[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
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An Excellent Investment
    In addition to being research-based and teacher tested, the RTL 
Television program also provides excellent value for our Federal 
dollars. In the last 5-year grant round, public broadcasting leveraged 
an additional $50 million in funding to augment the $73 million 
investment by the Department of Education for content production. 
Without the investment of the Federal government, this supplemental 
funding would likely end.
The Dangers of Consolidation
    The President's fiscal year 2015 budget proposes consolidating RTL 
into a larger grant program. APTS and PBS oppose this proposal as it 
would abandon the unique national-local partnership that has resulted 
in RTL's ground-breaking educational impact on kids nationwide, 
particularly those with limited access to other educational resources. 
The current model effectively uses an economy of scale to create high-
quality television and online content at the national level and then 
distribute it through local stations who can tailor outreach to the 
specific needs of their communities. This model allows PBS and local 
stations to annually reach 80 percent of America's children ages 2 to 8 
through television and another 13 million per month online and on 
mobile apps. The national-local partnership has made RTL tremendously 
efficient and effective and consolidation or elimination of the program 
would severely affect the ability of local stations to respond to their 
communities' educational needs, eliminating the critical resources 
provided by this program for children, parents and teachers. RTL 
symbolizes the mission of public media and is a successful public-
private partnership that leverages Federal funds to create the most 
appealing and impactful children's educational content that is 
supplemented by online and on-the-ground resources. Without the RTL 
program, millions of families would lose access to this incredible 
high-quality education content, especially the low-income and 
underserved households that are a particular focus of this program.
Conclusion
    Americans across the political spectrum rely on public 
broadcasting--on television, on the radio, online, and in the 
classroom--because we provide essential education, public safety, and 
informed citizenry services that are not available anywhere else. And 
none of this would be possible without the Federal investment in public 
broadcasting. A 2007 GAO report concluded that these Federal Community 
Service Grants are an irreplaceable source of revenue for public 
broadcasting, and a 2012 study requested by this Subcommittee and 
conducted by an independent third party for CPB came to the same 
conclusion as the GAO: Federal funding for public broadcasting is 
irreplaceable.
    For all of these reasons we request that Congress continue its 
commitment to the highly successful, hugely popular public-private 
partnership that is public broadcasting by providing level funding of 
$445 million in fiscal year 2017 for the 2-year advance of the 
Corporation for Public Broadcasting and pre-sequester level funding of 
$27.3 million in fiscal year 2015 for the stand alone Ready To Learn 
Program.
                                 ______
                                 
            Prepared Statement of the National Public Radio
    Dear Chairman Harkin, Ranking Member Moran and Members of the 
Subcommittee: Thank you for this opportunity to urge the Subcommittee's 
support for an annual Federal investment of $445 million in America's 
public media system through annual appropriations to the Corporation 
for Public Broadcasting (CPB). With your support, the public radio 
system, consisting of some 950 locally managed, locally controlled and 
locally programmed stations, serves communities all across America. And 
these stations are as diverse as the communities they represent. Public 
radio is committed to being America's public radio, bringing the 
diverse and changing voices of Americans to the airwaves and the new 
platforms that so many Americans are using. We strive to create a more 
informed public, one challenged and invigorated by a deeper 
understanding and appreciation of events, ideas, and culture within the 
United States and across the globe.
    The public radio system, a uniquely American public service, non-
commercial, media enterprise, includes stations in every State capitol 
and hundreds of American communities, large and small, urban and rural. 
Producers and distributors of public radio programming, including 
American Public Media (APM), Public Radio International (PRI), the 
Public Radio Exchange (PRX) and NPR are united by a commitment to the 
highest standards of journalist ethics. Every minute of every program 
broadcast to some 38 million Americans weekly is routed through the 
Public Radio Satellite System (PRSS), a content distribution utility 
owned by the public radio system.
    Partnerships and collaborations are integral components of the 
programming and service found in the public radio system. Available on 
air, online, and on new and emerging mobile platforms, public radio is 
expanding its ability to reach audiences. And as traditional media 
undergoes dramatic changes, public radio is positioning itself to serve 
the needs of a growing audience in a shifting media landscape and 
rapidly changing world.
    A clear example of these new adaptations to improve journalism and 
meet audience needs comes from the recently formed merger between St. 
Louis Public Radio and the St. Louis Beacon newspaper, the area's two 
largest nonprofit news organizations. This move combines newsrooms and 
significantly changes the face of independent local news in the region 
by providing more depth and perspective on issues and stories that 
impact the community. The consolidation creates an innovative model for 
a multiplatform news operation that results in more in-depth coverage 
of urban events and issues. St. Louis Public Radio's move to join 
forces and expand serves as an example of how public radio news 
organizations are adjusting to an ever-changing media environment that 
involves greater competition for consumers and financial support.
    This new merger is just one among a growing list of public 
broadcasters teaming up with other nonprofit news outlets to beef up 
their local and investigative journalism. In Denver, Rocky Mountain 
PBS, public radio station KUVO, and I-News, the Rocky Mountain 
Investigative News Network, merged to create a cross-platform news 
operation that could better cover Colorado. WWNO in New Orleans hired 
its first-ever news director last spring to expand its coverage of 
stories. Oregon Public Broadcasting is building a statewide news 
network with 40 to 50 small news outlets across Oregon. Lastly, Harvest 
Public Media, a reporting collaboration of public radio stations KCUR, 
KBIA, Iowa Public Radio, Nebraska Public Broadcasting, KUNC and WUIS, 
focuses on issues of food, fuel and field. Based at KCUR in Kansas 
City, Harvest covers these agriculture-related topics through an 
expanding network of reporters and partner stations throughout the 
Midwest.
    But the partnerships don't stop there for public radio. A recent 
collaboration includes Boston's WBUR and NPR joining forces to expand 
and re-launch the daily public radio show Here & Now as a two-hour 
national news program for audiences in the middle of the day. The 
program airs weekday afternoons and is aggressively updated to provide 
local audiences with live, updated news coverage during mid-day.
    Public radio's partnerships with public safety officials play a 
critically important role when natural or man-made disasters strike. 
Public radio stations provide essential and timely public emergency 
information, such as evacuation routes, shelter locations and severe 
weather updates. Effective emergency warnings allow people to take 
actions that save lives, and reduce damage and human suffering. Federal 
funding helps to bring crucial news and alerts to millions of 
Americans.
    Public radio's innovative partnerships also expand our public 
service mission by enabling radio reception to all Americans during 
local emergency situations. This year, 26 public radio stations based 
in Alabama, Florida, Louisiana, Mississippi and Texas are working with 
NPR Labs, the Public Radio Satellite System (PRSS) and the U.S. 
Department of Homeland Security/FEMA to demonstrate the delivery of 
emergency alerts to people who are deaf or hard-of-hearing. This is the 
first effort to deliver real-time accessibility-targeted emergency 
messages, such as weather alerts, via radio broadcast texts. Our hope 
is to expand the pilot over time to other regions of our country thru 
the use of radio equipment to reach people who are both deaf and blind 
and non-English speaking.
    In addition, many public radio stations provide critical services 
through partnerships with radio reading services. These long 
established centers are in every major market in the United States to 
provide millions of visually impaired persons the ability to function 
more independently in their communities.
    Music in America would sound very different without public radio. 
Local stations take creative risks, nurture new talent, and give 
emerging artists a chance to be heard. They celebrate traditional music 
genres like classical and jazz, and partner with local music 
organizations to take these art forms to new heights of performance 
excellence and new audiences. And they play a key role in their local 
music economies, sustaining and growing the careers of musicians by 
connecting them to local listeners. Across the country, more than 180 
local public radio stations have full-time music formats and more than 
650 stations air play music as part of their programming lineups.
    Mr. Chairman and Senator Moran, public radio is essential in 
providing news, information and cultural programming to America and 
connecting with audiences wherever they are. We're embracing America's 
changing demographics and using digital media to connect better, more 
quickly and in more diverse ways. Today's public radio isn't going 
away, it's going everywhere and we are working every day to earn the 
trust of the 38 million Americans who rely on us for news and insights 
that guide and inform. We ask for your continuing support in funding 
for stations that serve your communities, your constituents and 
America's Democracy.

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

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

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

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

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

                       NONDEPARTMENTAL WITNESSES

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

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

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


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

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

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

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

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

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


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

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

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

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

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


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

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

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

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

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

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

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




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

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

    [This statement was submitted by Mariell Jessup, M.D., President, 
American Heart Association.]
                                 ______
                                 
 Prepared Statement of the American Indian Higher Education Consortium
    This statement includes the fiscal year 2015 recommendations of the 
Nation's Tribal Colleges and Universities (TCUs), in two areas of the 
Department of Education: Office of Postsecondary Education and Office 
of Vocational Education.
                     higher education act programs
    Strengthening Developing Institutions.--Titles III and V of the 
Higher Education Act support institutions that enroll large proportions 
of financially disadvantaged students and have low per-student 
expenditures. The TCUs, which by any definition are truly developing 
institutions, funded under Title III-A Sec. 316 are providing quality 
higher education opportunities to some of the most rural/isolated, 
impoverished, and historically underserved areas of the country. The 
goal of HEA-Titles III/V programs is ``to improve the academic quality, 
institutional management and fiscal stability of eligible institutions, 
in order to increase their self-sufficiency and strengthen their 
capacity to make a substantial contribution to the higher education 
resources of the Nation.'' The TCU Title III-A program is specifically 
designed to address the critical, unmet needs of their American Indian 
students and communities, in order to effectively prepare them to 
succeed in a globally competitive workforce. Yet, in fiscal year 2011 
this critical program was cut by over 11 percent, by another 4 percent 
in fiscal year 2012, and hit by sequestration--on the lowered 
baseline--in fiscal year 2013. Although sequestration was not imposed 
in fiscal year 2014, the TCUs have not recovered from the earlier cuts 
to this vitally important program. The TCUs urge the Subcommittee to 
restore the discretionary funding for HEA Title III-A, Sec. 316 to 
$30,000,000 in fiscal year 2015.
    TRIO.--Retention and support services are vital to achieving the 
national goal of having the highest proportion of college graduates in 
the world by 2020. TRIO programs, such as Student Support Services and 
Upward Bound, were created out of recognition that college access is 
not enough to ensure advancement and that multiple factors work to 
prevent the successful completion of postsecondary programs for many 
low-income and first-generation students and students with 
disabilities. Therefore, in addition to providing the maximum Pell 
Grant award level, it is critical that Congress also sustain student 
assistance programs, such as Student Support Services and Upward Bound 
so that low-income and minority students have the Federal support 
necessary to allow them to remain enrolled in and ultimately complete 
their higher education degrees.
    Pell Grants.--The importance of Pell Grants to TCU students cannot 
be overstated. Approximately, 80 percent of TCU students receive Pell 
Grants, primarily because student income levels are so low and they 
have far less access to other sources of financial aid than students at 
State-funded and other mainstream institutions. Within the TCU system, 
Pell Grants are doing exactly what they were intended to do--they are 
serving the needs of the lowest income students by helping them gain 
access to quality higher education, an essential step toward becoming 
active, productive members of the workforce. However, the U.S. 
Department of Education has changed its regulations to limit Pell 
eligibility from 18 to 12 full-time semesters, without any 
consideration of those already in the process of earning a 
postsecondary degree. This change in policy has impeded some TCU 
students from completing a postsecondary degree, which is widely 
recognized as being critical for access to, and advancement in, today's 
highly technical workforce.
    TCUs are open enrollment institutions. Recent placement tests 
administered at TCUs to first-time entering students indicated that 74 
percent required remedial math, 54 percent required remedial reading, 
and 57 percent needed remedial writing. These results clearly 
illustrate just how serious this new Pell Grant eligibility limit is to 
the success of TCU students in completing a postsecondary degree. 
Students requiring remediation can use as much as a full year of 
eligibility enhancing their math, and or reading/writing skills, 
thereby hampering their future postsecondary degree plans. A prior 
national goal was to provide access to quality higher education 
opportunities for all students regardless of economic means, at which 
TCUs have been extremely successful. While the new national goal 
intends to produce graduates with postsecondary degrees by 2020, this 
change in policy does not advance that objective. On the contrary, the 
new regulations will cause many low-income students to once again 
abandon their dream of a postsecondary degree, as they will simply not 
have the means to continue to pursue it. The goal of a well-trained 
technically savvy workforce will be greatly compromised. This new 
policy evokes the adage ``penny wise--pound foolish.'' The TCUs urge 
the Subcommittee to continue to fund this essential program at the 
highest possible level, and to direct the Secretary of Education to 
implement a process to waive the very restrictive 12 semester Pell 
Grant eligibility for TCU students.
            perkins career and technical education programs
    Tribally-Controlled Postsecondary Career and Technical 
Institutions.--Section 117 of the Carl D. Perkins Career and Technical 
Education Act provides a competitively awarded grant opportunity for 
tribally chartered and controlled career and technical institutions. 
AIHEC requests $8,200,000 to fund grants under Sec. 117 of the Perkins 
Act.
    Native American Career and Technical Education Program (NACTEP).--
NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding to 
support American Indian career and technical programs. The TCUs 
strongly urge the Subcommittee to continue to support NACTEP, which is 
vital to the continuation of career and technical education programs 
offered at TCUs that provide job training and certifications to remote 
reservation communities.
  american indian adult and basic education (office of vocational and 
                            adult education)
    This program supports adult basic education programs for American 
Indians offered by State and local education agencies, Indian tribes, 
agencies, and TCUs. Despite the absence of dedicated funding, TCUs must 
find a way, often using already insufficient institutional operating 
funds, to continue to provide adult basic education classes for those 
American Indians that the present K-12 Indian education system has 
failed. Before many individuals can even begin the course work needed 
to learn a productive skill, they first must earn a GED or, in some 
cases, even learn to read. The new GED exam, which was instituted in 
January 2014, has a much stronger focus on mathematics. As noted 
earlier, placement tests for TCU entering students reveal a tremendous 
need for math remediation. Additionally, the new GED test is fully 
computerized. While younger GED seekers may be well versed and 
comfortable with computer-based testing, older and poorer citizens may 
not be. These factors indicate a further and growing need for adult 
basic educational programs and GED preparation on Indian reservations. 
TCUs must have sufficient and stable funding to continue to provide 
these essential activities and to ensure their communities residents 
have the same chances to succeed as others throughout the country have. 
TCUs request that the Subcommittee direct that $8,000,000 of the funds 
appropriated annually for the Adult Education State Grants be made 
available to make competitive awards to TCUs to help meet the growing 
demand for adult basic education and remediation program services on 
their respective Reservations.
further justifications for fiscal year 2015 appropriations requests for 
                                  tcus
    Tribal colleges and our students are already being 
disproportionately impacted by ongoing efforts to reduce the Federal 
budget deficit and control Federal spending. The fiscal year 2011 
Continuing Resolution eliminated all of the Department of Housing and 
Urban Development's Minority Serving Institutions (MSIs) community-
based programs, including a critically needed TCU-HUD facilities 
program. TCUs were able to maximize leveraging potential, often 
securing even greater non-Federal funding to construct and equip Head 
Start and early childhood centers; student and community computer 
laboratories and public libraries; and student and faculty housing in 
rural and remote communities where few and sometimes none of these 
facilities existed. Important STEM programs, administered by the 
National Science Foundation and NASA were cut, and for the first time 
since the NSF program was established in fiscal year 2001, no new TCU-
STEM awards were made in fiscal year 2011. While NSF-TCUP grants 
resumed in fiscal year 2012, a year of grant opportunity was lost. TCUs 
Additionally, TCUs and their students suffer the realities of cuts to 
programs such as GEAR-UP, TRIO, SEOG, and as noted earlier, are 
seriously impacted by the new highly restrictive Pell Grant eligibility 
criteria more profoundly than mainstream institutions of higher 
education, which can realize economies of scale due to large 
endowments, alternative funding sources, including the ability to 
charge higher tuition rates and enroll more financially stable 
students, and access to affluent alumni. The loss of opportunities that 
cuts to DoEd, HUD, NSF, and NASA programs represent to TCUs, and to 
other MSIs, is magnified by cuts to workforce development programs 
within the Department of Labor, nursing and allied health professions 
tuition forgiveness and scholarship programs operated by the Department 
of Health and Human Services, and an important TCU-based nutrition 
education program planned by USDA. Combined, these cuts strike at the 
most economically disadvantaged and health-challenged Americans.
    We respectfully request that the Members of the Subcommittee 
continue the Federal investment in the Nation's Tribal Colleges and 
Universities and full consideration of our fiscal year 2015 
appropriations needs and recommendations.
                                 ______
                                 
        Prepared Statement of the American Physiological Society
    The American Physiological Society (APS) thanks the subcommittee 
for its ongoing support of the National Institutes of Health (NIH). 
Research carried out by the NIH contributes to our understanding of 
health and disease, which allows all Americans to look forward to a 
healthier future. The APS urges you to make every effort to provide the 
NIH with a net funding level of $32 billion in fiscal year 2015. This 
is necessary to prevent further erosion of research capacity.
    Federal investment in research is critically important because 
breakthroughs in basic and translational research are the foundation 
for new drugs and therapies that help patients, fuel our economy, and 
provide jobs. The Federal Government is the primary funding source for 
discovery research through competitive grants awarded by the NIH. 
Although the private sector partners with academic researchers to 
develop research findings into new treatments, industry relies upon 
federally funded research to identify where innovation opportunities 
can be found. This system of public-private partnership has been 
critical to U.S. leadership in the biomedical sciences. However, this 
position of leadership is at risk as other nations, including China, 
increase their investments in research and development while the United 
States investment has lagged in recent years.
    Federal research dollars also have a significant impact at the 
local level: Approximately 85 percent of the NIH budget is awarded 
throughout the country to researchers who use grant funds to pay 
research and administrative staff, purchase supplies and equipment, and 
cover other costs associated with their research.
NIH funds outstanding science
    As a result of improved healthcare, Americans in the 21st century 
are living longer and healthier lives than ever before. However, 
chronic conditions such as cardiovascular disease, diabetes, 
respiratory illnesses, Alzheimer's and cancer continue to inflict a 
heavy burden in the United States and around the world. As the U.S. 
population ages, the prevalence and cost of these diseases will 
increase exponentially. The NIH invests heavily in basic research to 
understand the physiological mechanisms at work in health and disease. 
This knowledge is crucial to the development of safe and effective 
interventions and prevention strategies.
    Exciting new initiatives are underway at the NIH to advance 
science, including the Brain Research through Advancing Innovative 
Neurotechnologies (``BRAIN'') initiative and the Big Data 2 Knowledge 
project (BD2K). The BRAIN initiative will bring together researchers 
from diverse disciplines to tackle major gaps in current knowledge 
about the brain and brain diseases. BD2K will explore ways to 
capitalize on the immense volume of data being created by biomedical 
scientists, ultimately enhancing the work of the entire community by 
providing new tools and resources to make better use of that data. 
These important projects require significant resources, and at a time 
of constrained budgets, that will further diminish funding for 
investigator-initiated grants. The NIH system of allowing investigators 
to develop and propose ideas which are then evaluated by their peers 
and selected for funding based on their merit has fostered a research 
enterprise that is second to none. Increasing the NIH budget to $32 
billion would provide funding for large projects as described above, 
while also providing resources for individual scientists to pursue 
creative new avenues of research.
NIH nurtures the biomedical research enterprise
    In addition to supporting research, the NIH must also address 
workforce issues to ensure that our Nation's researchers are ready to 
meet the challenges they will face in the future. The pressures placed 
on the biomedical research enterprise after years of sub-inflationary 
budget increases were severely compounded by sequestration cuts in 
fiscal year 2013. One analysis showed that NIH supported approximately 
1000 fewer investigators in fiscal year 2013 as a result of its 
declining budget.\1\ Researchers who lose their funding face an 
uncertain future as there are few options to sustain their research 
without Federal grants. Losing Federal support puts at risk the 
investment that it took to build those programs over many years. It 
also means that talented individuals working in those labs will have to 
look elsewhere for increasingly scarce jobs. As a result of stagnant 
funding for NIH, scientists at all stages of their careers struggle to 
maintain their research programs.
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    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 
[email protected], if you have any questions or need further 
information concerning hematology research or ASH's fiscal year 2015 
funding request.
                                 ______
                                 
        Prepared Statement of the American Society of Nephrology
    The American Society of Nephrology (ASN) is the world's largest 
kidney health professional organization in the world, representing 
15,000 physicians, other healthcare providers, and scientists, and 
committed to advancing research, prevention, and treatment options for 
the more than 20 million adults, children, and adolescents with kidney 
disease in the United States today. The society requests at least 
$2.066 billion for the National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK) at the National Institutes of Health (NIH). The 
society also requests an additional $150 million/year over 10 years for 
kidney research above current funding for NIDDK.
    ASN believes these are crucial and necessary investments for 
preventing illness and maintaining fiscal responsibility. Investing in 
research to slow the progression of kidney disease and identify new 
therapies will save Medicare spending for the End-Stage Renal Disease 
(ESRD) Program in the long run.
    In 1972, Congress made a commitment to treat all Americans with 
kidney failure through the Medicare ESRD Program--the only health 
entitlement program that provides coverage regardless of age or 
disability. Today, ESRD patients account for less than 1 percent of the 
Medicare population but 7 percent of the Medicare budget. Meanwhile, at 
approximately $650 million per year, total Federal funding for kidney 
research is equivalent to less than 1 percent of the nearly $77 billion 
Medicare spends annually for the care of patients with kidney disease.
    Given that the Medicare ESRD Program is unique in that it covers 
treatment for all patients with kidney failure regardless of age or 
disability, preventing kidney disease and improving therapy--starting 
with innovative research at NIDDK--would yield significant savings to 
the Centers for Medicare and Medicaid Services.
    The vast majority of Federal research leading to advances in the 
care and treatment of patients with kidney disease is funded by NIDDK. 
Examples of critical discoveries arising from NIDDK-funded research are 
numerous.
    For instance, investigative studies supported by NIDDK led to a 
groundbreaking discovery that helps explain racial and ethnic 
disparities that increase risks for kidney disease, which can lead to 
earlier detection and treatment. The finding that African Americans 
with two variants of the APOL1 gene are likely to progress to kidney 
failure faster than other ethnicities paves the way for future research 
to unlock better preventive therapies and gene-based cures.
    Recent findings from NIDDK's Chronic Renal Insufficiency Cohort 
(CRIC) Study led to the discovery that the progression of kidney 
disease is associated with less efficient pumping of blood by the 
heart. Further research exploring the mechanisms for this development 
could lead to new interventions that could slow down the progression of 
kidney disease.
    Scientists supported by NIDDK have pursued cutting-edge basic, 
clinical, and translational research. While ASN fully understands the 
difficult economic environment, the society firmly believes that 
funding NIDDK is a sound investment to create jobs, support the next 
generation of investigators, and ultimately provide quality care that 
is less expensive in order to improve the public health of Americans.
    Medical research is a major force in the economic health of 
communities nationwide: every dollar invested in medical research 
generates $2.60 in economic activity. America must continue to 
capitalize on previous investments to drive research progress, train 
the next generation of scientists, create new jobs, promote economic 
growth, and maintain leadership in the global innovation economy--
particularly as other countries increase their investments in 
scientific research. Most important, a failure to maintain and 
strengthen NIDDK's ability to support the groundbreaking work of 
researchers across the country carries a palpable human toll, denying 
hope to the millions of patients awaiting the possibility of a 
healthier tomorrow.
    ASN urges Congress to uphold its longstanding legacy of bipartisan 
support for biomedical research. Should you have any questions or wish 
to discuss NIDDK or kidney research in more detail, please contact ASN 
Manager of Policy and Government Affairs Rachel Meyer at (202) 640-4659 
or [email protected].
                               about asn
    The American Society of Nephrology (ASN) is a 501(c)(3) non-profit, 
tax-exempt organization that leads the fight against kidney disease by 
educating the society's 15,000 physicians, scientists, and other 
healthcare professionals, sharing new knowledge, advancing research, 
and advocating the highest quality care for patients. For more 
information, visit ASN's website at www.asn-online.org.
                                 ______
                                 
     Prepared Statement of the American Society of Plant Biologists
    On behalf of the American Society of Plant Biologists (ASPB), we 
would like to thank the Subcommittee for its support of the National 
Institutes of Health (NIH). ASPB and its members strongly believe that 
sustained investments in scientific research will be a critical step 
toward economic recovery and job creation in our Nation. ASPB supports 
the maximum fiscal year 2015 appropriation for NIH and asks that the 
Subcommittee Members encourage increased support for plant-related 
research within the agency; 25 percent of our medicines originate from 
discoveries related to plant natural products, and such research has 
contributed in innumerable ways to improving the lives and health of 
Americans and people throughout the world.
    ASPB is an organization of some 4,500 professional plant biology 
researchers, educators, students, and postdoctoral scientists with 
members across the Nation and throughout the world. A strong voice for 
the global plant science community, our mission--achieved through work 
in the realms of research, education, and public policy--is to promote 
the growth and development of plant biology, to encourage and 
communicate research in plant biology, and to promote the interests and 
growth of plant scientists in general.
Plant Biology Research and America's Future
    Among many other functions, plants form much of the base of the 
food chain upon which all life depends. Importantly, plant research is 
also helping make many fundamental contributions in the area of human 
health, including that of a sustainable supply and discovery of plant-
derived pharmaceuticals, nutriceuticals, and alternative medicines. 
Plant research also contributes to the continued, sustainable, 
development of better and more nutritious foods and the understanding 
of basic biological principles that underpin improvements in the health 
and nutrition of all Americans.
Plant Biology and the National Institutes of Health
    Plant science and many of our ASPB member research activities have 
enormous positive impacts on the NIH mission to pursue ``fundamental 
knowledge about the nature and behavior of living systems and the 
application of that knowledge to extend healthy life and reduce the 
burdens of illness and disability.'' In general, plant research aims to 
improve the overall human condition--be it food, nutrition, medicine or 
agriculture--and the benefits of plant science research readily extend 
across disciplines. In fact, plants are often the ideal model systems 
to advance our ``fundamental knowledge about the nature and behavior of 
living systems'' as they provide the context of multi-cellularity while 
affording ease of genetic manipulation, a lesser regulatory burden, and 
maintenance requirements that are less expensive than those required 
for the use of animal systems.
    Many fundamental biological components and mechanisms (e.g., cell 
division, viral and bacterial invasion, polar growth, DNA methylation 
and repair, innate immunity signaling and circadian rhythms) are shared 
by both plants and animals. For example, a process known as RNA 
interference, which has potential application in the treatment of human 
disease, was first discovered in plants. Subsequent research eventually 
led to two American scientists, Andrew Fire and Craig Mello, earning 
the 2006 Nobel Prize in Physiology or Medicine. More recently 
scientists engineered a class of proteins called TALENs capable of 
precisely editing genomes to potentially correct mutations that lead to 
disease. That these therapeutic proteins are derived from others 
initially discovered in a plant pathogen exemplifies the application of 
plant biology research to improving human health. These important 
discoveries again reflect the fact that some of the most important 
biological discoveries applicable to human physiology and medicine can 
find their origins in plant-related research endeavors.
    Health and Nutrition--Plant biology research is also central to the 
application of basic knowledge to ``extend healthy life and reduce the 
burdens of illness and disability.'' Without good nutrition, there 
cannot be good health. Indeed, a World Health Organization study on 
childhood nutrition in developing countries concluded that over 50 
percent of child deaths under the age of five could be attributed to 
malnutrition's effects in weakening the immune system and exacerbating 
common illnesses such as respiratory infections and diarrhea. 
Strikingly, most of these deaths were not linked to severe 
malnutrition, but chronic nutritional deficiencies brought about by 
overreliance on single crops for primary staples. Plant researchers are 
working today to address the root cause of this problem by balancing 
the nutritional content of major crop plants to provide the full range 
of essential micronutrients in plant-based diets.
    By contrast to developing countries, obesity, cardiac disease, and 
cancer take a striking toll in the developed world. Research to improve 
and optimize concentrations of plant compounds known to have, for 
example, anti-carcinogenic properties, will hopefully help in reducing 
disease incidence rates. Ongoing development of crop varieties with 
tailored nutraceutical content is an important contribution that plant 
biologists can and are making toward realizing the long-awaited goal of 
personalized medicine, especially for preventative medicine.
    Drug Discovery--Plants are also fundamentally important as sources 
of both extant drugs and drug discovery leads. In fact, 60 percent of 
anti-cancer drugs in use within the last decade are of natural product 
origin--plants being a significant source. An excellent example of the 
importance of plant-based pharmaceuticals is the anti-cancer drug 
taxol, which was discovered as an anti-carcinogenic compound from the 
bark of the Pacific yew tree through collaborative work involving 
scientists at the NIH National Cancer Institute and plant natural 
product chemists. Taxol is just one example of the many plant compounds 
that will continue to provide a fruitful source of new drug leads.
    While the pharmaceutical industry has largely neglected natural 
products-based drug discovery in recent years, research support from 
NIH offers yet another paradigm. Multidisciplinary teams of plant 
biologists, bioinformaticians, and synthetic biologists are being 
assembled to develop new tools and methods for natural products 
discovery and creation of new pharmaceuticals. We appreciate NIH's 
current investment into understanding the biosynthesis of natural 
products through transcriptomics and metabolomics of medicinal plants. 
The recently released ``Genomes to Natural Products'' funding 
opportunity is also to be applauded as a potential avenue for new 
plant-related medicinal research, and we strongly encourage the 
continuation of these types of investments and other plant-related 
initiatives which can help further achievement of the NIH mission.
Conclusion
    Although NIH does recognize that plants serve many important roles, 
the boundaries of plant-related research are expansive and integrate 
seamlessly and synergistically with many different disciplines that are 
also highly relevant to NIH. As such, ASPB asks the Subcommittee to 
provide the maximum appropriation and direction to NIH to support 
additional plant research in order to continue to pioneer new 
discoveries and new methods with applicability and relevance in 
biomedical research.
    Thank you for your consideration of ASPB's testimony. For more 
information about ASPB, please see www.aspb.org.

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    [This statement was submitted by Joseph C. Isaacs, Chief Executive 
Officer, National Blood Clot Alliance.]
                                 ______
                                 
  Prepared Statement of the National Center for Learning Disabilities
    The National Center for Learning Disabilities (NCLD) works to 
ensure that the Nation's 60 million children, adolescents and adults 
with learning disabilities and attention issues have every opportunity 
to succeed in school, work and life. NCLD asks you to consider our 
request as you work on the fiscal year 2015 Labor, Health and Human 
Services, and Education Appropriations bill.
    As you begin work on the fiscal year 2015 Labor, Health and Human 
Services, and Education Appropriations bill, we urge you to support 
continued funding for special education at the President's request 
level of $11.57 billion for the Individuals with Disabilities Education 
Act (IDEA) and the President's $100 million for Results Driven 
Accountability Incentive Grants which would provide competitive grants 
to States to implement promising, evidence-based reforms that would 
improve service delivery for children with disabilities while building 
State and local capacity to improve long--term outcomes for those 
children
    We also urge you to support funding for the National Technical 
Assistance Center within the Higher Education Opportunity Act (Section 
777(a)) at $2 million to provide useful and comprehensive information 
to students with disabilities on the choices available to them in 
higher education and to provide much-needed training, technical 
assistance, and professional development to institutes of higher 
education.
IDEA Part B Grants to States & Results Driven Accountability Incentive 
        Grants
    Currently, there are over 6.5 million children eligible for special 
education services under the disability categories of the Individuals 
with Disabilities Education Act (IDEA). The comprehensive assessment 
and support services authorized by IDEA help to close the academic 
achievement gap and ensure a meaningful education for every student. We 
owe it to all students to provide a quality education that will help 
them graduate and enter successful careers.
    We support the Administration's request that would maintain funding 
for IDEA, Part B (Grants to States program) at $11.57 billion, which 
the Administration estimates would provide $1,758 per child for an 
estimated 6.6 million students with disabilities. Additionally we 
support the President's $100 million for Results Driven Accountability 
Incentive Grants, which would provide competitive grants to States to 
implement promising, evidence-based reforms that would improve service 
delivery for children with disabilities. We encourage innovation in the 
realm of service delivery to students receiving special education and 
believe that these grants have the potential to spark innovative ideas 
and a renewed focused on improved outcomes for students.
The National Technical Assistance Center
    In the HEA reauthorization of 2008, Congress authorized the 
establishment of National Center for Information and Technical Support 
for Postsecondary Students with Disabilities. This Center was intended 
to serve three primary purposes: (1) serve as a resource to parents and 
students with disabilities on the services available at various IHEs; 
(2) serve as a technical assistance center to IHEs and provide training 
to faculty and staff on how to improve services for students with 
disabilities; and (3) serve as an online database for the collection 
and dissemination of a variety of disability-related information for 
students with disabilities who are interested in higher education. 
Though the Center was authorized, it has never been funded.
How Students with Disabilities are Faring in Higher Education
    In recent years, due to the services provided to students with 
disabilities through the Individuals with Disabilities in Education Act 
(IDEA) or Section 504 of the Rehabilitation Act, students with learning 
and attention issues have graduated from high school at higher rates 
than ever before. In fact, a majority (54 percent) of students with 
learning disabilities have the goal to attend a 2- or 4-year 
college.\1\ Students with learning disabilities make up the largest 
population of students with disabilities who attend postsecondary 
schools, at 69 percent of all students with disabilities in 
postsecondary programs.\2\
---------------------------------------------------------------------------
    \1\ Cortiella, Candace and Horowitz, Sheldon H. The State of 
Learning Disabilities: Facts, Trends and Emerging Issues. New York: 
National Center for Learning Disabilities, 2014.
    \2\ Newman, L.A. & Madaus, J. W. (2013). Reported Accommodations 
and Supports Provided to Secondary and Postsecondary Students with 
Disabilities: National Perspective. Publication forthcoming.
---------------------------------------------------------------------------
    Unfortunately, students with disabilities are not attending 
postsecondary education programs at the same rate as students in the 
general population. In the general education population, within 4 years 
of graduating high school, 53 percent of students continue on to 
postsecondary education programs, compared to only 45 percent of youth 
with disabilities. Even worse, young adults with learning disabilities 
(LD) attend four-year colleges at half the rate of the general 
population.\3\ Students with disabilities would benefit from better 
outreach, recruitment, and assistance programs to bridge the gap 
between high school and postsecondary education programs. Comprehensive 
information on higher education programs and services is needed now 
more than ever. With more students with disabilities setting goals of 
attending college but few actually enrolling and completing college 
programs, it is critical that they have access to the information and 
support services they need.
---------------------------------------------------------------------------
    \3\ Cortiella & and Horowitz (2014).
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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).
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    The Purpose of the National Technical Assistance Center
    We recognize that providing useful and comprehensive information to 
parents and students on the choices available is not an easy task. 
Therefore, we recommend funding the National Technical Assistance 
Center, found in the 2008 authorization of HEA, at $2 million. The 
Center would serve several key purposes: (1) providing information and 
resources to students and parents on disability services and programs 
at IHEs; (2) providing training and technical assistance to IHEs; (3) 
providing training and professional development to faculty and staff at 
IHEs; and (4) information collection and dissemination on best 
practices, documentation requirements, financial aid, services 
available, policies, and accessible instructional materials.
    We urge you to continue your investment in students with 
disabilities through funding of IDEA and the RDA grants and support 
funding in fiscal year 2015 for the National Technical Assistance 
Center. Thank you for your consideration of our request.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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




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

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

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

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

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

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

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

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

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

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

Attachments:

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




  --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.]
                                 ______