than
    1,000 debilitating neurological and psychiatric diseases that strike
    over 100 million Americans each year, producing inestimable hardship
    for millions of America families and costing the U.S., in a
    conservative estimate, at least $760 billion a year, with expenses in
    the trillions looming for conditions such as Alzheimer's disease.
    Advances made possible by publicly-funded basic research will help
    better understand and treat traumatic brain injury, Alzheimer's,
    Parkinson's disease, Down syndrome, schizophrenia, epilepsy, and post-
    traumatic stress disorder, to name just a few. With so much promising
    research, now, more than ever, it is time to fan the flames of research
    in order to ensure lifesaving breakthroughs continue.
        Additionally, NIH funding is an investment in America's current
    economic strength. Funding for research supports quality jobs and
    increases economic activity. NIH supports approximately 400,000 jobs
    and $58 billion in economic output nationwide. Eighty-five percent of
    the NIH budget fund extramural research in communities located in every
    State.
        Finally, without robust, sustained investment, America's status as
    the preeminent leader in biomedical research is at risk. Other
    countries are investing heavily in biomedical research to take
    advantage of new possibilities. Even with the growing philanthropic
    support, private sector cannot be expected to close the gap. The lag
    time between discovery and profitability means that the pharmaceutical,
    biotechnology, and medical device industries need federally-funded
    basic (also known as fundamental) research to develop products and
    treatments. The foundation that basic research provides is at risk if
    federally-funded research declines.
    The BRAIN Initiative
        SfN appreciates that both Congress and the administration recognize
    brain science as one of the great scientific challenges of our time.
    The Brain Research through Application of Innovative Neurotechnologies
    (BRAIN) Initiative--announced by the President last April--will enable
    NIH and other Federal agencies to develop tools and plans that will
    help accelerate fundamental discoveries and improve the health and
    quality of life for millions of Americans. An eminent group of
    neuroscientists with diverse research interests is helping to formulate
    a scientifically-driven direction for the initiative, and SfN thanks
    public leaders for their interest and early support for a truly
    transformative scientific grand challenge that would need major
    financial emphasis in future years.
        The overarching goal of the BRAIN Initiative is to map the circuits
    of the brain and the activity within those circuits to understand our
    unique cognitive and behavioral capabilities. The Initiative has a
    strong focus on developing technologies which has the potential to
    benefit all of neuroscience and even non-neuroscience research. BRAIN,
    like other major brain-related initiatives around the world,
    demonstrates the global interest in tackling the mysteries of the
    brain. But BRAIN--as with all the neuroscience research that takes
    place with Federal support--can only be successful if it is part of a
    broad neuroscience commitment across Congress and the Administration.
    Such an investment will also help ensure the U.S. remains a global
    leader, as other nations and regions are now rapidly ramping up their
    investments in neuroscience research.
    Cross-Disciplinary Neuroscience and the Promise of Brain Circuits
        NIH-funded basic research continues to be essential for discoveries
    that will inspire scientific and medical progress for generations. Past
    NIH-supported projects have helped neuroscientists make tremendous
    strides in diagnosing and treating neurological and psychiatric
    disorders.
        A prime example of the importance of funding research at levels
    from the most basic to translational is the current focus on
    understanding brain circuits. Circuits in the brain underlie every
    thought, emotion, and action we take. Current knowledge about the
    intricate patterns connecting brain cells is extremely limited.
    Identifying these patterns is essential to understand healthy brain
    function and dysfunction in injury or disease. Research suggests that
    some brain disorders, like autism and schizophrenia, may result from
    errors in neural circuit development. Elucidating brain circuit
    structure and function is an enormously challenging endeavor; the brain
    consists of billions of cells, and each cell contacts thousands of
    others. These cells communicate with precisely-timed signals, which
    then activate a multitude of biochemical pathways that influence every
    process in the cell. However, scientists are beginning to map the
    functions of brain circuits with previously unheard-of specificity
    using cutting-edge technologies, and learning how these circuits
    produce behaviors.
        The following examples are just a few of the many basic research
    success stories in the science of brain circuitry emerging now thanks
    to interdisciplinary research funded by a strong historic investment in
    NIH and other research agencies.
    Optogenetics
        Optogenetics is a technique which uses light to activate specific
    populations of neurons with millisecond precision. It is difficult to
    overstate how revolutionary optogenetics is for neuroscience research.
    With optogenetics, flashes of light are used to activate neurons that
    have been genetically modified to contain a light-sensing protein. This
    precise control over specific populations of neurons at specific times
    was impossible until a confluence of basic research in marine biology,
    genetic engineering, cellular biology, and fiber optic technology
    facilitated its development; together these developments created an
    approach that enables the proteins to be used as ``on switches'' for
    cells. Introduced a decade ago, optogenetics is now used by hundreds of
    labs; it is one of the many neurotechnologies that today is
    transforming the field's ability to understand brain function, and is
    being used to study brain circuits in both normal function and disease,
    including Parkinson's disease, as described below. The development of
    this technology also perfectly demonstrates the often serendipitous
    nature of scientific discovery and the need to fund both research on
    all levels, from basic to translational to clinical.
    Understanding the Development of Vision
        My own area of research is the development of the circuits
    underlying vision. For binocular vision to function, the brain must
    receive information from both eyes. Nerve fibers from each retina grow
    to the `optic chiasm,' at the midline of the bottom of the brain. Here,
    nerve fibers from each eye cross to the other side of the brain. Other
    axons, however, are repelled at the midline and project to the same
    side of the brain. These connections underlie binocular vision which
    enables animals, including humans, to calculate how far objects lie in
    the distance. One area of my research focuses on this question and the
    molecular mechanisms that prompt some growing nerve fibers to ``stop in
    their tracks'' and reroute to the same side. These two groups of cells
    in the eye, each taking different routes, are endowed with distinct
    genes that direct their time of birth and their growth to the regions
    where they make their synaptic connections. Understanding their genetic
    ``signatures'' and growth helps us to learn how to encourage stem cells
    to be integrated into the diseased eye and injured nerve fibers to
    regrow in the correct circuits. We also investigate how the retinal
    pigment epithelium (RPE) surrounding the eye, directs retinal
    development. Perturbations in the RPE occur in albinism and in juvenile
    forms of macular degeneration, the latter leading to blindness, and our
    gene identification efforts are important for gene therapy at early
    stages of the disease. Moreover, understanding how tracts are laid down
    is essential for unraveling the basis of defects in fiber pathways and
    synapse formation in neurodevelopmental disorders such as autism. This
    research is made possible with support primarily from NIH, especially
    the National Eye Institute and with a team of innovative and
    collaborative scientists and trainees in my lab and in our community,
    and provides a foundation for future discovery and new understanding
    about diseases of the eye and other neurodevelopmental conditions.
    Deep Brain Stimulation
        Deep brain stimulation (DBS) is a tool that emerged as a result of
    advances in health research. DBS involves a surgical procedure in which
    a neurostimulator device--similar to a heart pacemaker--is implanted to
    deliver electrical stimulation to targeted areas in the brain. While
    both DBS and optogenetics have emerged as instrumental methods to
    influence circuits, DBS has also been developed into a revolutionary
    therapy for the treatment of neurological disease. The electrical
    pulses delivered through the electrodes can transiently disrupt
    abnormal activity that occurs in localized circuits of diseased brains,
    such as in Parkinson's patients.
        DBS has created a new way to approach the treatment of Parkinson's
    disease. Many patients experience pronounced relief from symptoms that
    include tremor, stiffness, slowed movement, and walking problems.
    Moreover, DBS can allow patients to reduce the dosage of their
    medication, providing relief from debilitating motor side-effects.
    Additionally, advances in materials science to create more flexible
    electrodes and in imaging research to produce higher resolution images
    of the brain will improve the precision and outcome of this
    intervention.
        At this time, how and why DBS works is unknown. Insight into its
    mechanism of action came from optogenetic studies in rodents of the
    brain circuits that control movement. By systematically manipulating
    precise areas of the circuit affected by this disease, scientists were
    able to implicate the connection between two areas of the brain as the
    most effective target for DBS. These studies will also inform the
    design of other interventions in Parkinson's, and establish a model for
    study of basic brain circuitry to inform DBS treatment.
        DBS has also had success in treating both intractable depression
    and epilepsy, and has the potential to improve therapies for a whole
    host of brain diseases and disorders--as long as the correct target is
    identified. Because stimulating adjacent regions in the brain can have
    vastly different effects, researchers are attempting to better
    understand the complex brain circuits that control our normal functions
    (e.g., movement, emotion) and how they can go wrong (e.g., addiction).
    They also are tweaking the physical devices used, as well as the
    frequency and strength of the electrical pulses delivered. As we
    understand more about language of the brain through the research made
    possible by NIH funding, new applications of DBS will be possible.
    The Future of American Science
        As the subcommittee considers this year's funding levels, please
    consider that significant advancements in the biomedical sciences often
    come from young investigators. As a director of the PhD training
    program of a leading neuroscience department, I see firsthand that the
    current funding environment is taking a toll on the energy and
    resilience of these young people and their career choice. America's
    scientific enterprise--and its global leadership--has been built over
    generations. Without sustained, consistent investment, we will quickly
    lose that leadership. Dramatic swings in funding have stifling and
    irreversible impacts on progress; a closed laboratory can't simply open
    again when funding is restored. The culture of entrepreneurship and
    curiosity-driven research could be hindered for decades.
        We live at a time of extraordinary opportunity in neuroscience. A
    myriad of questions once impossible to consider are now within reach
    because of new technologies, an ever-expanding knowledge base, and a
    willingness to embrace many disciplines. To take advantage of the
    opportunities in neuroscience we need an NIH appropriation that allows
    for sustained, reliable growth. That, in turn, will lead to improved
    health for the American public and will help maintain American
    leadership in science worldwide. Thank you for this opportunity to
    testify.

        [This statement was submitted by Carol Ann Mason, Ph.D., President,
    Society for Neuroscience.]
                                     ______

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

        [This statement was submitted by M. Elaine Auld, MPH, MCHES, Chief
    Executive Officer, Society for Public Health Education.]
                                     ______

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

        [This statement was submitted by Elaine Auld, Chief Executive
    Officer, Society for Public Health Education.]
                                     ______

         Prepared Statement of the Society for Women's Health Research
        The Society for Women's Health Research (SWHR) is pleased to have
    the opportunity to submit the following testimony urging renewed
    investment in scientific and medical research within the Department of
    Health and Human Services (HHS). For almost 25 years, our organization
    has been considered the thought leader in research on biological
    differences in disease and is dedicated to transforming women's health
    through science, advocacy, and education. We believe that a robust
    Federal research agenda that is inclusive of women's health research is
    critical for the U.S. to meet the needs and expectations of its
    citizens. We request that for fiscal year 2015, Congress fund the
    following agencies and programs at the following levels:
      --Agency for Healthcare and Research Quality-$471 million
      --Centers for Disease Control and Prevention-$6.904 billion
      --Health Resources Services Administration-$6.113 billion
      --National Institutes of Health-$32 billion
      --Substance Abuse and Mental Health Services Administration-$3.6
            billion
      --Office of Research on Women's Health at NIH-$42 million
      --HHS Office of Women's Health-$35 million
        SWHR remains concerned with the ramifications of the Budget Control
    Act and sequestration. Funding levels for Department of Health and
    Human Services (HHS), were significantly cut and those agencies that
    fall underneath the umbrella of HHS; The Agency for Healthcare Research
    and Quality (AHRQ), Centers for Disease Control and Prevention (CDC),
    Health Resources Services Administration (HRSA), National Institutes of
    Health (NIH), Substance Abuse and Mental Health Services Administration
    (SAMHSA), all play vital roles in improving and protecting the health
    of Americans but are forced to do more with less funding. Continued
    cuts to public health agencies decrease public health emergency
    preparedness and response capabilities, reducing funding for States to
    monitor air quality and offer mental health services, and increasing
    the risk for infectious disease outbreaks. These are essential public
    health services that save lives and protect our health. Currently,
    healthcare spending is the largest driver of the Federal deficit. By
    2021, estimates indicate that this spending will account for nearly
    one-fifth of the U.S. economy. Proper and sustained Congressional
    investment in medical and scientific research can ultimately save
    valuable healthcare dollars that are wasted on inappropriate and
    ineffective treatment. We realize that the current budgetary
    environment limits the amount of monies available for a substantial
    increase; however, the benefit from every dollar invested in medical
    research outweighs the cost many times over and is, perhaps, the single
    most cost effective strategy in reducing our Federal deficit. Past
    investments in medical research have allowed scientists to begin
    unraveling the biologic and genetic underpinning of disease. This
    research has shown that biological sex impacts every organ of the body,
    and plays an important role in disease susceptibility, prevalence, time
    of onset and severity. Sex differences are evident in all major disease
    categories, including cancer, obesity, and heart disease. These
    differences are also evident in drug absorption, distribution,
    metabolism and elimination. The medical community has now begun to
    tailor treatments to meet the needs of individual patients, taking the
    first step towards truly personalized medicine.
        National Institutes of Health-NIH serves as the America's premier
    medical research agency and is the largest source of funding for
    biomedical and behavioral research in the world. Many of the medical
    advances in recent decades are direct results from investments in the
    agency. Unfortunately, years of flat-funding, without controlling for
    rising inflation, has meant that NIH's overall budget has decreased by
    10 percent between 2004 and 2014, and its purchasing power has
    decreased by 22 percent. This number does not just impact NIH's campus
    in Maryland. Approximately 85 percent of NIH funding is spent in
    communities across the country, creating jobs at more than 3,000
    universities, medical schools, teaching hospitals, and research
    institutions. In 2013, NIH funded 750 fewer grants than in 2012 and
    grant funding fell to an all-time low of 20 percent. A shrinking number
    of available grants put scientists out of work. With limited
    opportunities for research funding, scientists have little choice than
    to pursue opportunities outside of academic research in the U.S.,
    resulting in the loss of skilled bench scientists and researchers to
    Asia, the European Union and the United Kingdom, who continue to
    heavily invest in research. Unfortunately, the Administration's request
    of a 0.7 percent increase doesn't make much headway in reversing the
    $1.5 billion cut the agency sustained under sequestration in fiscal
    year 2013, nor does it keep up with biomedical inflation rate,
    projected by the HHS's Biomedical Research and Development Price Index,
    to be 2.2 percent. Once that inflation rate is taken into account, the
    Administration's budget request results in another cut to the Agency.
    SWHR recommends that Congress set, at a minimum, a budget of $32
    billion for NIH for fiscal year 2015. Further we recommend that
    Congress expand NIH's mandate on the inclusion of women in basic
    research to include women in all phases of basic, clinical and medical
    research. Current practice only mandates sufficient female subjects
    only in Phase III research, and researchers often miss out on the
    chance to look for variability by sex in the early phases of research,
    safety and effectiveness is determined.
        Federal offices of women's health-The offices of women's health
    within the Federal health agencies do critical work, both individually
    and in collaboration with other offices and Federal agencies, to ensure
    that women receive the appropriate care and treatments in a variety of
    different areas. Under HHS, the agencies currently with offices,
    advisors or coordinators for women's health or women's health research
    include the AHRQ, CDC, FDA, HRSA, Indian Health Service (INS), and
    SAMHSA. These offices do important work, both individually and in
    collaboration with other offices and Federal agencies to ensure that
    women receive the appropriate care and treatments in a variety of
    different areas. In a time of limited budgetary dollars, Congress
    should invest in these offices that promote working in collaboration
    with other agencies, which shares much needed expertise while avoiding
    unnecessary duplication. SWHR recommends that these offices be
    sufficiently funded to ensure that these programs can continue to
    provide much needed services to women and their families in fiscal year
    2015.
        Office of Research on Women's Health--ORWH is the focal point for
    coordinating women's health and sex differences research at NIH, and
    supports innovative interdisciplinary initiatives that focus on women's
    health and sex differences research. ORWH promotes opportunities for
    and support of recruitment, retention, re-entry and advancement of
    women in biomedical careers. The Building Interdisciplinary Research
    Careers in Women's Health (BIRCWH) is an innovative, trans-NIH career
    development program that pairs junior faculty with senior investigators
    in a mentored environment. Approximately 500 scholars, the majority of
    them female, have been trained at 39 centers and have produced
    approximately 5,000 publications. ORWH's administrative supplements for
    research on sex and fender differences, a trans-NIH initiative to
    broaden the field of sex and gender differences research, adds new
    dimensions to on-going studies. The specialized centers of research on
    sex and gender factors affecting women's health (SCOR) are designed to
    integrate basic and clinical approaches to sex and gender research
    across scientific disciplines and has resulted in over 650 articles,
    reviews, abstracts, book chapters and other publications. To allow
    ORWH's programs and research grants to continue make their impact on
    the research community, Congress must direct that NIH continue its
    support of ORWH and provide it with a $1 million dollar budget
    increase, bringing its fiscal year 2015 total to $42 million.
        Health and Human Services' Office of Women's Health-The HHS OWH is
    the government's champion and focal point for women's health issues. It
    works to address inequities in research, healthcare services, and
    public education gaps, which have historically placed the health of
    women at risk. Without OWH's actions, the task of translating research
    into practice would be only more difficult and delayed. Considering the
    impact of women's health programs from OWH on the public, we urge
    Congress to provide an increase of $1 million for this office, a total
    of $35.7 million for fiscal year 2015.
        In conclusion, Mr. Chairman, we thank you and this Committee for
    its support for medical and health services research and its commitment
    to the health of the Nation. We look forward to continuing to work with
    you to build a healthier future for all Americans.
        [This statement was submitted by Leslie Ritter, Director of
    Government Affairs, Society for Women's Health Research.]
                                     ______

                 Prepared Statement of the Squaxin Island Tribe
        On behalf of the Tribal Leadership and members of the Squaxin
    Island Tribe, I am honored to submit our recommendation to this
    Subcommittee for appropriations to address the un-funded needs of
    American Indian and Alaska Native Treatment (AI/AN) Centers. The
    alarming statistics of increased alcohol and substance abuse use in the
    AI/AN communities speaks volumes to the need for improved and
    additional facilities to provide treatment and recovery opportunities
    to our citizens, our youths, our future leaders and the next seven
    generations. Although SAMHSA has limited discretionary funding and even
    less resources for residential care facilities, the Indian Health
    Service cannot keep pace with the growing need for these treatment
    centers. The only funding opportunity available in SAMHSA is the
    Treatment for Pregnant and Postpartum Women. In 2015, we respectfully
    request the Subcommittee:
      --$10 million--Expand access to residential care facility
            appropriations to include Treatment Centers and increase the
            annual appropriations to supplement inadequate funding for
            these centers from the Indian Health Service of which the NWITC
            will receive $1.5 million;
      --$50 million--SAMHSA's Behavioral Health Tribal Prevention Grant
            Program; and,
      --$15 million--SAMHSA for Behavioral Health
        The Squaxin Island Tribe has been operating the Northwest Indian
    Treatment Center (NWITC) since 1994. Ingenious in creativity, the
    center offers a wide variety of cultural activities and traditional/
    religious ceremonies, making it a natural place to heal--body, mind and
    soul. Fittingly, the center was given the spiritual name ``D3WXbi
    Palil'' meaning ``Returning from the Dark, Deep Waters to the Light.''
    NWITC is a residential chemical dependency treatment facility designed
    to serve American Indians from Tribes located in Oregon, Washington and
    Idaho who have chronic relapse patterns related to unresolved grief and
    trauma. NWITC is unique in its integration of Tribal cultural values
    into a therapeutic environment for co-occurring substance abuse and
    mental health disorders. It is a 28 bed, 30-60 day residential
    facility.
        Welcomed and hailed by Tribal Leaders who felt the urgent need for
    such a facility, NWITC is centrally located in Grays Harbor County
    between Olympia and Aberdeen, on 2.5 acres in the small rural town of
    Elma, Washington. NWITC accepts patients that are referred through
    outpatient treatment programs, parole and probation services,
    hospitals, assessment centers and child and family service centers.
    Medical care is provided through local Indian Health Service clinics
    and other medical service providers. NWITC has responded with an
    overwhelming success rate of nearly 65 percent.
        Since the original Congressional set-aside in 1993, NWITC has not
    received an adequate increase in the base Indian Health Service budget.
    It is critical to increase the NWITC's annual base in order to sustain
    the current services to the Tribes of the Northwest. An increase of
    $1.5 million would restore lost purchasing power and meet the need to
    add mental health and psychiatric components to the treatment program.
    This increase would allow NWITC to continue its effective treatment of
    Native Americans.
        In 2011, the NWITC served 225 patients from 28 Tribes and added
    intensive case management and crisis support to alumni in order to
    continue to promote positive outcomes for clients. Despite funding
    challenges, NWITC has continued to develop and deliver innovative,
    culturally appropriate services to meet increasingly complex demands.
        The Treatment Center's traditional foods and medicines program is
    supported through a partnership with the Northwest Indian College and
    is funded through grants from the Washington Health Foundation, the
    National Institute of Food and Agriculture, The Potlatch Fund and
    several Tribes. Weekly hands-on classes focus on traditional foods and
    medicines, including methods for growing, harvesting, processing, and
    preparation. Twice a month, Tribal elders, storytellers, and cultural
    specialists speak as part of the program. A monthly family class allows
    patients to share what they are learning with their loved ones.
    Patients gain hands-on experience by working in three on-site teaching
    gardens. This program serves as a model for other Tribal communities.
    $50 million--SAMHSA Behavioral Health Tribal Prevention Grant Program
        The Behavioral Health Tribal Prevention Grant will support
    behavioral health services that promote overall mental and emotional
    health, specifically substance abuse prevention and suicide prevention
    services. If funded, the grant program would be the only source for
    Federal substance abuse and suicide prevention funding exclusively
    available to Tribes.
    $15 million--SAMHSA for Behavioral Health
        This SAMHSA grant program has been authorized to award grants to
    Indian health programs to provide prevention or treatment of drug use
    or alcohol abuse, promotion of mental health, or treatment services for
    mental illness. To date, these funds have never been appropriated. An
    appropriation of $15 million would provide support to Indian health
    programs to meet the critical substance abuse and mental health needs
    of our citizens.
    Self-Governance--An Efficient and Effective Use of Federal Funds (Title
            VI of the ISDEAA)
        Self-Governance is the most successful policy in the history of
    Tribal--Federal relations and it inspires efficient and effective
    government spending. Through Self-Governance, Tribes are empowered, as
    sovereign nations, to exercise self-determination and to design
    facilities, manage programs and funds, and provide services that are
    responsive to the needs of our communities and Tribal citizens. Tribes
    participating in Self-Governance have become successful in the business
    of healthcare and perform several key roles, serving as, governments,
    employers, healthcare providers and patients.
        Self-Governance Tribes have made every attempt to be innovative to
    operate successful health programs given the budget constraints and
    cuts Tribal programs have incurred the past two decades. For more than
    a decade we have made every effort to expand Self-Governance to other
    programs and our efforts to seek expansion of the program will continue
    until we achieve our goal. We request that this Committee recognizes
    the success of Self-Governance and encourage HHS to work with Tribes to
    make the most efficient and effective use of Federal appropriations to
    fund Tribal programs.
        Thank you for this opportunity to submit written testimony.

        [This statement was submitted by Dave Lopeman, Chairman, Squaxin
    Island Tribe.]
                                     ______

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

                    Prepared Statement of the Trevor Project
        Dear Chairman Harkin and Senator Moran: The Trevor Project
    appreciates the opportunity to submit a statement on the critical and
    timely issue of funding for children's suicide prevention and mental
    health initiatives. We encourage you to support our Nation's most
    vulnerable youth by funding these vital programs:

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

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

        [This statement was submitted by Abbe Land, Executive Director &
    CEO, Trevor Project.]
                                     ______

               Prepared Statement of the Tri-Council for Nursing
        The Tri-Council for Nursing, comprising the American Association of
    Colleges of Nursing (AACN), the American Nurses Association, the
    American Organization of Nurse Executives, and the National League for
    Nursing, respectfully requests $251 million for the Nursing Workforce
    Development programs authorized under Title VIII of the Public Health
    Service Act (42 U.S.C. 296 et seq.) and administered by the Health
    Resources and Services Administration in fiscal year 2015.
        The Tri-Council is a long-standing nursing alliance focused on
    leadership and excellence in the nursing profession. The members of
    these respective organizations are acutely aware of the demand for
    nursing services due to a growing aging population, an increased focus
    on preventative care, and skyrocketing rates of individuals with
    multiple chronic conditions. In fact, according to the U.S. Bureau of
    Labor Statistics (BLS) Employment Projections for 2012-2022, the
    profession of registered nurses (RN) will grow by 19 percent for the
    10-year timeframe between 2012 and 2022. The number of job openings due
    to both the increasing demand for nursing services and the large number
    of retiring RNs, brings the total of RNs needed to 1.053 million by
    2022. A 2013 HRSA report, The U.S. Nursing Workforce: Trends in Supply
    and Education, indicates that over the next 10 to 15 years, the nearly
    one million RNs over age 50 (comprising approximately one-third of the
    current workforce), will reach retirement age.
        Moreover, the acute nurse faculty shortage is one significant
    reason why schools of nursing across the country turn away tens of
    thousands of qualified applications each year. The demand for nurses
    and the faculty who educate them is a serious impediment to improving
    the Nation's healthcare needs. Nurses continue to be the largest group
    of healthcare providers whose services are directly linked to quality
    and cost-effectiveness. The Tri-Council is grateful to the Subcommittee
    for your past commitment to Title VIII funding and respectfully asks
    that you continue to make the long-term investment that will build the
    nursing workforce necessary to deliver the quality, affordable care
    envisioned in health reform.
        A Proven Solution: Nursing Workforce Development Programs
        The Nursing Workforce Development programs, authorized under Title
    VIII of the Public Health Service Act, have helped build the supply and
    distribution of qualified nurses to meet our Nation's healthcare needs
    since 1964. Over these past 50 years, the original programs, newly
    added, and expanded programs have addressed all aspects of supporting
    the workforce--education, practice, retention, and recruitment. They
    have bolstered nursing education at all levels--from entry-level
    preparation through graduate study--and have provided support for
    institutions that educate nurses who practice in rural and medically
    underserved communities. A description of the Title VIII programs and
    their impact are included below.
        Advanced Nursing Education (ANE) Programs (Sec. 811) fund a number
    of grant activities--including several traineeships--that aim to
    increase the size and quality of the advanced nursing workforce.
    Supporting the preparation of RNs in master's and doctoral nursing
    programs, the ANE grants help prepare our Nation's nurse practitioners,
    clinical nurse specialists, nurse midwives, nurse anesthetists, nurse
    educators, nurse administrators, nurses in executive practice, public
    health nurses, and other nursing specialists requiring advanced nursing
    education. In fiscal year 2012, these grants supported the education of
    15,986 students. Under the ANE program are two critical traineeship
    programs that are particularly relevant as the demand for primary and
    acute care services rise.
        Advanced Education Nursing (AEN) Traineeships assist graduate
    nursing students by providing full or partial reimbursement for the
    costs of tuition, books, program fees, and reasonable living expenses.
    Funding for the AEN Traineeships supports the education of future nurse
    practitioners, clinical nurse specialists, nurse midwives, nurse
    anesthetists, nurse educators, nurse administrators, public health
    nurses, and other nurse specialists requiring advanced education.
        Nurse Anesthetist Traineeships (NAT) support the education of
    students in nurse anesthetist programs. In some States, certified
    registered nurse anesthetists are the sole anesthesia providers in
    almost 100 percent of rural hospitals.
        In fiscal year 2012, the AEN Traineeship and the NAT supported
    5,545 nursing students.
        Nursing Workforce Diversity (NWD) Grants (Sec. 821) prepare
    students from disadvantaged backgrounds to become nurses, producing a
    more diverse nursing workforce. This outcome will help meet the
    increasing need for culturally aligned, quality healthcare for the
    Nation's rapidly diversifying population and help close the gap in
    health disparities. This program awards grants and contract
    opportunities to schools of nursing for a variety of clinical training
    facilities to address nursing educational needs, not only for
    disadvantaged students, but also or racial and ethnic minorities
    underrepresented in the nursing profession. In fiscal year 2012, the
    program supported 12,077 students.
        Nurse Education, Practice, Quality and Retention (NEPQR) Grants
    (Sec. 831) help schools of nursing, academic health centers, nurse-
    managed health clinics, as well as State and local governments
    strengthen nursing education programs, thereby increasing the size and
    quality of the nursing workforce. The purposes of the NEPQR grants are
    broad and flexible, allowing the program to address emerging needs in
    nursing workforce development. For example, projects have been funded
    to develop and disseminate collaborative practice models that
    incorporate the full range of healthcare workers in team-based care are
    of certain interest. NEPQR supports infrastructure development to
    enhance the coordination and capacity building of interprofessional
    practice and education among health professions across the United
    States, and particularly in medically underserved areas.
        For other interests, a number of grant activities have been funded
    to support several legislative purposes such as expanding the size of
    academic programs that are able to confer a baccalaureate degree of
    science in nursing (BSN); recruiting and educating individuals as
    qualified personal and home care aides in occupational shortage and/or
    high demand areas; training qualified nursing assistants and home
    health aides to meet the growing healthcare needs of the aging
    population; and/or supporting nurse-managed health clinics that serve
    as primary care access points in areas where primary care providers are
    in short supply.
        NURSE Corps (formerly known as the Nursing Education Loan Repayment
    and Scholarship Program) (Sec. 846) provides monies to students by
    paying up to 85 percent of a student's loan in return for at least 3
    years of service in a designated health shortage area or in an
    accredited school of nursing. The NURSE Corps Loan Repayment Program
    (LRP) is a financial incentive program under which individual RNs and
    advanced practice registered nurses enter into a contractual agreement
    with the Federal Government to work full-time in a healthcare facility
    with a critical shortage of nurses, in return for repayment of
    qualifying nursing educational loans. In fiscal year 2013, the Nursing
    Education Loan Repayment Program supported 1,446 nurses working in
    these facilities. However, given the current climate, the HRSA 2015
    Congressional Budget Justification anticipates that they will only be
    able to support 1,296 in fiscal year 2014.
        Nurse Faculty Loan Program (NFLP) (Sec. 846 A) increases the number
    of qualified nurse faculty by creating a student loan fund within
    individual schools of nursing. Students agree to teach at a school of
    nursing in exchange for cancellation of up to 85 percent of their
    educational loans, plus interest, over a 4-year period. In fiscal year
    2012, these grants supported the education of 2,259 future nurse
    educators.
        Comprehensive Geriatric Education Program (CGEP) Grants (Sec. 855)
    provide support to nursing students specializing in care for the
    elderly. These grants may be used to educate RNs who will provide
    direct care to older Americans, develop and disseminate geriatric
    curriculum, prepare faculty members, and provide continuing education.
    They may also fund traineeships for individuals who are preparing for
    advanced education nursing degrees in geriatric nursing, long-term
    care, gero-psychiatric nursing or other nursing areas that specialize
    in the care of the elderly population. In fiscal year 2012, there were
    11,600 trainees supported by these grants.
        Our Nation is faced with a growing healthcare crisis that must be
    addressed on many fronts. Nurses are an important part of the solution
    to the crisis of cost, burden of disease, and access to quality care.
    To meet this challenge, funding of proven Federal programs such as
    Title VIII will help ease the demand for RNs. The Tri-Council
    respectfully requests your support for $251 million for the Title VIII
    Nursing Workforce Development Programs in fiscal year 2015. If our
    organizations can be of assistance, please contact AACN's Director of
    Government Affairs and Health Policy, Dr. Suzanne Miyamoto, at
    Smiyamoto@aacn.nche.edu.
        Sincerly,
                 Eileen Breslin, PhD, RN, FAAN, President, Geraldine
                ``Polly'' Bednash, PhD, RN, FAAN, Chief Executive Officer,
                American Association of Colleges of Nursing; Linda Knodel,
                MHA, MSN, RN, NE-BC CPHQ, FACHE, President, Pamela A.
                Thompson, MS, RN, CENP, FAAN , Chief Executive Officer and
                Sr. Vice President, American Organization of Nurse
                Executives; Karen Daley, PhD, MPH, RN, FAAN,President,Marla
                J. Weston, PhD, RN, FAAN, Chief Executive Officer, American
                Nurses Association, Marsha Howell Adams, PhD, RN, CNE,
                ANEF, President,Beverly Malone, PhD, RN, FAAN, Chief
                Executive Officer, National League for Nursing.
                                     ______

              Prepared Statement of the Trust for America's Health
        Trust for America's Health (TFAH), a nonprofit, nonpartisan
    organization dedicated to saving lives by working to make disease
    prevention a national priority, is pleased for this opportunity to
    provide written testimony on the State of public health funding. As
    this subcommittee works to develop a fiscal year 2015 Labor, Health &
    Human Services, Education and Related Agencies (LHHS) appropriations
    bill, I urge you to ensure adequate funding for public health
    prevention and preparedness programs at the Centers for Disease Control
    and Prevention (CDC) and other public health agencies.
        After several years of cuts, Congress included a significant
    increase to CDC in the fiscal year 2014 Consolidated Appropriations
    Act, and we thank you for recognizing the importance of public health.
    Eighty-five percent of the CDC's annual budget flows to your States and
    districts in the form of grants and contracts to State and local public
    health departments, and community partners, to conduct critical public
    health and prevention activities that every American relies on, such as
    protecting us from infectious disease by combating healthcare-
    associated infections, delivering immunizations, ensuring preparedness,
    and conducting nonstop surveillance.
        The CDC and its grantees across the country are working to help
    give Americans the information they need to adopt the healthy
    lifestyles that will reduce the chronic disease burden on our
    healthcare system. In 2012, we spent roughly 75 percent of our Nation's
    annual $2.8 trillion healthcare bill on treating preventable chronic
    diseases. Long-term healthcare spending at these levels is
    unsustainable for our economy and our Federal budget.
        There is a growing evidence base that demonstrates that the
    majority of chronic disease is preventable by addressing common risk
    factors. We have begun to see signs of success, with childhood obesity
    rates declining in cities and States that were among the first to adopt
    a comprehensive approach to obesity prevention. We must bring that
    knowledge to scale, so that Americans across the country have the
    opportunity to lead healthier lives. We were pleased that last year
    Congress made important new investments in community prevention that
    will help continue our efforts to transform our healthcare system to
    one that values prevention and wellness, and we urge the Committee to
    build on those investments in the fiscal year 2015 bill.
        The recently released Robert Wood Johnson Foundation 2014 County
    Health Rankings serve as another sobering reminder that an American's
    zip code is a strong predictor of whether or not they have the
    opportunity to lead a healthy life. Meeting these twin challenges of
    protecting the American people from natural and man-made threats and
    preventing disease can only occur with continued support for CDC.
    Centers for Disease Control and Prevention (CDC)
        From fiscal year 2010 to 2013, the CDC saw its budget authority cut
    by 18 percent. We were pleased that the fiscal year 2014 Omnibus
    Appropriations measure provided CDC with an increase of more than $550
    million, including $373 million from the Prevention and Public Health
    Fund, resulting in a nearly $175 million increase for chronic disease
    programs. For perspective, however, that increase simply brought CDC
    funding back to fiscal year 2013 levels. Scarce resources means CDC
    will be forced to make extremely difficult, sometimes life and death
    choices. We urge the Committee to maintain adequate CDC funding levels
    in fiscal year 2015.
    The Prevention and Public Health Fund (PPHF)
        TFAH was pleased to see Congress exercise its authority to allocate
    the Prevention and Public Health Fund in fiscal year 2014, and we urge
    this committee to do so again in the fiscal year 2015 appropriations
    bill. To date, the Fund had made investments in every State to support
    State and local efforts to transform and revitalize communities, build
    epidemiology and laboratory capacity to track and respond to disease
    outbreaks, address healthcare associated infections, train the Nation's
    public health and health workforce, prevent the spread of HIV, expand
    access to vaccines, reduce tobacco use, and help control the obesity
    epidemic.
    National Center for Chronic Disease Prevention and Health Promotion
            (NCCDPHP)
        Our Nation's doctors and hospitals are our trusted front line when
    illness appears, but we must continue to engage not only health systems
    but sectors such as education, housing, business and planning to
    transform communities to make the healthy choice the easy choice and
    prevent illness in the first place. The Chronic Disease Center has made
    progress in moving away from the traditional categorical approach to
    funding disease prevention and toward more coordinated, cross-cutting
    strategies. While we were disappointed at the premature termination of
    the Community Transformation Grants program, TFAH appreciates the new
    investments in community prevention made in fiscal year 2014. We hope
    the Committee restores funding for the Chronic Disease Center to fiscal
    year 2010 levels ($1.167 billion), building upon fiscal year 2014
    investments in diabetes, heart disease and stroke, the Partnerships to
    Improve Community Health initiative, the Racial and Ethnic Approaches
    to Community Health program and the Preventive Health and Health
    Services Block Grant program. For the block grant, TFAH calls upon the
    Committee to promote its use to modernize our public health system by
    supporting health department accreditation and other efforts to ensure
    the Nation's health departments can deliver foundational public health
    capabilities to all Americans.
    National Center for Environmental Health (NCEH)
        Critical programs conducted at the CDC National Center for
    Environmental Health support our chronic disease prevention and public
    health preparedness efforts. Yet it remains one of the most critically
    underfunded parts of CDC. We recommended that you fund NCEH at fiscal
    year 2010 levels ($181.004 million) in fiscal year 2015 to continue to
    rebuild the lead control program, grow our National Environmental
    Public Health Tracking Network, and pursue other priorities.
    Public Health Emergency Preparedness Grants
        The Public Health Emergency Preparedness (PHEP) Grants,
    administered by CDC, is the only Federal program that supports the work
    of health departments to prepare for all types of disasters, including
    bioterror attacks, natural disasters, and infectious disease outbreaks.
    The grants fund nearly 4,000 State and local public health staff
    positions, and support 15 core capabilities including public health
    laboratory testing, surveillance and epidemiology, community
    resilience, countermeasures and mitigation, and more. These funds are
    used for everyday preparedness activities, such as monitoring public
    health threats, and have been integral in expanding to respond to full-
    scale disasters such as Hurricane Sandy, the fungal meningitis
    outbreak, and the West Nile Virus outbreak in Texas. TFAH recommends
    $670 million for the Public Health Emergency Preparedness Cooperative
    Agreements in fiscal year 2015 to help States and localities restore
    some of the core capabilities lost due to significant cuts to the
    program.
    Hospital Preparedness Program
        The Hospital Preparedness Program (HPP), administered by the
    Assistant Secretary for Preparedness and Response (ASPR), provides
    funding and technical assistance to prepare the health system to
    respond to and recover from a disaster. The program, which began in
    response to 9/11, has evolved from one focused on equipment and
    supplies held by individual hospitals in response to a terrorist event,
    to a system-wide, all-hazards approach. The new HPP is building the
    capacity of healthcare coalitions--regional collaborations between
    healthcare organizations, providers, emergency managers, public sector
    agencies, and other private partners--to meet the disaster healthcare
    needs of communities. Through the coalition planning process,
    facilities are learning to leverage resources, such as developing
    interoperable communications systems, tracking beds, and writing
    contracts to share assets.
        HPP helped a prepared healthcare system save lives during recent
    events, including the Boston Marathon bombings and tornadoes in
    Kentucky and Joplin, MO. HPP appropriations have decreased from $426
    million in fiscal year 10 to $255 million in fiscal year 2014,
    including a one third cut in the fiscal year 2014 omnibus. TFAH
    recommends $300 million for fiscal year 2015 for HPP, an incremental
    step to rebuild the program. The significant reduction in fiscal year
    14 will likely result in fewer staff, fewer coalitions and less of the
    Nation prepared for disasters.
    Combatting Prescription Drug Abuse
        Prescription drug abuse is a growing public health crisis. Overdose
    deaths involving prescription painkillers have quadrupled since 1999
    and now outnumber deaths from all illicit drugs, including heroin and
    cocaine, combined. This is a multi-faceted problem, and the CDC,
    SAMHSA, NIH and a range of other agencies have a role to play in
    finding a solution. TFAH recommends a $15.6 million increase to the CDC
    Injury Center's Injury Prevention Activities line to enable the CDC to
    work with additional States with a high burden of prescription drug
    abuse to help address the main drivers of the epidemic of prescription
    drug overdoses, and also urge you to provide the funding to ensure that
    patients with prescription drug addiction have access to the treatment
    they need to turn their lives around.
    Conclusion
        Investing in disease prevention is the most effective, common-sense
    way to improve health and address our long-term deficit. Hundreds of
    billions of dollars are spent each year to pay for healthcare services
    once patients develop an acute illness, injury, or chronic disease. A
    sustained investment in public health and prevention is essential to
    reduce high rates of disease and improve health in the United States.

        [This statement was submitted by Jeffrey Levi, Executive Director,
    Trust for America's Health.]
                                     ______

       Prepared Statement of Rebecca Underwood, Parent/Guardian/Advocate
        Thank you for this opportunity to provide outside witness testimony
    for the record to the Senate Appropriations Subcommittee on Labor,
    Health and Human Services, Education and Related Agencies. I strongly
    object to the use of United States Department of Health and Human
    Services (DHHS) appropriations to develop coercive and subversive
    methods of deinstitutionalization resulting in the eviction of the most
    vulnerable individuals with intellectual/developmental disabilities
    from DHHS Medicaid licensed and funded facilities including
    intermediate care facilities for individuals with intellectual
    disabilities (ICFs/IID). I submit this testimony as a request that
    Congress prohibit Federal funds be allocated to Federal programs which
    are currently using their public funds to achieve dangerous public
    policies of forced deinstitutionalization, resulting in the eviction of
    eligible individuals with severe, profound and extreme intellectual and
    developmental disabilities (I/DD) from their HHS-licensed and funded
    homes, without regard to individual choice.
        I am the mother and co-guardian of an adult son, aged 34 who, as
    the result of brain and pulmonary hemorrhaging occurring during a
    premature birth, functions at the level of a 4-12 week old infant with
    chronic and complex medical issues. After providing his 24/7 care in
    our home for several years, we accepted the reality that our son would
    benefit from the extended care available in a highly specialized
    intermediate care facility for individuals with intellectual
    disabilities. Our son has benefitted tremendously from the highly
    specialized medical services provided in this setting as evidenced by
    his continued survival beyond any one's expectations.
        Our parenting decisions, our son's continued residence in his
    current DHHS funded facility and receipt of the services uniquely
    suited to meet his extensive and complex physical and medical needs,
    which have proven beneficial for his survival, are under attack. A
    number of DHHS funded programs are targeting forced displacement of our
    most fragile constituency without regard to individual choice, need and
    safety.
        Examples of how government dollars, through DHHS appropriations,
    are being misused in a cruel and absurd method by DHHS funded programs
    and policies to affect the downsizing and closure of DHSS licensed and
    funded facilities include:
      --Administration on Intellectual and Developmental Disabilities
            (AIDD) administers programs and grants created under Public Law
            106-402, Developmental Disabilities Assistance and Bill of
            Rights Act of 2000 (DD Act). The DD Act was last reauthorized
            in 2000. Authorizations for DD Act appropriations expired in
            2007; however Congress continues to fund these programs. DD Act
            programs, including Protection and Advocacy (P&A) and DD
            Councils, operate in every State. AIDD, now under the umbrella
            of the Administration for Community Living within DHHS,
            administers the DD Act programs. In 2011 AIDD's (f/k/a ADD)
            proposed recommendations included ``[d]evelop and implement
            plans to close public and private institutions''. There have
            been no hearings or recourse for families to address concerns
            as to the way in which programs, including AIDD, use/misuse
            Federal funds. DHHS has been unresponsive to complaints from
            families of persons with severe, profound and extreme forms of
            developmental disabilities about AIDD policies. DHHS has turned
            a blind eye to the tragic, but predictable, results for many
            individuals when they are forced from their specialized,
            Medicaid certified and funded congregate care settings.
            Independent oversight of Federal AIDD and DD Act programs is
            desperately needed. How long will Congress and society continue
            to ignore the increasing rate of tragic outcomes due to a
            misguided ideological agenda of forced deinstitutionalization
            of our most vulnerable citizens from their safe environments?
      --National Council on Disability (NCD) is an independent Federal
            agency funded through DHHS appropriations. In October 2012 the
            NCD released a 110 page policy document and an accompanying 201
            page ``tool-kit'' to assist opponents of congregate care to
            accomplish the closure of Medicaid-certified specialized homes
            of 4 or more beds in which individuals with severe and profound
            cognitive and other developmental disabilities receive supports
            and services. Families and guardians of these affected
            individuals are universally opposed to such closures and are
            united in their opposition to NCD's misuse of their authority
            as an independent Federal agency and their Federal funding. NCD
            has been called upon by these families to reject their stance
            on forced deinstitutionalization. The NCD has thus far ignored,
            and failed to respond to, the request of these most important
            stakeholders. Despite extensive documentation of widespread
            abuse in community settings, along with a nationwide crisis of
            understaffed, underpaid, and poorly trained direct care workers
            resulting in tragic outcomes, the NCD continues pressing
            forward with their position that ALL individuals with
            intellectual/developmental disabilities, even those who
            experience profound and complex medical, physical and/or
            behavioral challenges, be forced from their safe homes if that
            safe home is 4 or more beds. As an ``independent Federal agency
            charged with advising the President, Congress, and other
            Federal agencies regarding policies, programs, practices and
            procedures that affect people with disabilities'' NCD should
            not be taking any position which tramples on the rights of a
            portion of the disability community.
      --DHHS Incentive grants (increase in FMAP funds) to encourage States
            to move away from providing institutional care.
        --Money Follows the Person is a Federal ``reward'' for cash
                strapped States to move away from providing institutional
                care. Money Follows the Person (MFP) grants provide
                increased FMAP (Federal Medical Assistance Percentage)
                funds to States as a reward for each institutionalized
                person in the target population who transitions to an
                eligible non-institutional setting. Money Follows the
                Person grants ($4 Billion) have been acknowledged to
                disproportionately target individuals with developmental
                disabilities for transition.\1\ MFP has also been
                acknowledged as a way for States to transition individuals
                ``out the back door'' of institutions while ``closing the
                front door'' to new admissions in an effort to close
                facilities.
    ---------------------------------------------------------------------------
        \1\ Audra T. Wenzlow and Debra J. Lipson, ``Transitioning Medicaid
    Enrollees from Institutions to the Community: Number of People Eligible
    and Number of Transitions Targeted Under MFP'', Reports from the Field,
    Number 1, January 2009, Mathematica Policy Research,
    pg 6, http://www.mathematica-mpr.com/publications/PDFs/health/
    MFPfieldrpt1.pdf (accessed 20 March 2014).
    ---------------------------------------------------------------------------
        --Balancing Incentive Program (BIP) is another Federal incentive in
                the amount of $3 billion to cash strapped States to divert
                eligible individuals from institutional settings,
                disregarding choice and need.
        Combined total of $7 Billion in Federal funds through these
    Incentive grants, in addition to States' regular Federal Medical
    Assistance Percentage (FMAP), to encourage States to abandon
    institutional settings. Federal funds should not be utilized to favor
    one service setting over another, particularly as clarified in the
    Supreme Court's Olmstead ruling: ``We emphasize that nothing in the ADA
    or its implementing regulations condones termination of institutional
    settings for persons unable to handle or benefit from community
    settings...Nor is there any Federal requirement that community-based
    treatment be imposed on patients who do not desire it.'' Olmstead, 119
    S. Ct. 2176, 2187 (1999) (majority).
        It will be a travesty if the Federal Government is successful in
    pigeon-holing disability policy into a one-size-fits-all, eliminating
    choice, while continuing to ignore Supreme Court clarifications within
    Olmstead regarding the care of those with the most severe forms of
    developmental disabilities. We need an increasing array of viable
    options for services and supports for our most vulnerable, not less.
        How long will Congress and society continue to ignore the
    increasing rate of tragic outcomes (abuse, neglect, unnecessary &
    preventable deaths) of a misguided ideological agenda of forced
    deinstitutionalization of our most vulnerable citizens from their safe
    environments?
        In conclusion I call upon Congress to prohibit the Department of
    Health and Human Services' use of appropriations for
    deinstitutionalization activities that result in the eviction of
    eligible individuals with intellectual and other developmental
    disabilities from DHHS licensed and funded facilities.
                                     ______

              Prepared Statement of the United Negro College Fund
    Introduction
        I am Dr. Beverly Daniel Tatum, President of Spelman College in
    Atlanta, Georgia. Founded in 1881, Spelman College is a global leader
    in the education of women of African descent and a Historically Black
    College. Since 2008 Spelman College has averaged a 6-year graduation
    rate of 77 percent--one of the highest of the 105 Historically Black
    Colleges and Universities and substantially above the national average
    of 59 percent.
        Spelman College is one of the 37 private Historically Black
    Colleges and Universities (HBCUs) that are members of the United Negro
    College Fund (UNCF), which I am representing. UNCF is the Nation's
    largest higher education organization serving students of color,
    perhaps best known by the iconic motto--``A mind is a terrible thing to
    waste.''
        In its 70-year history, UNCF has raised more than $4 billion in
    scholarship aid to help more than 400,000 students of color attend
    HBCUs and 900 other colleges and universities across the country to
    obtain the education they need to excel in the 21st century economy.
    UNCF's largest scholarship is the Gates Millennium Scholarship offered
    to high-achieving, low-income African American, American Indian/Alaska
    Native, Asian Pacific Islander and Hispanic American students. UNCF has
    awarded $179 million in Gates Millennium Scholarships to help 3,200
    students from the States the Labor-Health and Human Services-Education
    Subcommittee represents earn college degrees.
    HBCU Value Proposition
        UNCF's core mission, however, remains its partnership with the
    Nation's 37 private HBCUs. The money raised by UNCF has become even
    more important today as HBCUs have suffered from a ``perfect storm'' of
    Federal disinvestments since 2011. Limitations on Pell Grant
    eligibility requirements, sequestration cuts to the Title III HBCU
    Program and Parent PLUS Loan reductions have resulted in a loss of more
    than $250 million in Federal support. Despite these challenges, HBCUs
    provide enormous value for students and the Nation. HBCUs represent
    approximately 4 percent of all 4-year colleges and universities; enroll
    9 percent of all African American college students; confer 16 percent
    of bachelor's degrees awarded to African Americans; and generate 27
    percent of the STEM bachelor's degrees awarded to African Americans.
    Moreover, HBCUs accomplish this while serving students with greater
    need: more than 70 percent of students who attend HBCUs are low-income
    students who depend on Federal Pell Grants for their education, a
    substantially greater share than the 43 percent of students at all
    other 4-year colleges and universities. At the same time, total cost of
    attendance at HBCUs is 30 percent lower, on average, than other 4-year
    institutions.
    Fiscal year 2014 Appropriations
        I would like to thank the Subcommittee and, in particular, Chairman
    Harkin and Ranking Member Moran for playing leadership roles in
    restoring some of the vital Federal resources to HBCUs and the students
    we serve in the fiscal year 2014 budget. UNCF appreciates you providing
    a maximum Pell award of $5,730, restoring sequestration cuts to other
    student aid programs, and restoring two-thirds of the sequestration
    cuts to the Title III HBCU Program.
    Fiscal year 2015 Appropriations Priorities
        Looking to fiscal year 2015, a national strategy to produce more
    college graduates, boost our economy and enhance global competitiveness
    must include greater investment in HBCUs. On behalf of the UNCF
    institutions and all HBCUs, I urge the Subcommittee to support our
    highest priority programs listed below:
      --I urge you to appropriate $267 million in discretionary dollars and
            $85 million in mandatory dollars for the Title III, Part B--
            Strengthening Historically Black Colleges and Universities
            Program. These are formula funds awarded to HBCUs for
            operational support and essential academic services. Let me
            note that during the 2007-2012 grant cycle, Spelman College
            received and expended more than $11 million in Title III
            funding. Spelman has enhanced its campus infrastructure to
            include upgrades in technology to facilities, classrooms, labs
            and centers. Title III assisted with the establishment of the
            SpelBots (Spelman's Robotic Team) a winning robotics
            initiative. Additional examples of the achievements that
            critical Title III funding has supported at Spelman are
            included as an attachment to my testimony. Please reinvest in
            this program and restore the $43 million cut from the program
            since fiscal year 2010.
      --The HBCU Capital Financing Program finances low-risk Federal loans
            to help HBCUs, especially private institutions, improve
            facilities, infrastructure and technology. Investing in capital
            projects not only enhances the educational environment for
            students but also reinvigorates our communities and provides
            much needed jobs. I urge you to increase the appropriation for
            loan subsidies to $25 million, which would leverage $390
            million in annual loans to meet the infrastructure needs of our
            institutions.
      --Without Pell Grants, most HBCU students could not pay for the
            college education that is essential in today's economy. I urge
            you to fund a $5,830 maximum Pell award to help our students
            persist and complete college. In addition, I encourage you to
            reinstate ``summer'' Pell Grants so students can earn their
            college degrees faster and at a lower cost.
      --UNCF also strongly supports the President's fiscal year 2015
            request of $75 Million for College Success Grants for Minority-
            Serving Institutions. These competitive grants would help
            Minority-Serving Institutions launch new innovations and best
            practices to improve student outcomes. I urge you to fully fund
            this important initiative.
      --I urge you to approve the proposed College Opportunity and
            Graduation Bonuses, which would reward institutions that enroll
            and graduate large numbers of low-income students. UNCF
            recommends that this proposal be amended to take into
            consideration both the numbers and percentages of low-income
            students graduating from institutions, given that some HBCUs
            have smaller enrollments.
      --Finally, I urge you to restore the Health Professions Training for
            Diversity programs to fiscal year 2012 levels and ask that you
            expand the National Institute on Minority Health and Health
            Disparities to $283 million to improve diversity in the
            workforce and research funding for minority populations.
        Chairman Harkin and Ranking Member Moran and members of this
    Subcommittee--you have the power to increase Federal resources for
    operating support, student assistance, best practices and innovations
    so that HBCUs can thrive in years to come. Or, you can adhere to the
    status quo and allow our institutions to merely survive.
        UNCF does not accept the status quo. We are accelerating our
    fundraising efforts, investing in capacity building at our member
    institutions, building new partnerships and leveraging our resources to
    enhance educational opportunities for minority students. In fact, UNCF
    has updated its motto to recognize education is an investment in better
    futures for everyone. We believe that, ``A mind is a terrible thing to
    waste, but a wonderful thing to invest in.'' Please help us invest in
    our youth, in our HBCUs, and most importantly, in our country so that
    millions more low-income, minority students can graduate from college
    and lead our country to heights we have yet to imagine. Thank you for
    the opportunity to submit written testimony.

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

    Attachments:

      --HBCU Coalition fiscal year 2015 Appropriations Priorities
      --Spelman College Title III Accomplishments
                                     ______

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

                                Spelman College
      highlights: title iii, part b, sec. 323--strengthening historically
                    black colleges and universities program
        Spelman College is the oldest historically black college for women.
    Located in Atlanta, Georgia, Spelman was founded in 1881 as the Atlanta
    Baptist Female Seminary. The College maintains a student population of
    approximately 2,000 from 45 U.S. States and 13 countries, and since
    2008 has had an average 6-year graduation rate of 77 percent.
        Title III--Strengthening Historically Black Colleges and
    Universities funding plays a critical role in obtaining resources that
    provide students and faculty with unparalleled opportunities for
    educational enrichment and advancement. In the 2007-2012 grant cycle,
    Spelman College expended more than $11 million in Title III funds.
    Those resources were expended on a number or projects with wide-ranging
    effects on student life, faculty engagement, and facility improvement.

      --Title III funding supports and enhances institutional efforts in
            four critical areas: Academic Quality, Student Services
            Outcomes, Institutional Management and Fiscal Stability. Our
            advancements in these key areas are reflected in key indicators
            related to enrollment, retention, graduation and fiscal
            stability.
      --Title III funding undergirds 100 percent of the Foundational
            Priorities of the College's Strategic Plan, enhancing academic
            rigor in new student orientation, freshman-year and sophomore-
            year experiences.
      --The College's retention rate is 90 percent. The average 5-year
            (2007-2011) second-year retention rate is 87 percent. Title III
            funds continue to assist the institution with providing
            supportive programs that ensure Spelman's first and second year
            students successfully progress to junior status.
      --The College's 6-year graduation rate has ranged from a high of 83
            percent to a low of 73 percent. The average 6-year (2001-2006)
            cohort rate is 77 percent.
      --Forty-nine Global STEM students have conducted STEM research abroad
            since 2011.
      --48 labs and 22 classrooms upgraded with state-of-the-art
            technology.
      --Between 2008-2012, Spelman had 722 students who were admitted to
            and attended graduate or professional degree programs in
            disciplines in which African Americans are underrepresented.
    Select Examples of Title III Activities that Support our Success
      --A campus classroom was transformed into a data analysis hub, with
            16 new workstations installed. More than 90 percent of students
            reported that their interest in and skills related to data
            analysis improved as a result of their work in this facility.
      --The College implemented DegreeWorks, an online auditing and
            advising system that aids students in proactively creating and
            fulfilling their individual academic plans and assists faculty
            advisors in providing effective support.
      --Spelman's Education Studies Program enlarged its interdisciplinary
            course offerings through the addition of a new course entitled
            ``History and Philosophy of African American Education.''
      --Creation and implementation of the Student Success Center, which
            provides a centralized location for student support services.
      --Spelman's Department of Computer and Information Science (CIS)
            achieved international recognition for the accomplishments of
            its graduates and for its award-winning robotics initiative.
            The SpelBots participated in the NSF Education Technology
            Senate showcase in November 2009.
        These accomplishments serve as evidence of the important role that
    resources from the Strengthening Historically Black Colleges and
    Universities program play at Spelman and on HBCU campuses across the
    Nation.

                                     ______

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

        [This statement was submitted by David M. Gipp, Chancellor, United
    Tribes Technical College.]
                                     ______

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

        [This statement was submitted by Douglas Wright, Ph.D., Professor
    and Vice Chair Principal Investigator, Kansas INBRE, Department of
    Anatomy and Cell Biology, University of Kansas Medical Center.]
                                     ______

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

           Prepared Statement of US Hereditary Angioedema Association
                  summary of fiscal year 2015 recommendations
    _______________________________________________________________________

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

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

        [This statement was submitted by Janet Long, Executive Vice
    President, US Hereditary Angioedema Association.]
                                     ______

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

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

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

          ``We emphasize that nothing in the ADA or its implementing
            regulations condones termination of institutional settings for
            persons unable to handle or benefit from community
            settings...Nor is there any Federal requirement that community-
            based treatment be imposed on patients who do not desire it.''
            Olmstead, 119 S. Ct. 2176, 2187 (1999) (majority).
          ``As already observed [by the majority], the ADA is not
            reasonably read to impel States to phase out institutions,
            placing patients in need of close care at risk ...`Each
            disabled person is entitled to treatment in the most integrated
            setting possible for that person--recognizing on a case-by-case
            basis, that setting may be an institution'[quoting VOR's Amici
            Curiae brief].'' Id. at 2189 (plurality).
        Likewise, Medicaid law and regulation requires that ICF/IID
    residents be ``[g]iven the choice of either institutional or home and
    community-based services.'' 42 C.F.R. Sec. 441.302(d)(2); see also, 42
    U.S.C. Sec. 1396n(c)(2)(C) and 42 C.F.R. Sec. 441.303.
        NCD's support for deinstitutionalization is contrary to Federal law
    and reckless. ICFs/IID have an array of services not often available
    elsewhere (e.g., on-site medical care, dental care, other specialties,
    and involvement in their broader communities). As discussed above,
    tragedies are predictable when residents are separated from life-
    sustaining supports.
    IV. Solution and Conclusion
        HHS-funded agencies should not be allowed to advance an ideological
    agenda in support of evicting eligible people from HHS-licensed homes,
    contrary to the DD Act, Medicaid law, and the ADA/Olmstead. Such
    actions are a cruel and absurd use of Federal funding that is exacting
    great harm on our nation's most vulnerable citizens, and contrary to
    societal values which respect individual and family decisionmaking.
        Please support language to prohibit the use of HHS appropriations
    in support of deinstitutionalization activities which evict eligible
    individuals with I/DD from HHS-licensed and funded homes. No Federal
    agency should define ``choice'' so narrowly and illegally as to
    disenfranchise the most vulnerable segment of our disabled population.
                                     ______

           Prepared Statement of the Workforce Data Quality Campaign
        Workforce Data Quality Campaign (WDQC)--a nonprofit initiative that
    advocates for inclusive, aligned and market-relevant data systems--
    urges Congress to support programs that provide crucial data needed to
    ensure that our Nation is educating its students and workers to succeed
    in the 21st century economy.
        Federal investments in State data systems, labor market information
    and statistical programs have real impacts for:
      --Students and workers trying to figure out which colleges and
            training programs are best at helping people land a job,
            continue their studies or advance in the labor market.
      --Policymakers who need to know whether education and workforce
            programs are preparing people for good jobs.
      --Business leaders wondering whether education and training programs
            are preparing enough prospective employees to meet their
            companies' needs.
      --Educators who want to know the long-term education and employment
            outcomes of their graduates, so they can continually improve
            their courses and curricula.
        Despite their profound impact on education and workforce
    development, a number of data-related programs and services have faced
    stagnant or declining funding in recent years. As Congress deliberates
    on fiscal year 2015 appropriations, we recommend halting this downward
    trend and increasing funding for the following programs.
        State longitudinal data system grants.--The State Longitudinal Data
    System grants provided by the Department of Education (ED) and the
    Workforce Data Quality Initiative grants from Department of Labor (DOL)
    have propelled the successful development, implementation and expansion
    of longitudinal data systems. Continued Federal support will
    incentivize the State interagency cooperation necessary to build and
    utilize systems that can hold education and workforce programs
    accountable for their results. Funding for these grants has been
    decreasing over the past several years, gradually eroding this
    important source of support for State data systems. The last grant
    competition was in fiscal year 2012. Additional funding is important to
    help more States improve their data infrastructure and conduct a new
    grant competition that focuses States on using data to improve policy
    and practice, as well as incorporating longitudinal data from
    postsecondary and workforce programs into their systems to allow more
    analysis of varied education and career pathways.
        Recommendation.--Double the fiscal year 2014 funding level, as
    requested by the President's Budget, to support about 20 grants and
    national activities designed to promote data coordination, quality, and
    use. Include report language directing ED and DOL to collaborate on
    providing technical assistance to grantees to ensure inclusive and
    aligned data systems.
        Workforce Information Grants/Electronic Tools. DOL awards grants to
    help States conduct research on local and regional labor markets,
    including shifts in industrial and occupational demand and its impact
    on the skills needed by the workforce. This information is critical to
    align education and training programs with employer needs, and help the
    workforce system guide students and workers to programs that will
    prepare them for high-demand occupations. Funding for these grants--
    included in the Workforce Information/Electronic Tools/System Building
    line item in the State Unemployment Insurance and Employment Service
    Operations Account--has not increased for over a decade, even as demand
    for labor market information has grown. This line item also funds
    important national data activities, including the dissemination of
    information on different types of credentials and O*NET, which collects
    and disseminates information about occupations including associated
    skills, knowledge and abilities. O*NET is used as the foundation for
    variety of tools to help workers explore careers, such as a new Skills
    to Work tool from Texas that helps veterans translate their military
    experience into skills appropriate for civilian resumes and match their
    skills to job openings.
        Recommendation.--Increase funding by $10 million to support an $8
    million increase in grants to States and a $2 million increase for
    O*NET.
        National Center for Education Statistics. This office at ED
    provides a number of important services, including labor market-
    relevant data products and tools on secondary and postsecondary
    enrollments, completions and credential attainment.
        Recommendation.--Increase funding to match fiscal year 2012 (pre-
    sequester) levels.
        Bureau of Labor Statistics. This DOL agency produces an array of
    important data, including employment and unemployment of individuals,
    jobs and earnings by industry and occupation, job openings and labor
    turnover, mass layoffs and occupational projections. As the Nation
    continues to face high unemployment, this data is vital to help align
    human capital policies with the needs of employers.
        Recommendation.--Increase funding by $23 million to support the
    following efforts.
      --Restore Current Employment Survey funding to 2010 levels (+$7
            million) to provide resources to enhance data quality and
            reduce employer response burden by encouraging businesses to
            voluntarily provide information through electronic data
            interchange. This survey is used by local leaders to provide a
            near real-time summary of employment conditions and to rapidly
            spot key trends in major industries.
      --Expand Current Population Survey supplements (+$4 million), which
            monitor labor market changes that can help State and local
            leaders understand the education and training needs in their
            communities.
      --Develop new cost-effective approaches for Occupational Employment
            Statistics and the National Compensation Survey (+$2 million)
            that allow data users to see occupational trends over time by
            locality.
      --Increase funding for cooperative agreements with States (+$10
            million) to enable State partners to produce a variety of labor
            market information that is critical for workers, educators and
            employers. Funding for these agreements has not risen in over a
            decade.

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

        Thank you for the opportunity to comment.

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